Every finding on record at Grand Meadows Senior Living & Health Care

Based on observation, resident and staff interview, and facility policy review the facility failed to ensure residents had a dignified dining experience for Resident #13 and four additional residents. The facility reported a census of 29 residents.Findings Include: Review of Resident #13's Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment. The MDS further revealed diagnosis of unspecified dementia without behavioral disturbance and Diabetes Mellitus. On 3/26/26 at approximately 6:45 AM, an observation was made of residents brought to the dining table by Staff K Certified Nursing Assistant (CNA). Five residents were observed at the table by 7:00 AM. Several residents including Resident #13 were heard repeatedly asking for something to drink. Resident #13 repeatedly asked for coffee and was told by Staff F it would be a little bit. Other residents were heard asking for water or a snack and wondering where their breakfast was. Staff F repeatedly responded to residents ok or it would be a little bit. On 3/26/26 at 7:30 AM Resident #13 queried about any concerns he had with meals. He advised they always brought (residents) out here so early and then had to sit and wait a long time. Resident #13 explained asked staff for coffee and they told the resident he had to wait. He explained there was no reason he couldn't have something to drink, even water. Resident #13 explained he was not in prison. The other four residents at the table also spoke up and explained if they had to sit there so long they would at least like something to drink. On 3/26/26 at 7:40 AM, observation revealed Staff K prepared drinks for the residents and placed them on a serving tray in the kitchenette area. After the drinks were prepared, Staff K stood in the kitchenette area and did not serve the residents their drinks. Approximately 10 minutes later Staff K was queried and explained waited to closer to the time the meal was served to pass out the beverages. When asked for clarification, Staff K shared if they gave the residents their drinks too soon, they would drink them and want more and would drink several if they were allowed to. Then the residents would have to go to the bathroom more often and would have to change their briefs. Staff K explained then would run out of briefs. When asked if the facility ran out of briefs often Staff K responded, not really. On 3/26/26 at 1:15 PM Staff L, Registered Nurse (RN) was queried about when the residents were brought out to the dining area for their meals. Staff L explained typically residents were brought out for meals closer to the meal time then what the CNA did that morning. Staff L advised she did not know why the residents were brought out for breakfast so early that morning and if they were going to be brought out that early, they should have been offered something to drink and a snack. On 3/26/26 at 1:30 PM, Staff C, CNA explained breakfast was usually at 8:00AM and residents started coming out around 7:20 AM. On 3/26/26 at 1:32 PM, Staff B, CNA explained breakfast was around 8 AM. Residents come out to the dining room about 7:20 AM to be ready by 7:45 AM. Per Staff B, the residents were provided drinks while they waited. Staff B was not aware of running out of briefs. On 3/26/26 2:24 PM the Director of Nursing (DON) explained she had observed staff bring residents to the dining room between 7:30 and 7:45 AM. The DON explained 6:30 AM was too early for residents to be in the dining room for breakfast unless it was the resident's request. Per the DON, it was her expectation that residents be offered a drink within five minutes. The DON further explained she ordered all of the briefs and they had never run out.On 3/26/26 at approximately 3:15 PM the Administrator explained it was the resident's preference what time they were brought out for breakfast. He explained unless the residents had requested, 6:30 AM would be too early to be brought out for dining. He further explained it was his expectation the resident was given something to drink right away. Per the Administrator, earlier this week dietary staff approached him with concerns of residents being brought out for meals too early. When queried, the Administrator explained the facility staff would never withhold a resident from beverages unless they had a beverage restriction. He was not aware of the facility ever running out of briefs. A review of the facility policy titled Resident Rights Policy, dated 12/24 revealed, Each resident residing in this community has the right and will be afforded the right to a dignified existence, self determination, and communication. Each resident will have autonomy and choice, to the maximum extent possible, about how each resident wish to live his/her everyday life and receipt of care, subject to the community's policies and procedures as long as those policies do not violate any requirement.

Based on record review, staff interviews and facility policy review the facility failed to notify the physician of change in resident transfer status and pain in left ankle for 1 out of 1 resident reviewed with injury of unknown origin (Resident #25). The facility identified a census of 29 residents. Findings include:Review of the Minimum Data Set for Resident #25 dated 12/5/25 revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. The MDS noted Resident #25 needed supervision or touching assistance for sit to stand transfers and toilet transfers. The MDS listed diagnoses of hypertension (high blood pressure), end stage renal disease, and diabetes. Review of the facility nurse progress notes from 2/13/26 through 2/15/26 lacked any documentation of left ankle pain or change in transfer status or ability to bear weight. The progress notes failed to reveal any physician notification. Review of the progress notes from dialysis on 2/16/26 for Resident #25, with no time indicated, revealed she arrived today with a complaint of much pain in left ankle and unable to stand on it. A Progress Note from dialysis Advanced Registered Nurse Practitioner noted on 2/16/26 at 8:02 AM revealed Resident #25 presented to dialysis with left ankle medial and lateral malleolar pain. It is exquisitely tender in nature. We can barely touch it. She denies any trauma. Review of a written statement dated 2/25/26 at 1:54 PM by Staff H, Licensed Practical Nurse (LPN) revealed she worked 6:00 PM to 6:00 AM on 2/15/26. During the shift Staff H was made aware Resident #25 requested 2 person assist with her transfer due to not being able to bear weight on her left leg. Later in the shift Resident #25 requested pain medication for a rating of moderate pain. Resident #25 requested assistance from two staff from a recliner to wheelchair to have breakfast. On 3/25/26 at 12:43 PM, Staff G, LPN confirmed she worked on day shift 6:00 AM to 6:00 PM on 2/14/26 in Resident #25's unit. Resident #25 had been complaining for a couple of days, she had a sore on her leg and she complained that her leg hurt. Normally she would transfer with one and she would hold onto and use the grab bar and transfer. She was not letting go of the transfer bar that day. Staff G didn't recall if she was bearing weight 100% or not. Staff G didn't transfer her very often. Staff G knew she had been complaining of pain for a couple days prior to that. Staff G explained usually, would document pain assessments in a progress note, if it was unusual. Staff G did not recall if gave her (resident) pain medication that day and it would be on the medication administration record. Staff G thought she was on scheduled Tylenol. Staff G looked at the whole knee down and thought along the lines of cellulitis, when the pain increased [Staff G] thought more cellulitis. Per Staff G, asked her (resident) to do a range of motion but she refused but that was not uncommon for Resident #25 to get upset with a lot of questions. Staff G further explained did pass it along to the nurse on the next shift that resident was having pain. Per Staff G, should have charted in the progress note anything that was out of the normal for the resident. On 3/25/26 at 3:47 PM of Staff E, CNA revealed she worked the evening shift 2:00 PM to 10:00 PM and Resident #25 requested more assistance with transfers. Resident #25 reported to Staff E, CNA it was hard for her to put weight on her left leg. She spoke with a coworker about it and normally Resident #25 did not require extra help and she requested more help that night. Staff E explained let the nurse know and she was going to talk to her about it. She could not recall who the nurse was that night. On 3/25/26 at 2:29 PM Staff F, Certified Nursing Assistant (CNA) revealed she worked 6:00 PM to 6:00 AM on 2/15/26. Staff F assisted Resident #25 in the bathroom and Resident #25 said she could not put any weight on her leg, so had to get a second person. A lot of times she would do it on her own and other times she would need assistance from one staff member, it would depend on how she was feeling. The nurse knew about the situation because she had to help with transfers that night and Resident #25 wasn't able to bear weight. On 3/26/26 at 11:40 AM Staff D, Registered Nurse (RN) revealed if change in status of resident transfer status and complaints of pain staff should notify the physician and potentially have evaluation at the emergency room or attempt to get a physician appointment. On 3/26/26 at 1:33 PM the Director of Nursing (DON) reported with condition changes for residents, staff should notify the on-call nurse, DON, and the on-call physician. The DON revealed Resident #25 was alert and oriented, and the resident should have been talked to about if she wanted follow up and staff should have offered her choices. The facility provided a policy dated 12/2024 titled Significant Condition Change and Notification which stated the purpose was to ensure the resident's family and/or representative and medical practitioner were notified of resident changes such as those listed below: -An accident or incident, with or without injury, that has the potential for needed medical practitioner intervention. -A significant change in the resident's physical, mental or psychosocial status. Sudden onset of shortness of breathMobility changesAbnormal, unusual or new complaints of pain

Based on record review, interviews, and the Medicare Claims Processing Manual the facility failed to provide a resident with form CMS-10055 (Centers for Medicare & Medicaid Services) at the end of therapy services when the resident planned to remain in the building for one of three residents reviewed for Beneficiary Notice (Resident #20). The facility reported a census of 29 residents.Findings include:A review of Resident #20's Minimum Data Set, dated [DATE] revealed he admitted to the facility on [DATE]. The resident ended his therapy and Medicare stay on 11/07/2025. His Brief Interview for Mental Status score was 11/15, which indicated moderate cognitive impairment.On 3/26/26 the facility was asked to provide documentation of the resident's CMS 10055 (Advance Beneficiary Notice of Non-Coverage or ABN) and CMS 10123 (Notice of Medicare Non-Coverage or NOMNC) forms.A document titled Notice of Medicare Non-Coverage (NOMNC, CMS 10123) dated 11/07/2025 documented the end of Resident #20's skilled services. It was signed by his power of attorney on 11/05/2025. The facility did not provide a CMS-10055. During an interview with the Administrator on 3/26/26 at 2:18 PM he stated he was unable to say if the facility completed the CMS 10055 for discharging residents. He indicated social services completed them.On 3/26/26 at 2:25 PM Staff I, Social Services stated she was not completing the CMS 10055 with any residents discharged from skilled services or therapy who remained in the facility. She indicated she was not aware they needed it. Chapter 30 of the Medicare Claims Processing Manual documented that the ABN form CMS 10055 was issued in order for a Skilled Nursing Facility (SNF) to transfer financial liability to an original Medicare beneficiary for items or services that Medicare was expected to deny payment (entirely or in part).

Based on clinical record review, staff interviews, and facility policy review, the facility failed to document targeted behaviors and provide non-pharmacological interventions prior to the use of an as needed antianxiety medication for 1 of 5 residents reviewed for unnecessary medications (Resident #9). The facility reported a census of 32 residents.Findings include:The Minimum Data Set assessment for Resident #9 dated 3/5/26 identified a Brief Interview for Mental Status score of 8 out of 15, indicating moderate cognitive impairment. The MDS identified a PHQ-2 (Patient Health Questionnaire, a screening tool used to assess the frequency of depressed mood) score of 0, which indicated no depression. The MDS documented the resident displayed no behavioral symptoms, hallucinations or delusions during the look back period. The MDS documented diagnoses that included non-Alzheimer's Dementia, anxiety, and depression. The Care Plan for Resident #9 dated 3/2/26 identified a focus area of depression and anxiety related to dementia. It directed staff to monitor, document and report signs and symptoms of depression and to administer medications as ordered. No targeted behaviors for antianxiety medication were documented on the Care Plan. The Medication Administration Record (MAR) for March 2026 documented Resident #9 received an order on 3/4/26 for Alprazolam (Xanax, an antianxiety medication), with instruction to give 1 tablet of 0.5 mg (milligram) every six hours as needed. The order was 14 days long. Between 3/4/26 and 3/18/26, eight doses were administered. A new order was written with a start date of 3/19/26. Between 3/19/26 and 3/25/26, an additional seven doses were administered.A Health Status Note dated 3/4/26 at 4:59 PM documented that the resident's daughter notified the facility that the resident had been calling family members during overnight hours. The daughter reported that the resident had been using alprazolam prior to admission and requested the facility inform the physician of this. The note further documented staff notified the physician and that was when the alprazolam order was initially prescribed. Daily Skilled Nursing Notes, documented twice daily, were reviewed for 2/27/26 through 3/20/26. The standardized form included an area to note if the was resident experiencing any cognitive concerns/behaviors. On 2/28/26, 3/2/26, and 3/5/26 it was documented the resident had confusion. On 3/11/26 it was documented the resident yelled at times. On 3/12/26 it was documented the resident was pleasantly confused and on 3/19/26 the resident experiencing moderate to severe confusion. A review of eMAR (electronic MAR) notes revealed that no behaviors or non-pharmacological interventions were documented prior to administration of any of the doses of the PRN (as needed) alprazolam.On 3/25/26 at 2:53 pm, the Director of Nursing (DON) explained, via email, that her expectation and the facility's practice was for the staff to document on the eMAR if the resident displayed behaviors and if so, to enter a detailed progress note outlining the specific behaviors, contributing factors, and interventions implemented. The DON also stated re-education had been provided to nursing staff. The email additionally documented that the expectation of the facility was that non-pharmacological interventions were attempted and documented prior to the administration of PRN (as needed) psychotropic medications. Further education regarding this was also provided to the nursing staff. In a separate email on 3/26/26 at 8:42 am, the DON stated no targeted behaviors for the use of alprazolam were on the Care Plan for Resident #9. She stated the facility had no documentation as to what the alprazolam was treating as Resident #9 was a recent admission to the facility. On 3/26/26 at 11:16 am, Staff B, Certified Nurse Aide (CNA) Resident #9 would at times pick at a scab on the right side of her head but she was not aware of any other behaviors she exhibited. She stated the resident did get more confused later in the day. Staff C, CNA stated that in the evenings, Resident #9 got more anxious and would roll back and forth in her wheelchair. She said if the resident was in her room and her call light was attached to her wheelchair (so she could locate it if needed), this would agitate the resident. She said if the resident became agitated, staff would bring her out of her room and talk with her which would usually help calm her down. She felt Resident #9 got bored and enjoyed having company. She stated she would report any behaviors to the nurse to document. She stated as a CNA she was unable to document behaviors on all residents, explaining behavior documentation was only shown for some of the residents in the CNA charting. On 3/26/26 at 11:32 am, Staff D, Registered Nurse (RN) stated Resident #9 normally did not have any anxious behaviors when she was on duty. She stated the resident was very confused when she was first admitted . The facility was a new environment and the resident would often climb out of bed or out of her chair but she was no longer doing that. She also stated Resident #9 did pick at the scab on her head from a fall earlier in her stay. She stated if Resident #9 was displaying anxious behaviors, it should be documented in progress notes if giving the PRN medication. The facility policy Psychotropic Medication Use, dated 2/2025 included the following documentation: Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to:AntipsychoticsAntidepressantsAntianxiety Hypnotics The policy further revealed, Staff will complete the Psychoactive Medication Review assessment on admission, when any new psychotropic medication is ordered, with a change of condition, and quarterly. This assessment will be completed for any medication prescribed to manage behaviors .Residents who are admitted from the community or transferred from a hospital and who are already receiving psychotropic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: Review PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or Re-evaluate the use of the psychotropic medication at the time of admission to consider whether the medication can be reduced, tapered, or discontinued per regulation.Complete the Psychotropic Medication Review assessment in the EHR (electronic health record).Based on assessing the resident's symptoms and overall situation, the medical practitioner will determine whether to continue, adjust, or stop existing psychotropic medication. No Psychoactive/Psychotropic Medication Review was located in Resident #9's Electronic Health Record

Based on observation, record review and staff interviews the facility failed to provide enhanced barrier precautions to prevent the spread of infections for 2 out of 4 residents ( Resident # 7) with a catheter and (Resident # 11) with an open wound. The facility identified a census of 29 residents. Findings include: 1.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had an indwelling catheter.The Care Plan for Resident #7 with a revision date of 3/16/26 revealed the resident had an indwelling foley catheter. Resident #7's Care Plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. The Care Plan failed to direct staff to use enhanced barrier precautions with the use of the catheter. On 3/26/26 at 11:25 AM Staff C, Certified Nursing Assistant (CNA) emptied the foley catheter for Resident #7 in her room. She did not utilize any personal protective equipment and failed to utilize enhanced barrier precautions. No supplies were outside of the room and no sign posted on the door to notify staff to use enhanced barrier precautions. 2. Review of the MDS dated [DATE] for Resident #11 revealed she had a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough). Review of Resident #11's Care Plan with a revision date 3/5/26 revealed a Stage 2 pressure ulcer to the coccyx on 2/19/26. The Care Plan failed to direct staff to use enhanced barrier precautions for Resident #11. On 3/26/26 at 7:47 AM observed the Assistant Director of Nurse (ADON) provided wound care to Resident #11's buttocks. The ADON completed the dressing change but failed to don personal protective equipment or utilize enhanced barrier precautions. There was no sign outside Resident #11 door and no supplies for personal protective equipment. On 3/26/26 at 11:36 AM Staff D, Registered Nurse (RN) stated enhanced barrier precautions should be used when a resident has an open wound, any colostomy, dialysis port, or tube feeding. On 3/26/26 at 1:46 PM, the Director of Nursing (DON) revealed enhanced barrier precautions should be utilized for multi drug resistant organisms (MDRO), anyone with a dialysis port, catheter, colostomy, chronic wounds and tube feedings. Enhanced barrier precautions should be utilized to protect the resident from infections. Per the DON, even if the wound was covered, should still use enhanced barrier precautions. Staff would know if they were on enhanced barrier precautions by a sign posted on the resident's door. The DON explained had recently done staff education for enhanced barrier precautions. The ADON and DON were responsible for putting the signs on doors. The facility provided an undated policy titled Infection Prevention and Control Manual-Enhanced Barrier Precautions which directed that enhanced barrier precautions were recommended for residents with any of the following:Infection of colonization with a MDRO or A wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheter, feeding tubes, tracheostomies/ventilators. High contact resident care activities where a gown and gloves should be used include: Bathing/showeringTransferring residents from one position to another (for example, from bed to wheelchair)Providing hygieneChanging bed linensChanging briefs or assisting with toiletingCaring for or using an indwelling medical devicePerforming wound care.

Based on record review, staff interview, and facility policy review the facility failed to screen residents for eligibility of the pneumococcal vaccine for 2 of 5 residents reviewed (Resident #7 and Resident #13). The facility reported a census of 29 residents.Findings Include: 1. The admission Minimum Data Set (MDS) assessment tool, dated 3/2/26 revealed Resident #7 admitted to the facility on [DATE]. The MDS revealed the resident had severely impaired cognition for daily decision making. The admission MDS documented the resident received a Influenza vaccine outside the facility, was not up to date with pneumococcal vaccination, and was not offered a pneumococcal vaccine. The Immunization Consent Form for Resident #7 dated 10/24/24 documented the resident received a Covid vaccine and Influenza vaccine. There was no documentation of a pneumococcal vaccine.The Immunization Consent Form for Resident #7 dated 10/16/25 documented the resident received an Influenza vaccine. The was no documentation of a pneumococcal vaccine.2. The Quarterly MDS assessment tool dated 2/01/26 listed diagnosis for Resident #13 which included unspecified dementia without behavioral disturbance and diabetes mellitus. The MDS listed his BIMS score was 10 out of 15, indicating moderate impairment. Resident #13 admitted to the facility on [DATE]. The Immunization Consent Form for Resident #13 dated 11/13/25 documented the resident received a Covid vaccine and Influenza vaccine. There was no documentation on a pneumococcal vaccine. The MDS also documented the resident was up to date on pneumococcal vaccination.Documentation from the pharmacist dated 1/13/26 revealed the resident qualified for Prevnar 20. During an interview on 3/26/26 at 2:01 PM, the Director of Nursing (DON) and Infection Control Preventionist was queried on the expectation of residents being vaccinated for pneumococcal and she advised, all resident vaccination history should be electronically entered into the Immunizations Section of the resident's EHR (electronic health record) within 48 hours of their admission. The DON queried she was unable to provide further vaccination documentation on either resident and both should have been offered the pneumococcal vaccination and if refused a declination and verification of education should be in the resident's EHR. The DON advised there had been a lot of staff turn over and there was no staff assigned to entering vaccinations.The Facility Policy titled Infection Prevention and Control Manual dated 2019 documented the following: It is the policy that this facility's Infection Prevention and Control Program (IPCP), is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible.

Based on observation, record review, staff interviews, and facility policy review the facility failed to assess and intervene for a resident with a fall which resulted in a fracture (Resident #1) and for a major injury of unknown origin (Resident #25) for 2 out of 2 residents reviewed with injuries. The facility reported a census of 29 residents. Findings include:1. Review of the Minimum Data Set for Resident #25 dated 12/5/25 revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. The MDS noted Resident #25 needed supervision or touching assistance for sit to stand transfers and toilet transfers. The MDS listed diagnosis of hypertension (high blood pressure), end stage renal disease and diabetes. Review of the nurse progress note 2/16/26 at 1:48 PM revealed Resident #25 went to the emergency department related to left ankle pain. The progress note dated 2/16/26 at 6:03 PM revealed Resident #25 had a tibial fracture on left leg. Resident #25 needed to be completely non weight bearing and wear a boot to move around. Review of the progress notes from dialysis on 2/16/26, no time documented, revealed the resident arrived that day with a complaint of pain in left ankle and was unable to stand on it. A progress note from the dialysis Advanced Registered Nurse Practitioner noted on 2/16/26 at 8:02 AM revealed Resident #25 presented to dialysis with left ankle medial and lateral malleolar pain. It was exquisitely tender in nature. We can barely touch it. She denies any trauma. Review of the facility nurse progress notes from 2/13/26 through 2/15/26 from the facility failed to reveal any documentation of left ankle pain or change in transfer status or ability to bear weight. Review of an incident report dated 2/15/25 at 10:00 PM revealed Resident #25 went to dialysis this AM and requested to be sent to the emergency room for ankle pain. Facility notified of fracture to left ankle. Resident #25 stated she had been assisted by a staff member when her leg got caught between staff members legs and her ankle twisted. A progress note from 2/16/26 6:37 PM revealed vital signs stable and fistula within desired limit after dialysis and the emergency room. The progress notes did not have any assessments on the left lower extremity or pain level. A written statement by Staff G, Licensed Practical Nurse (LPN)on 2/18/26 revealed on the evening of 2/14/26 Resident #25 complained of pain to the left lower leg. The resident does have a dressing change for a skin tear and she removed the dressing to assess for any signs and symptoms of infection. After supper during a transfer to the toilet Resident #25 did not want to stand on the left leg. She refused to use the easy stand and was assisted to the toilet by pivot on right leg and staff holding her by a gait belt. Staff G reported to the nurse at 6:00 PM who relieved her about the pain and to watch for signs and symptoms of infection. A major injury form signed on 2/18/26 revealed the resident had diffuse osteopenia and likely osteoporosis. Per the form, the resident had a diaphyseal fracture. The ankle mortise was noted to be intact (socket of the distal tibia and fibula). The section completed by the Physician, designee, or extender noted the resident had an excellent prognosis with recovery within 3 to 6 months without surgery. Treatment included non-operative management with boot and ortho follow up and evaluation. Review of a written statement dated 2/25/26 at 1:54 PM by Staff H, Licensed Practical Nurse (LPN) revealed she worked 6:00 PM to 6:00 AM on 2/15/26. During the shift Staff H was made aware Resident #25 requested 2 persons to assist with her transfer due to not being able to bear weight on her left leg. Later in the shift Resident #25 requested Tylenol (pain medication) for a rating of moderate pain. Resident #25 requested assistance from two staff from a recliner to wheelchair to have breakfast. No further complaints of pain or discomfort during the remainder of the shift. A written statement by Staff F, Certified Nursing Assistant (CNA) revealed on 2/15/26 sometime between 7:30-8:00 PM went to Resident #25 bathroom and the resident told her she could not put any weight on her left leg. Resident #25 requested to get another person to help. Resident #25 did not say she was in pain, only that she could not put weight on it. On 3/25/26 at 12:20 PM, the Director of Nursing (DON) stated she did fill out the incident report for Resident #25 after the ankle injury. The resident could not specify when the transfer occurred or who it was with initially Resident #25 stated she thought it was a male and then after she changed her statement and said she could not recall. On 03/26/26 at 11:40 AM, Staff D, Registered Nurse (RN) stated if a resident had a change in status for transfers and complaints of pain she would complete an assessment. Staff D would see if the resident could bear weight, would check the resident range of motion and assess where pain was located. Staff D would check the resident's pulse and circulation and notify the physician. Staff D explained they would document the assessment in the progress notes, and if they returned with a fracture from the emergency room, would need to do circulation checks, and make sure pain was controlled, and follow any restrictions. On 3/26/26 at 1:33 PM, the DON revealed she was notified of the left ankle fracture for Resident #25 after she did not return from dialysis. The DON stated it occurred during a transfer and her leg hit something or got caught between staff member legs. The nurse should have documented in the progress notes or incident report. The nurse should do a proper assessment. After she returned from the emergency room and the information the nurse had of the fracture, she should have done a baseline assessment and documented a pain assessment. 2. The MDS for Resident #1 dated 1/31/26 documented diagnoses of dependence on renal dialysis with stage 5 chronic kidney disease, heart failure, and respiratory failure. The BIMS score of 12 out of 15 indicated moderately impaired cognition. The MDS documented the resident was dependent for toileting hygiene and needed partial to moderate assistance with toilet transfers. Resident #1 did not wander or reject care. The resident's Care Plan, with a readmission date of 1/26/26, documented the resident was at risk for falls related to gait/balance problems. Another focus area documented the resident had an ADL (Activities of Daily Living) self care performance deficit and required assistance of 1 for transfers and toileting. During an interview with Resident #1 on 3/23/26 at 1:40 PM, she stated she had been in and out of the hospital since December, one of them for a femur fracture. She reported she fell in her bathroom by her toilet. She asked the CNA to hold her longer, stated they didn't, and then she fell. She felt afraid before the fall and the break caused her pain. An Incident Report dated 2/01/26 at 11:30 PM documented the resident was assessed post fall and complained of right leg pain that ranged from 8 to 10. The resident was assessed for injuries and assisted to bed via full body lift. Vital signs were taken as well as neuros (neurological checks). All appeared to be intact. Per the Incident Report, the resident had no injuries, including skin tears, punctures, and hematomas. The list did not include range of motion assessment. The resident was alert to person, place, situation, and time. The Health Status Note dated 2/02/26 at 12:47 AM documented the resident lost her footing on her right leg and fell to the floor. The CNA stated she was assisting the resident when her right leg gave out and she lost her balance. The resident hit her arm on the floor. The CNA denied the resident hit her head. The resident placed her hand on the right side of her head and stated she hit her head. The resident was very vocal about experiencing pain to the right leg. The resident was hoyered into bed by the nurse and the aide. Peri cares were completed during this time. The resident accepted Tylenol 500 mg (milligram). Vitals and neuros were 'intact' and the resident did not complain of additional pain thereafter. This progress note did not include an attempt to assess range of motion or discussion regarding sending the resident to the emergency room. Per the note, the on-call Provider was notified, as well as the DON and resident's responsible party. The Daily Skilled Nurse's Note dated 2/2/26 at 12:02 PM revealed the resident had decreased movement to the right lower extremity, had a fall last evening, and had extreme pain noted to the right lower extremity. Review of the resident's February 2026 Medication Administration Record (MAR) revealed Tylenol 500 mg was administered to the resident on 2/1/26 at 11:43 PM for pain score of 8, on 2/2/26 at 5:45 AM for pain score of 6, and at 6:45 AM for pain score of 10. A document titled Dialysis Communication Form dated 1/02/26 (additional dates indicated it should have been 2/02/26) documented Resident #1 had a fall on 2/01/26 at 11:30 PM, complained of right leg pain, and took a pain medication that morning. Dialysis records dated 2/02/26 indicated the resident was sent to the ER by ambulance and was unable to bear weight. An additional page documented the resident left dialysis 1 hour and 29 minutes early due to pain. The resident reported to dialysis staff that the facility did not offer to send her to the ER. A progress note labeled Health Status Note dated 2/02/26 at 12:55 PM documented the resident was sent to the emergency room (ER) from dialysis for right lower extremity pain. A note on 2/04/26 labeled IDT (Interdisciplinary Team) Fall Note documented the Director of Nursing (DON), Staff I, Social Services, and the Dietary Manager met to review the fall. It indicated the resident was assisted by 1 staff member, a gait belt, and the bathroom grab bar when her right leg gave out and she fell to the floor. General weakness contributed to the fall, and the cause was determined to be related to recent infections (pneumonia and a urinary tract infection). A hospital encounter note dated 2/04/26 at 6:19 PM indicated the resident presented with an acute right femur fracture after a ground level fall and was transferred to this location from another ER due to history of end stage renal disease. On admission, the resident was awake. She confirmed the history of present illness of falling at the facility. At (current) time, the resident reported feeling generally achy all over. She denied pain specifically in the right leg. During an interview with Staff B, CNA on 3/25/26 at 1:15 PM, she reported Resident #1 told her Staff A, CNA 'dropped her' and was crying because of pain in her right leg. When asked if the resident complained about any other pain, Staff B reported the resident did not complain about pain in her arm or head or any other pain. When asked if the resident was scared, Staff B said it didn't seem like it. During an interview on 3/25/26 at 3:11 PM, Provider J, Dialysis nurse stated that the resident was in horrible pain in her right leg. Resident #1 told her that her leg gave out and she hit her head on the toilet. Provider J reported the resident screamed out in pain. The resident told them the facility did not assess her leg before sending her to dialysis or offer to send her to the ER, telling her dialysis would do it. Provider J observed the resident's right leg was swollen, warm to the touch, inverted, and definitely not straight. She was unable to determine if the damage occurred at the time of the fall, during the night, or during transportation and said the injury was pretty obvious. On 3/25/26 at 4:33 PM, Staff A stated that when she answered the resident's room call light, the resident was already at the grab bar in the bathroom so she helped her on the toilet. While the resident was on the toilet, Staff A got her bed ready. She then pulled the toilet chair to the grab bar so the resident could stand up. Staff A said Resident #1 stood fine, said she was ready, and then her right leg just gave out. It looked like she just collapsed on it. Her left leg was straight out in front of her and her right knee was bent but in front of her. She stated it happened really fast and didn't look broken. Staff A confirmed the resident said she hit her head but Staff A didn't see that happen. The resident complained that her leg hurt while she was on the floor. The nurse helped Staff A with the full body lift, and they got Resident #1 into bed. She saw the nurse complete the neurological assessment and vitals, but it was after they put the resident in bed. She did not see her assess for range of motion. Staff A stated the resident still complained of pain when she was in bed. At 1:10 PM on 03/26/26 the Director of Nursing (DON) stated the nurse completing the initial assessment on Resident #1 was an agency nurse and she was not sure what her assessment entailed. The nurse texted the DON at midnight even though it was facility policy to call, so she wasn't aware of the fall until morning when she arrived at 6:00 AM to cover a shift. It was at that time she was notified of the resident's complaints of pain. The DON was not sure what information was provided to the nurse practitioner because it was not documented. She stated the resident was tearful when she saw her that morning, complained of pain that was at a 10, and took pain medication. She was not sure if the medication was effective because the resident went to dialysis. The resident reported to the DON that her leg gave out, and the DON believed that the CNA didn't let go too fast but rather the resident was already falling because her leg gave out. The DON reported she offered to send the resident to the ER twice because she was not her normal self, but the resident wanted to go to dialysis. She reported that she called dialysis who said they would provide her treatment and then send her to the ER. The facility provided a policy titled Significant Condition Change and Notification dated 12/2024. The policy directed documentation will include an assessment of the resident's current status as it related to the change in condition. Charting will be done each shift for 72 hours for residents with a change of condition. A change of condition is reviewed by DON or designee for the continued need for additional documentation.

Based on observation, clinical record review, resident interview, staff interview, and review of the facilities Resident's Rights form revealed staff failed to treat 1 of 3 residents with dignity and respect during cares as a means to maintain their individual resident rights (Resident #3). Findings include: A Minimum Data Set (MDS) assessment form dated 3.27.25 indicated Resident #3 was admitted to the facility on 3.12.25 with diagnoses that included Chronic Kidney Disease, Osteoarthritis, and Sjorgren Syndrome (autoimmune disease). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact). An interview was conducted 6.11.25 at 12:38 p.m. with the resident and the Administrator present per the resident's suggestion as her story would not have swayed from the truth of what occurred and everyone could have heard about the incident. The resident indicated she had been told by an unknown person to report the incident to the Social Services (SS) designee who went to the resident's room on 3.24.25 first for a routine SS visit/assessment post new admissions to the facility and the 2nd time that day with Staff B, Certified Nursing Assistant (CNA), for completion of a formal grievance form The resident indicated she arrived at the facility a Friday night following a week long hospitalization stay. The resident went to bed but in the middle of the night she felt someone as they pulled her blanket off. The room had been dark so she thought she dreamed the situation and pulled the blankets back up. The situation occurred again so the resident again pulled the blankets up, tucked them under her body and rolled on her side. At that point the covers came all the way down along with her cotton pajama bottoms which were not all the way removed but at this point the resident knew the situation was not a dream. The next thing she knew the nurse pulled her legs apart and tried to take off her panties so the resident held onto them and pulled opposite the staff member which ultimately ended up in the panties having ripped. The resident asked the person that pulled down her blankets what had been going on and the staff member told her a required skin assessment. When the resident asked the staff member the time, she stepped into the bathroom while the motion light lit up and the staff member stated 2:30 a.m. At that point the resident told the staff she had not understood that situation and directed the staff to get the f*&^ (explicit) out of her room. The resident described the encounter as having felt violated and she now knew how a rape victim felt when their perpetrator pulled their cloths off. The resident indicated she just could not understand why the staff failed to announce themselves, turn on the light in the room and/or have tapped on her person as a means to awaken her prior to the removal of the blankets which startled her. The resident indicated after the whole incident she went to the bathroom in her room and took off underwear because she was so scared following the event she accidentally peed her pants. The resident indicated when she informed the SW designee about the situation the SW informed her any further contact by the staff member and the resident would not have been allowed but the next day she came into her room and administered her pills so the situation had not been handled from the facility standpoint. The resident indicated she would have been OK post the incident with the planned no contact however that ended up not to be the case. The resident went on to say, she had been so scared following the event she placed her walker in front of her room door for safety. During an interview 6.11.25 at 1:13 p.m. the SW designee indicated she knew nothing about the torn panties, rather, all she had been told during her grievance investigation were the sheets/blankets had been pulled way back and the resident asked the staff member what hell they were doing. During an interview 6.10.25 at 2:28 p.m. the SS Designee confirmed the resident arrived at the facility on a Friday in March for a skilled stay and apparently the 3rd shift nurse, Staff A, LPN entered her room in the middle of the night and ripped her covers back. When questioned Staff B indicated she attempted to have performed a thorough skin assessment because it had not been completed. The outcome of the situation resulted in Staff A had been given the directive to not work with the resident. During an interview 6.11.25 at 4:11 p.m. Staff B, CNA confirmed she accompanied SW Designee to the resident's room for completion of the grievance form and interview with the resident. Staff B indicated the resident told the SW Designee a nurse on the night shift came into her room around 2-3 a.m. for a skin assessment and ripped off her blankets but the resident never mentioned her undergarments having been exposed however her pajamas were. The resident attempted to pull the blankets back up because of not having been aware of the nurses actions. Staff B failed to recall if the resident stated the staff separated her legs but she said she felt violated because of the way the nurse performed the assessment and at that time she felt unsafe. Review of the resident's Medication Administration Record (MAR) dated 3.1.25 thru 3.31.25 Staff A, Licensed Practical Nurse (LPN) administered medications to the resident after the grievance was issued on 3.24.25, 3.25, 3.30 and 3.31. During an interview 6.11.25 at 2:52 p.m. Staff A, Licensed Practical Nurse (LPN) confirmed she had not recalled the resident and/or the incident and she only found out about the grievance on that day (today). A facility summary of events form dated 6.12.25 included the following: On March 24, 2025, during a routine social service assessment, the resident mentioned to the SS Designee of an alleged interaction that occurred on March 22, 2025. The resident reported to her, while she slept, two (2) staff members, which included a nurse and an aide came into her room without any form of communication or direction and started a skin assessment on the resident. The resident claimed they pulled the sheets off her to look at her skin. She also claimed she asked the staff what they were doing, as she attempted to pull the sheet back over her body. Staff replied they a skin assessment. The resident asked the staff why the assessment could not have been completed earlier or later in the morning and complained the staff ignored her. The resident claimed she directed both staff members out of her room and to have not returned without a knock. When the SS Designee performed her assessment it had been when the resident told her what occurred (was on a Monday). Following the assessment the SS Designee asked the resident how things had been going. The resident stated good after the 1st night. That was when a Grievance Form had been completed. The Resident's [NAME] of Rights signed by the facilities Administrator at the time and the Resident 3.21.25 included the following: a. Each Resident had the right to a dignified existence. b. Each Resident had the right to considerate and respectful care with a reasonable accommodation to their individual needs.

Based on observation, kitchen record review, interview, and policy review the facility failed to store food according to professional guidelines and to clean dishes under sanitary conditions during 1 of 2 kitchen observations. Dry storage and the refrigerator contained expired, unlabeled, and undated items. Dishwasher sanitizer logs were not maintained and the sanitizer sink did not register chemical content. The facility reported a census of 29 residents. Findings include: During the initial kitchen observation on [DATE] from 09:57 AM to 10:24 AM the surveyor observed the following: a. 16 - 1 pound boxes of baking soda that expired in [DATE] b. sliced cheese wrapped in saran wrap without a label or open date c. opened, undated 5 pound container of cottage cheese d. clear plastic bins of vegetable soup, tomato paste, and pickles covered with saran wrap dated [DATE] (11 days prior) e. clear plastic bin of chicken gravy, undated f. dishwasher chemical logs recorded concentration testing until [DATE] g. staff tested the dishwasher chemical with a test strip that did not register the chemical h. the sanitizing sinks for bigger items also did not register the sanitizing chemical with a different test strip The facility Certified Dietary Manager (CDM) participated in the observation and tour. She stated she took over the facility kitchen the week before from a contracted provider and was aware there was a lot of work they still had to do. She reported she talked to staff during her initial tour about labeling and dating items. The CDM indicated she expected items in the refrigerator and dry storage to be labeled with a date of receipt and an open date. She preferred lids to saran wrap for freshness, and would generally keep items stored that way ,d+[DATE] days, certainly no longer than 7 days. She stated the dishwasher test strip was probably not the right one and they would have to look at that. While reviewing additional paperwork with the surveyor, the CDM was unable to locate additional dishwasher chemical testing documentation. During a subsequent conversation on [DATE] at 12:40 PM the CDM reported she had found additional expired items that had to be thrown away. An undated policy titled Dish Machine Operation documented Dining Services staff should check the dials to ensure the wash and rinse cycles were achieving proper temperature, and if a chemical sanitizer was used, check the concentration using the correct test tape for the type of sanitizer in use. An undated policy titled Food Storage (Dry, Refrigerated, and Frozen) documented all food items would be labeled. The label must include the name of the food and the date it should be sold, consumed, or discarded. Food that passed the expiration date should be discarded, and food prepared in the facility should be discarded after 7 days.

Based on observation, record review, staff interview, and policy review the facility failed to provide range of motion services to improve or maintain functioning in all extremities for 1 out of 1 residents reviewed (Resident #11). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #11 indicated a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition. The MDS documented diagnoses of symptoms and signs involving the musculoskeletal system (include muscle weakness, joint pain, limited range of motion, tremors, and gait disturbance), reduced mobility, and spasmodic torticollis (neck muscles contract involuntarily). It further recorded the resident did not receive active or passive range of motion (ROM) restorative nursing in the prior 7 calendar days. Resident #11's Care Plan initiated of 03/29/24 revealed he had a self care performance deficit due to fatigue and required assistance of 1 staff for bathing, dressing, and personal hygiene. He required the assistance of 2 staff for bed mobility and a standing lift for transfers. A focus area for pain, dated 10/10/24 included an intervention to observe and report a decrease in functional abilities or a decrease in ROM. The Care Plan did not include treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Review of an occupation therapy discharge summary with dates of service from 1/6/25 - 1/30/25 revealed the resident received hands on care focused on bilateral upper extremity strength, safety and independence with functional mobility, transfers, ADL (activities of daily living) completion, activity tolerance, balance, reaching, and cardiopulmonary tolerance. A restorative program was not indicated and a functional maintenance program was discussed regarding cardiopulmonary tolerance activity with the facility exercise bike (brand name removed). Documentation included the resident's wish to return home and improve transfers and ambulation. A review of the physical therapy discharge summary with dates of services from 1/3/25 - 1/30/25 documented improvements in transferring from sitting to standing with the use of a standing lift (brand name removed). Neither a restorative program nor a functional maintenance program was established. On 03/03/25 at 1:11 PM observed the resident in his recliner in his room with his eyes closed. The blinds were drawn and he was listening to the television. During an interview with Resident #11 on 03/04/25 at 8:52 AM again observed his blinds closed and his door was partially closed. He stated he didn't know if he would participate in range of motion with staff but they didn't ask. He didn't like the option of group exercise because he liked to be in his room. On 03/05/25 at 02:40 PM Staff B, Occupational Therapy (OT) indicated the resident participated in therapy in January and returned to baseline. She reported the activities staff encouraged him to participate in group activity and he regularly refused. She stated he had actually been in therapy multiple times, always returned to baseline, then declined again. While meeting with Staff F, MDS Coordinator on 03/06/25 at 09:46 AM, she stated the facility did not have a staff member specifically designated for restorative therapy, confirmed it was not in the resident's Care Plan, and there was no formal program to ensure residents maintained functioning. If there was a concern about decline, they just screened for Part B therapy services. During an interview on 03/06/25 at 10:26 AM Staff A, Physical Therapy (PT) stated the facility did not have a formal restorative program. He stated he offered the resident could come in to use the exercise bike and acknowledged the resident preferred to stay in his room. The facility provided an undated policy titled Restorative Nursing Policy and Procedure that documented it was the policy of the facility to provide restorative nursing which promoted the resident's ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focused on achieving and/or maintaining optimal physical, mental, and psychological function of the resident. The restorative nurse, RNA (restorative nursing assistants), along with the IDT (interdisciplinary team) would determine what programs would be initiated for the residents. Residents would be screened using the restorative assessment in the electronic health record to identify candidates for programs and included resident who required programs to maintain their current level of functioning.

Based on observation, resident interview, staff interview, and record review the facility failed to provide trauma informed care for 1 of 5 residents reviewed (Resident #15). The resident arrived at the facility on 2/17/25 with diagnoses of PTSD (Post Traumatic Stress Disorder), anxiety, adjustment disorder, and depression and was not assessed for potential triggers that could cause re-traumatization. The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) for Resident #15 documented diagnoses of adjustment disorder with depressed mood, PTSD, depression, and anxiety disorder. The MDS included a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated moderately impaired cognition. Resident #15's Care Plan indicated the resident had current thoughts of suicide, the primary care provider was notified, and the resident was seen by psych. The resident had no active plans as of 2/24/25. Interventions included face to face consults with the primary provider and psych, monitoring and documenting behaviors, and social service visits with the resident. Another focus area documented the resident had depression disease process. Interventions included administering medications and monitoring for side effects, monitor/record/report risk for harm to self, and monitor/record/report risk for harm to others. The Care Plan did not address anxiety, adjustment disorder, or PTSD. The Care Plan did not include mental health triggers, medications, examples of side effects to watch for, behaviors, or non-pharmacological interventions to address these diagnoses. A Progress Note dated 2/21/2025 at 10:34 PM revealed the resident was seen by her provider that day for a psychiatry appointment with new orders to: 1. Continue Duloxetine 90 mg daily. 2. Continue Seroquel 25 mg po at HS (by mouth, at bedtime) for insomnia, nightmares, anxiety, depression, and history of hallucinations. Patient is at risk for decompensation if not continued. 3. Start Buspar 5 mg po daily in AM (by mouth in the morning). Signed and noted. A Progress Note titled Daily Skilled Note dated 3/3/25 at 10:00 PM documented the resident had the following indicators of a mood issue: Yells out at times. The resident had the following behavioral issues: Yells out at times. Additional comments: none. The note did not include the reason the resident was yelling out or how the staff responded to her needs. A Progress Note titled Daily Skilled Note dated 3/4/25 at 11:54 PM documented the resident had the following indicators of a mood issue: Crying at times. Speech inaudible. The resident had the following behavioral issues: crying. Additional comments: none. The note did not include the reason the resident was crying, why her speech was inaudible, or how the staff responded to the crying. On 03/03/25 at 01:37 PM the surveyor observed the resident in her room. She was in her wheelchair, staring ahead. She did not initially respond to the surveyor's knock, then shook her head and looked up. Resident #15 confirmed her PTSD diagnosis and said she thought they (staff) knew about it. She did not want to discuss it further at that time. During a follow up interview on 03/05/25 at 10:19 AM the resident again confirmed her mental health diagnoses. She did not think facility staff had asked about her mental health diagnoses or what caused her to feel anxious. She stated she felt anxious and depressed when she thought about not going home, about wanting to be done with therapy, and about things that happened to her. The resident stated she did not want to hurt herself. She reported changes in her health were hard and made her sad. When asked if she thought her mental health was being managed, she shrugged. An interview with Staff C, Certified Nursing Assistant (CNA) on 03/05/25 at 01:35 PM revealed Resident #15 could get 'really down.' She would walk or stand for some staff and not others, had poor mental health, and did not like being there. During a follow up interview on 03/06/25 at 08:42 AM Staff C stated she was never told about triggers to watch for related to the resident's PTSD and mental health. On 03/06/25 at 09:46 AM Staff F, MDS Coordinator stated it was her fault that the diagnoses, medications, and PTSD triggers did not get into Resident #15's Care Plan. When asked, she stated she didn't see it when the resident came in, and saw the diagnoses later in a doctor's note. At that time she added the information to the diagnoses list but not to the Care Plan. When asked who was responsible for asking a resident about their PTSD triggers, she stated the social worker would ask about that. During an interview with Staff E, Life Enrichment/Social Services on 03/06/25 at 10:14 AM she stated the surveyor should ask the MDS Coordinator who was responsible for asking about mental health triggers, behaviors, and interventions.

Based on observation, record review, interviews, and policy review the facility failed to ensure psychotropic medications were used only to treat documented conditions for 1 of 5 residents reviewed for unnecessary medications (Resident #25). The facility did not respond to the pharmacist's request to document resident behaviors or implement non-pharmacological interventions to help reduce anxiety. The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) for Resident #25 dated 01/21/25 included documentation that the resident was unable to complete the Brief Interview for Mental Status (BIMS) due to long and short term memory problems and severely impaired daily decision making. Diagnoses on the MDS included non-Alzheimer's dementia, anxiety disorder, and depression. Resident #25's Care Plan included a focus area dated 10/10/24 indicating she was at risk for falls, wandering, poor decision making, and forgetting her walker due to dementia. A focus area dated 11/25/24 documented the resident had dementia with behavior disturbance. An intervention dated 1/20/25 directed staff to administer Olanzapine as ordered and to monitor/document for side effects and effectiveness. An intervention dated 11/25/24 directed staff to give Buspirone as ordered and to monitor/document side effects and effectiveness. An intervention revised 1/6/25 documented pharmacy review per protocol. A focus area dated 10/10/24 indicated the resident had a mood problem, depression, and anxiety. Staff were directed to monitor/document/report to the doctor as needed ongoing signs and symptoms of depression unaltered by antidepressant medications including but not limited to slowed movement, agitation, disrupted sleep, fatigue, changes in cognition, unrealistic fears, attention seeking, anxiety, and constant reassurance. The resident's Medication Administration Record (MAR) for March documented the resident received Alprazolam .25 MG for anxiety, Escitalopram 10 MG for depression, Mirtazapine 15 MG for depression, Olanzapine 2.5 MG for psychotic disorder, and Buspirone 30 MG for depression. Another order for PRN (as needed) Alprazolam .25 MG for anxiety for 90 days was included. Alprazolam, Escitalopram, and Mirtazapine were not addressed in the Care Plan. Triggers for PRN medications were not addressed in the Care Plan. The MAR included orders to observe for depressive behaviors, anxious behaviors, clinical worsening, suicidality, unusual changes in behavior, and side effects related to antidepressant and antianxiety medications. Staff were directed to document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift effective 10/1/24. These sections were marked with a check mark and did not follow the directed protocol for monitoring. On 03/03/25 at 12:19 PM observed Resident #25 eating in the dining room. She crossed and uncrossed her legs 6 times in 1 minute, and the right leg over her left knee repeatedly bounced. The resident's arms were folded and shook. She stood up and sat down twice, once walking around her walker to get to the door, about 15 feet. On 03/04/25 at 1:01 PM the resident was seated in the common area of her neighborhood at a table. No staff were in the area. The resident stood up and walked toward her room without her walker. She walked about 30 feet before a CNA saw her and assisted her back to the chair. A progress note titled Consulting Pharmacy Note dated 2/25/2025 at 04:59 PM documented the resident's monthly medication review was completed. The facility was asked to add behavior notes to support the use of psych medications, and to include non-pharmacological methods attempted to help reduce anxiety. Between this note and 3/5/25 the progress notes did not show behavior monitoring or non-pharmacological interventions. Resident #25's electronic health record included a section labeled Tasks. Under heading of Behavior Monitoring 2 there were 0 responses documented over the prior 30 days. During an interview with Staff F, MDS Coordinator on 03/06/25 at 09:46 AM she stated they tried to include behavior monitoring in the care plans as soon as possible so it was included on the point of care (POC) screen the Certified Nursing Assistants (CNAs) saw. She stated all departments could enter information in the care plan. It was typical for nurses to enter orders for behavior monitoring, to chart as a progress note, and potentially include monitoring in the MAR depending on the resident's needs. On 03/06/25 at 10:35 AM the Director of Nursing stated behavior monitoring should be on the POC if triggering from the care plan, and could also be in the progress notes. She reported that all residents need behavior monitoring for instances such as confusion or changes in condition. A facility policy titled Medication Regimen Review revised 6/1/24 documented the consultant pharmacist would conduct reviews and make recommendations based on information made available in the resident's health record. The facility should ensure the pharmacist had access to physician/prescriber progress notes, nursing notes, medication administration records and any other documents which might assist the consultant pharmacist in making a professional judgment as to whether irregularities exist in the medication regimen. The facility should inform the pharmacist of any physical and/or mental conditions of the resident which were likely to affect his/her medication therapy outcome.

Based on observations, staff interviews and facility policy review the facility failed to secure and supervise access to 2 out of 2 hot steam table surfaces. This failure resulted in the ability of eight cognitively impaired and independently mobile residents to access the areas that held the steam tables, therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of February 15, 2024 on April 17, 2024 at 3:10 p.m. Facility staff removed the Immediate Jeopardy on April 17, 2024 through the following actions: a. The meals will be served in the Bistro common dining room. b. All meals will be served in this location until the barriers can be placed between resident care areas and the kitchen serving area where the steam tables are located. c. The two steam tables were disabled from use to prevent any cognitively impaired residents in the units from possibly getting burned. d. The keys that turn the steam tables on have been removed from the households. e. Education to staff will be provided verbally and on paper using [NAME] Manor's protocol for communication which includes email, text, Alerts & Messages in Matrix, and signage. The scope was lowered from J to D at the time of the survey after ensuring the facility implemented their removal plan. The facility also failed to investigate or do a root cause analysis for a fall with injury for 1 out of 3 falls. The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #23 dated 4/6/24, included diagnoses of non-traumatic brain dysfunction, anemia, and depression, The MDS's Brief Interview for Mental Status score of 1 out of 15 indicated severely impaired cognition. The MDS identified her independent with ambulation and transfer with an assistive device. The Care Plan for Resident #23 dated 2/22/24, identified impaired decision making related to dementia. The Care Plan directed she will continue to walk independently with the front wheeled walker. The Certified Nurses Aid (CNA) Resource list undated, identified six residents at risk for elopement. The Registered Nurse Consultant (RNC) provided his Consultant Summary undated, Environmental Rounds failed to identify the hot steam table top hazard or the broken barrier gate to the B wing kitchenette. On 4/15/24 at 11:30 AM, as Staff K, Certified Nurses Aid opened the lids of the steam table, steam filled the air above the steam table. On 4/15/24 at 2:00 PM, Resident #23 opened another resident room door and wandered in. Resident #18 directed her out. On 4/15/24 at 2:30 PM, Resident #23 wandered the halls and the dining room (DR). Staff were not always in the area Resident #23 wandered. Two other residents also wandered in the DR. On 4/16/24 at 10:02 AM, the B wing kitchenette, failed to provide staff in the area and failed to ensure a barrier across the opening to the kitchenette, the lower part of the wall held a bracket that may have held a gate. On 4/16/24 at 10:30 AM, Resident #23 wandered the halls and the DR in the B wing. Staff not always present to supervise in the area she wandered. On 4/16/24 at 10:30 AM, in the B wing kitchenette the surface of the steamtable felt very hot to the touch. The entrance to the kitchenette lacked a barrier gate. On 4/16/24 at 11:23 AM, the Staff J, CNA left the kitchenette area while three residents sat in the DR at the tables. On 4/16/24 at 11:26 AM, Staff M, Licensed Practical Nurse (LPN), walked through the area and passed by 3 residents that sat in the DR. Two residents sat in their wheel chairs and one independently ambulatory resident sat in a DR chair. Staff M went into the hall. On 4/16/24 at 11:32 AM, Staff J, directed Resident #23 and Resident #14 into the DR area to sit for the meal. The Staff J left the area. On 4/16/24 at 11:47 AM Staff M, LPN told the CNA she needed so go chart something, they both left the DR kitchenette area leaving the residents unsupervised. On 04/16/24 at 12:08 PM, the staff opened the lid from the steam table and the steam rolled up from the steam table. On 04/16/24 at 1:09 PM, Resident #23 wandered the hall and walked right by the open kitchen area and talked to a woman at the table, she pulled up the chair and sat down. On 04/16/24 at 1:12 PM, Resident #10 wandered out and around the tables in the B wing. On 4/16/24 at 1:14 PM, the kitchenette failed to have staff in the area. Food remained on and in the steam table. The steam table checked and it felt hot to the touch. On 04/17/24 at 9:11 AM, the steam tables in the B wing were turned on, the tops felt hot to the touch. On 4/17/24 at 9:53 AM, the top of the steam table in the B wing remained hot to the touch. On 4/17/24 at 1:13 PM, the top of the last steam table well remained hot to touch. On 4/17/24 at 1:20 PM, the facility thermometer used to temp the food in the C wing, placed the thermometer on the surface of the steam table lid and it showed a temperature of 160.3 degrees. Facility staff failed to be in the area to supervise residents. On 4/17/24 at 1:40 PM the Environmental Services Director checked the surface temperature of the steam table top in the C wing and confirmed it was 160 degrees. He then went to the B wing and checked the surface temperature of the steam table top, it reflected a temperature of 155 degrees. On 4/17/24 at 8:45 AM, Staff I, CNA reported three residents in the B wing wandered daily. On 4/17/24 at 1:15 PM, Staff K, CNA reported she worked here for 2 years. She revealed the barrier gate to the B wing kitchenette used to be in place because of a resident who used to go into the kitchenette, but after he passed away it broke months ago and the facility removed it. On 4/17/24 at 1:27 PM, Staff H, Registered Nurse (RN) reported the C wing held seven wandering confused residents. She stated they use the barrier gate at times on the day shift. She revealed the nursing department turned the steam tables on in the morning leave them on for the morning and try to turn them off after lunch at some point. On 4/17/24 at 1:40 PM, the Environmental Services Director reported if a staff isn't in the kitchenette, then the barrier gate needed to be in place. He report the gate in B wing broke a few weeks ago and he failed to have the parts to fix it at this time. He confirmed the surface of the steam table tops were too hot to touch and may result in a burn. On 4/22/24 at 02:25 PM, the Environmental Services Director reported he completed a walk though of the units daily and looked for potential hazards. On 4/23/24 at 9:52 AM the Administrator reported that Environmental Services used an online work order system that staff, residents, or families may submit a request. She continued to report at their daily morning meeting a discussion is held for any maintenance needs and follow up on emails/requests over the past day. On 4/23/24 at 12:28 PM, the Administrator reported she noticed the kitchenette barrier gate in B wing failed to work, but later thought the staff fixed it. She reported her expectation is the staff supervised the steam table area while the stream tables were on and hot. She stated she expected the staff kept the gait closed. The Administrator revealed the Environmental Service Director obtained a work order to fix the B wing gait in February. The facility provided a Work Order dated 2/15/24, reported the gate to keep resident out of the kitchen broke. The facility provided an undated list that identified each resident BIMS and mobility status, the list revealed 8 independently mobile cognitively impaired residents. The facility Equipment Safety policy dated 2013, at point #9 directed that equipment should not be left on when unattended. The Foodwarmers Installation & Operation Manual dated 6/2017, revealed at page 5 General Operation Instruction point #1 All food service equipment should be operated by trained personal. #2 Do not allow your customers to come in contact with any surface labeled caution hot. Page 11 included a Warning: Steam can cause serious burns. Always wear some type of protective covering on your hands and arms when removing lids or pans. Lift the lids or pans in a way that will direct escaping steam away from your face. 37072 2. The MDS for Resident #138 dated 9/26/23 revealed a BIMS score of 10 which indicates moderate cognitive impairment. The MDS indicated the resident needed substantial assist of staff for transfers and toileting. A incident report dated 9/14/23 at 11:25 PM revealed Resident #138 was found sitting on the floor in front of the bathroom in his room. The walker was near by. Resident was assisted to bed with a mechanical lift and assist of 2 staff. An 8 centimeter by 7 centimeter red area noted to right hip. No external or internal rotation of both lower extremities. The Progress Note dated 9/15/23 at 8:46 AM revealed the resident had increased pain with movement. A physician order was obtained for a portable X ray. The Progress Note dated 9/15/23 7:09 PM revealed the X ray of the right hip showed an irregularity of the cortex of the right hip. The Progress Note dated 9/16/23 at 1:04 AM revealed the nurse spoke with the hospital and Resident #138 was admitted with a fractured right hip. On 04/16/24 at 12:12 PM during an interview with corporate nurse he stated they are unable to locate any investigation or root cause analysis completed after the fall for Resident #138. He stated when the new administrator was hired they found things were not being completed or missing. He stated they spoke to the Director of Nursing at the time of the fall who is also still employed at the facility and she had no recollection of the incident. On 04/18/24 at 2:45 PM Staff G, Registered Nurse (RN) stated Resident #138 got up out of his bed or chair and he fell right before the bathroom in his room. He was toileted before the incident and had been in bed before he got up by himself and fell . On 04/18/24 at 2:53 PM Staff H, RN stated at the time of Resident #138 fall with fracture, I was the Director of Nursing. I am not aware of an investigation or root cause analysis for it. When a fall occurs there should be an investigation and try to determine why the resident fell and then put interventions in place to prevent further falls. I do not recall anything about Resident #138's fall. It would have been the responsibility of the DON. On 04/22/24 at 2:38 PM the current DON stated the responsibility of the investigating for falls would be with the DON but the Administrator has been doing them since he started at the facility. He will be responsible for investigating falls. The facility provided a policy last reviewed 7/18/2017 titled Falls Policy, the policy failed to direct staff to complete an investigation or root cause analysis after a fall. The policy did have a procedure to complete a fall risk assessment within 24 hours of admit, quarterly, and with any significant change and after any fall. Review intrinsic and extrinsic risk factors. Intrinsic risk factors may include: cardiovascular problems, neurological problems, orthopedic problems, psychological and cognitive factors, medications, pain, sleep disorders and incontinence. For extrinsic risk factors, observe how the resident: transfers, ambulates, used the bathroom handrails, and uses assistive devices such as walkers or canes.

Based on observation, policy review, and staff interview the facility failed to date opened foods, use gloves appropriately for serving meals, keep hands off the drinking surfaces of drinking glasses, keep the ice machine clean, and keep the kitchen and household kitchenettes clean in order to serve meals under sanitary conditions. The facility reported a census of 30 residents. Findings include: During a continuous observation of the kitchen on 4/15/24 from 10:00 AM to 10:28 AM the following was revealed: A. [NAME] streaks running down the lip of the ice chute in the ice machine B. Egg noodles opened and undated C. Mandarin oranges in a Styrofoam cup covered in plastic wrap undated in the refrigerator D. Food matter on the floor by the heating unit and the two-compartment sink near the refrigerator During an observation on 4/15/24 of the [NAME] Household kitchenette at 10:38 AM the following was revealed: A. Food particles in the fridge B. Food splatters and particles in the freezer bins C. Open, undated frozen pancakes D. A moldy calcified water spot on the fridge under the water dispenser E. Orange splatters on the refrigerator door F. Splatters and food particles on the front of the oven G. Crumbs on the stovetop H. Splatters and crumbs inside the oven A follow-up observation of the kitchen on 4/16/24 at 9:50 AM and the kitchenette at 9:58 AM revealed no cleaning or dating of food items had been conducted. During a continuous observation of the noon meal on 4/16/24 from 11:42 AM to 1:29 PM the following was observed: 1. [NAME] Household: A. Staff A, Dietary Services Manager, Staff B, Dietary Aide, and Staff C, Dietary Aide wore gloves and touched utensils, plates, hot well lids, meal tickets, and failed to change gloves before touching buns and plating them. This occurred 9 times affecting 9 residents. B. Water on room trays were transported uncovered. This occurred 3 times affecting 3 residents. C. The handle of a serving scoop was placed in the serving container with the handle directly touching the food. The food was then served to residents. D. A sticky substance coated the floors. 2. [NAME] Household: A. Staff A wore gloves and touched utensils, plates, hot well lids, meal tickets, and failed to change gloves before touching buns and plating them. This occurred 15 times affecting 15 residents. B. Room trays were delivered with water and coffee uncovered. This occurred 4 times affecting 3 residents. C. Staff C transported mandarin oranges to a resident's room uncovered. D. Staff C wore gloves, touched a bread bag, and failed to change gloves before she touched the bread, plated it, and transported it uncovered to a resident's room. E. A sticky substance coated the floors. In an interview on 4/17/24 at 9:16 AM Staff A explained he expected Dietary staff to clean equipment right after use, and the ice machines as indicated on the cleaning schedule. He expected the Dietary Aides to clean it as needed if found dirty between scheduled cleanings. He further explained the kitchen staff must clean counters in between making food and at end of the shift. They must sweep and mop at the end of the night. He reported the cleanliness of kitchenettes are the responsibility of the staff in those areas. Staff A explained he expected staff to put gloves on if touching anything ready-to-eat. They must change gloves between touching food and touching something else as the other item may be contaminated. He clarified as long as staff do not touch anything in between they can use gloves to serve bread products. He noted handles of the scoops should not touch food items. He expected all food to be dated upon receiving it and staff must mark the date food is opened and use it within 7 days. He noted staff must not touch the drinking surfaces of glasses and must cover everything on room trays including the glasses. He expected staff to follow all facility policies. In an interview on 4/17/24 at 9:39 AM Staff D, Registered Nurse verbalized she was told the dietary company only serves for 15 minutes and won't clean the tables or kitchenette. She noted household staff were trying to clean things but were not given a cleaning list or schedule. In an interview on 4/17/24 at 9:46 AM Staff E, Certified Nursing Aide (CNA)/Certified Medication Aide (CMA) reported dietary should be cleaning the counters and sweeping. She explained it often falls on household staff as dietary is not doing it. She denied any instruction from the facility on how to clean or how often. She stated it was getting done whenever they had time. She further verbalized she received no education on serving food or safe handling of foods. During an interview on 4/17/24 at 9:51 AM Staff F, CNA reported household staff are to sweep after meals and third shift is to do a deep clean of the kitchenette. She explained household staff disinfect tables between meals, wipe out the fridge, and clean out the oven as scheduled. During an interview on 4/17/24 at 10:03 AM the DON reported who is responsible for cleaning the kitchenettes depends on the day. Sometimes household staff does it and sometimes the dietary staff do. He expressed it was a team effort between the two of them until ownership of the tasks gets decided. He explained Dietary has their own training on food handling and practices and facility staff take a Food Safety & Sanitation course upon hire. He reported cleaning is not scheduled anywhere it would be charted off on. The undated policy titled Storage directed staff to make sure all goods are dated with receiving date and use-by-date. The undated policy titled Ice Machine Usage instructed staff to clean and sanitize parts of the ice machine considered food contact surfaces according to manufacturer's guidelines. The undated policy titled Policy and Procedure for Activity Handling of Food directed staff to wash their hands and wear gloves or wash hands and use a utensil to pass out food. Clean utensils and proper food handling must be followed. The undated policy titled Cleanliness and Sanitation of the Dining Room instructed staff to handle all dishes, glasses, cups, and flatware by non-food contact surfaces only when assisting with meal service. According to the cleaning schedule, staff are to routinely clean all areas of the dining room, including equipment such as service refrigerators etc. It further explained it is the responsibility of staff from all departments to ensure the dining room is cleaned after meals. The undated policy titled Pest Control directed staff to clean and sanitize the facility thoroughly and regularly. It further directed the Food and Nutrition Services Director to: 1. Supervise daily cleaning routines. 2. Monitor completion of all cleaning tasks daily against master-cleaning schedule. 3. Review and change the master-cleaning schedule every time there is a change in menu, procedures, or equipment.

Based on observation, policy review, and staff interview the facility failed to keep garbage cans covered near food preparation surfaces to provide a sanitary cooking environment. The facility reported a census of 30 residents. Findings include: During an observation of the kitchen on 4/15/24 at 10:00 AM the trash can next to the meat slicer was found with the lid on the floor and trash in the can. The trash can directly contacting the food preparation counter was also without a lid and trash was present in the can. At 2:18 PM the trash can next to the food preparation counter was uncovered with canned fruit exposed in a bowl next to the trash can. On 4/16/24 at 9:50 AM both trash cans were found without lids. The trash can contacting the food preparation counter had a soiled plastic sheet overflowing out of the can. During an interview on 4/17/24 at 9:16 AM Staff A, Dietary Services Manager explained his expectation is for trash cans to be covered when not in use. During food preparation they can be left open to avoid staff touching lids when working with food, but should otherwise remain covered. He further explained he expected all facility policies to be followed. The policy titled Pest Control directed staff to dispose of garbage quickly and correctly. They are to keep garbage containers clean, in good condition, and tightly covered in all areas (indoor and outdoor). Staff must clean up spills around garbage containers immediately. They must wash, rinse, and sanitize containers regularly.

Based on record review, resident and staff interview and policy review the facility failed to prevent a resident from neglect for 1 out of 1 residents who reported abuse (Resident #35). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #35 had a Brief Interview Memory Score (BIMS) of 15 which indicated cognitively intact. The MDS indicated he was dependent for toilet transfers and toileting hygiene. The reason for admission was amputation. Resident #35 had blindness of the right eye. On 04/17/24 at 9:28 AM during an interview Resident #35 stated a staff member became frustrated because he needed to use the call light frequently. She told me I was wearing a depend and to use it, then I don't have to come in here every few minutes. The staff member left and when I went to hit the button it was gone. She came back in for some reason and gave me trouble about wanting to use the buzzer and said oh there it is and it was curled up on the end of the table too far away for me to reach. The rest of the night it was gone and I could not find it again. Someone came in first thing in the morning and said why don't you stay in bed for a few extra hours since feeling bad and then it was past breakfast time and I had wet self several times and when they finally came in it was about time for lunch and I was soaked head to toe and could not find the call light. It made me feel like I didn't matter at all. They told me if it happens again you need to call but I had no way to call since I didn't have my call light. He stated it is pretty demeaning for a [AGE] year old man to have to just wet themselves and then lay in it. At the very least she could have left me a urinal. I felt like I was in the way and she didn't want to do her job. Review of the electronic health record Nurse Progress Notes failed to document anything regarding the incident or follow up with the resident. On 04/17/24 at 1:51 PM the Scheduling Coordinator/Recruiter stated Staff L, Licensed Practical (LPN) agency staff worked the last on 4/8/24 and she was made a Do Not Return on 4/9/24. On 04/17/24 at 2:33 PM the Scheduling Coordinator/Recruiter stated that she was told on 4/9/24 to make Staff L a Do Not Return (DNR) due to being rude to other residents and because she took a call light away from a resident. It was the Director of Nursing and the Administrator who told her to make her a DNR. The facility provided a policy titled Dependent Adult Abuse Prevention last updated 7/14/22 which stated abuse is defines as Denial of Critical Care (Neglect): The deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult's life or physical or mental health. Neglect is defined as the failure of a facility, it's employees or service providers to provide good and services to a resident necessary to avoid physical harm, mental anguish, or emotional distress. Resident upon resident assaults could result from lack of supervision and therefore a denial of critical care by the facility caretaker staff.

Based on observation, record review, resident and staff interviews the facility failed to complete a thorough investigation of allegation of abuse to prevent further abuse. The facility reported a census of 30 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #35 had a Brief Interview Memory Score (BIMS) of 15 which indicated cognitively intact. The MDS indicated he was dependent for toilet transfers and toileting hygiene. The reason for admission was amputation. Resident #35 had blindness of right eye. On 04/17/24 at 9:28 AM during an interview with Resident #35 he states a staff member became frustrated because he needed to use the call light frequently. She told me I was wearing a depend and to use it, then I don't have to come in here every few minutes. The staff member left and when I went to hit the button it was gone. She came back in for some reason and gave me trouble about wanting to use the buzzer and said oh there it is and it was curled up on the end of the table too far away for me to reach. The rest of the night it was gone and I could not find it again. Someone came in first thing in the morning and said why don't you stay in bed for a few extra hours since feeling bad and then it was past breakfast time and had wet self several times and when they finally came in it was about time for lunch and I was soaked head to toe and could not find the call light. It made me feel like I didn't matter at all. They told me if it happens again you need to call but I had no way to call since I didn't have my call light. He stated it is pretty demeaning for a [AGE] year old man to have to just wet themselves and then lay in it. At the very least she could have left me a urinal. I felt like I was in the way and she didn't want to do her job. Review of the electronic health record Nurse Progress Notes fail to document anything regarding the incident or follow up with the resident. On 04/22/24 at 9:58 AM the Administrator stated when I found out about the incident with Resident #35 I immediately reported it to the staffing agency on 4/9/24 and thought this was all I had to do since it was their employee. I told them Staff L, Licensed Practical Nurse (LPN) would be Do Not Return (DNR). I then thought more about it the next day and contacted management company and was informed I needed to report it to the state agency this was on 4/10/24. I thought it occurred the night before the wife reported it. I received a phone call from the wife on 4/9/24 and this is when I contacted the staffing agency. The only thing I did to report it to the state agency was summarize what the wife informed me had occurred. I did not interview any of the staff or follow up with any sort of investigation. On 4/22/24 at 11:01 AM interview with the Nurse Consultant stated he talked to regional staff and basically I can't give you an excuse of why it was not done I am going to tell you I am looking at things across the board. I know it should have been reported within 2 hours of learning of the incident and then investigated which entails who was working where they were working and what times working. We need to self report to Department of Inspections and Appeals and Licensing (DIAL) then the alleged perpetrator is to be separated from the residents. The facility provided a policy titled Dependent Adult Abuse last updated 7/14/22 it directed the Administrator will report the incident to the Department of Inspections and Appeals (DIA) immediately when notified of incident. The Department of Inspections and Appeals (DIA) must be notified within 2 hours after an allegation of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property occurs. The Department of Inspections and Appeals (DIA) will be notified within 24 hours if the event that causes the allegation does not involve abuse and does not result in serious bodily injury. After reporting the incident to DIA a comprehensive facility investigation will then be completed within 5 working days of the incident's occurrence. All related documents will be sent to DIA upon request or kept on file for later review by DIA.

Based on staff interviews, facility record review, and facility policy review the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey and cited in previous surveys. The facility reported a census of 30 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 9/13/22, reflected deficiencies identified for accidents and hazards. The CMS 2567 form dated 2/28/23, reflected deficiencies identified for accidents and hazards. The CMS 2567 form dated 9/14/23, reflected deficiencies identified for accidents and hazards. During the current recertification, complaint, and facility reported incident survey dated 4/23/23, the team identified the same deficiency, Accident and Hazards (F689). On 4/22/24 at 3:19 PM, the Registered Nurse Consultant (RNC) reported he's worked on the accidents and hazards in the building, however he failed to know if the previous team worked on that citation. On 4/23/24 at 12:30 PM, the Administrator reported she monitors and audits the effectiveness of the QAPI process and she confirmed the concern related to the pattern of deficiencies at F689. The facility provided the QAPI Plan dated 12/1/22, that included feedback, data systems, and monitoring that stated the facility will put into place systems to monitor care and utilize data from various sources. It directed it will include tracking, investigating, and monitoring adverse events every time they occur, and actions implemented through the Plan, Do, Study, Act (PDSA) cycle of improvement to prevent recurrence.

Based on clinical record review and staff interviews, the facility failed to provide appropriate assessment and interventions for one of three residents reviewed. (Resident #1). The facility reported a census of 26 residents. Findings include: Resident #1's MDS (Minimum Data Set), an assessment tool, dated 5/16/2023 revealed the resident transferred from one surface to another with extensive assistance of two staff, failed to ambulate, and had a fall history prior to admission. The resident had falls since admission without injury. The MDS reported the resident had diagnoses including other fracture of the right lower extremity, diabetes, renal insufficiency, asthma, cirrhosis of the liver, and chronic obstructive pulmonary disease. Resident #1's Care Plan initiated 5/10/2023 identified the resident had a potential for falls related to a history of falls and dementia. The Care Plan directed staff to assist the resident with pivot transfers, and ensure non weight bearing of the resident's right lower extremity. The Care Plan identified the resident had impaired skin related to a surgical wound and directed staff to assist to reposition self to eliminate pressure and administer a high protein diet, vitamins, and medications. The Care Plan also instructed staff to keep the skin clean and dry to promote healing. The Care Plan identified the resident had an indwelling catheter and had a potential for infection. It instructed staff to maintain a closed drainage system, monitor for symptoms of UTI (urinary tract infection) and report promptly to physician, assess for adequate output, color and odor of urine. On 5/22/2023 the Care Plan added: Administer Bactrim DS (antibiotic) per physician order for UTI. According to the resident's Nurse's Notes, On 5/19/2023 the physician ordered a urinalysis, staff collected the urine, the lab analyzed the urine and the physician ordered Bactrim DS for seven days. According to the lab report, the lab made the urine culture available on 5/21/2023 at 8:31 AM. Staff A, RN electronically signed the report on 5/22/2023 at 8:38 AM. The facility faxed the report to the physician on 5/22/2023 at 8:40 PM. On 5/23/2023 at 2:49 PM the physician responded with a new order to change the antibiotic based on the culture report. The resident received the initial dose of Amoxicillin on the evening shift of 5/23/2023. On 9/13/2023 at 11:00 AM, Staff A, RN reported the facility had an interface with the lab and they receive results electronically. In their computer charting an alert shows up on the screen letting staff know that there are lab results ready to view. At 2:30 PM, Staff A indicated the lab report revealed on 5/22/2023 at 8:38 she viewed the lab. However, she may not have been working the floor, and it is the responsibility of the floor nurse to review and follow up with labs. Resident #1 admitted to the facility with two surgical scars on her lower right extremity, medial (inside) and lateral (outside). The physician's admitting orders included to leave the dressing on, keep it clean, dry, and intact until the clinic visit on 5/25/2023. On 9/13/2023 at 9:30 AM, Staff C, RN revealed on 5/21/2023 the resident's surgical dressing was crusty, hard, and saturated. Staff A indicated the bandages needed changing. The elastic wrap had to be discarded and they ordered a new one. Staff A applied a sterile dressing. The resident's surgical incision and surrounding skin appeared intact without any concerns. Staff A notified the physician and the physician had no new orders. The Nurse's Notes dated 5/24/2023 at 3:52 PM revealed Staff A removed the resident's bandages and observed a right lateral incision had a small 0.2 by 0.1 dehiscence (slitting open of the wound) in the lower part of the incision. Staff A failed to provide the physician the assessment. The Progress Note revealed the incision had clear serosanguineous (yellowish with small amounts of blood) drainage, no redness, no warmth present. Sutures intact and sterile dressing applied. On 9/14/2023 at 11:00 AM, Staff A reported changing the dressing on 5/24/2023 and she would have sent a fax to the physician unless it was concerning, then she would have called. Staff A failed to provide a copy of the fax sent to the physician with the updated assessment.

Based on observation, clinical record review, and staff interviews, the facility failed to appropriately supervise one of three residents to ensure their safety. (Resident #1). The facility reported a census of 26 residents. Findings include: Resident #1's MDS (Minimum Data Set), an assessment tool dated 5/16/2023 revealed the resident transferred from one surface to another with extensive assistance of two staff, failed to ambulate, and had a fall history prior to admission. The resident had falls since admission without injury. The MDS reported the resident had diagnoses including other fracture of the right lower extremity, diabetes, renal insufficiency, asthma, cirrhosis of the liver, and chronic obstructive pulmonary disease. The discharge MDS dated [DATE] revealed the resident had two falls without injury and one with major injury since the prior assessment. Resident #1's Care Plan initiated 5/10/2023 identified the resident had a potential for falls related to a history of falls and dementia. The Care Plan directed staff to assist the resident with pivot transfers, and ensure non weight bearing of the resident's right lower extremity. On 5/22/2023 the Care Plan added instructions for staff to monitor the resident with thirty minute checks and they were not to leave the resident alone in the room unless in bed. Facility incident reports documented the resident had falls on 5/13/2023, 5/18/2023, 5/22/2023, 5/24/2023, and two falls on 5/24/2024. A. 5/13/2023 at 2:45 AM in the resident's room. The resident reached for the remote control and slid out of bed with no injury identified. B. 5/18/2023 at 6:30 PM in the resident's room. Staff heard a crash and found the resident on the floor near the entryway of the room. The resident stated she went to get something off the table. No injury identified. C. 5/22/2023 at 7:15 PM in the dining room. The resident tipped her wheel chair over and landed on her left arm. Range of motion was within normal limits. No injury identified. D. 5/24/2023 at 4:40 AM in the resident's room. Staff found the resident attempting to self transfer out of her bed. Staff was unable to safely help the resident back to bed. Staff lowered the resident to the floor onto buttocks. E. 5/24/2023 at 6:15 PM in the resident's room. Staff A, RN (Registered Nurse), DON (Director of Nursing), witnessed the resident standing in the middle of her room, holding on to the tray table. Staff A stood by the resident and called for help. The resident lost her balance and fell backwards, hitting her head on the bed. The resident suffered a scalp abrasion and Staff A applied pressure. The resident transferred to the ER (emergency room ). The Emergency Report in included an X-Ray report of the resident's right Tibia and Fibula. The final result dated 5/24/2024 included: 1. No definite acute fracture 2. There may be hardware complications involving both medial as well as lateral hardware. CT Abdomen and Pelvis and Cervical Spine results included: 1. Mildly displaced fracture of the anterior Lumbar 1 vertebral body. 2. Subtle nondisplaced fracture left Cervical 6 lamina. The head CT images revealed no intracranial hemorrhage, mass, or acute infarction. Old bilateral nasal bone fractures and posterior scalp soft tissue laceration. On 9/13/2023 at 11:00 AM, Staff A, RN reported working the floor in [NAME] household on 5/24/2023. At approximately 6:15 PM she went into Resident #1's room to check on her and found her standing in the room, using the tray table for support. Staff A held onto the resident and called for help. The resident yelled at staff to stop yelling and she did not need any help. The resident lost her balance and fell backwards. Staff A reported she could not keep the resident from falling backwards. Staff E, LPN (Licensed Practical Nurse) and Staff F, CNA (Certified Nurse Aide) arrived, assisted Staff A and called for EMS (Emergency Medical Services). Staff A indicated the resident's husband visited the resident that afternoon. She was not aware that he left and did not recall that he told her he was leaving the resident in the room. That day, Staff A had a discussion with the resident's husband about the option of adding a camera monitor in the resident's room. The husband agreed and Staff A planned to order the monitor. Staff A reported the resident sat in her lift chair prior to the fall. The resident transferred to the facility from the hospital where she had an alarmed bed and a monitor, and the hospital never informed the facility. The transferring hospital failed to inform the facility of these interventions; the facility would not have accepted her. The Care Plan revealed staff were to be doing 30 minute visual checks on the resident. Staff A failed to provide documentation that staff were doing the checks. On 9/14/2023 at 1:30 PM, Staff A revealed she educated staff regarding fall interventions including documentation of 30 minute checks.

Based on observation, record review, and staff interview the facility failed to provide adequate supervision for one of three residents reviewed (Resident #1) to prevent a fall with injury. Resident #1 fell and sustained multiple facial fractures. The facility reported a census of 28 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had diagnoses that included [CONDITION(S)], [CONDITION(S)] and anxiety. Resident #1 scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognitive status. The resident needed extensive assist of 1 staff with transfers and ambulation. The MDS revealed the resident had poor balance and limited range of motion of the lower extremity and has had 1 fall without injury and two falls with an injury since the prior assessment. The Care Area assessment dated [DATE] indicated the resident had a fall risk score of 21 (score greater than 10 indicates high risk). Resident #1 transfered with one, and hand held assist. Fracture of the right humerus with one fall. Therapy working with the resident and will address falls. The Incident Report dated 5/23/22 at 10:25 AM showed the resident tripped and fell over nurses bag which was left in the middle of the hallway. Investigation and follow up revealed staff provided education to nurse to keep pathways free of clutter. The Incident Report dated 5/25/22 at 3:35 PM indicated resident was eased to the floor while ambulating with therapy. The investigation/follow up indicated therapy to continue to provide services. The Incident Report from 5/30/22 at 12:55 PM indicated resident was ambulating with staff and bumped her back on a nightstand and needed to be lowered to the floor. The investigation/follow up indicated the staff is to provide one to one assist with cares and provide assist of one with ambulation. The Incident Report dated 6/4/22 at 6:20 PM indicated resident had a fall outside her room while ambulating independently. The investigation follow up section indicated the resident is still wanting to get up per self and does not remember to call for assistance. The care plan updated staff will ambulate before and after meals. Ensure residents needs are met prior to leaving alone. Review of the Incident Report dated 8/27/22 55 at 4:55 PM revealed resident was attempting to sit down in the dining room chair and missed the chair. There was no follow up or investigation on the report regarding this fall. Review of the Incident Report dated 8/29/22 revealed resident fell in her room near her bed. The nurse arrived in the room to find resident on the floor screaming out in pain and blood coming from her mouth. The notes stated resident was toileted 20 minutes prior and was in the dining room 5 minutes prior to the fall. No investigation or follow up was indicated on the incident report. The emergency room notes from 8/29/22 revealed resident sustained multiple facial fractures from fall on 8/29/22. The computed tomography scan report of the Maxillocfacial without contrast from 8/29/22 revealed 1.) fracture right maxillary sinus involving the anterior, lateral, and medial walls. 2.) Fracture right maxillary hard palate. 3.) Nondisplaced fracture right orbital floor cannot be excluded. The Incident Report from 8/30/22 revealed Resident #1 was found in the hallway on her back. The front wheeled walker was there also. No investigation or follow up was indicated on the incident report. The Care Plan intervention, dated 9/8/22 indicated related to fall on 8/30/22, Hospice would complete medication review related to falls. Review of the residents medical record failed to reveal a medication review completed by Hospice. The Incident Report dated 9/2/22 at 5:05 AM noted when staff entered the room resident lying on the floor. Resident was last seen around 4:30 AM. The Incident Report stated the resident actively bleeding above left eyebrow. The resident was sent out to the emergency room . The Care Plan revealed an intervention to add half hour checks at night. The emergency room Note from 9/2/22 revealed the reason for admit was fall with a [CONDITION(S)]. The orders indicated can keep the area to left eyebrow dry for today then can clean the area. The skin glue will dissolve on its own over time. If any signs of infection please follow up with her doctor or return to the emergency room . The Incident Report dated 9/9/22 at 11:15 AM revealed resident was found face down on abdomen in the main hallway outside her room. The resident had a 2 centimeter skin tear on fifth finger of left hand. Staff added intervention of half hour checks day and night. The Care Plan with a start date of 3/27/22 indicated Resident #1 had potential for falls related to impaired mobility, cognitive impairment as manifested by history of falls. The intervention dated 9/8/22 resident should be ambulated with assist of one and front wheeled walker. The Care Plan failed to address increased supervision regarding falls. Review of the undated wing sheet used by Certified Nursing Assistant (CNA) to provide cares directed staff assist times one with front wheeled walker. It indicated resident is a fall risk and the only intervention on the wing sheet was 30 minute checks at night. Observation on 9/8/22 at 7:43 AM Resident #1 in bed, bed in low position, walker next to her bed, call light in reach. Yellow discoloration on left side of face with laceration above eyebrow noted. Eyes closed resident appears comfortable. During an interview on 9/12/22 at 9:50 AM with Staff A, Certified Nursing Assistant (CNA) stated when Resident #1 fell I was in another residents room, the nurse asked me to go to the room and she had already fallen. It is usually busy around that time getting residents for supper but it was a normal evening. Resident #1 was roaming around the unit like she always does. I don't know who took her to the dining room and then we were both busy with other patients and the last time I knew she was in the dining room and then the next time she was in her room and had fallen. She has a walker and she would get up and walk around by her self. She is kind of forgetful and she did not have her walker by her that evening. She could be up independently by herself with her walker at the time. So they have a paper that says what the care is, what each resident needs and tells us their diet and different things about the resident. It has their transfer status and how much assistance they need for transfers. It probably could be updated more often, there are some of the things that their status has changed and they have not updated it. I worked there a few times and some things about residents have changed but the sheet was not changed and the nurses and the CNA will say no it is this but it has not been updated. During an interview on 9/12/22 at 10:05 AM with Staff B, Registered Nurse (RN) the wing sheets are being updated by the CNA. Recently not sure who should be updating them on a regular basis or if they were being updated. They have their transfer status on them and the nurses should update when therapy changes someone transfer status. During an interview on 9/12/22 at 10:21 AM with Staff C, Licensed Practical Nurse (LPN) regarding Resident #1 fall on 8/29/22 she stated Resident #1 was out at the dining room table just 5 minutes prior when I was doing medications. The staff had said they toileted her 20 minute prior, she is fast and she forgets to use her walker. Her transfer status at the time of the fall she was assist of one with front wheeled walker. She was constantly getting up by herself. I tried to get her to sit down and redirect her when I would see her up by herself. It is on the wing sheets to let the CNA know what assist they need to provide for ambulation and transfers. I know when she was up she would never have her walker and you have to walk her back to her room and get her walker. The Director of Nursing would be the one responsible for keeping the wing sheets updated. During an interview on 9/12/22 at 1:00 PM with the Director of Nursing stated she did get an email from the nurse Resident #1 fell . I was notified of the incident report and just what the incident report stated. I expect with every fall the nurses are to add an intervention to the care plan. This is documented in the care plan. Any interventions put in place were added to the care plan. I updated the care plan with the interventions on 9/8/22. After each fall they should be updated. I did not do anything prior to the fall on 8/29/22. After the fall on 8/27/22 the staff would assist her and remind her to use her walker according to the care plan which I updated on 9/8/22. I am not clear on how much assistance she needed when she fell . We have wing sheets for the CNA to know what level of care the resident needs. They are updated by the nurse as we get orders and as things change with the residents. During an interview on 9/12/22 at 2:51 PM Staff D, CNA stated there is multiple places where it is posted, there is a sheet that is updated frequently and it shows how much assist they need through out the day. They also have it posted in the door. There is a magnet inside the room and this tells you how much assistance a resident needs. I believe you can also see it in the EHR. There are fall interventions on the wing sheet also to indicate if they are a fall risk and what the interventions are for them. There is a CNA book where they update it if they have recent fall. Thirty minute checks are documented on a clipboard with a piece of paper with them on it each day. The wing sheet is where I would find any fall interventions in place for the residents. During an interview on 9/12/22 at 3:02 PM Staff E, CNA stated was in with another resident and opened the door and seen her fall. I basically just seen her hit the floor. She was in her bedroom and she was just wandering around. We catch her walking up and down the hall by herself all the time and we redirect her or attempt to get her to sit down. She was in bed the last time I checked on her and then in the next 5-10 minutes she was on the floor. We get information on how to care for the residents by the nurse or in the nurses office there is a paper in the schedule book, we check every shift the wing sheets. The wing sheet is updated every time there is a new resident or anything major that changes. The facility provided a policy titled Policy and Procedure for Falls revised 2/21/2018 which stated the facility will evaluate each resident to determine the risk of falls and to identify interventions to minimize or mitigate falls from occurring. The policy directed staff to implement interventions that are individualized according to the residents needs. Intervention may include: k.) Provide added supervision when out of bed. Encourage socialization as able. The procedure also directed staff to document in the Care Plan all interventions that are used to minimize the potential for a fall. Include the interdisciplinary team, the physician, pharmacist, therapists and responsible party in the process.

Based on clinical record review, observation and staff interviews the facility failed to provide assessment/intervention and supervision for one of five residents when the resident exhibited increased confusion and verbalized a desire to exit the facility. (Resident #1). Facility front entrance/exit door not alarmed allowing Resident #1 to exit the facility without staff knowledge, resulting in immediate jeopardy to health and safety.The facility reported a census of 27 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 had severe cognitive impairment, no wandering behaviors exhibited, transferred from one surface to another with extensive assistance of two staff, and had [DIAGNOSES REDACTED]. The Care Plan indicated Resident #1 had cognitive loss/dementia, history of TIA ([MEDICAL CONDITION]) (stroke) as evidenced by deficits in short and long term memory, initiated on 09/4/2020. The Care Plan instructed staff to use environmental cues and gestures to assist with communicating and to promote memory and problem solving, keep routine consistent, anticipate needs if unable to do so, ask yes/no questions if having difficulty responding to open ended questions and present just one thought, idea, question or comment at a time if having difficulty comprehending. On 02/10/2021, the Care Plan added impaired behavior related to [DIAGNOSES REDACTED]. The Care Plan directed staff to intervene as necessary to ensure safety of resident and others, divert attention from stimulus, attempt redirection, Accu-tech (Wander Guard) monitoring device, and when wandering ask what he is looking for and assist as appropriate. Interdisciplinary Notes include the following nurse's notes: -11/22/2020 at 11:38 p.m. - Resident had confusion shift. At 9:00 p.m. he came out of his/her room with coat on, and a bag of apples thinking his son was coming to pick him up. Resident asked how to get to the stairs so he could leave. Staff tried to re-orient resident but the resident disagreed. Staff called the resident's daughter to talk to the resident and the resident asked her when she was coming to get him. After talking to the daughter, resident stated he would stay with them that night, and staff brought the resident back to his room and helped with night time cares. Daughter called back after an hour to check on the resident. -02/10/2021 at 4:24 a.m. - Resident up at 2:00 a.m. and got dressed, found sitting in recliner. At 4:00 a.m. resident was observed about to self-transfer again, assisted to the bathroom and back to recliner. Resident then came out of room walking behind wheel chair. Nurse put a gait belt on the resident, grabbed the walker and ambulated up the hallway for a bit. Resident confused to place and time, looking for a way out. Resident re-directed back to his room and recliner. Resident refused snack, re-oriented to call light and placed within reach. -02/10/2021 at 6:48 a.m.- Staff B, Registered Nurse (RN), documented, Resident confused to time and place. Self-transferring, asking to go home, left household and returned by another staff person. Resident unable to say where he was going. -02/10/2021 at 2:44 p.m., the physician ordered a urinalysis and directed staff to monitor the resident's blood pressure for five days. 02/10/2021 at 5:45 p.m., Social Services added a new goal to the Care Plan due to resident leaving the household and wearing an Accu-tech device. The Elopement Incident Report dated 02/10/2021 reported Staff A, Housekeeping, observed Resident #1 sitting in between the two front entrance doors. When Staff A pulled up and stopped her car, the resident opened the door and wheeled out about two feet. Staff A immediately assisted resident back into the building and household and notified the nurse. Resident #1 Elopement/Wandering Assessments included: -02/10/2021 - Score of 22. Resident at risk for elopement/wandering. -12/10/2020 - Score of 8. Resident not at risk for elopement/wandering. 10 or more = risk. Surveyor observation on 02/18/2021 at 11:30 a.m. revealed Resident #1 seated in his wheel chair, pleasant, neatly dressed and wearing an Accu-Tech Wander Guard bracelet on the right ankle. The resident sat calmly in his room. When asked if had gone outside lately? Resident replied with a smile, Yes I did, someone told me I had better get back inside. It was slippery out there. I went out the back. Observation of facility camera surveillance footage from 2/10/2021 revealed: -At 6:09 a.m., a staff entered the facility. -At 6:17 a.m., Staff A pulled up to the front entrance -At 6:17:48 a.m., Resident #1 self-propelled out the door in his wheel chair and Staff A brought the resident back inside. Climatologist report: February 10, 2021 at 6:00 a.m. Dubuque airport reported a temperature of 2 degrees Fahrenheit with a negative 14 degrees Fahrenheit wind chill. During an interview on 02/18/2021 at 11:10 a.m., Staff D, RN, Director of Nursing (DON), revealed staff witnessed Resident #1 in his room seated in the wheel chair on 02/10/2021 at approximately 6:10 a.m., the resident reported he went through the therapy room to the front door and waited for a ride. Staff A arrived and observed the resident exit barely outside the door, approximately 1-2 feet. Staff A asked the resident where he planned on going. The video indicated the incident occurred at 6:17 a.m During an interview on 02/18/2021 at 2:00 p.m., the Administrator revealed at the time of the incident, Resident #1's household only had a Wander Guard type alarm on its exit into the corridor. After the incident, they added a wireless keypad system that requires staff or visitor to enter a code. The front entrance/exit has a Wander Guard system located in the hallway leading to the door. Anyone without a Wander Guard can exit. In order to enter the facility, each staff carries a FOB that they scan to release the door. A visitor has to call for assistance by ringing the doorbell. The Administrator revealed the front entrance reception desk is staffed from approximately 7:30 a.m. until 4:30 - 5:00 p.m. Monday through Friday. During an interview on 02/23/2021 at approximately 11:45 a.m., the Administrator revealed he began working at the facility in April 2020, the front entrance had no functioning keypad alarm, only a Wander Guard alarm when exiting the facility. It had the capability for an additional alarm, and a key pad had been in place prior to the pandemic. The Administrator learned the front entrance keypad alarm had been disabled since they were not allowing visitors during the pandemic. On 02/18/2021, maintenance moved the keypad alarm to the Conlon household as an additional precaution until a new FOB system could be installed. During an interview on 02/22/2021 at 2:15 p.m., Staff B, RN reported working the night shift on 02/9/2021 from 6:00 p.m. until 6:00 a.m. on 02/10/2021. Staff B reported the resident often got up during the night, got dressed and self-transferred. Throughout the shift, staff checks the resident and ask him to use the restroom, however the resident often refuses. The resident fails to ask for assistance. That early morning on 02/10/2021, the resident self-transferred from the bed to wheel chair, got dressed, and sat in the recliner. Around 4:00 a.m., the resident came out of the room and stated, I'm trying to find a way out. Staff B put a gait belt on the resident, walked for a bit and then assisted the resident to the recliner. Staff B informed the resident there had been a big snowstorm the night before. The resident seemed satisfied to return to the recliner and made no further remarks. Staff B recalled a long time ago the resident made a similar confused statement, and indicated he wanted to wait for the bus to go to St Anthony's Church. The resident never went to the door and attempted to exit the facility. During an interview on 2/22/2021 at 2:30 p.m., Staff C, RN reported working on 02/10/2021 from 6:00 a.m. until 6:00 p.m At approximately 6:10 a.m., Staff C observed Resident #1 seated in the wheel chair in his room doorway. Staff C went to care for another resident and the two Certified Nurse Aides (CNA's) were busy assisting residents. A little while later, Staff A reported he brought the resident back. Staff C, surprised and unaware the resident left the household immediately put the Wander Guard bracelet on the resident. Staff C indicated the resident had no prior attempts to exit the household. During an interview on 02/22/2021 at 10:00 a.m., Staff A, Housekeeping, reported she typically arrived to work early, pulls up to the front entrance and goes inside to the reception area. Staff is required to have Covid-19 screening prior to starting her shift. As Staff A approached the entrance, she noted Resident #1 seated inside the door. Staff A thought the resident possibly had an appointment and waited for transportation. As Staff A exited the car, the resident exited the front doors and Staff A assisted the resident back inside the building. The resident had no coat on and stated he was going home. Staff A returned the resident to the household and the resident said, There's my room. Staff A reported the incident to Staff C. Staff A revealed the resident's daughter drives a similar vehicle. Staff Education provided after the incident included: Staff are required to respond to all alarms in the facility. If it is noted that a resident has increased confusion or is noted to make statements regarding leaving the facility, an Accu-tech is to be applied immediately. During an interview on 02/25/2021 at 12:10 p.m., Staff E, Maintenance reported that initially the Conlon household had no FOB system, only a Wander Guard type system.(NAME)household had both a FOB and Wander Guard system. Staff E indicated he currently reached out to vendors and waited for bids to add a FOB system in Conlon. The front entrance initially had a keypad alarm system, however they disabled it when the facility prohibited visitors during the pandemic. Staff used an employee entrance at that time. The facility Policy and Procedure for Elopement, Risk Prevention and Management of Missing Residents dated 06/09/2019 included: Policy:(NAME)Manor Communities - Grand(NAME)Campus strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement prevention strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission and conduct a missing resident procedure. Procedure: A. Assessment 1. An elopement risk assessment is completed by the nursing staff on all residents on admission, quarterly and upon change of condition. 2. A facility approved risk assessment tool is utilized. The assessment is based on various risk factors that may precipitate an elopement event. The risk score includes a defined parameter which, when reached, indicates an increased risk and prompts prevention strategies. B. Prevention 1. Interventions that may be used for residents identified as high risk for elopement include: a. Designate resident as an elopement risk b. Place an Accu-tech bracelet on him/her. c. Include in activities that are in full view of staff d. Notify the staff of which residents are at risk for elopement e. Develop an elopement Care Plan f. Update families g. Transfer to a secured unit as needed The situation detailed above resulted in Immediate Jeopardy (IJ) for the facility. The facility was notified of the Immediate Jeopardy on 02/23/21. The facility removed the IJ situation on 02/23/21. The scope and severity of the deficiency was lowered from a J to a D. The facility removed the IJ by placing an alarm system on the facility front door (Wire Response Care keypad) which audibly alerts to the pagers of staff members, the nurses' company cell phones, and the message boards in the households.Wander guards were applied to all mobile residents in the Conlon Household and staff education was provided to include: 1. Resident(s) that experience increased confusion or is noted to make statements regarding leaving the facility, a wander guard will immediately be applied. Social worker and MDS Coordinator to be notified of the change. Family notification to occur. 2. Staff shall not change the settings on the household cell phone to silence or turn off notifications related to door alarms. 3. Nurse shall notify the Administrator or Director of Nursing immediately following an elopement or attempted elopement. Grand(NAME)provided further staff education on February 23, 2021, to include: 1. It is the responsibility of all staff to respond to a door alarm. 2. Staff must check the alarming door and its immediate surroundings. If no one is visible or there is no cause seen for the alarm to sound, then a complete check of all households will be done and all residents must be accounted. 3. Staff shall respond to an alarm immediately. If alarms are noted to be on for an extended period of time, all staff working at the time will be subject to disciplinary action. 4. Staff will appropriately use the alarms while entering and exiting facility. 5. Nurses' cell phones and C.N.A./C.M.A. pagers are to be carried at all times. These are part of the uniform. Random audits will be conducted. Observation on 02/23/2021 at 3:40 p.m. revealed the facility front entrance/exit door had a wireless keypad alarm installed and functioned. The Administrator demonstrated the function of the recently installed alarm for the surveyor. On 02/18/2021, maintenance staff moved the keypad alarm from the front entrance door to the Conlon household. On 02/23/2021, maintenance staff moved the keypad alarm from the Conlon household to the front entrance/exit door.