Every finding on record at Heritage Park Rehabilitation and Skilled Nursing C

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services timely to maintain good grooming and personal hygiene for two of seven residents (Resident #128, Resident #135) reviewed for ADLs. The facility failed to ensure Resident #128 and Resident #135 fingernails were trimmed and maintained. This failure could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.Findings included: Record review of Resident #128's Face Sheet, dated 02/19/2026, reflected an [AGE] year-old male, admitted [DATE] with diagnoses that included dementia (is the loss of cognitive functioning, thinking, remembering, and reasoning), cognitive communication deficit (a condition that affects how individuals think and communicate), muscle wasting (is the loss or thinning of muscle tissue, leading to decreased muscle mass and strength), need for assistance with personal care (requires help with ADL's), edema (is swelling from trapped fluid building up in tissues in your body), chronic combined systolic heart failure (systolic and diastolic dysfunction, leading to impaired heart function and various symptoms), and major depression (is a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems).Record review of Resident #128's quarterly MDS dated [DATE], reflected a BIMS Score of 10, which indicated mildly cognitively impaired.Record review of Resident #128's Care Plan, dated 11/28/2025, reflected Resident #128 required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #128 to maintain current level of function with assistance in his ADL care needs.Record review of Resident #128's nail care and facial hair removal file in point click care dated 02/20/2026 reflected nail care and facial hair removal were to be completed every Tuesday, Thursday, and Saturday 6:00 a.m. to 2:00 p.m. There was no ADL documentation for fingernail trimming for the past month in the ADL tasks checklist. Record review of nursing progress notes file in point click care dated 02/20/2026 reflected no documentation that Resident #128 received ADL care services for fingernail trimming in the past three months. Record review of Resident #135's Face Sheet, dated 02/19/2026, reflected a [AGE] year-old female, admitted [DATE] with diagnoses that included respiratory failure with hypoxia (is defined as a condition where there is insufficient oxygen in the blood hypoxemia without elevated carbon dioxide levels hypercapnia), major depression (is a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), morbid obesity (is a chronic medical condition characterized by excessive body fat that significantly increases the risk of serious health problems), contracture to left and right hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility), muscle wasting (is the loss or thinning of muscle tissue, leading to decreased muscle mass and strength), need for assistance with personal care (requires help with ADL's), and cognitive communication deficit (a condition that affects how individuals think and communicate.Record review of Resident #135's quarterly MDS dated [DATE], reflected a BIMS Score of 11, which indicated mildly cognitively impaired.Record review of Resident #135's Care Plan, dated 02/04/2025, reflected Resident #135 required dependent assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. The goals were for Resident #135 to maintain current level of function with assistance in his ADL care needs.Record review of Resident #135's nail care and facial hair removal file in point click care dated 02/20/2026 reflected nail care and facial hair removal are to be completed every Tuesday, Thursday, and Saturday 6:00 a.m. to 2:00 p.m. There was no ADL documentation for fingernail trimming for the past month in the ADL tasks checklist. Record review of nursing progress notes file in point click care dated 02/20/2026 reflected no documentation of Resident #135 receiving ADL care services for fingernail trimming in the past month. During an interview on 02/18/2026 at 1:30 p.m. with Resident #128, he stated he did not like his fingernails long. Resident #128 stated it bothered him that the facility staff told him multiple times in the past that facility staff would come by to trim his fingernails but never came by to provide him nail care. Resident #128 stated he had not had his fingernails trimmed by the facility staff or even offered to have his fingernails trimmed in a couple of months. Resident #128 stated he scratched himself doing things with his long fingernails.During an observation on 02/18/2026 at 1:31 p.m. of Resident #128 revealed the resident had long and not trimmed fingernails with jagged edges. During an interview on 02/19/2026 at 12:14 p.m. with Resident #135, she stated staff did not assist her with clipping fingernails. She stated that she asked nursing staff to clip her fingernails on multiple occasions and they did not do that. She stated that her fingernails were too long and not comfortable for her to use her hands during ADL activities.During an observation on 02/19/2026 at 12:15 p.m. of Resident #135 revealed her left hand had long fingernails on her index finger, thumb, and pinky finger. During an interview on 02/19/2026 at 1:10 p.m. with Resident #128, he stated the facility staff still had not come around to offer him fingernail trimming or any care services for his fingernails. During an observation on 02/19/2026 at 1:11 p.m. of Resident #128, revealed Resident #128's fingernails were still not trimmed or showed any signs of nail care being completed. Resident #128's fingernails had jagged edges and approximately one inch long from his fingernail bed on all his fingers to both his left and right hand. During an interview on 02/19/2026 at 1:28 p.m. with CNA A, he stated he worked at the facility for 3 months. The CNA A stated he received training on ADL care and trimming residents' fingernails timely. CNA A stated training on ADL care and trimming residents' fingernails timely went over residents' fingernails were to be trimmed or to tell a nurse if a resident refused. CNA A stated residents' fingernails should be trimmed and cleaned routinely once a week. CNA A stated if resident's fingernails were not trimmed, it was considered to be neglectful, but residents refused sometimes. CNA A stated after telling a nurse, the nurse followed up with residents about fingernail trimmings. CNA A stated ADL care and trimming residents' fingernails are monitored by the RNs or LVNs. CNA A stated he had not trimmed any residents' fingernails since working at the facility. CNA A stated he had not received complaints from residents that staff were not trimming their fingernails. CNA A stated it's the responsibility of all nursing staff to ensure ADL care and trimming residents' fingernails was taking place such as the CNAs. CNA A stated if ADL care and trimming a resident's fingernails was not taking place, it could affect and diminish the resident's quality of life and potentially their dignity. CNA A stated it's ultimately the overall responsibility of the ADM and DON to ensure ADL care and residents' fingernails were trimmed timely for all residents. During an interview on 02/20/2026 at 1:34 p.m. with CNA H, she stated residents' fingernails were done every shower, 3 times a week. The CNA H stated that she verbally notified charge nurse a few days prior that Resident #135 refused to clip her fingernails. CNA H could not remember exact date of the notification and name of the nurse. CNA H stated the nurse documented refusals. CNA H stated that she had an in-service on ADLs and trimming fingernails in which nursing staff needed to offer fingernail care to residents so residents could feel good and prevent infections. During an interview on 02/20/2026 at 1:35 p.m. with the RN, she stated she offered Resident #135 to clip her fingernails earlier this week and Resident #135 refused. RN stated that she did not document it, and she knew that she should have as if she did not document it, it did not happen. The RN stated that she had the in-service on ADL a few months ago and she was aware of the need for trimming residents' fingernails every week during showers and as needed. She stated that CNAs communicated to charge nurses if residents refused to have their fingernails trimmed and charge nurses were responsible for documenting it in the patients' clinical records. She stated that not trimming fingernails could lead to an accumulation of dirt and bacteria and potentially could cause the spread of infection.During an interview on 02/20/2026 at 1:41 p.m. with LVN B, she stated she worked at the facility for 7 years. LVN B stated she received ADL care and trimming resident's fingernails timely training. LVN B stated ADL care and trimming resident's fingernails timely training goes over during shower days that residents' fingernails need to be observed and offered a fingernail trimming, if the resident had diabetes only nurses could trim those residents' fingernails, and sometimes residents refused in which staff would document it and care plan it. LVN B stated the last time that she received the ADL care training was an in-service yesterday that she did it verbally. LVN B stated it's the responsibility of the CNAs and nursing staff to make sure residents' fingernails were trimmed and cleaned. LVN B stated ADL care and trimming resident's fingernails timely were monitored by the nurses. LVN B stated she has not received complaints from residents that staff were not trimming their fingernails. The LVN B stated it's the responsibility of the LVN and nursing staff to ensure ADL care and trimming resident's fingernails was taking place for residents. The LVN B stated if ADL care and not trimming a resident's fingernails was not taking place, it could affect and diminish the resident's quality of life by the resident's potentially cracking a fingernail and hurting themselves. The LVN B stated it's ultimately the overall responsibility of the DON to ensure ADL care and resident's fingernails are trimmed timely for the residents at the facility. During an interview on 02/20/2026 at 3:38 p.m. with the DON, she stated she worked at the facility for 28 years. The DON stated she received training on ADL care and trimming for residents' fingernails. The DON stated that training on ADL care and trimming residents' fingernails timely for the nursing staff went over that during showers the nursing staff needed to examine residents' fingernails and for nursing staff to ask residents if they wanted a fingernail cleaning or trimming. The DON stated ADL care and trimming of residents' fingernails were monitored by all nursing staff, she did morning rounds and shook residents' hands to examine their fingernails. The DON stated she had not received complaints from residents that staff were not trimming their fingernails. The DON stated if ADL care and trimming residents' fingernails was not taking place, it could affect and diminish the residents' quality of life as it could bother the residents and or residents may feel embarrassed. The DON stated it's the responsibility of the DON to ensure ADL care and trimming residents' fingernails was taking place including is the responsibility of facility nurses. The DON stated it's the responsibility of the nursing staff to document if residents were getting their fingernails trimmed or not for all residents. The DON stated it's ultimately the overall responsibility of the DON and the ADM to make sure residents are getting ADL care services for their fingernails. During an interview on 02/20/2026 at 3:58 p.m. with the ADM, he stated he worked at the facility for 9 years and 3 months. The ADM stated he received training on ADL care and trimming residents' fingernails, and his nursing staff received training in ADL care and fingernail trimming. The ADM stated that ADL care with trimming fingernails was the job of nursing staff, nondiabetic residents would get fingernail trimmings from CNAs , and nurses completed fingernail trimmings for residents who were diabetic or if needed by a podiatrist. The ADM stated ADL care and trimming residents' fingernails were monitored by the direct CNA care staff, nurse managers, treatment nurses, and the entire nursing staff team during rounds. The ADM stated nursing staff was to be documenting ADL and fingernail trimmings for residents. The ADM stated he had not received complaints from residents that staff were not trimming fingernails. The ADM stated it's the responsibility of nursing staff and ambassadors to ensure ADL care and trimming residents' fingernails was taking place. The ADM stated if ADL care and trimming residents' fingernails was not taking place, it could affect and diminish the residents' quality of life by potentially causing bacteria issues, skin tears, infection control issues, and it can make a resident feel a certain way in which should not take place as it was a problem. The ADM stated it's ultimately the overall responsibility of the DON and ADM to ensure ADL care and residents' fingernails were trimmed for all residents. The ADM stated it's his expectation for ADL care and fingernails being trimmed is taking place for residents and it's his expectation that it's being appropriately provided as needed and requested by residents. Record review of facility in-service education for ADL documentation dated 08/07/2025 reflected to have been provided and completed by nursing staff, LVN B, the RN, and not completed by CNA A or CNA H. Record review of ADLs policy dated 05/26/2023 reflected the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living, bathing, dressing, grooming, and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Documentation shall be completed at the time of service, but no later than the shift in which care service occurred.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the open date for insulin and secured med cart for 2 (med cart #2 and med cart #1) of 6 med carts reviewed for medication storage. The facility failed to ensure that Resident #195 and Resident #75's insulin pens were labeled with an open date on med cart #2.The facility failed to ensure that med cart #1 was locked when RN was not present.This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of their medications, a decline in health status, and adverse effects if they had access to an unlocked MC. Findings included:During an observation on 02/18/2026 at 4:52PM an unlocked medication cart #1 was observed unattended outside of a resident's bedroom on the 2400 hall. During an observation on 02/18/2026 at 4:56PM the same MC was further down the same hallway, unlocked with the red mark showing which indicated the lock was open and not secure. The observation also revealed that the hall was free from residents wandering. Record review of Resident #195's face sheet, dated 2/20/2026, revealed a 65-years-old male admitted on [DATE]. Resident #195's diagnosis included type 2 diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar resulting from insulin resistance) with hyperglycemia (high blood sugar). Record review of Resident #195's orders, revealed that Resident #195 had an active order, started on 02/18/2026, Lantus Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously at bedtime related to TYPE 2DIABETES MELLITUS WITHOUT COMPLICATIONS.Record review of Resident #75's face sheet, dated 2/20/2026, revealed a 51-years-old female admitted on [DATE] and readmitted on [DATE]. Resident's #75's diagnosis included type 2 diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar resulting from insulin resistance). Record review of Resident #75's care plan, dated 12/12/2023, revealed Resident #75 had altered endocrine status related to Diabetes Mellitus with interventions to monitor for signs of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Record review of Resident #75's orders, revealed that Resident #75 had an active order, started on 08/12/2025, for Lantus Subcutaneous (administering medication into the fatty tissue layer just below the skin and above the muscle) Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 60 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS. During the observation of the 2200/2500-hall nursing med cart on 02/20/2026 at 10:18 a.m., revealed an insulin pen with 100 units/ml of insulin glargine for Resident #195 and an insulin pen with 100 units/ml of insulin glargine for Resident #75 without open date information available.In an interview on 2/20/2026 at 10:05 a.m. with LVN G, she said she received the medication storage and proper insulin labeling in-service 2-3 months ago. She said that according to the facility's policy insulin pens must be dated when opened and discarded after 28 days. LVN G said that she forgot to check for the open date labeling for the insulin for Resident #195 and Resident #75. She stated that the potential risk for residents receiving insulin injections with unlabeled insulin pens could be not getting the intended therapeutic benefits from the medications.An interview on 02/20/2026 at 3:04PM with MA J, who stated he had been employed at the facility for 5 years. MA J stated he had received training on MCs which included locking the MC when he was not at the MC. MA J stated the MC should be locked whenever he was away, included if he was inside a resident's room. MA J stated the MC could be unlocked if he was at the cart actively working inside of the MC. MA J stated if a MC was left unlocked it could be bad because residents could open the cart and take the medications potentially leading to harm. An interview on 02/20/2026 at 3:10PM with RN K, who stated she had been employed at the facility for 2 years. RN K stated she had received training on MC which included that staff were expected to keep the MCs locked and secure. RN K stated every time she left the cart; she was supposed to lock the MC. RN K stated the MC could be kept unlocked if she was working inside the cart actively. RN K stated residents could take the medications out of the cart if the MC had been left unlocked, potentially leading to harm for residents. In an interview on 2/20/2026 at 3:39 p.m. with the DON, she said she was trained in the facility's medication storage annually. She stated that nursing staff was in-serviced on medication storage including labeling insulin pens before opening annually, and throughout the year. She stated that once insulin was placed on the nursing med carts and before opening, they should be labeled with the open date and discarded after 28 days. The DON said the charge nurses and medication aides were responsible for monitoring accurate labeling of medications before administering them to residents and daily checking their med carts for expired meds. She said that DON, ADONs and pharmacist were auditing med carts for proper labeling on a weekly/monthly basis. She stated that potentially if expired medications were administered to residents, it could reduce the therapeutic effect of medication to treat their medical conditions. The DON stated her expectation for the MC was they should be locked at all times unless staff are actively working inside the MC. The DON stated the RNs were responsible for ensuring the MC was kept locked. The DON stated residents, and staff could have access to the medications inside the MC if they were left unlocked. In an interview on 2/20/2026 at 3:59 p.m. with ADM, he said he did not have any training on medication storage, but all nursing staff were trained on medication storage and were supposed to label insulin pens before opening and using it. He said that DON, ADONs, charge nurses and medication aides were responsible for monitoring their medication carts for proper labeling of medications. He said that potentially if not properly labeled and administering expired medications to residents, it could not provide an intended therapeutic effect to treat their medical conditions. The ADM stated the facility regarding MC was that MC was to be secured at all times, especially when away from the MC. The ADM stated licensed staff and staff assigned to the MC would be responsible for keeping the MC locked. The ADM stated there would be potential for a drug diversion if the MC were left unlocked. Record review of facility's Insulin Pen policy, dated 07/03/2023, revealed 8. Once opened, clearly labeled insulin pens may be stored at room temperature. 9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendations.Record review of facility's in-services for last 12 months (February 2025 - February 2026) did not reveal any record of completed nursing staff training on labeling insulin pens before opening.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 10 residents (Resident #20) reviewed for rights.The facility failed to ensure CNA B closed Resident #20's door while providing incontinent care. The deficient practice could place residents at risk of feeling embarrassed and diminish the residents' quality of life. Findings included:Review of Resident #20's Face Sheet dated 02/20/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20's diagnoses included depression (persistent sadness), insomnia (difficulty sleeping), muscle wasting, hypertension (high blood pressure), abnormalities of gait and mobility, hyperlipidemia (high cholesterol), schizophrenia (severe, chronic brain disorder causing disconnect from reality through hallucinations), and obstructive pulmonary disease (chronic progressive lung disease).Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed Resident #20 had a BIMS score of 15 indicating intact cognitive response. The MDS also revealed that Resident #20 was substantial/maximal assistance with toileting. Record review of Resident #20's care plan dated 08/27/2025, [Resident #20] had an ADL self-care performance deficit related to schizophrenia (severe, chronic brain disorder causing disconnect from reality through hallucinations). Interventions were The resident requires supervision to limited assist by 1 staff for toileting.Observation of Resident #20 on 02/18/2026 at 2:07 p.m., revealed staff took Resident #20 to his room because he had feces on the back of his pants and shirt. Staff entered the resident's room, took the resident by his bed, pulled the privacy curtains, and proceeded to change the resident without closing the resident's bedroom door. During an interview with Resident #20 on 02/20/2026 at 1:44 p.m., he said staff had changed him with the door open before. He said most of the time staff just closed the curtain. He said he wanted staff to close the door all the time when they helped him change. He said when staff did not close the door it upset him. He also said he had to ask the staff to close the door when they helped him change. During an interview with CNA B on 02/20/2026 at 2:25 p.m., he said he had been trained on resident rights. He said he had resident rights training last month. He said the policy for providing care to residents was that staff had to draw the curtain and close the bedroom door. He stated staff were responsible for providing privacy to the residents during care. He said if privacy was not provided during care the residents may feel ashamed or neglected. He said the charge nurse or the DON monitored to ensure staff were providing privacy during care. He said the charge nurse or the DON would monitor by checking on how staff were taking care of the residents. He said he did not plan to be stopped by the nurse to change Resident #20 because Resident #20 had feces on him while in the hallway. During an interview with the DON on 02/20/2026 at 3:39 p.m., she said she had been trained in resident rights. She said she last had the training was last week. She said the policy for privacy was that staff were to get all the materials needed, close the door, close the curtain, and provide the resident with the care needed. She said the CNAs or any staff providing care to the residents were responsible for providing privacy for the residents. She said it could be a dignity issue if staff did not provide privacy during care. She said, if the staff did not provide privacy to the residents during care the residents could feel embarrassed. She said the nurse monitored to ensure staff are providing privacy. She said the nurse monitored by observation. She said CNA B did not close the door because he could not remember if he had closed the door after taking Resident #20 into the room. She said CNA B did make sure he closed the privacy curtain.During an interview with the ADM on 02/20/2026 at 4:02 p.m., he said he had been trained on resident rights. He said he had resident rights training last month. He said the policy was to preserve the residents' dignity. He said that staff should have the door closed, and the privacy curtain pulled closed when providing care to a resident. He said all direct care staff were responsible for providing privacy to the residents. He said that if staff did not close the door and the privacy curtain when providing care, the residents might feel uncomfortable. He said the ADM, unit managers and nurses monitored to ensure staff were providing privacy during care. He said the ADM, unit managers and charge nurse monitored by observation rounds. He said he did not know why CNA B did not close the door while providing care to Resident #20.Record review of Promoting/Maintaining Resident Dignity Policy dated 01/13/2023, revealed It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: Maintain resident privacy.Record review of Resident Rights Policy not dated revealed, Each resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident including each of the following rights: Each resident has a right to privacy.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #164) observed for infection prevention.The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed when CNA D and CNA E performed peri care for Resident #164.This deficient practice could place residents at risk for the spread of infection.Findings included:Record review of Resident #164s face sheet on 2/19/2026 revealed he was a [AGE] year-old male with an initial admission of 3/27/2025, with a readmission date of 12/19/2025. Diagnoses included: Stage 5 chronic kidney disease, Type II Diabetes Mellitus, Legal blindness, Hypertension. The record also revealed the resident has a dialysis fistula to his left arm (surgical connection of an artery to a vein enabling high flow repetitive needle insertion for routine blood cleansing) Record Review of Resident #164's Physician's Orders revealed an order with start date 1/20/2026, Enhanced Barrier Precautions. Use of gown and gloves for high contact resident care activities for those with known to be colonized or infected with CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices).Record review of Residents #164's Care Plan dated 1/20/2026 revealed a problem which included Resident has need for Enhanced Barrier Precautions due to: Dialysis status. This was noted as initiated on 8/8/2025. Interventions included: Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated.In observation on 2/19/2026 at 11:29 AM revealed staff members CNA D and CNA E performed peri care for Resident #164. The CNAs performed peri care following aseptic technique. The CNAs changed gloves and cleansed their hands at appropriate intervals. The CNAs failed to wear gowns when providing peri care to Resident #164. Signage noted outside of Resident #164's door reflected that resident in bed A was on EBP. PPE was stored in hanging storage on Resident #164s door. In an interview on 2/19/2026 at 11:40 AM with CNA D and CNA E they stated that they did not wear gowns because the resident was not on EBP that the resident in bed B was. They could not explain why the letter A was on the sign and not the letter B. The CNAs stated that if a resident was on EBP they would wear gowns and gloves when providing care to the residents to prevent infection or the spread of germs from their clothing to another resident. They stated they were frequently in-serviced on infection control.In an additional interview on 2/20/2026 at 2:00 PM CNA D and CNA E stated they discussed with the DON and Resident #164 was on EBP and the resident's roommate was no longer on EBP. They stated they should have worn gowns when providing care to Resident #164.In an interview on 2/20/2026 at 2:15 PM with CNA F, she stated she was in-serviced on infection control including EBP. She stated that if a resident was on EBP she would wear a gown and gloves when performing care such as peri care, or bathing. She stated if the proper PPE was not worn then infections and germs could spread from one resident to the other. In an interview on 2/20/2026 at 2:35 PM with CNA C, he stated that he was regularly in-serviced on infection control. He stated that the in-service for infection control included training for EBP. In an interview on 2/19/2026 at 10:30 AM with RN I, the wound care nurse, she stated that she was frequently in-serviced on infection control which included EBP. She stated that if a resident was on EBP then any close contact care that was provided to a resident required staff to wear a gown and gloves while providing the care to prevent the spread of germs. She stated most residents on EBP had something going on that made them more susceptible to infection. In interview on 2/20/2026 at 3:47 PM with the DON, who worked in the facility for 28 years and 16 years as the DON, stated she frequently in-serviced her staff on infection control and the training included EBP, and isolation status. She stated that she expected staff to wear gowns and gloves to perform care when they have an order for EBP. She stated that if staff did not follow the set protocols for PPE there was a chance that cross-contamination could occur. She stated the staff know who as on EBP and other precautions by the sign on the door and they put which bed for example A, B, C. The DON stated that they did not have a specific policy for enhanced barrier precautions and followed their Infection control policy that included Isolation types.In an interview on 2/20/2026 at 4:00 PM with the ADM, he stated he has worked in the facility for 9 years. He stated that the staff and himself were frequently in-serviced on infection control which includes EBP. He stated that he expected staff to follow the guidelines that they have been in-serviced on when there is an order for EBP. He stated the staff knew a resident was on EBP by could spread infection. Every door with the resident has PPE and a sign designating which bed [NAME] EBP orders and it was on the Kardex, care plan. He stated the clinical administration and infection control person perform surveillance.In record review of facility policy, Infection Prevention and Control Policy, dated 5/13/2023, reviewed 5/21/2025, thee policy revealed This facility has established and maintains infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines, 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: - c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.

Based on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 6 medication carts (2200/2500-hall med cart) in the facility effecting 2 residents (Resident #156 and Resident #71) reviewed for pharmacy services.The facility failed to ensure LVN G accurately reconciled Resident #156 and Resident #71's narcotic medication log when she administered but did not sign for Resident #156's Hydrocodone APAP 5-325mg (controlled medication used for pain) 1 tablet and for Resident #71's Hydromorphone Hch 2mg (controlled medication used for pain) 1 tablet on 02/20/2026 between 6:00 a.m. and 10:00 a.m. These failures could place residents at risk for loss of prescribed medications, potential for not receiving their prescribed medications, and risk of drug diversion. Findings included:Record review of Resident #156's face sheet, dated 2/20/2026, revealed a 66-years-old male admitted on [DATE]. Resident's #156's diagnoses included chronic pain, hypertension (high blood pressure), and cervical disc disorder with myelopathy (compression of the spinal cord in the neck).Record review of Resident #156's admission MDS assessment, dated 1/16/2026, revealed BIMS score of 6 indicating the severely impaired cognition. Record review of Resident #156's care plan, dated 01/13/2026, revealed Resident #156 had ADL self-care performance deficit related to chronic pain syndrome and low back pain. Record review of Resident #156's orders, revealed that Resident #156 had an active order, started on 02/09/2026, for HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day for PAIN. Record review of Resident #71's face sheet, dated 2/20/2026, revealed a 72-years-old female originally admitted on [DATE] and readmitted on [DATE]. Resident's #71's diagnoses included fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain and intense fatigue), bipolar disorder (a chronic mental health condition characterized by intense mood swings), and muscle spasm of back.Record review of Resident #71's annual MDS assessment, dated 1/15/2026, revealed BIMS score of 15 indicating the intact cognition. Record review of Resident #71's care plan, dated 01/30/2026, revealed Resident #71 had acute/chronic pain related to fibromyalgia and chronic pain with interventions identified to respond timely to any complaint of pain and monitor/document for side effects of pain medications. Record review of Resident #71's orders, revealed that Resident #71 had an active order, started on 02/19/2026, for HYDROmorphone HCl Oral Tablet 2 MG (Hydromorphone HCl) Give 1 tablet by mouth every 8 hours as needed for PainDuring observation of the 2200/2500-hall med carton 02/20/2026 at 10:18 a.m., the controlled medication log revealed a discrepancy in the count for Resident #156's Hydrocodone APAP 5-325mg with 80 pills in the blister pack and 81 pills counted on the controlled medication log for Resident #156 with one pill of Hydrocodone APAP 5-325mg was taken out, but not signed. In addition to that, the controlled medication log revealed a discrepancy in the count for Resident #71's Hydromorphone Hch 2mg with 12 pills in the medication bottle and 13 pills counted on the controlled medication log for Resident #71, with one pill of Hydromorphone Hch 2mg was taken out but not signed. During an interview on 2/20/2026 at 10:05 a.m. with LVN G, she said that she administered Resident #156's Hydrocodone APAP 5-325mg 1 pill to him this morning but did not sign for it in the controlled medication log. She said that she was busy with one resident leaving the facility and needed her medications before she went out. LVN G said she got busy and forgot to sign for controlled medications administered to Resident #156 and Resident #71 this morning about an hour ago, on 02/20/2026 between 8:00 a.m. and 10:00 a.m. She said that not documenting administration of controlled medications could cause a discrepancy in the count or a medication error, since other nurse could not know the resident had already received the controlled medication. She stated that she received the controlled medication administration training annually but could not recall the exact date.During an interview on 02/20/2026 at 3:39 p.m. with DON, she said that she had the medication administration in-service annually and provided this training to nursing staff in the facility annually and on as needed basis. The DON said that charge nurses were responsible for monitoring accurate controlled medication count and signing controlled medications as soon as they administered to each resident. She said that she and the ADONs were auditing the med carts on a weekly basis. She stated if the administration of controlled medications were not properly counted and signed for, it could lead to a drug diversion and medication error.During an interview on 01/20/2026 at 3:59 p.m. with the ADM, he said that he was not trained in medication administration and storage as he was not medically licensed. He said that DON, ADON, charge nurses, and medication aides were responsible for counting controlled medications at shift change and monitoring medications' discrepancies especially with controlled medication to prevent drug diversion. He said if a discrepancy was noted, the nurse or med aide was responsible for notifying the ADON, DON or himself. The ADM said that if the controlled medications were not monitored and properly counted it could potentially harm the residents.Record review of facility's Medication Administration policy, revised 10/01/2019, indicated that 17. Sign medication administration record after administration of medication.18. If medication is a controlled substance, sign narcotic book. Record review of facility's Medication Carts and Supplies for Administering Meds policy, revised 10/24/20, indicated that 11. Document administered medications as they are passed. Record review of facility's In-Services for last 12 months did not reveal any record of completed nursing staff training on medication administration and signing controlled medication after administration to residents.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.The facility failed to ensure the cook performed hand hygiene while preparing puree foods. This deficient practice could place residents who were served from the kitchen at risk for foodborne illnesses.Findings Included:Observation of puree being prepared by the [NAME] on 02/19/2026 at 9:55 a.m., revealed she had gloves on. She put the meat and potatoes in the puree machine. She then put the meat and potatoes in a pan. She tasted the puree, threw the spoon away, covered the meat and potatoes, and put the puree meat on the steam table. She opened a heated cabinet and got the beans. She checked the temperature, wiped the thermometer with an alcohol wipe. She did not change gloves or wash her hands. She poured the beans in the clean puree machine. She added a little thickener to the beans. She got a spatula and put the beans back in the pan she took them out of. She tried the beans, threw the spoon away, covered the beans and put them on steam table. She still did not wash or sanitize her hands. She went to the pantry, touched the door to the walk-in refrigerator, moved the clear flaps hanging down, opened the steam cabinet, got the corn out, checked temperature, wiped the thermometer with alcohol wipe, took off the plastic, and threw it away. She still did not wash her hands or change her gloves. She poured the corn in the puree machine and added thickener. Once the corn was at the correct thickness she put it into a pan. She tasted the corn and then threw the spoon away. She covered the corn and put the corn on the steam table. She went to the freezer and got a pan of a mix (a cinnamon and butter broth type mix) she said she used for the bread. She still had not washed her hands or changed her gloves. She put slices of bread in the puree machine and poured the mix onto the bread. She added more bread to the puree machine. She then got a pan to put the bread in. She tasted the bread, threw the in pan tried bread threw spoon away. She did not wash or change her gloves during the whole puree process. During an interview with the DM on 02/20/2026 at 11:13 a.m., she said she had been trained on infection control in the kitchen. She said she had the training two weeks ago. She said the policy was anytime staff went into the kitchen, when staff touched something, they were to wash their hands. She said all staff in the kitchen were responsible for washing their hands. She said if staff did not wash their hands the resident could be at risk of germs, and becoming ill. She said she monitored to ensure staff were washing their hands. She said she monitored through observation and asking the staff if they washed their hands. She said the [NAME] did not wash her hands or change her gloves because she had on fake nails. She said the [NAME] did not want the surveyor to see her nails and get a citation.During an interview with the [NAME] on 02/20/2026 at 12:11 p.m., She said she had been trained on infection control in the kitchen. She said she had the infection control training last month. She said the policy for washing your hand was that anytime staff touch raw food, cook food, and go in or out of the kitchen staff should be washing their hands. She also added that any time staff switched tasks they should wash their hands. She said everyone should be washing their hands in the kitchen. She said if proper hand hygiene was not done a resident could get sick. She said the DM monitored to ensure staff were washing their hands. She said the DM would ask staff if they washed their hands and did observations. She said she did not want the surveyor to see her nails because she just got back from vacation. During an interview with the ADM on 02/20/2026 at 3:58 p.m., revealed he had training on infection control in the kitchen. He said he had the infection control training in December. He said the policy for washing hands in the kitchen was staff should be washing their hands when the staff entered the kitchen, when the staff touched their clothing, and when staff were switching tasks. He said all staff in the kitchen or going into the kitchen were responsible for washing their hands. He said if staff were not performing hand hygiene in the kitchen could potentially cause a resident to get an infection or food borne illness. He said the DM monitored to ensure staff were washing their hands. He said the DM monitored by doing weekly audits and monthly audits in the kitchen. He said the audits had hand hygiene on them. He said he did not know why the [NAME] did not sanitize her hands when fixing the puree foods. Record review of the Hand Hygiene Policy dated 10/24/2022 revealed All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The use of gloves does not replace hand hygiene.

Based on observation, interview and record review the facility failed to ensure that the resident environment remains as free of accidents and hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 resident ( Resident #1) reviewed for adequate supervision. The facility failed to ensure Resident #1 was not left unattended on 10/10/2025 at an off-site medical appointment that was an unfamiliar location. Resident #1 had neither appropriate supervision nor arrangements for return transportation. Resident #1 was left alone in an unfamiliar place, with diminished cognition and altered physical ability. An Immediate Jeopardy (IJ) situation was identified on 10/11/2025. While the IJ was removed on 10/14/2025 the facility remained out of compliance at a scope of isolated that is immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of physical harm due to lack of mobility device, emotional and/or mental distress and feelings of abandonment. Findings included: A review of Resident #1's health records shows that she is a [AGE] year-old woman who was admitted to the facility on [DATE]. She has several health issues, including dorsalgia (back pain), schizophrenia (a mental health disorder affecting thoughts, feelings, and behaviors), and constipation (difficulty in passing stools). Additionally, she suffers from osteoporosis (weakening of bones due to age, with no current fractures), left hip pain, insomnia (trouble sleeping), and visual disturbances (issues with eyesight). Other diagnoses include hypertension (high blood pressure), major depressive disorder (recurrent) characterized by persistent sadness and loss of interest, abnormal weight loss, and dementia (a decline in mental ability). She also has vitamin D deficiency (not enough vitamin D for bone health) and polyosteoarthritis (arthritis affecting multiple joints). Bilateral impacted cerumen (earwax buildup in both ears) may affect her hearing, while frontotemporal neurocognitive disorder impacts her personality and behavior. Furthermore, she has paranoid schizophrenia, hypertensive heart disease (heart problems from high blood pressure, without heart failure), age-related cataracts (clouding of both lenses due to aging), melena (black, tarry stools indicating digestive bleeding), and iron deficiency hemorrhage (bleeding from the anus or rectum). She experiences gastroesophageal reflux disease (GERD), obesity (excess body weight), chronic obstructive pulmonary disease (COPD), kidney stones, abnormalities of gait and mobility (issues with walking), and muscle wasting and atrophy (loss of muscle mass and strength). These conditions affect her overall health and daily functioning.Record review of Resident #1's Resident Care Plan, dated 6/13/2025, reflected Resident #1 had diagnoses which included ADL self-care performance deficit, Dementia (a memory problem), Osteoporosis (bone weakness), and Impaired balance (unsteady or off-balance), Ambulation: The resident was independent to supervised w/ambulation- uses walker. The resident will maintain current level of mobility with propelling in her wheelchair. Record Review of the MDS dated [DATE], reflects Resident# 1 with a BIMS score of 09 that indicated a moderate level of cognitive impairment. Resident marked to use a [NAME] in the Mobility Devices sections of the MDS. Resident # 1 was assessed to not have long or short-term memory problems. Interviewed a Health Center staff member on 10/10/2025, at 7:25pm, she revealed that Resident #1 was found unsupervised outside in a hospital courtyard by a security guard, who reported the situation to hospital staff. They subsequently contacted the facility to inform them that no one was present to accompany or return the resident from her appointment. Record review of facility incident report on 10/11/2025, reflects a head-to-toe assessment that was performed on Resident #1 and no injuries or skin issues were noted. During an interview on 10/11/2025, at 1:28pm, Resident #1 stated, I was told I was supposed to have an appointment. I believe, I was dropped off by a new facility driver. She said she was not frightened but was hungry since she had not eaten breakfast. Interviewed Van Driver C on 10/11/2025, at 2:23pm, he revealed that on the morning of the incident, he arrived at 5:00 AM for a 6:00 AM transport assignment. After confirming the details with an overnight nurse who he does not recall the name of and gave no special instructions, he transported the resident to Health Center A at 5:30 AM. Upon arrival at 5:50 AM, he parked in the designated area, assisted the resident from the vehicle, and watched her enter the building before leaving. Later notified that the appointment was canceled, he returned to retrieve the resident. Later that day he was notified that he was suspended pending investigation. Interviewed the Director of Nursing on 10/11/2025, at 3:23pm, she confirmed that the facility requires staff to accompany residents to off-site appointments when supervision is indicated. The DON acknowledged that the staff involved did not follow this recommendation, which was inconsistent with the Resident #1 care plan requiring supervision during ambulation with a walker due to physical mobility needs. Interviewed the Administrator on 10/11/2025, at 3:45pm, he confirmed that the facility requires staff to accompany residents to off-site appointments when supervision is indicated, and that the staff involved did not follow this recommendation. The Administrator acknowledged that the Van Driver did not use proper protocols and would have been the aid responsible for monitoring the resident at the appointment. Record review of the facilities appointment book on 10/11/2025, reflects Resident #1 had a 6 am appointment at the Health Center. The appointment was written in the book in pencil. Record review of facility incident reports on 10/10/2025, reflects a handwritten note from Scheduler B indicating that Resident #1 was scheduled for a colonoscopy procedure on 10/10/2025. However, on 10/1/2025, the MDS coordinator informed her, following a conversation with the resident's Guardian, that the appointment had been canceled. Unfortunately, she neglected to notify the Van driver and update her appointment book, resulting in the resident being transported to a canceled appointment. Review of the facility's policy Abuse, Neglect and Exploitation reflects It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This was determined to be an Immediate Jeopardy on 10/11/2025 at 06:08 PM. The ADM was notified. The ADM was provided with the IJ template on 10/11/2025, at 06:08 PM. The POR (Plan of Removal) was accepted on 10/12/2025 at 2:57 p.m., and included:The following Plan of Removal submitted by the facility was accepted on 10/12/2025 at 2:57 PM: Plan of RemovalImmediate Jeopardy LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDYOn October 11, 2025, at approximately 6:08 PM, the surveyor notified the Administrator that an Immediate Threat had been called for Resident #1. The facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate Threat allegations are as follows:Issue: F-Tag: 600 Freedom from Abuse, Neglect and Exploitation Problem:The facility failed to ensure that Resident #1 was free from neglect when staff left the resident unattended at an off-site medical appointment without appropriate supervision or arrangements for return transportation. This deficient practice placed the resident at risk for physical harm, emotional distress, and feelings of abandonment for the affected resident. Immediate Actions Taken: *Residents were assessed for emotional distress by the Social Worker on 10/10/2025. Results of the assessment were no emotional distress noted. Resident in good spirits. *RN Treatment Nurse conducted a head to toes skin assessment with no abnormalities noted on 10/10/2025.*Resident reassessed for BIMS cognitive score by the social worker on 10/10/2025. BIMS assessed at 11.*Guardian aware of the incident, discussed with Care Management Nurse on 10/10/2025.*The physician was notified of the incident by the Director of Nursing on 10/10/2025.*Van Driver immediately suspended pending investigation by the Administrator/designee on 10/10/2025.*The scheduler immediately suspended pending investigation by Administrator/designee on 10/10/2025.*Charge Nurse immediately suspended pending investigation by Director of Nurses/designee on 10/10/2025. Identify residents who could be affected The facility Social Worker conducted Safe Surveys with residents that have recently attended appointments, and no issues were identified on 10/10/2025. Action Taken *Re-education began on 10/10/2025, 100% staff in services on Abuse, Neglect, and Exploitation was completed 10/11/25 by Administrator/Director of Nurse or designee. Re-education will be verified by roster by the Human Resource Coordinator. The re-education will be assessed by posttest provided to staff. New hires, staff out on leave, agency, and PRN staff will receive in-service training upon hire and return from leave.*The Administrator and Director of Nurses received in-service training on Abuse, Neglect, and Exploitation on 10/11/2025 by the Regional Clinical Specialist.*All facility back-up drivers were immediately re-educated by the Director of Nursing on 10/10/2025 and again on 10/11/2025 regarding the facility appointment process:*Confirm residents' appointment with nurse *Verify with charge nurse if resident requires to be accompanied by transportation aide based on BIMS score of greater than 12.*If residents do not require to be accompanied by transportation aide, the driver must physically escort resident to appointment location and have the resident sign in to the appointment location (i.e., MD's office, surgical centers). The driver will not leave the resident unaccompanied.*Ensure to obtain paperwork necessary for appointments from the nurse.*Verify that the appropriate assistive devices are transported with the resident to the appointment.*Meet with scheduler during weekdays to ensure accuracy of appointments.*The re-education will be assessed through question and response to the training. New hires, staff out on leave, agency, and PRN staff will receive in-service training upon hire and return from leave. Systemic Change *DON and/or ADONs will review and confirm appointments for the following day and assign residents escorts as deemed appropriate on 10/11/2025. *DON and ADONs will enter an order in PCC regarding the resident's scheduled appointment on 10/11/2025. Order(s) will include:* Reason for the appointment * Name of the MD/Practice *Address of appointment*Time of appointment*Assistive device notation *Escort requirement*The order will be scheduled to fire off the day before and the day of the appointment. *Charge nurses re-education on resident appointment process completed on 10/11/2025 by Director of Nurses/designee. *The scheduler re-educated by the Administrator/designee regarding posting the scheduled appointment list daily during stand down meeting by the scheduler. List will be posted at each nurse station by the scheduler.*Administrator/designee educated the newly identified scheduler to meet with van driver daily to review appointments scheduled to ensure cancelations are communicated on 10/11/2025. *Director of Nurses/designee re-educated Charge nurse verify appointment order in PCC prior to releasing the resident's paperwork to van driver. *Any new hire staff members that are involved in the resident transportation procedures will receive education related to the process for scheduling and transportation of facility residents. Monitoring *DON/Designee will monitor the appointment schedule and PCC orders to identify any residents with new appointments to ensure the following are completed: a physician order with time, address, MD/location, Escort requirements, and assistive device. Weekly for the next 90 days.*During clinical morning meetings Director of Nurse/designee will verify and confirm appointments for the following day with charge nurses and scheduler. *During standdown, the facility scheduler will review any schedule changes with Director of Nurses or designee, and the appointment order will be updated as needed and appointment list will be verified for the following day. *DON/ designee will report on the monitoring results to the QAPI Committee monthly x 3 months. The Survey Team monitored the Plan of Removal as follows: Interview on 10/12/2025, at 12:19pm, Van Driver J, stated that he was in-serviced on Abuse, Neglect, Exploitation & Misappropriation and received a staff individual in-service record on transporting residents to appointments on 10/11/2025. Interview on 10/12/2025, at 12:31pm Scheduler B, stated she received an email from the MDS nurse stating that Resident # 1's appointment was canceled by her guardian. However, Scheduler B failed to mark the cancellation in her calendar and, while notifying a nurse on Monday morning, forgot to inform the driver. Scheduler B admitted the facility's protocol requires recording appointments in a calendar book, documenting changes, and entering updates in the 24-hour report for shift continuity. Interview on 10/12/2025, at 12:59pm, LVN C, stated she was in-serviced on Appointment process, Appointment verification, Transportation when she arrived on shift. She stated the Assistant Director of Nursing (ADON) explained the facility's transportation procedures for resident appointments. Orders must include doctor information, address, appointment type, and escort requirements, scheduled one day prior. The scheduling coordinator creates weekly appointment lists with resident names, times, and addresses. Charge nurses are responsible for providing necessary assistive devices like wheelchairs, canes, or walkers before transport. Interview on 10/12/2025, at 1:42pm, with Van Driver D, stated that she has served as backup van driver and also a CNA at the facility for three years. Her transport responsibilities include reviewing appointment schedules, confirming with nurses, notifying residents, and ensuring necessary assistive devices are available. She will determine if all residents need someone to accompaniment them before each trip. Van Driver B completed official safety transfer training approximately six months ago and has received abuse and neglect prevention training, demonstrating knowledge of various abuse types including financial, physical, verbal, social media, and sexual abuse. Interview on 10/12/2025, at 2:20pm with Medical Director E, affirmed that Resident# 1 requires supervision and always needs her assistive device. He also acknowledged the facility's protocol gap and confirmed Heritage Park is implementing a new policy ensuring supervised patients receive continuous support, including warm handoffs for appointments. The Medical Director expressed commitment to preventing similar incidents through this policy. Interview on 10/12/2025 at 3:00pm with Regional Clinical Specialist F, stated she in serviced the Administrator and DON on Abuse, Neglect, and Exploitation. She stated she in serviced them related to the incident that occurred related to resident transfer on 10/10/2025. Record review on 10/12/2025, revealed in-services provided to staff by the DON with class attendance records for Abuse, Neglect, Exploitation & Misappropriation. Additionally, records revealed in services for the Appointment process, Appointment verification, Transportation and staff individual in-service records. Record review of Resident #1's progress notes dated 10/12/2025, revealed that following the incident the resident was followed up for emotional distress, Resident# 1 was in bed stable, even unlabored breathing call light in place no complaint of pain or distress. No refusal of care. Calm and cooperative with staff and residents. Observations and interviews on 10/14/2025, at 2:55pm revealed Resident# 1 lying in bed watching Tv. Resident # 1 was dressed for the day and told me she had just completed her daily smoke break. She had lunch in her room and stated that she preferred to eat later in the evening. Interview on 10/14/2025, at 8:59am with Guardian G, stated Resident #1 was mistakenly transported Resident # 1 to an unscheduled appointment without her walker. Security found her outside at 7:00am after being dropped off at 6:00am. The facility acknowledged their error and implemented corrective measures. Family Elder Care has served as Resident # 1's court-appointed Guardian since 2020 due to dementia. Despite these lapses, the respondent notes Resident# 1, generally remains content at Heritage Park, which she considers home. Interview on 10/14/2025, at 12:14pm, CNA H, stated that she had only been working for the facility for two years. She stated she recently attended in-service training covering procedures for doctor appointments and the requirement to always remain with residents during appointments. She stated the training emphasized completing all documentation and contacting facility nurses or supervisors with any questions. CNA H also stated she received abuse and neglect training and explained that leaving residents unattended poses serious risks including wandering, falls, and undetected health deterioration. Additionally, residents attending appointments without assistive devices face increased risks from falls or accidents, potentially worsening their medical conditions. Interview on 10/14/2025, at 1:27pm with LVN I, stated she discovered her former hospice patient Resident # 1 had been improperly transported to a canceled medical appointment. The facility failed to verify the appointment status before allowing transport, leaving Resident # 1 unattended outside the building without staff supervision, and sent her without her required walker despite her wandering history and cognitive impairment. LVN I, learned from Guardian A that Resident # 1 had been waiting alone since early morning. The night shift failed to remove the canceled appointment from the schedule. Record review of Resident #1's progress notes dated 10/14/2025, at 1:08 pm revealed Resident # 1 continues behavior monitoring for emotional distress. Resident # 1 alert and oriented to person, place and situation, no signs of distress notes. Resident #1 is currently in her room awaiting lunch, denies pain or discomfort. An IT was identified on 10/11/2025at 06:08 pm. The ADM was notified of the IT, and the IT Template was provided to the facility on [DATE] at 5:23p.m. While the IT was removed on 10/14/2025, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate threat.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 4 (Resident #3, Resident #4, Resident #5 and Resident #6) of 7 residents reviewed for environment. The facility failed to ensure Resident #3, Resident #4, Resident #5 and Resident #6's linens were free of tears, free of holes or not stained on 08/07/2025. These failures placed residents at risk of discomfort, embarrassment and diminished quality of life. Findings included:Review of Resident #3 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Wernicke's encephalopathy (neurological condition caused by vitamin b1 deficiency), unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions) and mood disorder (mental health condition characterized by significant disturbances in a person's emotional state). Review of Resident #3 quarterly MDS dated [DATE] reflected a BIMs score of 11 which indicated mildly impaired cognition. Review of Resident #3 care plan dated 03/13/2025 reflected Resident #3 was dependent on staff for meeting emotional, intellectual, physical and social needs. Observation on 08/07/2025 at 9:37 AM revealed Resident #3's sheets had a hole in it. Resident #3 was not in her room at this time. During an observation and interview on 08/07/2025 at 2:10 PM, Resident #3 stated that she did not notice any holes in her blankets or sheets. Resident stated that her linen looked dirty now, but it did not bother her. Resident's bedding was observed with food crumbs. Review of Resident #4's face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnoses of schizophrenia (severe mental health condition that significant impact's a person's ability to think, feel and behave clearly), unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions), and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness). Review of Resident #4's quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated moderate cognitive impairment. Review of Resident #4's care plan dated 10/11/2021 reflected communication problem related to dementia and schizophrenia with intervention to anticipate and meet needs. During an interview an observation on 08/07/2025 at 1:01 PM, revealed a small hole observed in Resident #4's sheets. Resident #4 stated that there was a hole in her sheet and that it did not make her feel very good. She stated she sometimes has a hole and depending on the time-of-day staff will give her another blanket or sheet. Review of Resident #5 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of major depressive disorder (serious mental health condition characterized by persistent feelings of sadness), and unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions). Review of Resident #5 annual MDS dated [DATE] reflected a BIMS of 0 which indicated a severe cognitive impairment. Review of Resident #5 care plan dated 06/03/2024 reflected Resident #5 had impaired cognitive function and through process related to dementia. During observation an attempted interview on 08/07/2025 at 1:00 reflected a small hole in Resident #5's sheets. Resident was unable to answer questions due to cognition. Review of Resident #6 face sheet reflected a [AGE] year-old mane admitted on [DATE] with diagnoses of vascular dementia (cognitive difficulty with reasoning and judgement caused by an impaired supply of blood to the brain), type 2 diabetes and chronic kidney disease. Review of Resident #6 annual MDS dated [DATE] reflected BIMS score of 5 which indicated severe cognitive impairment. Review of Resident #6 care plan dated 05/08/2023 reflected Resident #6 had an impaired cognitive function related to multiple strokes. Review reflected Resident #6 had communication problem related to slurring, weak or absent voice with intervention to anticipate and meet needs. Observation on 08/07/2025 at 9:26 AM revealed Resident #6's bed was made with grey blanket with tattered edges. Resident was at an appointment and unable to be interviewed. Observation of clean linen on 08/07/2025 at 12:45 PM, reflected beige blanket with tattered edges and folded white flat sheet with a yellow stain. During an interview on 08/07/2025 at 1:24 PM, CNA E stated that she has not seen linen with any holes and if they were observed they would be sent back to laundry. CNA E stated it was not okay for residents to have blankets that were tattered or with holes. CNA E stated she was not aware Resident #6's blanket was tattered. During an interview on 08/07/2025 at 1:33 PM, CNA F stated that he has seen linen with holes, but if he saw them he threw them away. CNA F stated it was not okay for a resident's blanket to be in a tattered condition. During an interview on 08/07/2025 at 2:12 PM, CNA I stated she has not observed linen with holes or stains. She stated if she did observe holes or stains, she would change the linen. During an interview on 08/07/2025 at 2:19 PM, LA G stated that if looked at linen after they were washed and if they still had marks on it they were discarded. LA G stated if linen were observed with holes they were also discarded. LA G stated no linen should be provided to residents with holes or stains and that her supervisor ordered new linen often. During an interview on 08/07/2025 at 2;24 PM, RN A stated she has sometimes seen bedspreads with stains after they were washed but it was not frequent. RN A stated that she had not heard what to do if linen was observed stained. RN A stated that linen with holes was thrown away but has not seen any linen with holes. During an interview on 08/07/2025 at 3:52 PM, the DON stated that she expected staff to get rid of any stained, tattered or linen with holes. The DON stated it was important for residents to have linen without holes or stains because it could be a dignity issues. During an interview on 08/07/2025 at 4:05 PM, HSK H stated that she expected staff to dispose of linen with holes or stains and that they should not return to the residents. HSK H stated she ordered new linen every month. During an interview on 08/07/2025 at 5:00 PM, the ADM stated he expected for torn or stained linen to be disposed of. The ADM stated HSK H ordered linen monthly. Review of facility in-service dated 08/07/2025 reflected all stained linen must be disposed of and it was not to be kept training was conducted with laundry staff. Review of invoice dated 07/03/2025 reflected blankets were shipped on 07/03/2025 to the facility. Review of purchase order dated 07/04/2025 reflected pillowcases ordered were shipped to the facility on [DATE]. Review of purchase order dated 07/04/2025 reflected towels, fitted sheets and washcloths were shipped to the facility on [DATE]. Review of purchase order dated 08/04/2025 reflected, bath towels, flat sheets, fitted sheets, and pillowcases orders was approved by the ADM. Facility provided policy titled Exercising Your Rights by the State Long-Term Care Ombudsman Program dated 10/2024 as their Resident Rights policy. Review reflected you have the right to a safe, clean and comfortable environment and you have the right to be treated with dignity and respect.

Based on interviews and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is a deterioration in health, mental or psychosocial s tatus in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 7 residents reviewed for physician notification, in that: The facility failed to notify Resident #1's physician when she developed a rash on 07/26/2025 and no skin assessment was conducted for Resident #1 on 07/26/2025 after the rash was found and there was no notification to physician to obtain orders for treatment. The facility failed to notify Resident #1's family when she refused showers regularly. Resident #1 was admitted on [DATE], discharged on 08/05/2025, and refused a shower on 07/18/2025, 07/23/2025, 07/25/2025, and on 08/01/2025. Resident #1 was bathed twice during her stay at the facility. This failure could result in decreased continuity of care, and/or a delay in treatment or services. Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old female admitted on [DATE] and discharged on 08/05/2025 with diagnoses of osteomyelitis (bone infection), encounter for orthopedic aftercare following surgical amputation (need for care and monitoring after amputation), encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (need for care and monitoring on outer layers of skin), acquired absence of right leg below knee(amputation of leg below knee), phantom limb syndrome with pain (condition where individuals experience pain in a limb that has been removed), unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions), depression (mood disorder characterized by persistent feelings of sadness and loss of interest in activities that were once enjoyable), and adjustment disorder(condition where a person experiences emotional or behavioral symptoms in response to a stressful life event or change). Review of Resident #1 admission MDS dated [DATE] reflected BIMS score of 10 which indicated moderate cognitive impairment. Further review reflected Resident #1 sometimes felt lonely or isolated from those around her. Review reflected Resident #1's current behavior status, care rejection or wandering was worse than previous assessments. Review of section F reflected it was very important for Resident #1 to have family involved in discussions about her care. Review of section m reflected resident was at risk of developing pressure ulcers with only skin alterations as surgical wounds. Review of Resident #1 care plan dated 07/24/2025 reflected Resident #1 did not let staff assist her and preferred wanted family to provide her care. Interventions included to explain or reinforce why behavior or inappropriate or unacceptable to Resident #1. Further review reflected Resident #1 has impaired cognitive function or impaired through processes related to dementia with interviews to communicate with the resident/family/caregivers regarding residents' capabilities and needs. Review of care plan dated 08/06/2025 reflected Resident #1 was at risk for impaired skin integrity related to impaired mobility and incontinence. Interventions included conducted skin inspections weekly and as needed and document findings. Review of shower hall schedule reflected Resident #1 had showers scheduled on Tuesday, Thursday and Saturdays. Review of POC response history for Resident #1 reflected Resident #1 refused a shower on 07/18/2025, 07/23/2025, 07/25/2025 and on 08/01/2025. Further review reflected Resident #1 was bathed twice during her stay at the facility and had a bed bath on 07/21/2025 and a shower on 07/30/2025. Review of Resident #1 dated 07/21/2025 H&P reflected Resident #1 was alert and oriented x 1-2 (oriented to self and family) at baseline and disoriented to place, time and situations which was also baseline. Resident was overwhelmed by below knee amputation and inability to ambulate. Review of Resident #1 nursing progress notes dated 07/18/2025 reflected Resident #1 knows her name and place, but does not know the date, time or day. Further review of progress note dated 07/26/2025 by RN A reflected Resident's back was found to be covered in significant rash by resident's (family member) today. During a discussion between floor CNA and RN A and FM, it was determined that the resident had been refusing showers. Review of progress note dated 07/27/2025 reflected Resident #1 was offered a shower and initially refused, staff provided education on importance of showering as Resident #1 was observed with rashes to her right flank area and back. Resident #1 verbalized understanding and declined shower but agreed to bed bath. Resident #1 received a bed bath and treatment nurse was made aware. Review of progress notes reflected Resident #1's family was not notified prior to 07/26/2025 that she refused showers and bed baths. Review also reflected Resident #1's family was not notified of her shower refusal on 08/01/2025. Review of Resident #1 progress notes reflected NP was not notified that Resident #1 was found with a rash on her back. Review of Resident #1 NP progress note dated 07/29/2025 reflected Resident #1 had some skin irritation to her back per wound care nurse likely to resident refusal to shower. During an interview on 08/07/2025 at 10:49 AM, FM stated that Resident #1 had redness on her back and sores that were bleeding. FM stated that she saw the sores when she visited Resident #1 at the facility. FM stated that she was not informed Resident #1 did not want to bath prior to 07/26/2025. FM stated she went to the facility on [DATE] and assisted with Resident #1's bath and Resident #1 was okay with bathing with FM there. FM stated that due to Resident #1's dementia she became anxious. During an interview on 08/07/2025 at 1:24 PM, CNA E stated that when resident refused showers, the nurse was notified so the nurse could talk with the resident. CNA E stated refusals were documented in the POC. CNA E stated that any changes in skin such as rashes were reported to the nurse immediately. During an interview on 08/07/2025 at 1:33 PM, CNA F stated that if a resident refused a shower, then the nurse was notified, and it was documented in the POC as a refusal. CNA F stated any new rashes were reported to the nurse. During an interview on 08/07/2025 at 2:12 PM, CNA I stated if a resident refused a shower, she would give the resident some time and then report to the nurse if they refused again. CNA I stated refusals were documented and the nurse was notified. CNA I stated any changes in skin or rashes were reported to the nurse. During an interview on 08/07/2025 at 2:24 PM, RN A stated when residents refused a shower the nurse was informed by the CNAs. RN A stated she tried to identify a pattern of refusals from the resident and would then ask the resident. RN A stated if a resident refused showers, the approach may change, and RN A did not want secretions like sweat to weaken the resident's skin. RN A stated staff provided paperwork if a resident refused and RN A would sign and acknowledge the refusal. RN A stated if the resident's family was involved and the facility then she would speak with them about the resident refusing showers. RN A stated she recently tried to get Resident #1 to take a shower but Resident #1 did not want to shower. RN A stated that she then asked FMs to get involved in showers. RN A stated that was the only time she spoke with Resident #1's FM about showers. RN A stated the shower refusals did not go on for that long and stated it was about three days. RN A stated family was involved and in a agreement to come to facility on shower days with the CNAs so that Resident #1 was comfortable. RN A stated a rash was found on Resident #1's back and it was filled pustules. RN A stated, it looked like it had been there for a long time. RN A stated Resident #1's skin was dry and the rash had some bleeding and she asked the wound care nurse to take care of it. RN A stated she reported this to the wound care nurse but did not report to the physician. RN A stated, I probably should have reported it to the nurse practitioner and may have gotten an order. RN A stated I don't think I did the right thing, and I should have told the nurse practitioner. RN A stated for new skin issues, she was supposed to report to the nurse practitioner and wound care nurse. RN A stated she was supposed to document any time she reported something to the nurse practitioner. During an interview on 08/07/2025 at 2:42 PM, RN B stated that when residents refused showers, staff should ask the resident again or why the resident refused. RN B stated staff should have offered a different time or the resident could refuse. RN B stated in the meeting, the team was notified of any refused showers. RN B stated if refusals were several days in a row, then she would get the resident's RP involved or family. RN B stated that if there were any changes in the resident's skin such as a rash the nurse would go assess and notify the treatment nurse and put in a note. RN B stated any rash should be reported to the provider and document the notification in the nurses notes. RN B stated that education provided to the resident on the importance of taking showers should be documented in progress note. RN B stated showers were important to the resident's health to keep the resident health overall and prevent skin issues. During an interview on 08/07/2025 at 2:53 PM, TN C stated that after notification of skin issues from the charge nurse were received, an assessment was completed, and the TN would notify the NP to put a treatment in place. TN C stated that the assessment would be documented as a skin and wound note or as an assessment. TN C stated she did not treat Resident #1 and that TN D did. TN C stated that a new rash should have been documented in the assessment or progress wound not and active rash would be reported to the NP. During an interview on 08/07/2025 at 3:00 PM, NP stated she did not recall getting a call regarding Resident #1's rash and read it during a chart review. She stated that she asked TN D for clarification about the rash and TN D stated that Resident #1 took a shower and it went away. NP stated she did not physically look a Resident #1 when she saw her on 07/29/2025 and talked with Resident #1's family. NP stated she would have been expected to be notified of a new rash especially if it was bleeding or had puss. During an interview n 08/07/2025 at 3:05 PM, TN D stated that any changes in skin would have to be reported to the NP right away to initiate treatment as needed. TN D stated she received a report about Resident #1 and when TN D assessed Resident #1 her skin was blanchable and pink and she instructed aides to apply lotion because Resident #1's skin was dry. TN D stated she did not observe any pustules and would have reported it right away. TN D stated she thought there was a note that she followed up and stated that she honestly did not think she put a note in and if she had found something she would have put in a note. TN D stated most likely she completed a head-to-toe assessment, but if she did is should be in Resident #1's chart. TN D stated as far as she knew, Resident #1 was compliant with showers and often had bed baths. TN D stated that showers were important to keep residents clean and free of infection. During an interview on 08/07/2025 at 3:52 PM, the DON stated that her expectation for shower refusals included to notify the charge nurse and attempt to get the resident to take a shower and if not the nurse should document the refusal. The DON stated family got involved if the resident refused several days in a row. The DON stated education should be provided by the nurse to the resident on the benefits of a shower. The DON stated that the nurse should document education provided in the progress notes. The DON stated showers were important to keep resident's clean. The DON stated Resident #1's family encouraged her to accept help from staff but Resident #1 wanted her family to provider her care. The DON stated hat she did not recall receiving a notification about Resident #1 having a rash. DON stated she did not expect staff to notify her of a rash and she would review it weekly on the wound report. The DON stated that she expected staff to get treatment nurse on board, resident's family and the provider. DON sated when there was a change such as a rash, the nurse would be notified and the treatment nurse as well as the provider. DON stated any assessment should be documented on wound or skin assessment. The DON stated she expected the TN to document in a nurses not that nothing was found if there was no issues. During an interview on 08/07/2025 at 5:00 PM, the ADM stated that he expected change of skin such as a rash were to be assessed and notification to physician to obtain orders for treatment. The ADM stated that the potential risk would be that the resident go untreated. The ADM stated showers were discussed as an IDT and noted in the point of care system and approached by the IDT prospective and a nurse manager and charge was sent down to speak with the resident. The ADM stated the facility always had success with that approach. The ADM stated that shower refusals were primarily handled in-house and notification to the family would be provided is the family is involved and would be contacted to assist with showers. The ADM stated he did not recall anything recently of notifying family to become more involved with showers. The ADM stated that the importance for showers was for hygiene issues. The ADM stated the generation that was cared for have injuries or wound and they wanted to keep the area clean. Review of in-service dated 08/07/2025 with topic of skin conditions and reporting reflected to assess skin which included lesions, color, size distribution and excoriation and notify MD and RP was conducted with nursing staff by DON. Review of facility policy titled Notification of Changes with implementation date of 10/24/2022 reflected the purpose of the policy was in ensure the facility promptly informs the residents, consults the resident's physician, and notifies, consistent with his or her authority, the residents representative when there is a change require notification. Circumstances requiring notification include: signification changes in a residents physical, mental or psychosocial status such as deterioration in health, mental or psychosocial condition. Circumstances that requires a need to alter treatment may include new treatment. Further review reflected: Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. b. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to assess Resident #1 and report a new rash to the physician on 07/26/2025. There were no orders added for rash/skin treatments from 07/26/2025 to 08/07/2025 for Resident #1. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization. Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old female admitted on [DATE] and discharged on 08/05/2025 with diagnoses of osteomyelitis (bone infection), encounter for orthopedic aftercare following surgical amputation (need for care and monitoring after amputation), encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (need for care and monitoring on outer layers of skin), acquired absence of right leg below knee(amputation of leg below knee), phantom limb syndrome with pain (condition where individuals experience pain in a limb that has been removed), unspecified dementia (general loss of intellectual abilities impacting memory and other cognitive functions), depression (mood disorder characterized by persistent feelings of sadness and loss of interest in activities that were once enjoyable), and adjustment disorder(condition where a person experiences emotional or behavioral symptoms in response to a stressful life event or change). Review of Resident #1 admission MDS dated [DATE] reflected BIMS score of 10 which indicated moderate cognitive impairment. Further review reflected Resident #1 sometimes felt lonely or isolated from those around her. Review reflected Resident #1's current behavior status, care rejection or wandering was worse than previous assessments. Review of section F reflected it was very important for Resident #1 to have family involved in discussions about her care. Review of section m reflected resident was at risk of developing pressure ulcers with only skin alterations as surgical wounds. Review of Resident #1 care plan dated 07/24/2025 reflected Resident #1 did not let staff assist her and preferred wanted family to provider her care. Interventions included to explain or reinforce why behavior or inappropriate or unacceptable to Resident #1. Further review reflected Resident #1 has impaired cognitive function or impaired through processes related to dementia with interviews to communicate with the resident/family/caregivers regarding residents' capabilities and needs. Review of care plan dated 08/06/2025 reflected Resident #1 was at risk for impaired skin integrity related to impaired mobility and incontinence. Interventions included conducted skin inspections weekly and as needed and document findings. Review of Resident #1 orders reflected there was no orders added for rash/skin treatments from 07/26/2025 to 08/05/2025. Review of skin assessments reflected no skin assessment was conducted for Resident #1 on 07/26/2025 after the rash was found. Review of Resident #1 skin assessment dated [DATE] reflected no new skin issues were found. Review of Resident #1 skin assessment dated [DATE] reflected no new skin issues were found. Review of Resident #1 dated 07/21/2025 H&P reflected Resident #1 was alert and oriented x 1-2 (oriented to self and family) at baseline and disoriented to place, time and situations which was also baseline. Resident was overwhelmed by below knee amputation and inability to ambulate. Review of Resident #1 nursing progress notes dated 07/18/2025 reflected Resident #1 knows her name and place, but does not know the date, time or day. Further review of progress note dated 07/26/2025 by RN A reflected Resident's back was found to be covered in significant rash by resident's daughter today. During a discussion between floor CNA and RN A and FM, it was determined that the resident had been refusing showers. Review of progress note dated 07/27/2025 reflected Resident #1 was offered a shower and initially refused, staff provided education on importance of showering as Resident #1 was observed with rashes to her right flank area and back. Resident #1 verbalized understanding and declined shower but agreed to bed bath. Resident #1 received a bed bath and treatment nurse was made aware. Review of progress notes reflected Resident #1's family was not notified prior to 07/26/2025 that she refused showers and bed baths. Review also reflected Resident #1's family was not notified of her shower refusal on 08/01/2025. Review of Resident #1 progress notes reflected NP was not notified that Resident #1 was found with a rash on her back. Review of Resident #1 NP progress note dated 07/29/2025 reflected Resident #1 had some skin irritation to her back per wound care nurse likely to resident refusal to shower. During an interview on 08/07/2025 at 10:49 AM, FM stated that Resident #1 had redness on her back and sores that were bleeding. FM stated that she saw the sores when she visited Resident #1 at the facility. FM stated that she was not informed Resident #1 did not want to bath prior to 07/26/2025. FM stated she went to the facility on [DATE] and assisted with Resident #1's bath and Resident #1 was okay with bathing with FM there. FM stated that due to Resident #1's dementia she became anxious. During an interview on 08/07/2025 at 1:24 PM, CNA E stated that any changes in skin such as rashes were reported to the nurse immediately. During an interview on 08/07/2025 at 1:33 PM, CNA F stated any new rashes were reported to the nurse. During an interview on 08/07/2025 at 2:12 PM, CNA I stated any changes in skin or rashes were reported to the nurse. During an interview on 08/07/2025 at 2:24 PM, RN A stated when residents refused a shower the nurse was informed by the CNAs. RN A stated she tried to identify a pattern of refusals from the resident and would then ask the resident. RN A stated if a resident refused showers, the approach may change, and RN A did not want secretions like sweat to weaken the resident's skin. RN A stated staff provided paperwork if a resident refused and RN A would sign and acknowledge the refusal. RN A stated if the resident's family is involved and the facility then she would speak with them about the resident refusing showers. RN A stated she recently tried to get Resident #1 to take a shower but Resident #1 did not want to shower. RN A stated that she then asked FMs to get involved in showers. RN A stated that was the only time she spoke with Resident #1's FM about showers. RN A stated the shower refusals did not go on for that long and stated it was about three days. RN A stated family was involved and in a agreement to come to facility on shower days with the CNAs so that Resident #1 was comfortable. RN A stated a rash was found on Resident #1's back and it was filled pustules. RN A stated, it looked like it had been there for a long time. RN A stated Resident #1's skin was dry and the rash had some bleeding and she asked the wound care nurse to take care of it. RN A stated she reported this to the wound care nurse but did not report to the provider. RN A stated, I probably should have reported it to the nurse practitioner and may have gotten an order. RN A stated I don't think I did the right thing, and I should have told the nurse practitioner. RN A stated for new skin issues, she was supposed to report to the nurse practitioner and wound care nurse. RN A stated she was supposed to document any time she reported something to the nurse practitioner. During an interview on 08/07/2025 at 2:42 PM, RN B stated that when residents refused showers, staff should ask the resident again or why the resident refused. RN B stated staff should have offered a different time or the resident could refuse. RN B stated in the meeting, the team was notified of any refused showers. RN B stated if refusals were several days in a row, then she would get the resident's RP involved or family. RN B stated that if there were any changes in the resident's skin such as a rash the nurse would go assess and notify the treatment nurse and put in a note. RN B stated any rash should be reported to the provider and document the notification in the nurses notes. RN B stated that education provided to the resident on the importance of taking showers should be documented in progress note. RN B stated showers were important to the resident's health to keep the resident health overall and prevent skin issues. During an interview on 08/07/2025 at 2:53 PM, TN C stated that after notification of skin issues from the charge nurse were received, an assessment was completed, and the TN would notify the NP to put a treatment in place. TN C stated that the assessment would be documented as a skin and wound note or as an assessment. TN C stated she did not treat Resident #1 and that TN D did. TN C stated that a new rash should have been documented in the assessment or progress wound not and active rash would be reported to the NP. During an interview on 08/07/2025 at 3:00 PM, NP stated she did not recall getting a call regarding Resident #1's rash and read it during a chart review. She stated that she asked TN D for clarification about the rash and TN D stated that Resident #1 took a shower, and it went away. NP stated she did not physically look a Resident #1 when she saw her on 07/29/2025 and talked with Resident #1's family. NP stated she would have been expected to be notified of a new rash especially if it was bleeding or had puss. During an interview n 08/07/2025 at 3:05 PM, TN D stated that any changes in skin would have to be reported to the NP right away to initiate treatment as needed. TN D stated she received a report about Resident #1 and when TN D assessed Resident #1 her skin was blanchable and pink and she instructed aides to apply lotion because Resident #1's skin was try. TN D stated she did not observe any pustules and would have reported it right away. TN D stated she thought there was a note that she followed up and stated that she honestly did not think she put a note in and if she had found something she would have put in a note. TN D stated most likely she completed a head-to-toe assessment, but if she did it should be in Resident #1's chart. TN D stated as far as she knew, Resident #1 was compliant with showers and often had bed baths. TN D stated that showers were important to keep residents clean and free of infection. During an interview on 08/07/2025 at 3:52 PM, the DON stated that she did not recall receiving a notification about Resident #1 having a rash. DON stated she did not expect staff to notify her of a rash and she would review it weekly on the wound report. The DON stated that she expected staff to get treatment nurse on board, resident's family and the provider. DON sated when there was a change such as a rash, the nurse would be notified and the treatment nurse as well as the provider. DON stated any assessment should be documented on wound or skin assessment. The DON stated she expected the TN to document in a nurses note that nothing was found and if there were no issues. During an interview on 08/07/2025 at 5:00 PM, the ADM stated that he expected change of skin such as a rash were to be assessed and notification to physician to obtain orders for treatment. The ADM stated that the potential risk would be that the resident go untreated. Review of in-service dated 08/07/2025 with topic of skin conditions and reporting reflected to assess skin which included lesions, color, size distribution and excoriation and notify MD and RP was conducted with nursing staff by DON. Review of facility policy titled Notification of Changes with implementation date of 10/24/2022 reflected the purpose of the policy was in ensure the facility promptly informs the residents, consults the resident's physician, and notifies, consistent with his or her authority, the residents representative when there is a change require notification. Circumstances requiring notification include: signification changes in a residents physical, mental or psychosocial status such as deterioration in health, mental or psychosocial condition. Circumstances that requires a need to alter treatment may include new treatment. Further review reflected: Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. b. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally.

Based on interview and record review, the facility failed to ensure the residents' environment remained as free of accident and hazards as is possible and ensure each resident received adequate supervision for 1 (Resident #1) of 10 residents reviewed for accidents and hazards. The facility failed to ensure CNA B and CNA C appropriately utilize the mechanical lift on 06/11/2025 while transferring Resident #1 to her wheelchair causing her foot to get trapped underneath her in the wheelchair and fractures to her lower leg. This failure could place residents at risk of harm, injury, fractures, and hospitalization. Findings included: Record review of Resident #1's admission record, dated 06/23/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including osteoporosis (a condition that weakens bones and increases the risk of breaking a bone), peripheral vascular disease (a condition that impairs the blood flow to the legs), moderate intellectual disabilities (a significant limitation in cognitive functioning and adaptive behavior), muscle wasting and atrophy (the loss of muscle mass and strength), history of falling, need for assistance with personal care, and conversion disorder with seizures or convulsions (a complex mental health condition where the brain does not send the correct messages to the body leading to seizures). Record review of Resident #1's quarterly MDS assessment, dated 07/03/2025, a BIMS was not conducted due to her rarely/never being understood. Section C - Cognitive Patterns reflected Resident #1 had memory problem with short-term and long-term memory. Record review of Resident #1's care plan, undated, reflected a problem, undated, [Resident #1] has a left distal tibia and fibula fracture r/t Dx of Osteoporosis Interventions, undated, included Handle gently when moving or positioning. Maintain body alignment. Record review of Resident #1's care plan, undated, reflected a problem, undated, [Resident #1] has an ADL self-care performance deficit r/t delusional d/o (a psychotic disorder where individuals experience persistent strongly held beliefs that are not based in reality), Cerebral Palsy (a condition that affects movement and posture due to brain damage often occurring before or during birth), impaired balance, debility (physical weakness), dementia (a group of symptoms affecting memory, thinking and social abilities), severe intellectual disability, OP[unknown abbreviation] with interventions, undated, that included TRANSFER: The resident requires Mechanical Lift/hoyer lift with (2) staff assistance for transfers. TRANSFER: The resident requires total dependence assist of 2 staff to move between surfaces; not steady, only able to stabilize assist. Record review of Resident #1's nurses notes, dated 06/11/2025 at 2:00 PM, written by LVN A reflected at 1150am CNA reported to this nurse that resident was complaining of pain to the left ankle, upon assessment resident was noticed to be grimacing and reaching towards left side of leg. Left ankle and leg were assessed and no swelling, discoloration, or warmth were noted. PRN Tylenol was administered, resident was repositioned, and NP [D] was notified, and gave new order for L ankle Xray 2v, Xray was completed, result findings are: AP and lateral (from the side) views of the left ankle are submitted. The bones are osteoporotic. The mildly displaced distal tibial diaphyseal fracture and fibular diaphyseal fracture are visualized. The distal fibular metaphyseal irregularity is present. (both bones in the lower part of the leg had a break that was slightly out of alignment). Record review of Resident #1's social services referral provided in the provider investigation report, dated 06/11/2025 reflected During resident transfer via mechanical lift, resident's left foot was caught by the wheelchair causing fracture of her left tibia. Social Services referral initiated to check on resident's well-being and monitor for emotional distress. Record review of Resident #1's nurses notes, dated 06/11/2025 at 06:40 PM, written by RN G reflected Resident's Xray results reviewed, which revealed fracture of the left tibia and fibula.NP was notified, and an order was received to transfer the resident to the hospital for further evaluation and treatment. Record review of Resident #1's X-ray results, dated 06/11/2025, reflected AP (front to back) and lateral (side to side) views of the left ankle are submitted. The bones are osteoporotic (a condition that weakens the bones and increases the risk of fractures). The mildly displaced (not aligned) distal (part of the leg that is furthest from the body) tibial (the larger lower leg bone) diaphyseal (long portion of the bone) fracture (break) and fibular (the smaller lower leg bone) diaphyseal fracture are visualized. The distal fibular metaphyseal (the part of the bone that connects the long portion to the head of the bone) irregularity is present. Record review of Resident #1's history and physical performed by an emergency room physician in the emergency room, dated 06/11/2025, reflected .Given the patient's history of recurrent falls and underlying medical conditions, the mechanism of injury (how the injury occurred) remains unclear, though pathologic fracture (a bone fracture that occurs due to an underlying disease or weakness in the bone structure, rather than from an external force or injury) versus occult trauma (traumatic injury that is not apparent on initial evaluation) are being considered. Record review of Resident #1's physicians note, written by a doctor specializing in bones, dated 06/12/2025, reflected .Patient lives in a nursing facility and deformity (a condition in which a part of the body is distorted from the usual) was noted to the left lower extremity (leg). No noted trauma or specific event causing the injury.Additionally patient appears to be comfortable at rest and the fracture is in a position that can be splinted (a device used to support an injured body part). Record review of Resident #1's physicians note, written by a doctor specializing in hospital care, dated 06/12/2025, reflected Nursing home staff reported that they discovered the limb deformity during routine care but denied witnessing any recent falls or traumatic events that might have precipitated the injury.Given the patient's history of recurrent falls and underlying medical conditions, the mechanism of injury remains unclear, though pathologic fracture versus occult trauma are being considered. Record review of Resident #1's physicians note, written by the doctor specializing in bones, dated 06/14/2025, reflected This was a very low energy trauma (fractures that occur from minimal force) and the swelling response as expected is minimal. Record review of Resident #1's provider notes, written by NP D, dated 7/3/2025, reflected .recent hospitalization from 6/11-6/16 for acute spontaneous left tib/fib (bones of the lower leg) fracture managed conservatively with splint. An observation on 07/14/2025 at 12:50 PM, revealed Resident #1 was sitting up in a specialty wheelchair with a splint to lower left leg. Resident #1 made no attempts at communication when this investigator attempted to initiate conversation. Resident appeared clean and well-groomed with no grimacing or signs of pain. During an interview on 07/15/2025 at 09:39 AM with Resident #1's RP, she stated she was notified by someone, name unknown, that Resident #1 sustained a fracture due to osteoporosis. She stated she felt confident that Resident #1 received good care. RP stated she had not noticed any changes in mood or behaviors since the incident. She stated that Resident #1 did not talk very often, but when she did, it was only a word or two. During an interview on 07/15/2025 at 11:26 AM with LVN A, she stated she worked on 06/11/2025 when the incident with Resident #1 occurred. She stated a CNA reported to her that during the transfer of Resident #1 to her wheelchair using the mechanical lift, Resident #1's left foot got caught in the sling underneath her. LVN A stated she assessed Resident #1's left lower leg and noticed an abnormality and grimacing with movement of Resident #1's left lower leg. LVN A stated she contacted NP D and received an order for an X-ray for the left lower leg. LVN A stated she administered medication for pain to Resident #1 and notified the DON. During an interview on 07/15/2025 at 11:45 AM with NP E, who specialized in geriatric psychiatry, she stated she was notified that Resident #1 had a fracture to her left lower leg. She stated Resident #1 did[SH1] [VH2] not speak or make eye contact, but in her opinion, the resident had not had any changes in her psychosocial status due to the injury. During an interview on 07/15/2025 at 12:25 PM with NP D, she stated Resident #1 had osteoporosis. She stated she thought the fractures to Resident #1's left lower leg were pathologic. NP D stated, any wrong move or bumping it could have possibly caused it due to osteoporosis. NP D stated Resident #1 had remained at her baseline mood since the incident. During an interview on 07/15/2025 at 12:41 PM with CNA B, she stated CNA C and CNA B used the mechanical lift to transfer Resident #1 from her bed to her wheelchair. She stated when Resident #1 was in the sling in the air, she attempted to position the wheelchair under Resident #1. CNA B stated Resident #1 started to lean to the left while in the air due to Resident #1's contractures (a shortening and stiffening of muscles, tendons, skin or other tissues that limits joint movement). CNA B stated CNA C had the remote for the mechanical lift and started to lower Resident #1 into the chair prior to CNA B repositioning Resident #1's legs. CNA B stated Resident #1's legs were trapped under herself in the chair when that happened. CNA B stated Resident #1 did not yell out or show signs of pain during the transfer. She stated Resident #1 was lifted back up and repositioned. CNA B stated when she repositioned Resident #1, Resident #1's left ankle felt loose and Resident #1 grimaced in pain. CNA B stated she reported the incident to LVN A and the DON. During an interview on 07/15/2025 at 02:05 PM with RN F, she stated she was working the day of the incident with Resident #1. She stated she was instructed to perform a skin assessment on Resident #1 after the incident. RN F stated Resident #1 had no swelling or redness to her left leg. RN F stated Resident #1 would grimace indicating pain with movement of her left lower leg. Attempted a phone interview on 07/15/2025 at 04:07 PM, voicemail was left without a return phone call with RN G. Attempted a phone interview on 07/15/2025 at 04:13 PM, voicemail was left without a return phone call with CNA C. During an interview on 07/15/2025 at 04:54 PM with the DON, she stated she was notified that during a transfer, two CNAs noticed Resident #1's ankle was loose, and Resident #1 was grimacing in pain. The DON stated she instructed LVN A to notify NP D, administer pain medication and immobilize Resident #1's leg. The DON stated she was not informed, during her investigation of the incident, of Resident #1's foot being trapped under her in the wheelchair. The DON stated Resident #1 had remained at her baseline since the incident. She stated CNA B and CNA C performed proficiency check offs after the incident on the same day and passed. The DON stated in-services for contractures and osteoporosis were started that same day. During an interview on 07/15/2025 at 05:26 PM with the ADMIN, he stated he was notified on 06/11/2025, Resident #1 was complaining of pain to the left lower leg. He stated an X-ray was performed and a fracture was found. He stated after discussion with NP D, Resident #1 was sent to the emergency room. The ADMIN stated he was not informed of Resident #1's leg being trapped under her during the transfer. He stated the CNAs were required to perform a re-creation of the event and that detail was not mentioned. He stated that was concerning to him. Record review of facility in-service, dated 5/18/2025, revealed policy titled, Incidents and Accidents, dated 08/15/2022, reflected: Policy: It is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Definitions:Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Policy Explanation:.4. The following incidents/accidents require an incident/accident report but are not limited to:. Entrapment Equipment Malfunctions. Observed accidents/incidents. Resident injuries due to staff handling.11. The nurse will enter the incident/accident information into the appropriate form/system within 8 hours of occurrence and will document all pertinent information. Record review of facility in-service, dated 06/11/2025, revealed facility assessment titled Mechanical Lift Skill Assessment. Steps listed in assessment included 13.Push gently on knees as resident is being lowered into chair to correct position and maintain balance. Lower resident slowly. Record review of facility in-service, dated 06/11/2025, revealed contents .Osteoporosis in the Elderly; Common but not a natural part of aging. Attached in-service revealed .Large gaps form in the framework ad structure of your bones, causing them to weaken and become prone to fractures. Record review of facility in-service, dated 06/16/2025, revealed topic Safe Handling and Care for Osteoporotic (Residents with a diagnosis of osteoporosis) and Atrophied (Residents with chronic weakness) Residents. Summary of training revealed *Definition of osteoporosis and muscle atrophy *Safe handling during transfers, bed mobility and peri care of high risk residents *Reviewed specific case of resident with fracture of unknown origin, discussed post surgery precautions. No attachment of discussed material noted.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control effectively treat the building for cockroaches. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Review of Resident #1's face sheet, undated, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (brain impairment of at least two brain functions), COPD (airflow obstruction affecting breathing), and cerebrovascular disease (conditions affecting the brains blood supply). Review of Resident #1's quarterly MDS assessment, dated 11/27/2024, reflected a BIMS of 04, indicating severe cognitive impairment. Review of Resident #1's care plan, revised on 6/5/2023, reflected he had impaired cognitive function/dementia or impaired thought processes. Review of Resident #6's face sheet, undated, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (brain impairment of at least two brain functions), chronic obstructive pulmonary disease (airflow obstruction affecting breathing),and chronic pain syndrome. Review of Resident #6's quarterly MDS assessment, dated 12/31/2024, reflected a BIMS of 15, indicating cognition was intact. Review of Resident #6's Care Plan, revised on 6/5/2023, reflected a high risk for communicable infections due to age and resident lived near others. Review of Resident #7's face sheet, undated, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including bipolar disorder (extreme mood swings), chronic obstructive pulmonary disease (airflow obstruction affecting breathing), and hypertension (high blood pressure). Review of Resident #7's quarterly MDS assessment, dated 12/2/2024, reflected a BIMS of 15, indicating cognition was intact. Review of Resident #7's care plan, revised on 6/26/2023, reflected an ADL self-care deficit related to aspiration pneumonia and COPD. Observation on 2/2/2025 at 10:10am of Resident #1's room revealed an over the bed roll tray positioned to the side of the bed. The area underneath the table and directly under the bed was noted to have 20 live roaches, in various sizes and colors, crawling on the floor and under the bed. Resident #1 laid on the bed appearing to be asleep. Continued observation of the room next door, 2208 revealed one live roach crawling on the connecting wall. During an observation and interview on 2/2/2025 at 12:50pm with the Maintenance Director revealed he was not aware of there being a roach problem on hall 2200. He stated they have been having the building sprayed frequently and he thought the pest issues had improved. Observations were made with the Maintenance Director in Resident #1's room, which had been cleaned since observations earlier in the day. Roaches were not observed. Continued observation while reentering the hallway revealed Resident # 7 approached the Maintenance Director and asked if he had told the surveyor about the nest of roaches they had found today in her room underneath her roll tray table. The Maintenance Director responded I took it out of your room and put it here pointing to a tray table in the hallway outside room [ROOM NUMBER]. During an interview on 2/2/2025 at 10:16am with Resident #7's room, which was across the hall from room [ROOM NUMBER], revealed she does have issues with roaches in her room. Resident #7 stated she does not have as many as she has seen crawling in Resident #1's room but she does have them. She stated they do have people from a pest company come spray the rooms but it was not working whatever they are spraying. During an interview on 2/2/2025 at 10:45am with Resident #6 in room, 2310, revealed she and her roommate have seen some bugs in their room recently. Resident #6 stated there are not as many bugs as there had been previously. During an additional interview on 2/2/2025 at 1:05pm with the Maintenance Director who clarified that no one had told him about the roach problem on 2200 prior to today. He explained the staff are supposed to be documenting any sightings of pest in the Sighting's Log which the technician from the pest control company will look at and initial when they come to spray. During an interview on 2/2/2025 at 1:47pm with CNA A revealed he has seen roaches in the facility second floor and notifies the maintenance person. CNA A stated he also has seen that a pest control company does come out to spray. During an interview on 2/2/2025 at 2:47pm with CNA B revealed she had recently informed the nurse that there were roaches on the 2200 hall. CNA B stated she believed that the roaches are from a previous resident that had been storing food in the wall. CNA B stated she has not personally seen the pest control technician but believes one was coming because the bait traps are being changed. During an interview on 2/2/2025 at 2:55pm with CNA C revealed he currently works with residents on the 2400 hall. He stated they do not have a problem with roaches. CNA C stated he worked with Resident #1 a long time ago he had roaches then too. He stated when he sees pests he reports to the nurse. During an interview on 2/2/2025 at 3:23pm with RN D revealed he has not seen any roaches on the 2200 hall. RN D stated if staff told him about seeing roaches he would document in the sightings log. RN D stated as old as the building was that they are in, bugs are expected. He has seen the pest control men spraying the building. During an interview on 2/2/2025 at 3:45pm with the facility DON revealed she knew there were still bugs in the facility and that they had been trying to get rid of them. She stated there used to be pest in the offices and conference rooms and they do not now so she knows the treatments from the pest control company have made a difference. The DON stated they are having the building sprayed frequently as they know the pest are not good for the residents. The DON stated that the building is over [AGE] years old so it is hard to get rid of the pests. She does not know if different types of treatments have been tried. Review of the facility's sighting logs from December 31, 2024, through February 2, 2025, reflected the following: Entered: 1/22/2025 Pest sighting description: room [ROOM NUMBER] insects in bathroom door. Entered: 1/22/2025 Pest sighting description: room [ROOM NUMBER] roaches in ceiling/Bathroom Entered: 1/31/2025 Pest sighting description: room [ROOM NUMBER] roaches Entered: 2/2/2025 Pest sighting description: room [ROOM NUMBER] roaches Review of a facility provided Sales Agreement, with a pest control company, with signatures by facility staff dated 11/2016 and 2/24/2017 revealed the initial term of the agreement was 3 years from the date and will be automatically renewed for additional terms of one year thereafter. Visits from the pest control company since 12/31/2024 were noted on 1/2/2025, 1/6/2025, 1/10/2025 and 1/28/2025. Review of the facility's Exercising Your Rights as a Nursing Facility Resident, undated, reflected the following: Your Right to Safety and Quality Care: Freedom From Abuse, Neglect, and Exploitation: You have the right to be free of abuse, neglect, and exploitation. People inside or outside of the facility must not harm you physically or mentally or misuse your property or money. Your facility must: o Protect you from abuse, neglect, and exploitation. o Train all staff on how to prevent, identify, stop, and report abuse, neglect, and exploitation. Safe Surroundings: You have the right to a safe, clean, and comfortable home environment. The facility must: o Have enough housekeeping and maintenance staff to keep the building clean and safe. o Clean your room daily. o Have a pest control program. Quality Care: You have the right to receive all the care necessary for you to have the highest possible level of health. This includes medical care, mental health care, rehabilitative therapies, and supplies. The facility must have enough staff to provide you with care and respond to your needs. Facility staff must be qualified and trained to care for you. Your Right To Be Treated With Dignity and Respect: You have the right to be treated with dignity and respect. You have the right to courtesy and fair treatment from facility staff. Being treated with dignity and respect also means you have the right to make decisions about your life and care. Your facility must respect your choices and preferences.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices cleaning the ice machine, cleaning the cooktop range drip pans, utilization of an ice scoop receptacle that was not cracked and broken on the bottom were used. 2. The facility failed to label and date all food items in the kitchen. 3. The facility failed to refrigerate products after opening per the manufacturer label. 4. The facility failed to ensure food items were covered, secured and stored properly. These failures could place residents at risk of foodborne illness. Findings included: Observation on 11/12/2024 at 9:19 AM revealed an ice scoop storage receptacle had cracks and pieces missing from the bottom of the storage receptacle. Observation on 11/12/2024 at 9:20 AM revealed the inside of the ice machine had a brown and white substance on the upper inside of the door. Observation on 11/12/2024 at 9:21 AM the lower shelf of prep table in main part of kitchen had a bus tub of individually wrapped slices of wheat bread with a food label that did not include the following information: preparation date, time, product name, or discard date. Observation on 11/12/2024 at 9:25 AM the stovetop range revealed the drip pans had orange and brown dried food particles and substances and on foil liners. Observation on 11/12/2024 at 9:31 AM of dry storage area revealed: 1. A gallon bag of coconut flakes with date of 7/1/24 (unsure if this is open date or use by date) 2. A gallon bag of yellow cake mix with date of 11/5/24 (unsure if this is open date or use by date) 3. A gallon bag of carrot cake mix with a date of 8/14/24 (unsure if this is open date or use by date) 4. A wrapped package of gravy mix with a date of 10/15/24 (unsure if this is open date or use by date) 5. A wrapped package of fettuccine noodles dated 11/7/24 (unsure if this is open date or use by date) 6. A gallon bag of elbow macaroni noodles dated 10/26/24 (unsure if this is open date or use by date) 7. A gallon jug of Italian dressing dated 9/12/24 that had been opened and was half full. Manufacturer label says to refrigerate after opening. 8. A 50 lb. bag of dry pinto beans tied close with plastic wrap unlabeled and undated, bag was half full. 9. A bag of yellow cornmeal loosely tied with plastic wrap unlabeled and undated, bag was half full. 10. A gallon jug of Teriyaki marinade & sauce undated and unlabeled that had been opened and was less than half full. Manufacturer label says to refrigerate after opening. 11. A gallon jug of soy sauce dated 12/11/2023 that had been opened and was less than half full. Manufacturer label says to refrigerate after opening. Observation on 11/12/2024 at 9:38 AM of walk-in refrigerator revealed a steam table pan of meatballs with a label of item being salsa, prep date of 11/11/2024 no discard date recorded. In an interview on 11/14/2024 at 12:05 PM the DDS stated their expectation for labeling and dating of food products in the kitchen was that items would be dated upon receipt, then dated again when prepared with prep date and discard date. The DDS stated they expected all food items to be labeled and dated. The DDS stated staff was trained on labeling and dating during their new employee on the job training and during in-service training that they conduct with staff. The DDS stated it was their responsibility to ensure the staff are trained on labeling and dating of food items. The DDS stated it could negatively affect residents if food items are not labeled and dated by residents getting sick and going to the hospital or possibly death. In an interview on 11/14/2024 at 4:30 PM the ADM stated their expectation for labeling and dating of food products in the kitchen was that all food items were labeled and dated. The ADM stated it was the DDS, Assistant DDS, and all the staff responsibility to ensure this occurred. The ADM stated it could negatively affect the residents if food items were not labeled and dated by them having a negative health outcome. Review of daily kitchen cleaning schedule dated November 2024 week 3 reflected under item stove and cooks area had been completed with cook initials for Monday. Further review revealed the ice machine was not on the cleaning schedule. Review of In-service records reflected the following: 5.6.24 training topics: labeling, dating, storage, hazardous food storage, and sanitation with 12 staff in attendance 6.3.24 training topics: sanitation, labeling, dating, and hazardous food storage with 11 staff in attendance 7.3.24 training topic: proper sanitation with 13 staff in attendance 7.8.24 training topics: sanitation and labeling with 13 staff in attendance Review of Food Storage policy dated 12/01/2011 reflected under heading policy: The consultant dietitian will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the state and Federal Food Codes. The following guidelines should be followed. Under heading Guidelines: 1. Dry storage rooms d. To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. f. Where possible, items are left in the original cartons placed with the date visible. g. The first-in, first-out (FIFO) rotation method is used. Packages are dated and new items are placed behind existing supplies, so that the older items are used first. 2. Refrigerators a. All refrigerated foods are stored per state and federal guidelines. e. All refrigerated foods are dated, labeled, and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old are discarded. Record review of FDA Food Code 2022 reflected established standards for food safety to protect public health. 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TOEAT FOOD such as fruits and vegetables, (b) Cooked READY-TO-EAT FOOD, and (c) Fruits and vegetables before they are washed; (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food (2) Except when combined as ingredients, separating types of raw animal FOODS from each other such as beef, FISH, lamb, pork, and POULTRY during storage, preparation, holding, and display by: (a) Using separate EQUIPMENT for each type, or (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented, and (c) Preparing each type of FOOD at different times or in separate areas; (3) Cleaning equipment and utensils as specified under 4-602.11(A) and sanitizing as specified under S 4-703.11; (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings; (5) Cleaning hermetically sealed containers of food of visible soil before opening; (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened; (7) Storing damaged, spoiled, or recalled food being held in the food establishment as specified under S 6-404.11; and (8) Separating fruits and vegetables, before they are washed as specified under S 3-302.15 from READY-TO-EAT FOOD. (B) Subparagraph (A)(4) of this section does not apply to: (1) Whole, uncut, raw fruits and vegetables and nuts in the shell, that require peeling or hulling before consumption; (2) PRIMAL CUTS, quarters, or sides of raw MEAT or slab bacon that are hung on clean, SANITIZED hooks or placed on clean, SANITIZED racks; (3) Whole, uncut, processed MEATS such as country hams, and smoked or cured sausages that are placed on clean, SANITIZED racks; (4) FOOD being cooled as specified under Subparagraph 3-501.15(B)(2); or (5) SHELLSTOCK. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and subingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. (C) Bulk FOOD that is available for CONSUMER self-dispensing shall be prominently labeled with the following information in plain view of the CONSUMER: (1) The manufacturer's or processor's label that was provided with the FOOD; or (2) A card, sign, or other method of notification that includes the information specified under Subparagraphs (B)(1), (2), (5) and (6) of this section. (D) Bulk, unPACKAGED FOODS such as bakery products and unPACKAGED FOODS that are portioned to CONSUMER specification need not be labeled if: FDA Food Code 2022 Chapter 3. Food Chapter 3 - 38 (1) A health, nutrient content, or other claim is not made; (2) There are no state or local LAWS requiring labeling; and (3) The FOOD is manufactured or prepared on the PREMISES of the FOOD ESTABLISHMENT or at another FOOD ESTABLISHMENT or a FOOD PROCESSING PLANT that is owned by the same PERSON and is regulated by the FOOD regulatory agency that has jurisdiction. 3-602.12 Other Forms of Information. (A) If required by LAW, CONSUMER warnings shall be provided. (B) FOOD ESTABLISHMENT or manufacturers' dating information on FOODS may not be concealed or altered. (C) The PERMIT HOLDER shall notify CONSUMERS by written notification of the presence of MAJOR FOOD ALLERGENS as an ingredient in unPACKAGED FOOD items that are served or sold to the CONSUMER

Based on observations, interviews, and record reviews, the facility failed to maintain an effective ongoing pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control effectively treat the building for insects. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Observation on 11/12/24 at 9:15 AM, there was a fly, flying around on 300 halls, outside of room [ROOM NUMBER] by the meal service cart. Observation on 11/12/24 at 9:58 AM, revealed 4 gnats flying around the tea urn and landing on the wall and counter in the dining room. Observation on 11/12/2024 at 11:56 AM revealed Resident #142 had visible flies and gnats on cups that were sitting on the bedside table. The cups had coffee and a clear liquid. He had three flies that were flying around the resident's lower extremities above the blanket. Flies were landing on and off his exposed chest. Observation on 11/13/24 at 8:24 AM, there was a small brown and black roach crawling on the conference room wall. Observation on 11/13/24 at 8:30 AM, there was a small black roach crawling across the table in the conference room. Observation on 11/13/24 at 9:20 AM, there was a small black roach crawling across the table in the conference room. Observation and interview on 11/13/24 at 11:58 AM revealed in Resident #54's room gnats were next to her refrigerator. The resident voiced she thought they are from her refrigerator because it would not close. Observation on 11/13/24 at 01:17 PM revealed on Resident #142's bedside table were flies and gnats and flying on his bedsheets. Observation on 11/13/24 at 04:02 PM revealed flies and gnats flying around coffee and juice on Resident #142's bedside table; flying on bedsheets; and landing on his skin periodically. Observation on 11/14/24 at 9:15 AM, there was a fly on the inside of the window in the conference room. Observation on 11/14/24 at 4:43 PM during interview with ADM revealed a gnat flying around the conference room. During an interview on 11/14/24 at 09:15 AM Charge nurse A sated the gnats and flies were in resident rooms because Maybe because it is dirty could be a reason there are gnats. For the flies maybe for the same reason. If gnat can mean, there is something sweet in the room that they like. She stated, It's uncomfortable. During an interview on 11/14/24 at 4:39 PM the ADM revealed the facility had been treated for pests. The ADM stated the facility was going to increase the frequency and amount of pest treatments. The ADM stated he was surprised to see any pests. The ADM stated I have no idea how the residents felt about flies and gnats flying on their bedside table, landing on their bedsheets and skin. The administrator stated pests could cause infection. During interview on 11/14/24 at 11:40 AM, the DON stated there was no specific policy for pest control. Record review of resident council meeting minutes revealed the following: *Dated 08/21/2024 revealed increase roach infestation .advised to write grievance to administrator. Resident council meeting minutes *Dated 09/18/2024 revealed residents complained the roaches are horrible. *Dated 11/13/2024, during the resident council meeting, several residents complained about the roaches. Record review of the pest control invoices indicated the following: * Dated 8/21/24 revealed service description as follow up for small cockroaches. Comments included Inspected and treated kitchen, dish pit room, tray return room, dry storage, kitchen office and service hallway for German roaches. Activity has drastically gone down. Replaced a few insects monitors as needed. Dusted cracks and crevices in base boards, wall boards, and equipment. Treated all baseboard perimeters, behind and under equipment, office, dry storage, and service hallway with a chemical residual and insect growth regulator. Will follow up next Wednesday. *No pest invoice provided for 8/22/24-9/29/24. * Dated 9/30/24 revealed service description as Flying insect program and Regular pest service. Comments included inspected and serviced exterior perimeter and rodent bait stations. Inspected and serviced interior kitchen areas, dining rooms, employee areas, restrooms, nursing stations and entryways. Activity was observed on insect monitors in kitchen. Treated these areas with liquid application. Replaced glue boards in mechanical catch traps with no activity observed. Replaced glue boards in insect light traps with flying insect activity observed. * Dated 10/25/24 revealed service description as flying insect program and regular pest service. Comments included Inspected and serviced exterior perimeter and rodent bait stations. Replaced old bait with no activity observed. Baited perimeter with granular bait for large cockroaches, occasional invaders, and ants. Inspected and serviced interior kitchen areas, dining room, entryways, restrooms, nursing stations, break room, closets, and other employee areas. Activity was observed in kitchen. Liquid application was applied throughout, and placed insect monitors out. Replaced glue boards in mechanical catch trap with no activity observed. Replaced glue boards in insect light trap with flying insect activity observed. * Dated 11/13/24 revealed emergency service for small flies. The tech comment on the invoice included complaints were from the coffee/tea area in 1st & 2nd floor dining rooms. Recommend removing bins from counter and cleaning them well. As well as discarding trays with food on them that are stacked on the same counter. Aerosol was used for knocking down and applied liquid application in these areas. Placed fly bait throughout. Spoke to [MD] upon arrival. Did a thorough inspection and could not find him again. Treated upstairs conference room as a request from [MD].

49097 Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 9 of 9 (Resident #292, Resident #12 Residents #6, 17, #22, #27, #60, #93, and 103's) residents reviewed for dignity. 1. The facility failed to ensure Resident #292, and Resident #12 had a privacy cover on their urinary catheter bag. 2. The facility failed to promote Residents #6, 17, #22, #27, 60, #93,103's dignity while dining when staff did not serve the residents their lunch tray at the same time as other residents at the same table for lunch on 11/12/2024 and Resident #6 for lunch on 11/14/2024. These failures could affect the resident's dignity and affect their quality of life and contribute to poor self-esteem and unmet needs. Findings included: Resident #6 Record review of Resident #6's face sheet dated 11/14/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with an admitting diagnosis of unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities), muscle wasting and atrophy (a decrease in size of a body part or tissue) of right and left upper arm, a principal diagnosis of type 2 diabetes mellitus with hyperglycemia (a condition that happens because of a problem in the way the body regulates and uses sugars as a fuel and blood sugars are high), and recent diagnosis of cognitive communication deficit (speech disorder that affects how people use and understand language due to impaired cognition). Record review of Resident #6's quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating cognition intact. Record review of Resident #6's care plan revised on 12/30/2029 under ADL self-care performance revealed resident required supervision/tray set up by staff to eat. Revision dated 03/04/2021 revealed resident had a communication problem and was able to make her needs known through verbal communication and responding yes/no to questions. Revision dated 06/16/2023 revealed resident was at risk for weight variance due to dysphagia (difficulty swallowing), anemia, depression, dementia, diabetes, and anxiety. Resident #22 Record review of Resident #22's face sheet dated 11/14/2024 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with an admitting diagnosis of unspecified dementia, other Cerebrovascular disease (condition that affect blood flow to the brain), muscle wasting and atrophy of both arms and legs, underweight, and adult failure to thrive. Record review of Resident #22's quarterly MDS dated [DATE] revealed the resident was unable to complete the brief interview of mental status. Under cognitive patterns, it revealed resident was rarely/never understood. The MDS also revealed that the resident needed assistance with set up and clean up. Record review of Resident #22's care plan under ADL self-care performance revealed resident required supervision/tray set up by staff to eat. Revision dated 11/16/2020 revealed resident had impaired communication due to resident's primary language was Vietnamese and spoke minimal English. Resident was able to understand basic commands and directions. Revision on 06/16/2023 revealed resident was at risk for weight variance due to depression, dementia, failure to thrive, and stroke. Resident received regular diet, pureed texture, honey thickened liquids. Resident #27 Record review of Resident #27's face sheet dated 11/14/2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with a principal diagnosis of paranoid schizophrenia (type of brain disorder when a person experiences paranoia, delusions, and hallucinations) and admitting diagnoses of type 2 diabetes mellitus with hyperglycemia, spastic hemiplegia (neuromuscular condition of spasticity that results in the muscles on one side of the body being in a constant state of contraction), and delusional disorder (a type of psychotic disorder with the presence of an unshakeable belief in something that is not true). Record review of Resident #27's quarterly MDS dated [DATE] revealed a BIMS score of 9, indicating moderately impaired cognition. The MDS revealed that the resident was independent when eating. Record review of Resident #27's care plan revised 05/31/2022 under ADL self-care performance revealed resident required supervision/tray set up by staff to eat. Resident #93 Record review of Resident #93's face sheet dated 11/14/2024 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], and 09/23/2024 with a principal diagnosis of encephalopathy (syndrome of overall brain dysfunction), and other diagnoses of vascular dementia, unspecified dementia, schizophrenia, aphasia (disorder that affects language abilities due to brain damage) and dysphagia following cerebral infarction (also known as a stroke when the blood supply to part of the brain is blocked). Record review of Resident #93's quarterly MDS dated [DATE] revealed the resident was unable to complete the brief interview of mental status Under cognitive patterns, it revealed resident was rarely/never understood. The MDS also revealed that the resident needed assistance with set up and clean up. Record review of Resident #93's care plan revised on 09/24/2024 under ADL self-care performance revealed resident is independent to supervised with setup help only when eating. Resident #60 Record review of Resident #60's face sheet dated 11/14/2024 revealed a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with primary diagnoses of schizoaffective disorder and (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (a mental disorder characterized by a persistently low or depressed mood and a loss of interest in normally enjoyable activities), and morbid obesity (a disease involving having too much body fat). Record review of Resident #60's quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating cognition intact. The MDS also revealed that the resident needed assistance with set up and clean up. Record review of Resident #60's care plan revised on 07/08/2021 resident requires supervision with tray setup from staff to eat. Resident #17 Record review of Resident #17's face sheet dated 11/14/2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with a principal diagnosis of unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities). Record review of Resident #17's quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating cognition intact. The MDS also revealed that the resident needed assistance with set up and clean up. Record review of Resident #17's care plan revised on 04/20/2018 revealed resident requires supervision with tray setup from staff to eat. Resident #103 Record review of Resident #103's face sheet dated 11/14/2024 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with an admitting diagnosis of schizoaffective disorder, bipolar type (a mental illness marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, and manic episodes) and principal diagnosis of unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities). Record review of Resident #103's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating cognition intact. The MDS also revealed that the resident needed assistance with set up and clean up. Record review of Resident #103's care plan revised on 12/05/2024 revealed resident requires supervision with tray setup from staff to eat. Resident #12 Record review of Resident #12's face sheet dated 11/12/2024 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralyzed), muscle spasm, , urinary tract infection, disorder of urinary system, chronic pain due to trauma, and lack of coordination. Record review of Resident #12's Quarterly MDS assessment dated [DATE] reflect a BIMS score of 14 indicating the resident was cognitively intact. The MDS also reflected Resident #12 had an indwelling catheter. Record review of Resident #12's care plan dated 07/20/2024 reflected Resident #12 had an indwelling catheter. Observation of Resident #12 on 11/12/2024 at 11:11am revealed Resident #12 was laying in her bed. Her catheter bag did not have a privacy cover on it. An interview with Resident #12 on 11/14/2024 at 7:41am revealed that normally she had a privacy bag on her catheter. She said she would make sure the staff put one on. She said it bothers her a lot when there was not a privacy bag on her catheter. She said she does not want everyone to see her pee. Resident #292 Record review of Resident #292's face sheet dated 11/12/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of retention of urine. Record review of Resident #292's admissions MDS assessment dated [DATE] did not reflect a BIMS score and did not reflect Resident #292 had an indwelling catheter. Record review of Resident #292's care plan dated 11/09/2024 reflected Resident #292 had an indwelling catheter. Interventions included change catheter as needed for leakage or patency, or dislodgment Date Initiated: 11/09/2024 Revision on: 11/09/2024. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 11/09/2024, Revision on: 11/09/2024. Monitor and document intake and output as ordered. Date Initiated: 11/09/2024. Record review of Resident #292's orders dated 11/08/2024 indicated to monitor for privacy bag placement. Observation of Resident #292 on 11/12/2024 at 9:35am revealed the resident was in his bed laying down. Resident #292's catheter bag was connected to the base of the bed without a privacy bag on it. Observation of Resident #292 on 11/12/2024 at 3:22pm revealed that Resident #292 was walking down the hall with a staff member and his catheter bag did not have a privacy cover on it. An interview with Resident #292 on 11/13/2024 at 2:01pm revealed he had not thought about a privacy bag on his catheter. He said now that he thought about it the catheter should be covered. He said having the privacy bag on the catheter was a respect thing for him. An interview with RN A on 11/14/2024 at 8:51am revealed that she had been trained on resident rights. She said catheters were supposed to be checked every day and in a privacy bag. She said the staff are supposed to make sure the catheter bag was always in a privacy bag. She said if a resident did not have a privacy bag on their catheter bag, they may feel embarrassed or ashamed. She said she did not know why Resident #292 and Resident #12 did not have a privacy bag on their catheters. An interview with CNA U on 11/14/2024 at 8:58am revealed that she had been trained on resident rights. She said that the catheter was supposed to be always in a privacy bag. She said if a resident did not have a privacy bag it may cause the resident to feel upset or the resident may not want the bag to show. She also said she did not know why Resident #292 and Resident #12's catheters did not have privacy bags. She said normally when they are missing the nurse will replace the privacy bag. An interview with the DON on 11/14/2024 at 9:20am revealed she had been trained on resident rights. She said staff are to change the catheter bag as needed and the catheter bag had to have a privacy cover on it. She said the catheter bag should always have a privacy cover on them. She said if the catheter bag did not have a privacy cover on it the resident may feel embarrassed. She stated she did not know why Resident #292 and Resident #12 did not have a privacy bag on their catheters. An interview with the DON on 11/14/2024 at 10:50am revealed the facility did not have a policy for catheters. An interview with the ADM on 11/14/2024 at 1:15pm revealed he had been trained on resident rights. He stated that staff were supposed to have a privacy cover on all catheter bags. He said catheter bags should always have a privacy cover on them. He stated by not having a privacy bag on a catheter bag could potentially affect the residents dignity. He stated he did not know why Resident #292 and Resident #12's catheters did not have a privacy bag on it. Observation of dining services on 11/12/2024 at 12:08 PM revealed that Resident #60 received his meal tray at 12:09 PM while his table mate, Resident #22, did not get her tray until 12:18 PM. Resident #60 had already eaten his lunch. During an observation and attempted interview on 11/12/2024 at 12:09 PM, Resident #22 repeated lifted her empty cup up in the air towards the surveyor and patted the table with her hand as she looked at surveyor and around the dining room while waiting for her meal tray. Resident #22 did not respond to questions and only responded, Hi or okay. Observation of dining services on 11/12/2024 at 12:16pm revealed Resident #17 received his meal tray at 12:16 PM while his table mate, Resident #27, did not get his tray until 12:28 PM. Observation of dining services on 11/12/2024 at 12:17pm Resident #103 received her meal tray at 12:17 PM while her table mates, Resident #93, and Resident #6, did not get their trays until 12:28 PM. Observation further revealed that after Residents #60, #17, and #103 got their meal trays, Residents (#22, #27, #93, and #6) sitting at the same table were not served. Staff passed trays to the other residents in the dining room sitting at different tables before they received their meal trays. Observation of dining services on 11/14/2024 at 12:06 PM revealed that Resident #60 received his meal tray at 12:06 PM while his table mate, Resident #6, did not get her tray until 12:14 PM. Observation further revealed that after Resident #60 got his meal tray, staff passed trays to the other residents in the dining room sitting at different tables before Residents #6 received her meal tray. During interviews with Residents #93, #6, and #27 on 11/12/2024 at 12:30 PM revealed Resident #93 did not like that she was served her meal tray late as she was hungry. Resident #6 stated it was okay that she received her lunch tray after her table mate. Resident #27 stated that it did not bother him, and it happened all the time that residents sitting at the same table did not receive their meal trays at the same time. An interview with CNA O on 11/14/2024 at 09:24 AM revealed he had been trained on resident rights. There was a policy about passing meal trays that explained putting bids on residents, helping feed them, and hand hygiene. CNA O stated that was important for residents sitting at the same table to receive their meal trays at the same time so that they felt important, like they were a priority and not forgotten by staff. An interview with ADON C on 11/14/2024 at 09:45 AM revealed she had been trained on resident rights. The facility's policy on meal service regarding dining tray pass was that all residents sitting at the same table get their trays before moving on to the next table. Residents sitting at the same table watching other residents eat could make them uncomfortable or feel like they had forgotten to give them their food. It was also a dignity issue. ADON C stated that when she helped with meal service, she would ensure dining trays were passed according to policy. An interview with CNA N on 11/14/2024 at 11:21 AM revealed dining trays should be passed according to seat assignments. Residents sitting at the same table need to be served at the same time because it was good manners. Also, a resident that was hungry might reach for another resident's food and that was a safety concern if the resident got food that was not consistent with their diet. CNA N stated it could be a dignity issue with sitting there watching another resident eat, especially if the other resident was hungry. An interview with the DON on 11/14/2024 at 03:36 PM revealed she had been trained on resident rights. The facility's policy on dining tray pass was that all residents sitting at the same table get their trays before moving on to the next table. The DON stated it was a dignity issue of not getting meal trays at the same time and this would not meet her expectation. An interview with the ADM on 11/14/2024 at 04:17 PM revealed the facility's policy on meal service dining tray pass was standard and all residents sitting at the same table get their trays before moving on to the next table. The ADM stated, It's a dignity issue and we all know better. It was not a homelike environment and did not meet his expectations. He stated that he did not know why the residents did not get their meal trays together. Record review of Incontinence care Proficiency Checklist with or without Foley (not dated) revealed assure drainage bag is in a privacy bag (this also protects from contamination). Record Review of Meal Service Policy dated 12/01/2011 revealed All residents at one table are served at the same time prior to serving residents at other tables. 50176

Based on interviews, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for 12 of 12 residents 9 confidential residents and 3 of 3 residents (Residents #128, Resident #140, Resident #101) reviewed for resident rights. 1. The facility failed to ensure the SS did not search residents' wheelchairs and belongings (Resident #128, #101, and #140) for contraband without their permission. 2. The facility failed to ensure an unidentified staff did not conduct random searches on residents' rooms (Residents #128, Resident #140, 9 confidential residents) on undisclosed dates without residents' permission or remove items from their rooms without permission. This failure could place all residents at risk of emotional distress, feelings of disrespect, lack of dignity, and could decrease residents' self-esteem and/or quality of life. Findings included: Resident #128 Record review of Resident #128's face sheet dated 11/14/2024 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] and 03/01/2024 with a principal diagnosis of fusion of the spine. Her other diagnoses included, Chronic Obstructive Pulmonary Disease (COPD- an ongoing lung condition caused by damage to the lungs), dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities) muscle wasting and atrophy (a decrease in size of a body part or tissue), and need for assistance with personal care. Record review of Resident #128's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating cognitively intact. Record review of Resident #128's care plan revised on 11/13/2023 revealed resident was a smoker and would not smoke without supervision. Interventions included instruct resident about smoking policy on locations, times, and safety concerns. Record review of Resident #128's progress note dated 10/10/2024 created by SS revealed: This social worker was in the front lobby when this resident and her roommate were headed outside. It is a well-known fact that when a resident that smokes go out at this hour they are going out to smoke and will have a lighter and cigarettes on them. This resident did and refused to hand them over when asked to. She did not deny having these prohibited products on her. She stated that she was going to smoke off the property. Social worker reminded her that on August 5, 2024, she signed the Smoking/Tobacco/Vaping Acknowledgment which states .Under no circumstances will smoking materials .be allowed to be kept in the resident's room OR ON THEIR PERSON. Social worker took the items out of the back pouch of her wheelchair. She yelled and cursed. Social worker followed her outside and gave her 2 cigarettes (1 for her the other for the roommate}. After she lit her cigarette social worker requested that she give social worker the lighter. She cursed and yelled at social worker, who let her keep the lighter rather than argue with her or listen to her vicious profanities. This social worker was adhering to the policies of this facility. During an interview on 11/12/2024 at 03:19 PM, Resident #128 stated the SS had searched her person, pockets, belonging, and wheelchair, on several occasions, without her permission. The SS told the resident she was searching for cigarettes and contraband. Resident #128 stated she knew she could not have cigarettes or a lighter in her room and stated she stashed these items next door at an abandoned building for her use in the evenings off premises. There was an incident on 10/09/2024 when the SS grabbed cigarettes out of resident's hands when returning from a smoke visit and in the process, bend the resident's glasses, and now her glasses do not fit correctly. Resident #128 reported it to the ADM, and she showed the surveyor copies of text message sent to the ADM. Resident #128 stated these searches made her feel embarrassed, harassed, angry, and singled out. During an interview on 11/13/2024 at 07:46 AM, Resident #128 clarified that her allegation of assault against the SS had occurred off property. However, these searches occurred on property while trying to exit and enter the facility. Resident #128 stated that she felt sad, depressed, angry, and it made her cry. Her depression was worse. She felt like she was not wanted at the facility and worried that the SS would not help her anymore. Resident #128 worried about filing a complaint for fear of retaliation. On 10/30/2024, the SS had followed her outside of the facility and told the resident she had to sign a 30-day eviction notice. Resident #128 stated she told the SS that she would sign the eviction notice but would write on the notice that the SS had been stalking them off property. When she returned to the facility, she asked to sign the eviction notice and the SS threw up her hands and said never mind. The SS was getting out of control. Resident #140 was also present during the interview and recalled the incident as well. Resident #140 stated that she was upset and cried. She felt like no one cared about her and she was not wanted at the facility. She stated the SS treated her like a child. Resident #101 Record review of Resident #101's face sheet dated 11/14/2024 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a principal diagnosis of cerebral infarction (stroke occurs when the blood supply to part of the brain is blocked or reduced). Her other diagnoses included, muscle wasting and atrophy (a decrease in size of a body part or tissue), need for assistance with personal care, and history of falling. Record review of Resident #101's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating cognitively intact. Record review of Resident #101's care plan revised on 11/13/2023 revealed resident was a smoker and would not smoke without supervision. Interventions included to notify charge nurse immediately if it was suspected resident had violated facility smoking policy. Record review of Residents #101 progress notes from 7/01/2024 to 11/13/2024 did not reveal any mention of concerns with the smoking policy or refusal for search. Record review of Resident #101 progress and nurse's notes from 06/13/2024 to 11/13/2024 revealed no incidents or concerns with the smoking policy. During an interview on 11/14/24 at 09:11 AM, Resident #101 stated in August 2024, the SS searched her wheelchair, without her permission, because resident was caught smoking pot outside. When resident came back into the facility around 8:30 PM, the SS thought she had marijuana on her, and the SS searched the back of her wheelchair. The SS did not say anything to Resident #101 and did not ask her if it was okay to search her. Resident #101 was very upset, and it made her mad and feel bad. Resident #101 denied that she had marijuana on her and only had one cigarette in her cigarette case. The SS took resident's cigarette case and resident knocked the box out of the SS's hand and picked up the box. Resident #101 stated that the SS told her, You're gone. I'm going to request that you get moved. Resident said the SS reported the incident to the ADM and the ADM told the resident not to worry about it; that she would not be moved; and that the SS should not be searching her. Resident #101 stated that it has not happened again, but she had heard other residents talk about being searched by the SS without their permission but could recall any of the residents' names. Resident #140 Record review of Resident #140's face sheet dated 11/14/2024 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses included dementia, other psychoactive substance abuse with psychoactive substance-induced mood disorder, bipolar disorder, mild cognitive impairment, and need for assistance with personal care. Record review of Resident #140's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating cognitively intact. Record review of Resident #140's care plan revised on 07/17/2023 revealed resident was a smoker and would not smoke without supervision. Interventions included instruct resident about smoking policy on locations, times, and safety concerns. Record review of Residents #140 progress notes from 07/01/2024 to 11/13/2024 did not reveal any mention of concerns with the smoking policy or refusal for search. During an interview on 11/12/2024 at 03:19 PM, Resident #140 stated that she was a witness to the incident with Resident #128. Resident #140 stated that she too had been searched by the SS when exiting and entering the facility. Resident #140 stated that she and her roommate leave cigarettes and a lighter in a hiding spot next door at the abandoned building for her use when off premises because she knew she could not have those items in her room. Resident #140 stated that these searches made her feel embarrassed, harassed, angry, and singled out. Resident #140 now left her purse in her room for fear that it will be searched when she returned to the facility. During an interview on 11/12/2024 at 03:54 PM, the ADM stated that the facility had cameras, but they were not in use. There was an incident with Resident #120 and #140 in October 2024 when they complained that the SS followed residents out of the facility and took the cigarettes out of Resident #128's hand. Their facility policy stated that the residents cannot have cigarettes in the facility. Those two residents were leaving their room and had cigarettes in their hands, which was against facility policy. Those residents bring in illegal substances. The ADM stated that the SS put a progress note in Resident #128's file about the incident. During the resident council meeting on 11/13/2024 at 11:31 AM, 9 confidential residents raised their hands to indicate that their rooms had been searched by facility staff at undetermined dates without their consent. Residents stated that staff do random searches of residents' rooms without their permission. During the resident council meeting, 1 of 9 confidential residents stated that an unidentified staff member in blue scrubs came into her room about two weeks ago and searched her belongings and her roommate's belongings in their drawers without her permission. Her roommate was not in the room. The staff member stated they needed to clean up the room before State arrived. On another occasion, an unnamed CNA went through her closet and took clothes without her permission. The unnamed CNA told the resident that the clothes would not fit her, and she did not need them. This made the resident very angry because these were clothes and items, she received from family members and other visitors that came to see her. 1 of 9 confidential residents reported this to the ADM and DON and was told they would investigate it, but nothing happened. 2 of 9 confidential residents stated that an unidentified staff member came into his room without permission and took items (toiletries and clothing) that he bought and give it to another resident without his permission. That made him mad because he paid for those items, and they were his. 3 of 9 confidential residents stated that an unnamed CNA had come into her room on an unidentified date without permission and took incontinence supplies (diapers/briefs) that her family member bought for her and gave it to another resident without her permission. That made her upset because her family member paid for those and they were meant for her, not another resident. 4 of 9 confidential residents stated that several staff members on different dates have search her shopping bags, without permission, when she came back into the facility after going to the store. Her room was searched last week. 4 of 9 confidential residents stated that she knew her room was searched when she was not there because when she returned, items in the room had been moved around. She stated that staff were looking for contraband items such as cigarettes and lighters. 5 of 9 confidential residents stated that the SS had searched her body, clothes, and purse without her permission. During an interview and record review on 11/13/2024 at 12:02 PM, the ADM provided the State surveyor with a copy of an investigation note. The ADM stated that the incident that was investigated involving Resident #128 and the SS on 10/09/2024, which had occurred on site in the facility. The front desk receptionist was a witness. The ADM stated that Resident #128 changed her narrative of what happened and told the surveyor to review the progress note in the resident's file. The ADM stated residents were asked if they have any prohibited items in their possession, but they are not searched unless the resident consents. Staff do not take items away from the residents, but rather, residents were encouraged to give the facility the items, such as cigarettes and lighters. If the resident refused, then they would deal with it in an Interdisciplinary team meeting. The ADM stated residents' rooms were searched when the resident gave consent. The ADM was not aware of any facility policy regarding searching the residents. Record review of the investigation note revealed the ADM had received a text message on 10/09/2024 at 9:27 PM from Resident #128 that the SS had assaulted her. On 10/10/2024, the ADM had contacted Resident #128 and told her an investigation would be completed with police notification. Resident #128 did not want the police notified. Resident #128 stated that the SS did not touch her. Her feelings were hurt when the SS took away her cigarettes and she only wanted her cigarettes returned to her. On 10/11/2024, the ADM met with Resident #128 in his office and Resident #128 stated she was fine, the SS did not touch her when the SS took away the packet of cigarettes. A witness statement was provided by the RECP that on 10/09/2024 at appropriately 8:45 PM, Residents #128 and #140 came downstairs to go outside to smoke and the SS said, It (sic) you have cigarettes in your possession, you need to turn them over to me, and once you turn them over to me you will need to sign this form stating that you know the smoking policy. The residents went back upstairs and returned to the lobby about 15 minutes later. As they were going outside, the SS saw the cigarettes in the back pocket of Resident #128's wheelchair. The SS reached inside Resident #128's wheelchair pocket and Resident #128 reacted by swinging at the SS and calling her all kinds of derogatory words. Resident #128 did not consent to the search and Resident #140 told the SS, You must be crazy if I let you search me. During an interview on 11/13/2024 at 03:14 PM, the SS denied searching any resident without permission. The SS stated she asked residents if she could search their bags, but if they said no, she respected that and said, no problem, I'll see you later. Residents offer to give her cigarettes and hand them to her. The SS denied taking anything from the residents. The SS was not aware of any facility policy regarding searching the residents. The SS stated she had never taken anything out of a resident's wheelchair. When asked about the incident with Resident #128, the SS could not recall the specific date, but stated it was in the evening about a month ago in October 2024 when Residents #128 and #140 came back inside the facility, after being outside and Resident #128 said SS scratched her and was going to call the State. The SS stated nothing happened. The residents went upstairs and returned to their room. The SS went upstairs and asked the nurse to do a skin assessment, which was refused. When the surveyor asked the SS about the progress note in Resident #128's file, the SS said she took something out of the resident's wheelchair, but then stated maybe she looked at some paper but did not take anything out of the wheelchair. The SS denied ever taking cigarettes away from Resident #128. The SS stated that there were no cigarettes involved in this incident. She informed the DON of the incident. The SS stated she was very surprised to learn Resident #128 had a problem with her. The SS repeated stated, Why would I risk my license? She denied searching any residents without permission. Record review of Resident #128's electronic medical file did not show any skin assessment or refusal in October 2024. During an interview on 11/13/2024 at 05:08 PM, the RECP stated she saw the SS searched the back pocket of Resident #128's wheelchair without the resident's consent. It made Resident #128 very mad, and resident screamed and cursed at the SS. The RECP stated that the SS searched the back of the wheelchair, but did not find any cigarettes, only some papers. The RECP stated that the SS would stand in the lobby and searched residents without their consent. The RECP reported it to the DON and her supervisor. She stated that the ADM talked to her yesterday (11/12/2024) about the incident between SS and Resident #128 on 10/09/2024 and asked her to write down a statement. The RECP stated that in August of 2024, the SS searched Resident #101 without her consent. Resident #101 was smoking marijuana outside and when the resident came back inside the facility, the SS asked for the marijuana and Resident #101 told her no. The SS searched Resident #101's wheelchair without her consent and found marijuana and cigarettes and kept them. The resident was extremely upset and said, You can't do that. The RECP reported it her supervisor, the DON, and the ADM. The ADM made a joke about it and said, why can't she smoke marijuana to help her sleep? The RECP stated that she was told by the ADM and her supervisor that only the SS could search residents. During an interview on 11/14/2024 at 09:24 AM, CNA O stated that residents' wheelchairs and rooms (bed, closet, dresser drawers) were searched by staff if they suspected the resident had contraband or the room smelled like cigarette smoke. CNA O reported to the nurse, who then would talk to the resident and ask permission to search their room. During an interview on 11/14/2024 at 09:45 AM ADON C stated that she was not sure if the facility had a policy about searching a resident. ADON C asked permission to search residents belonging because the residents cannot have cigarettes or lighters for their own safety. Usually, residents will allow her, and she had never had a resident refuse. During an interview on 11/14/2024 at 10:22 AM, the SW stated she was not sure about the facility's policy about searching a resident. She had never searched a resident without their consent, and she had never had a resident refuse. During an interview on 11/14/2024 at 03:36 PM, the DON stated she had been trained on resident rights. She stated the facility does not have a policy on searching residents. The DON stated they ask residents for permission to search. If the resident refused, they would get another staff member involved to convince the resident to comply with the search. If the resident was suspected of having contraband and would not consent to a search, then they called the police. If the resident refused a search, it must be documented in the resident's chart under nurses' notes. The DON stated that Resident #128 accused the SS of searching resident without her consent. The SS took cigarettes out of her hand while on property in the parking lot. The DON stated that she was not aware of the incident with Resident #101. This behavior would meet her expectations. During an interview on 11/14/2024 at 04:17 PM, the ADM stated that the facility had no policy for searching residents. The ADM stated that these residents have a history of bringing in illegal substances. The ADM stated that they ask the residents to give the facility the drugs, cigarettes, lighters, or other contraband that it is obvious these residents have contraband on them. The ADM stated they generally get consent before searching and if a resident refused, it would be documented in the resident's progress notes. Regarding Residents #128. #101, and #140, the ADM stated they have a history of bringing in illegal drugs. The ADM stated that the SS saw cigarettes inside Resident #128's wheelchair and the SS took the cigarettes away. The ADM stated that Resident #101 was very combative. The ADM was not aware of an incident with Resident #101 being searched, but that Resident #101 had violated the smoking policy and was smoking marijuana outside and she (Resident #101) naturally got upset when we tried to take her marijuana. The ADM stated these residents are not your grandmas and grandpas that live here. We search their rooms and these residents. The ADM stated that illegal drugs were brought into the facility and said, We get it out and we do get the police involved. The ADM asked, What the hell are we supposed do? The ADM stated that he dealt with it by searching the residents, their belonging, and their rooms without their consent. The ADM stated, I don't believe that's a resident right. How is that their right? We are doing just what a reasonable person would do to keep residents safe. Review record of the facility's policy titled Promoting/Maintaining Resident Dignity dated 01/13/2023 revealed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, which maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 11. Respect the resident's living space and personal possessions. At no time will staff search a resident's body or personal possessions without consent from the resident, or if applicable, the resident's representative. The resident or representative must understand the search is voluntary and why the search is being conducted.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 9 residents (Residents #33, 151, and 176) reviewed for care plans. The facility failed to ensure Resident # 33's care plan addressed her oxygen orders. The facility failed to ensure Resident # 151's care plan addressed his dental needs and food allergies. The facility failed to ensure Resident # 176's care plan addressed her present on admission diagnosis of PTSD-Post Traumatic Stress Disorder needs. These failures could place residents at risk of not having their care and treatment needs met and a potential diminished quality of life. Findings included: Resident # 33 Review of face sheet dated 11/13/2024 for Resident # 33 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Cerebrovascular disease, anemia, foot drop right and left, schizoaffective disorder bipolar type, atrial fibrillation, anxiety disorder, bipolar disorder, atherosclerotic heart disease, vascular dementia, pain in right hip, dysphagia, cognitive communication deficit, pressure ulcer of sacral region stage 4, anxiety disorder, chronic pain, insomnia, hypertension, major depressive disorder, diaphragmatic hernia, and macular degeneration. Review of Resident # 33 Quarterly MDS assessment dated [DATE] reflected a BIMS score of 3 indicating significant cognitive impairment. Resident # 33 no documentation under respiratory treatments oxygen therapy recorded. Review of care plan for Resident # 33 dated 11/6/2024 reflected no documentation regarding oxygen use and care. Review of clinical physician orders for Resident # 33 dated 11/27/2023 and revised on 3/4/2024 reflected oxygen saturation-check frequency every shift for hypoxia. Further review of physician orders dated 3/25/2024 reflected oxygen at 1-4 LPM via nasal cannula as needed for hypoxia. No documentation in orders to change or clean oxygen tubing or nasal cannula. During an observation /interview on 11/13/2024 at 10:24 AM of Resident # 33 revealed Resident # 33 with oxygen nasal cannula in nostrils. Resident # 33 stated they must wear the oxygen all the time. In an interview on 11/14/2024 at 2:30 PM with MDSN revealed MDSN stated if a resident's oxygen order was on their comprehensive assessment or on their medication admission orders then the MDSN staff are responsible for updating the care plan if the resident receives a new order for oxygen after admission, then the responsibility for updating the care plan would be on the ADON or DON. MDSN stated if resident care plans are not accurate and complete then this could potentially negatively affect the resident by not receiving the care they need. Resident # 151 Review of face sheet dated 11/13/2024 for Resident # 151 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of the bladder (bladder cancer), anemia, type 2 diabetes with foot ulcer, muscle wasting and atrophy, atrial fibrillation, hypertension, hyperlipidemia, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, acquired absence of other toes, abnormalities of gait and mobility, malaise, lack of coordination, and vitamin D deficiency. Listed under allergies it reads beets. Review of Resident # 151 Quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Review of Resident # 151 care plan dated 05/22/2024 reflected no documentation regarding ADL's including dental care or any documentation of dental visits. Further review of care plan reflected no documentation regarding food allergies recorded. Review of admission form dated 5/17/2024 reflected the resident checked that they requested a dental exam. Record review of Resident #151's medical record from (5/7/2024) to (11/14/2024) revealed there was no record of dental an exam . In an interview on 11/12/2024 at 2:56 PM with Resident # 151 revealed he has a food allergy to beets, and it was documented on his meal slip tickets but he keeps receiving meal trays with beets on them. Resident # 151 stated he missed his dental appointment to have castings done to receive a set of dentures. Resident # 151 stated he had made a dental appointment himself with the dentist. Resident # 151 stated he had let CST know of when the appointment was so it could be put in the transportation binder. In an interview on 11/14/2024 at 12:05 PM the DDS stated the resident care plan should be updated for any food allergies. The DDS stated it was their responsibility to ensure that the dietary staff had been trained on food allergies and to update the resident care plan. Resident # 176 Review of face sheet dated 11/13/2024 for Resident # 176 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis was PTSD (a mental health condition that can develop after someone experiences or witnesses a traumatic event),. Review of Resident # 176's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Resident # 176 had a diagnosis of PTSD checked under active diagnoses. Review of Resident # 176's care plan dated 10/22/2024 reflected no documentation regarding Resident # 176's diagnosis of PTSD. In an interview on 11/14/2024 at 1:40 PM Resident # 176 stated no one from the facility had ever asked her about her PTSD and what her triggers are or what interventions she needed to maintain her mental health. Resident # 176 stated her PTSD was because she had been abused by males in the past. Resident # 176 stated she preferred female care staff because male care staff make her very uneasy due to her past. Resident # 176 also stated she preferred to be spoken to in the English language or have care staff that speak English as care staff speaking another language while providing care also makes her very uneasy. In an interview on 11/14/2024 at 2:15 PM the SW stated they were unsure if they needed to update a resident care plan when a resident has a diagnosis of PTSD as they had never had that diagnosis come up before. SW stated they were responsible for updating resident care plans regarding changed behaviors, advance directives, visual, dental, or auditory needs, dementia, cognition loss, and discharge needs. SW stated the initial assessment conducted with the resident is done by verbal communication with the resident and any information entered is only from what the resident verbally tells the SW. SW stated that if a diagnosis of PTSD is on the resident list of diagnoses, then the resident should be asked about the diagnosis to see if any accommodations are needed to manage the residents care at the facility. SW stated they were unsure who was responsible for asking about accommodations pertaining to a PTSD diagnosis. SW stated if accommodation of needs is not updated on the care plan, then that could negatively affect the resident by the staff not knowing what the resident's triggers are. In an interview on 11/14/2024 at 2:30 PM with SS revealed SS stated if a resident had a diagnosis of PTSD, then the resident care plan would be a custom care plan including their symptoms or triggers and the interventions needed to address those triggers. SS stated they are responsible for updating a resident's care plan regarding behaviors and mental illness diagnoses. SS stated if a resident's care plan was not updated to address a resident with a diagnosis of PTSD, then it would depend on the resident symptoms or if the resident were asymptomatic as to whether it could negatively affect a resident. In an interview on 11/14/2024 at 3:45 PM the DON stated their expectation was that resident care plans were updated accurately and timely. DON stated it was the responsibility of the SW to update care plans regarding behaviors The DON stated it could negatively affect a resident if their care plan was not updated or by the resident potentially not receiving the services or care needed. In an interview on 11/14/2024 at 4:30 PM with the ADM reflected the ADM stated it was their expectation that resident care plans were completed and accurate. The ADM stated it was the responsibility of the interdisciplinary team which included SW, SS, DDS, DON, ADON, Assistant ADM, and ADM to ensure resident care plan were completed and accurate. ADM stated if resident care plans were not completed or accurate then resident needs could not be met. Review of comprehensive care plan policy dated 10/24/2022 reflected under heading policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under heading definitions: Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumata. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. Under heading policy explanation and compliance guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the president's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable. physical, mental, and psychosocial well-being. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

50176 Based on observations, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of ten residents (Resident #142, Resident #54, Resident #39 and Resident #60) reviewed for quality of life. The facility failed to ensure Resident #142, Resident #54, Resident #39 and Resident #60 received regular showers. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Review of Resident #142's Face Sheet reflected he was an [AGE] year-old male with an original admitted [DATE] and readmitted on [DATE] with diagnoses Unspecified viral hepatitis C (a viral infection that affects the live and can be life-threatening) without hepatic coma ( is a coma-like state that can occur due to liver failure), Schizophrenia ( is a chronic mental disorder that affects a person's ability to think, perceive reality, and interact socially) , Anemia due to enzyme disorder (is a type of hemolytic anemia that occurs when red blood cells break down faster than the body can replace them), Essential (primary) Hypertension (a type of high blood pressure that develops gradually over time and usually has no identifiable cause). Review of Resident #142's MDS dated [DATE] reflected a BIMS score of 11 which indicates his cognition is moderately impaired. MDS indicated a #03 (section GG - I) rating for personal hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygiene). #3 on MDS indicated Partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides more than half the effort. Review of Resident #142's Care Plan dated 02/07/2023 reflected resident #142 is at risk for impaired skin integrity related to: anemia, impaired circulation, or sensation. The resident will remain free from alterations in skin integrity. Record review of shower schedule revealed Resident #142 shower schedule was Tuesday, Thursday, and Saturday in the morning 6 a.m. to 2 p.m. shift. Record review of Resident #142's shower log (dated 11/14/2024) for the past 30 days revealed the following: *Resident not available had been marked on 11/12/2024. *Resident refused had been marked on 10/26/2024, 10/31/2024, 11/02/2024, 11/05/2024 and 11/07/2024. *Not applicable had been marked on 10/23/2024, 10/34/2024, 10/28/2024, 11/02/2024, 11/07/2024 and 11/09/2024. During an interview and observation on 11/13/2024 at 1:17 p.m., Resident #142 stated he does not get his showers regularly. He stated that he asked staff yesterday (11/12/2024) for a shower and staff never took him one. He added that his shower day was tomorrow on 11/14/2024 and he hopes he gets one. Resident #60 was dressed in a hospital gown and his hair appeared oily and dirty. There were flies hovering over his blankets and gnats on his bedside table where he had clear drinks sitting. During an interview and observation on 11/13/2024 at 04:02 p.m., Resident #142 was sitting in his room with a hospital gown on. Resident #60 stated he did not refuse his shower on 11/12/2024 and stated, he loves hygiene - I didn't refuse. During an interview and observation on 11/14/2024 at 03:25 p.m., Resident #142 stated he had received his shower and he was a [NAME] for hygiene, and I like to be clean. 2. Review of Resident #54's Face Sheet reflected she was a [AGE] year-old female with an initial admitted [DATE] and readmitted on [DATE] with diagnoses of other cerebral vascular disease (a term for a range of conditions that impact blood flow and the blood vessels in the brain and spinal cord), Hyperlipidemia (a condition where there are abnormally high levels of lipids or fats in the blood)and diabetes (a chronic disease that occurs when the body can't produce or use insulin properly, resulting in high blood sugar levels). Review of Resident #54's MDS dated [DATE] reflected a BIMS score of 15 which indicated she is cognitively intact. MDS indicated a #03 (section GG - I) rating for personal hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygiene). #3 on MDS indicated Partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides more than half the effort. Review of Resident #54's Care Plan dated 09/14/2023 reflected Resident #54 was at risk for impaired skin integrity related to: bladder incontinence, contractures, decreased subcutaneous tissue / lean muscle mass, diabetes with/or potential for fluctuating blood sugar level, hemiplegia/paresis, impaired circulation or sensation, impaired cognition, Impaired mobility. Resident will remain free from alterations in skin integrity. Record review of shower schedule revealed Resident #54 shower schedule was Monday, Wednesday, and Saturday in the evening 2 p.m. to 10 p.m. shift. Record review of Resident #54's shower log (dated 11/14/2024) for the past 30 days revealed the on the following: *Resident refused had been marked on 11/16/2024. *Not applicable had been marked on 10/23/2024, 10/34/2024, 10/28/2024, 11/02/2024 and 11/07/2024. During an interview and observation on 11/13/2024 at 11:58 a.m., Resident #54 stated she has not had a shower and there was a male on the second shift who refuses to give her a shower. Resident stated the staff flat out told her no because he was the only one. Resident has been proactive and has already informed the ADON. Resident #54 stated tonight is her shower night, so we'll see. During an interview and observation on 11/14/2024 at 09:31 a.m., Resident #54 stated she received a shower last night. Resident voiced it was not the male that normally refuses it was a female staff member. Resident verbalized she never refuses her showers. Resident stated I am a clean person I am not incontinent. I never feel nasty, dirty because I change my clothes every day and I go pee on the toilet. I still feel clean it is not like I need my shower. I just like it. 3. Record review of Resident #39's Face Sheet dated, 11/14/2024, reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with primary diagnoses of hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, other transient cerebral ischemic attacks and related syndromes, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, essential primary hypertension and major depressive disorder. Record review of Resident #39's Quarterly MDS Assessment, dated 10/22/2024, reflected Resident #39 had a BIMS score of 14 which indicate he is cognitively intact. MDS indicated a #03 (section GG - I) rating for personal hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygiene). #3 on MDS indicated Partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides more than half the effort. Record review of Resident #39's Comprehensive Care Plan, with a revision date of 02/12/2024, reflected Resident #39 has an ADL self-care performance. With a goal of: The resident will maintain current level of function with ads through the review date. Interventions included a revision on 02/04/2020 with the following: Bathing/Showering: The resident requires supervision to limited assist by 1 staff with (bathing/showering) 3x/week and as necessary and Provide sponge bath when a full bath or shower cannot be tolerated. Record review filed grievance report dated 10/10/2024 filed by Resident #39 indicated that he was not getting showered on his shower days. Record review of shower schedule revealed Resident #39 shower schedule was Monday, Wednesday, and Friday in the evening 2 p.m. to 10 p.m. shift. Record review of Resident #39's shower log (dated 11/14/2024) indicated the following: * Not applicable had been marked on 10/16/2024, 10/18/2024, 10/21/2024, 10/23/2024, 10/27/2024, 10/28/2024, 10/30/2024, 11/01/2024, 11/02/2024, 11/04/2024, 11/06/2024, 11/07/2024 11/08/2024 and 11/11/2024. During an interview and observation on 11/14/2024 at 10:08 a.m., Resident #39 was non interviewable. Observed resident sitting in wheelchair in room watching TV. Would not answer questions. 4. Record review of Resident #60's face sheet dated 11/14/2024 revealed a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with primary diagnoses of schizoaffective disorder and (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (a mental disorder characterized by a persistently low or depressed mood and a loss of interest in normally enjoyable activities), and morbid obesity (a disease involving having too much body fat). Record review of Resident #60's quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating cognition intact. Resident #60 weighed 338 pounds, had frequent bowel incontinence, occasional urinary incontinence, and required supervision or touching assistance with shower/bathe task. Record review of Resident #60's care plan dated 11/14/2024 revealed under ADL self-care resident required limited-extensive assistance with staff for bathing and showering three times per week and as necessary and to provide sponge bath when a full bath or shower could not be tolerated. Record review of posted shower schedule in linen closet revealed Resident #60 shower schedule was Tuesday, Thursday, and Saturday in the evening 2 PM to 10 PM shift. Record review of Resident #60's shower log (dated 11/14/2024) revealed Not applicable had been marked on 10/29/2024, 10/30/2024, 11/08/2024, 11/09/2024, 11/10/2024. During an interview and observation on 11/12/2024 at 09:58 AM, Resident #60 stated he had not had a bath or shower in 10 days. He stated the facility did not have enough CNAs to give showers consistently. Resident #60 was dressed in a hospital gown and stated he wanted a shower, and his shower day was 11/12/2024. During an interview and observation on 11/13/2024 at 05:05 PM, Resident #60 was sitting in the dining room dressed in hospital gown with no socks or shoes. Resident #60 stated he did not receive a shower on 11/12/2024 but did receive one on 11/13/2024 and he felt better. Resident #60 stated he had not moved to a different room, been out of the facility, or unavailable during his shower schedule, which was Tuesdays, Thursdays, and Saturdays. He was not on hospice and stated the CNAs were supposed to shower him. There had been a couple of times that he refused a shower because he was not feeling well. He had not received a sponge bath in lieu of a shower. Resident #60 stated he had not received his showers regularly and he believed it was because the facility did not have enough CNAs. Not getting his showers made him feel nasty and bad because he had bowel movements on himself and on the floor. During an interview on 11/14/2024 at 08:47 a.m., CNA I stated that he gave residents showers on their shower days. CNA explained that residents have shower days scheduled every three days. If residents need frequent showers, then that is fine, but they usually have showers ordered for every three days. CNA explained that in the shower log, Not applicable meant maybe the resident is not there, they are out on leave, in the hospital or not available right now; So, cannot provide care, because resident is not there. When that occurred, the residents were asked when they returned if they wanted a shower. If they refused, the CNA voiced he would report that to the Charge Nurse. During an interview on 11/14/2024 at 09:01 a.m., CNA J stated that she gave residents showers on their shower days or whenever they ask for one. As my schedule permits it. I try to get the ones that scheduled that day and then I try to get the ones that asked for it. CNA explained that in the shower log, Not applicable meant they were not here for a shower. Or it is not their shower day, and they just have it wrong in PCC. Usually put NA when they are out on a pass. I wait until end of the shift to document. Cannot document at the beginning because they might come back. There is no way of changing the documentation or option for NA or Resident not available once I select that option. Unless, sometimes in PCC it says it is their shower day and it is not. Sometimes they get moved from another room and their shower day changed. But if they come back at any time of the day while I am here, they get their shower and sometimes they still get their shower on second shift. It depends on if they want it or not. CNA explained if a resident refuses their shower we let the nurse know. But we come back a few more times to ask them at least three times because sometimes they change their mind. We wait an hour or so and ask them. Try different approaches to see if that will make them want to take a shower. CNA verbalized it is important for resident to get regular showers for cleanliness; Good for their health if they have any sores, their skin and everything. During an interview on 11/14/2024 at 09:15 AM, the RN A stated that the CNAs were to report to the charge nurse when the resident refused their scheduled showers. RNA A voiced that this is documented in the progress note by the RN. RNA A verbalized that if a resident is not in their room, the CNA is supposed to find them right away. RNA did not know why CNAs might mark Not applicable in the shower log. RNA A added that it is important for residents to shower regularly because it is good for their well-being. During an interview on 11/14/2024 at 09:24 AM, CNA O stated that he gave residents showers. CNA explained that in the shower log, Not applicable meant either another agency, such as hospice, was responsible for giving showers; it was not a scheduled shower day (such as Sundays) or that residents were in line for a shower and staff ran out of time to give resident a shower. When that occurred, the resident's shower was delayed to the next shift or the next day. During an interview on 11/14/2024 at 2:09 PM with DON. DON indicated that CNAs are responsible for taking residents showers. If a resident refuses a shower the CNA should continue to try to make them take a shower and if they still refuse they should try asking the resident the next day again. DON voiced it is important for residents to get regular showers so they can feel clean. Administrator was not asked about showers. During an interview on 11/14/2024 at 3:51 PM with DON. DON verbalized that it is important for residents to get their showers regularly so they can feel clean and just be clean. DON verbalized a negative outcome for the resident if they do not get a regular shower could be that they would smell bad and the resident won't be clean. They will have body odor and it can make the resident feel very uncomfortable. During an interview on 11/14/2024 at 09:45 AM, the ADON C stated that the shower log was posted in the linen closet and CNAs knew when their residents were supposed to receive showers. The ADON had heard residents complain about not getting showers regularly. CNAs might mark Not applicable if the resident moved rooms and the shower schedule needed to be updated. Record review of the Facility's Policy on Activities of Daily Living (ADLs), implemented on 05/26/2023 reflected: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: #1. a.) Bathing, dressing, grooming and oral care. b.) Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. c.) Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment; counsel and/or offer alternatives to the resident or representative. #3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for the rooms of 4 of 20 residents (Resident room [ROOM NUMBER], #43, #106, and #176) reviewed for cleanliness and sanitization. The facility failed to ensure that the rooms of Residents #12, #43, #106, and #176 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: Resident #12 Review of face sheet dated 11/13/2024 for Resident # 12 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her primary diagnoses were quadriplegia (paralysis of all four limbs and the torso), cerebral palsy (a group of conditions that affect movement and posture), and Cauda equina syndrome (severe type of spinal stenosis where all the nerves in the lower back suddenly become severely compressed). Review of Resident # 12's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 14 reflecting intact cognition. Resident # 12 had impairment on both sides of the lower extremity (hip, knee, ankle, foot) and required total assistance for ADL care of toileting hygiene, shower/bathe self, dressing, and transfers. Review of Resident # 12's Comprehensive Care Plan dated 08/26/2024 reflected an ADL self-care performance deficit related to history of multiple fractures, quadriplegia, cerebral palsy with interventions for bathing/showering, dressing, mobility, transfers, toileting, and personal hygiene with total assistance required. During an observation and interview on 11/12/2024 at 11:11 AM of Resident #12 stated that the flies were bad. Resident kept swatting at a fly in the room throughout interview. Resident #43 Record review of Resident #43's face sheet dated 11/14/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included bipolar disorder (a mental disorder that causes extreme mood swings) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations. Record review of Resident #43's quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating cognition intact. Review of Resident # 43's Comprehensive Care Plan revised 08/28/2024 reflected an ADL self-care performance deficit related to aspiration pneumonia and COPD with interventions for bed mobility, eating, transfers, and toileting, with supervision X1 staff assistance required. Resident had bladder incontinence due to impaired mobility. During an observation on 11/12/2024 at 09:34 AM Resident room [ROOM NUMBER] was cluttered with dirty clothes on the bed and floor, and containers of opened and unopened food (soup cans, chips, bread, crackers, cookies) were on all surfaces in room and on the floor. A soiled hospital gown was on floor. Luggage, plastic shopping bags, bottles of water and other drinks, and stuffed animals were on the floor. Random boxes and an opened bag of briefs were piled on top of the luggage. The trash can in the bathroom was full of trash. During an interview on 11/12/2024 at 09:34 AM Resident #43 stated she asked the CNAs for help cleaning her room and no one had helped her. The resident wanted to leave the facility due to the situation. She had recently returned from the hospital due to COPD and was on oxygen. During an observation and interview on 11/14/2024 at 11:11 AM Resident #43 stated that she requested assistance from the CNAs with cleaning and organizing her room and no one had helped her. It had been several days since her request. The CNAs told her they were too busy to help clean and the dirty room and clutter made her feel claustrophobic. The room was cluttered with clothes on the floor and on the bed. On the floor, there were wipes, bottles of water and Gatorade and other drinks, books, stuffed animals, plastic bags, food, shoes, oxygen tubing, and some kind of machine/medical equipment. An interview with CNA O on 11/14/2024 at 11:31 AM revealed Resident #43 had asked him to help clean and organize her room on 11/13/2024 or before. CNA O stated he had not helped her yet but would later. During an observation on 11/14/2024 at 02:16 PM Resident #43's room was cluttered and had not been clean. Clothes were on the floor and on the bed. On the floor there was a box of Christmas decorations, wipes, bottles of water and Gatorade and other drinks, books, stuffed animals, plastic bags, food, shoes, oxygen tubing, and some kind of machine/medical equipment. Resident #106 Record review of Resident #106's face sheet dated 11/14/2024 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosed included major depressive disorder. Record review of Resident #106's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating cognition intact. Review of Resident # 106's Comprehensive Care Plan revised on 08/31/2024 reflected an ADL self-care performance deficit related to impaired balance, history of amputation to left leg, convulsions, chronic pain, hypertension, PTSD (a mental health condition that can develop after someone experiences or witnesses a traumatic event), and CAD (coronary artery disease) with interventions for bathing/showering, bed mobility, transfers, and toileting, with some supervision or set up required, but was able to carry out tasks for self. During an observation and interview on 11/12/2024 at 11:56 AM Resident #106's room, bed linens were dirty and stained with only a sheet, no blanket, and no pillowcase. The pillow was also dirty, and the room smelled like cigarette smoke. Resident stated he would like a clean pillowcase, blanket, and sheet. The resident kept falling asleep during the interview, and additional information could not be obtained. Resident # 176 Review of face sheet dated 11/13/2024 for Resident # 176 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder bipolar type, PTSD, depressive disorder, anxiety disorder, muscle wasting and peripheral vascular disease. Review of Resident # 176's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Resident # 176 had impairment on one side of the lower extremity (hip, knee, ankle, foot). Resident # 176 required supervision or touching assistance for ADL care of toileting hygiene, shower/bathe self, and transfers. Resident # 176 was occasionally incontinent of bladder and frequently incontinent of bowel. Review of Resident # 176's Comprehensive Care Plan dated 10/22/2024 reflected an ADL self-care performance deficit related to impaired balance, limited mobility, limited ROM, pain (L-foot) with interventions for bathing/showering, dressing, and oral care with assistance required. Resident # 176 had the need for enhanced barrier precautions due to surgical wound on the top of the left foot and was at risk for infection and decline in physical activity. Interventions in place included gown and gloves only for high-contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care, wound vac), with no room restrictions. During interview on 11/12/2024 at 11:24 AM with Resident #176 stated the housekeeper does not clean the room. Resident stated they must ask to get their room cleaned. Resident stated the baseboard was coming off the bathroom wall and this was where the roaches crawled out from. Resident stated linens were only cleaned when State came into the facility and when linens were changed, they received linens with stains and holes. Due to Resident's recent toe amputation and the dirty room, the resident was afraid to walk on the floor. Observation of resident's room revealed room to be cluttered and baseboard in bathroom had come loose from the wall. An interview with RN P on 11/14/2024 at 02:50 PM revealed he was not aware that Resident #43 had asked for someone to clean/organize her room. He stated that CNAs and housekeeping should clean the room daily. RN P stated that requests for help from residents should be responded to As soon as possible and the delay with CNA O would not meet his expectation. He did not have any concerns for the resident's safety. An interview with the DON on 11/14/2024 at 03:36 PM revealed she had been trained on resident rights. The facility's policy was that housekeeping and staff should clean resident's rooms daily. If a resident requested help from her, she would assign it to staff. Resident #43 had requested help with cleaning her room in the past, but not recently. The DON stated that her expectation was that staff would help a resident as soon as possible. The DON stated a cluttered room was not homelike and a CNA not helping the resident clean their room would not meet her expectation. An interview with the ADM on 11/14/2024 at 04:17 PM revealed ADM stated that staff should provide cleaning assistance to the residents. Clutter in the room was not homelike and he would expect staff to aid residents within a reasonable time frame. Review of facility's policy named General Housekeeping Policies undated stated: Each occupied resident room is cleaned and put in order daily and as needed. Review of facility's policy named Promoting/Maintaining Resident Dignity dated 01/13/2023 stated: Respond to requests for assistance in a timely manner.

50872 Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 16 residents (Residents #9, 58, and 130) reviewed for activities. The facility failed to ensure Residents #9, 58, and 130 received activities according to their preference on their comprehensive assessments. This failure placed residents at risk of boredom and diminished quality of life. Findings include: Resident #9 Review of Resident #9's face sheet revealed a [AGE] year-old male with admitted [DATE]. Diagnoses include Intellectual disabilities, kidney failure, Alzheimer's disease (a progressive disease that affects the memory and eventually the bodily functions), and seizures (an uncontrolled jerking cause by abnormal activity in the brain). Review of Resident #9's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 0 reflecting severe cognitive impairment. Review of Resident #9's Care Plan revealed Resident #9 has little involvement related to decreased cognitive and physical abilities. He was not verbal but will watch what was going on around him. He does like to attend most big events. The Goal revealed: Resident #9 will participate in sensory stimulation activities 1 to 2 times per week by review date. Resident #9 will participate in 1:1 in-room activities with staff 3 times per week until next review period. The interventions include Staff will escort resident to activity functions, The resident's past preferred activities appeared to be music, touch therapy and according to his family member he loved watching sports. Staff will interact with him during personal care. Staff will put the sports station on for him or play gospel music. Staff will do 1:1 with him 2-3 times a week. Observation on 11/12/24 at 11:20 AM revealed Resident #9 sitting in wheelchair next to bed awake without any stimulation. Observation on 11/12/24 at 2:47 PM revealed Resident #9 lying in bed awake looking at the ceiling. No stimulation in room. Observation on 11/12/24 at 3:53 PM revealed Resident #9 was asleep in bed. No stimulation in room. Observation on 11/13/24 at 9:42 AM revealed Resident #9 was sitting up in wheelchair next to the bed awake without any stimulation in the room. Resident 58 Review of Resident 58's face sheet revealed an [AGE] year-old male with admitted [DATE]. Diagnosis includes schizoaffective disorder (a mental health condition that causes delusions, hallucinations, and fluctuating moods), vascular dementia (brain damage caused by multiple episodes of blood loss to the brain), and Cerebrovascular disease (a condition that affects the blood vessels to the brain). Review of Resident #58's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 12 indicating mild cognitive impairment. Review of Resident #58's Care Plan revealed Resident #58 prefers to stay in his room more often and has difficulty socializing due to cognitive deficit. The goals are Resident #58 will participate in at least one activity weekly through end of review. The interventions are given Resident #58 an activities calendar and staff will encourage Resident #58 to participate in activities. The care plan also stated the resident has no activity involvement related to disinterest, physical limitations and due to his recent decline in health. The goal is the resident will participate in 1:1 in-room individual activities with staff 2-3 times per week by review date. The interventions include Establish and record the resident's prior level of activity involvement and interest by talking with the resident, caregivers, and family on admission and as necessary, Explain to the resident the importance of social interaction, leisure activity time. Encourage the resident's participation, and Staff will visit resident 2-3 times per week for 1:1 in-room individual activities. Observation on 11/12/24 at 11:21 AM revealed Resident #58 was in bed asleep. Observation on 11/12/24 at 2:48 PM revealed Resident #58 was asleep in bed. No stimulation in room. Observation on 11/12/24 at 3:54 PM revealed Resident #58 was awake in bed. No stimulation in room. Observation on 11/13/24 at 9:43 AM revealed Resident #58 was asleep in bed. No stimulation noted in the room. Observation and interview on 11/13/24 at 1:38 PM revealed Resident #58 was awake in bed. When asked about if he liked the TV. Resident stated the TVs in the room were not his. He also stated he preferred to stay in his room. Resident #58 kept repeating his family comes to visit him and brings him gifts. Resident's speech was difficult to understand, and no further conversation was understood. Resident #130 Review of Resident #130's face sheet revealed an [AGE] year-old male with admitted [DATE]. Diagnosis include dementia (difficulty with memory and thought processes), neoplasm of prostate (cancer), diabetes mellitus (difficulty in regulation of blood sugar levels), and contracture of left elbow(inability to move left elbow). Review of Resident #130's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score was not completed due to short- and long-term memory issues. Review of Resident #130's Care Plan revealed Resident #130 is not involved in activities due to a decline in health and now being on hospice. The goal stated Resident #130 wishes regarding activities will be honored through review. The interventions stated Offer Resident #130 one on one activities in his room. Observation on 11/12/24 at 10:51 AM revealed Resident # 130 asleep in bed. No stimulation in room. Observation on 11/12/24 at 2:30 PM revealed Resident # 130 asleep in bed. No stimulation in room. Observation on 11/13/24 at 9:19 AM revealed Resident # 130 asleep in bed. No stimulation in room. Interview on 11/14/24 at 10:53 PM the AD revealed he had obtained the position as activity director 2 weeks ago. He stated he has been catching up because the facility has not had an activities director in a while. The AD stated he is still in the process of introducing himself to all residents. He stated he has a list of bed bound residents and those residents who prefer activities in room. The AD stated the goal was to provide 1:1 activity in their room [ROOM NUMBER]-5 times per week. The AD stated he had stopped by the room for Resident #9 that morning and was going to take Resident #9 to activities, but a CNA stopped him and stated they were fixing to change Resident #9 first. Denied following up afterward. The AD stated he wants all the activity aides to work together to take care of all the resident's and not have assigned staff to each resident. He also stated Resident # 58 was not in his room this morning, but in the past the AD has worked with Resident #58. He stated Resident #58 gets the daily chronicles and staff was encouraged to bring all residents to activities. The AD stated that lack of person-centered activities for the residents could cause depression. The AD stated he expected documentation for the activities but was unable to provide documentation for the activities for Resident's #9, 58, and 130. Interview on 11/14/24 at 3:48 PM with the DON revealed her expectations for residents that are bed bound are to have an in-room activity. She stated activities should have a plan and visit a few times a day and be reading or provide the radio to those residents in their rooms. The DON explained that her expectation would be all activities are to be documented each time. She stated residents could become bored and withdrawn if no activities are provided to those resident's that are in their room all the time. Interview on 11/14/24 at 4:39 PM with the ADM revealed his expectations for residents that are bed bound are that residents should be provided activities in accordance with the standard. He stated all the activities should be care planned and all residents should have some type of activity daily. The ADM state without activities it could affect their quality of life. Record review of the list of bedbound residents and those residents who prefer in room activities dated 11/1/24 revealed Residents # 9 and 58 on list. Review of Activity Policy dated 9/14 revealed a policy statement: The facility has an on-going program of activities designed to meet the interests and the physical, mental, spiritual, and psychosocial well-being of each resident in accordance with his/her comprehensive assessment. The Policy Interpretation and Implementation stated the purpose: The facility will provide activities that are designed to appeal to the residents' interests and enhance their highest practicable level of physical, mental, spiritual, and psychosocial well-being. In Room Activities: All residents, particularly bedfast and those residents unable to participate in group activities will be visited by Activity Director, Activity Assistant, and/or volunteers at least 3 times a week.

Based on observations, interviews, and record reviews, the facility failed to the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for elopement. The facility failed to put interventions in place to prevent Resident #1 from eloping from the facility after she broke her window and attempted to leave through her window on 10/29/24. Resident #1 broke her window again and successfully eloped from the facility on 11/01/24. An IJ was identified on 11/06/24. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on 11/08/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for unsafe elopements, injuries, and hospitalization . Findings included: Review of Resident #1's admission record, dated 11/06/24, reflected she was a [AGE] year old female who initially admitted to the facility on [DATE], readmitted on [DATE], was discharged to the hospital on 11/01/24, had an RP, and had diagnoses including cerebral infarction due to embolism of left middle cerebral artery (a medical condition that occurs when an embolism blocks blood flow to the middle cerebral artery, resulting in an ischemic stroke), essential (primary) hypertension (a common condition that occurs when the pressure of your blood is consistently too high), aphasia (a language disorder that makes it difficult to understand, speak, read, or write), flaccid hemiplegia affecting left dominant side (a condition that causes paralysis in the left side of the body, making it difficult or impossible to move), hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side (a condition that occurs when a stroke or other brain injury damages the right side of the brain, causing weakness or paralysis on one side of the body), chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe), unspecified anxiety disorder, muscle wasting and atrophy (terms for the loss of muscle tissue and strength), other abnormalities of gait and mobility, other lack of coordination, and need for assistance with personal care. Review of Resident #1's comprehensive MDS assessment, dated 10/29/24, reflected no BIMS indicated, no wandering behaviors exhibited, no wander/elopement alarms used, and required supervision with walking. Review of Resident #1's BIMS assessment, dated 10/28/24, reflected staff couldn't conduct a BIMS evaluation because Resident #1 was rarely/never understood. Review of Resident #1's care plan, closed 11/06/24, reflected Resident #1 used anti-anxiety medications related to adjustment issues. Staff were required to monitor, document, and report PRN any adverse reactions to anti-anxiety therapy, such as unexpected side effects, including mania, hostility, rage, aggressive or impulsive behavior, and hallucinations. Resident #1's care plan also reflected that she had a behavior problem where she got agitated and broke the window related to visual hallucination of someone trying to get in her room through the window. Staff were required to administer medications as ordered, monitor and document for side effects and effectiveness, discuss Resident #1's behavior if reasonable and explain/reinforce why behavior was inappropriate and/or unacceptable to the resident, praise any indication of Resident #1's progress/improvement in behavior, and provide a program of activities that is of interest and accommodates Resident #1's status. Resident #1's care plan also reflected she had a communication problem related to cerebrovascular accident (stroke). Review of Resident #1's progress notes, from 10/07/24 through 11/07/24, reflected, -A note by LVN B on 10/29/24 at 3:14 AM, which stated, New admit day 7/7. Resident [Resident #1] was awake and going back and forth from dining area and her room multiple times at hour of sleep. This writer asked resident if she needed anything, if she was feeling okay. Resident nodded yes that she was okay and resident nodded yes on not feeling sleepy. No discomfort noticed. Resident returned back to her room at approximately 1:50 AM. -A note by LVN B on 10/29/24 at 7:22 AM, which stated, Heard glass braking at approximately 6:00 AM; this writer and other nursing staff started checking room to see if something was broken. Heard yelling coming from resident room. Resident was blocking the door from opening and yelling. This writer was able to coach resident to let nursing staff in the room. Once the door open resident immediately went to this writer and was bleeding from her left arm. Holding pressure to try to stop the bleeding. One cut is bleeding profusely on the left forearm which was wrapped with a pressure dressing. Called EMS due to the possibility of needing stitches. Did notice other small cuts on the left arm which weren't bleeding much. Staff members check resident room and outside resident room signs of any intruder none were seen. Nursing staff which was in the processes of coming in to shift change saw resident breaking the window. EMS took resident to hospital for evaluation for possible stitches. -A note by LVN B on 10/29/24 at 7:26 AM, which stated, Notified RP of resident going to hospital. Notified the NP of resident going to hospital. -A note by LVN C on 10/29/24 at 1:33 PM, which stated, Resident returned with no new orders from the hospital. -A note by LVN B on 10/30/24 at 1:56 AM, which stated, Resident up multiple times throughout the night. Continue to educate on safety and fall precautions. Will continue to monitor. -A note by LVN B on 10/30/24 at 6:27 AM, which stated, Resident went to sleep for around 2 hours then was again awake walking in hallway, and dining area. Watching TV in dining area. Resident continues to express fear this writer assure resident no one was going to break in to the facility. Assure resident that there are plenty of staff members here to keep her safe. Resident had her door open due to afraid of someone breaking in through the window. Resident also express pain to her eye and ear, resident express it had to do with the door but denies getting hit and denies bumping into the door. Resident also denies another person harming her. Gave PRN Acetaminophen. Also place medical fax for provider. Resident currently in dining area. -A note by LVN C on 10/30/24 at 11:34 AM, which stated, Resident up in dining room area watching tv. Night shift report her being awake most of the shift and remain in dining room because she didn't want to be alone. -A note by LVN B on 10/31/24 at 3:01 AM, which stated, At 2:15 AM; heard crying from resident room. Resident had pushed bed away from wall and was searching for something on the floor. Resident was squeezing herself between there. Then resident showed this writer a picture of a little girl she got from the floor. Resident continued crying showing the picture to this writer. Noticed resident was stuck this writer helped resident out of between the wall and bedside. Resident was helped to dining area. The resident kept trying to show picture to this writer. From what this writer can assess no new injuries noticed. Resident refused full assessment. Resident kept pointing at her arm making a gesture of something biting her. This writer asked resident if something bite her she said no asked if she hurt her arm again resident first said yes then said no. Resident showing her left arm to this writer. This writer reminded resident she had a previous injury from the window glass resident first said yes then said no. This writer asked resident if she hurt her arm when she pushed the bed out resident first said yes than said no. This writer asked resident if this writer can check her vitals but resident refused. Resident currently in dining area in wheelchair. -A note by LVN B on 10/31/24 at 5:42 AM, which stated, Resident yelling out multiple times this morning started at approximately 5:00 AM. Resident would point at another resident and yell. This writer would assure resident that the other resident was okay. At approximately 5:30 AM resident was standing in the dining room bending down as if she was reaching for something and dangling her arms. This writer went to resident to remind resident of her weakness due to the stroke. Resident kept pointing at her arm this writer asked if it hurt resident said no this writer asked if resident if she couldn't move it like before resident nodded yes. This writer reminded resident of her being in the facility for rehab so she can recover from her recent stroke. Resident continues in dining area. -A note by LVN B on 10/31/24 at 6:05 AM, which stated, At approximately 5:50 AM; resident standing in front of back patio door and started doing back kicks. Resident did 5 back kicks to glass door. This writer and other staff were able to stop resident before damage to door. Resident went to back patio and sat herself onto the floor refusing to enter the building. Resident wanted to go home. Resident agreed come back in to facility and resident called family member. Called on-call provider NP to notify of resident behaviors. -A note by LVN C on 10/31/24 at 9:44 AM, which stated, Resident alert and oriented x 2 visited with boyfriend this morning, but still anxious/restless. Remain in dining room area with staff. -A note by LVN B on 10/31/24 at 1:37 PM, which stated, Resident has new orders melatonin 5mg q hs for insomnia, Ativan 0.5mg q 8 PRN for agitation/anxiety and psychiatrist evaluate/treat. RP notified. -A note by MA D on 10/31/24 at 9:35 PM, which stated, Melatonin Oral Tablet 5 MG Give 1 tablet by mouth at bedtime for insomnia. Note didn't mention anything about the refusal entry indicated in Resident #1's MAR/TAR for October 2024. -A note by LVN B on 11/01/24 at 5:48 AM, which stated, At approximately 3:20 AM; resident broke her window and left running. Resident left running down the street. CNA tried to follow resident down the street but lost sight of resident and unable to find resident. Police was called, ADON and management was contacted. CNAs started driving around to see if they can find resident. Police officers were given a description of resident wearing a green long sleeve shirt with camouflage pants, possibly no shoes. Called RP left a message called again spoke with RP at 4:20 AM also called resident's at approximately 3:50 AM; he states he plans on searching for resident too. Multiples management currently searching for resident. this writer double checked around the outside of the facility. Also staff members check residents rooms. -A note by LVN B on 11/01/24 at 6:49 AM, which stated, At approximately 2:30 AM resident was sleeping in bed. -A note by LVN C on 11/01/24 at 7:00 AM, which stated, Resident RP notified that staff did find [Resident #1] running up the street but refused staff assistances or come to facility. Resident entered coffee shop where staff remained with her until EMS/Police arrival. Transported by EMS to Hospital. -A note by LVN B on 11/01/24 at 7:59 AM, which stated, At 4:42 AM; On-Call provider NP was notified of resident leaving facility and police being notified also of multiple staff looking for resident. -A note by LVN B on 11/01/24 at 9:35 AM, which stated, Resident was located by staff about 2 blocks from facility, as she saw the staff members, she went into a coffee shop where she stayed sitting down. Staff remained outside monitored resident through window and securing exit doors. Barista came outside and stated the resident appeared to get more agitated when she saw the staff. EMS and police was activated. Resident was taken to hospital in 4-point restraint and multiple seat belts as she was refusing to go to the hospital. Per staff report, resident refused EMS assessment and became very agitated when asked to roll up sleeves. Review of Resident #1's physician progress note, dated 10/31/24 and electronically signed by the NP on 11/02/24 at 11:49 PM, reflected the NP visited Resident #1 on a chief complaint related to following up on emergency room visit for anxiety and insomnia. The NP stated, On 10/29, patient [Resident #1] was transferred to the ER after she sustained a laceration with bleeding to the left forearm after she broke the window and tried to exit the building. In the ER, the laceration was approximated with steri-strip. CT head showed no acute changes. X-ray left forearm showed no foreign body. Patient was discharged back to the facility. Nurse reports that patient is very anxious and possibly hallucinating in the night and is not sleeping. Patient seen sitting on the wheel chair. She has expressive aphasia, but calm and cooperative and nods her head to yes or no questions. She denies any pain or discomfort. Left forearm laceration covered with Kerlix dressing. Nurse reports that patient is ambulatory but is impulsive and with unsteady gait. Will start on Ativan 0.5mg q 8 hours PRN anxiety and Melatonin 5mg q HS for insomnia. Will refer to psych services in house to eval and treat. Review of Resident #1's orders, dated 11/06/24, reflected Resident #1 was started on giving one tablet by mouth of 5 mg of Melatonin at bedtime on 10/31/24 at 8:00 PM and order ended on 11/02/24. Resident #1 was also started on giving one tablet by mouth of 0.5 mg of Ativan every eight hours as needed for anxiety/agitation for 30 days on 10/31/24 at 1:00 PM and order ended on 10/31/24 and started again on 10/31/24 at 1:30 PM and order ended 11/02/24. Resident #1 was also started on psychiatrist to evaluate and treat her one time only for five days on 10/31/24 at 1:15 PM and order ended on 10/31/24 and started again on 10/31/24 at 1:45 PM and order ended on 11/02/24. Review of Resident #1's order summary report, dated 11/06/24, reflected, -Prescriber Written order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation for 30 Days ordered and started on 10/31/24 and ended on 11/30/24 -Prescriber Written order for Melatonin Oral Tablet 5 MG (Melatonin) Give 1 tablet by mouth at bedtime for insomnia ordered and started on 10/31/24 and no end date. -Prescriber Written order for psychiatrist to evaluate/treat one time only for five days ordered and started on 10/31/24 and ended on 11/05/24. Review of Resident #1's MAR/TAR schedule for October 2024 and November 2024 reflected Resident #1's administration entries for Ativan oral tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation for 30 Days were blank from 10/31/24 through 11/02/24. Resident #1's administration entries for Melatonin Oral Tablet 5 MG (Melatonin) Give 1 tablet by mouth at bedtime for insomnia indicated Resident #1 refused the tablet on 10/31/24 and it was blank on 11/01/24. Review of Resident #1's admission wandering evaluation, dated 10/22/24, reflected she had no history of wandering/elopement and was not a wandering risk. There were no wandering reevaluations in Resident #1's assessments. Review of Resident #1's plan of care, from 10/22/24 through 11/01/24, reflected Resident #1 exhibited wandering behavior and frequent crying on 10/30/24 at 9:59 PM. Review of the facility's investigation file for Resident #1's incident on 11/01/24 reflected on 11/01/24, ADON reviewed residents at risk for elopement, IDT reviewed Resident #1's chart to determine timeline of events for investigation process, staff were interviewed regarding if they seen anyone trying to leave the facility and none were identified, nursing, dietary, housekeeping and activities staff were reeducated on elopement procedure, broken window was monitored until maintenance repaired it, maintenance inspected the facility windows and no issues were noted, and all exit door codes were changed. Resident #1's self-inflicted injury incident, dated 11/01/24, reflected, At approximately 2:30 AM, resident was sleeping in bed. At approximately 3:20 AM; This writer heard a loud noise of glass breaking. This writer ran to resident room and CNA went to the front of the building. This write did not see resident in the room and noticed the broken window. When this writer went outside this writer saw all the broken glass. A staff member which was sitting outside in the front porch of the building she heard the crash of the glass and saw the resident jump out the window and started running down the street and she and a CNA started to run after resident. This nurse returned to the building and called the police, description was provided, also called management. She was wearing a green blouse and camouflage pants and no shoes. CNA followed resident in the direction she was traveling, she then outran him, and he lost sight of her momentarily, however, other staff were dispatched to assist with the situation and search sorrowing area. Resident was traveling west and staff came down heading east. When the resident saw staff she ran into a coffee shop. Staff stayed monitoring resident through coffee shop window and also secured the exit doors. Barista stepped outside and informed the staff that the resident appeared to not want the staff inside the coffee shop. He went back inside and provided the resident with coffee and water as she sat at the coffee bar. EMS and police were activated. Up on arrival, 2 police officers and 2 EMS attendants restrained resident to the stretcher for transport to the hospital. Staff on sight noticed resident refused assessment by EMS. Resident out of facility. RN E wrote a statement, undated, and stated, I was contacted via telephone by ADON A regarding assistance with a resident that broke a window and left the facility. The nurse stated she was behind resident heading west towards downtown area on the street. Immediately headed towards that direction in my vehicle. Resident was spotted on the street heading to coffee shop. I followed resident in my vehicle and parked my care when I noticed resident going into the coffee shop. On arrival, [ADON A] was present. EMS and police department were on their way. We waited outside the coffee shop until they arrived. ADON A wrote a statement, undated, and stated, I received a call from the staffing ADON around 3:36 AM on 11/01/24 regarding a resident that broke the window, run away from the building but followed by staff. I immediately headed to the location of the resident and spotted her in abandon building in the street close to the facility. It was too dark around the area; I did not get close to her because I didn't want her to run. I kept in contact with co-workers around the area. When my co-worker came, she walked faster heading [NAME] of MLK as she was running from us until she reached the coffee shop. It appeared like she had seen me following her. We stayed outside of the coffee shop monitoring her through the window and keeping exit doors safe. All of the staff posted on the perimeter arrived at the coffee shop to assist. LVN B wrote a statement, dated 11/01/24, and stated, At approximately 2:30 AM resident was sleeping in bed. At approximately 3:20 AM; I heard a loud noise of glass breaking. This writer ran to resident room and CNA went to the front of the building. I did not see resident in the room and noticed the broken window. When I went outside I saw all the broken glass. A staff member which was sitting outside said resident jump out the window and started running down the street and CNA had ran after resident. CNA lost sight momentarily due to her already too far away. Both staff members stated the resident was wearing a green long sleeve shirt with camouflage pants, CNA said it looked like she possibly did not have shoes on. Police was called and given a description of resident also Management was called. 2 CNAs were driving around the area to see if they can spot resident. Also one C.N.A. and a nurse followed the resident on foot. Staff were told to no approach resident by them self's due to resident behavior to call for help if they see resident. I walked around the building to double check if resident had returned and also I and other staff members check all residents rooms in the facility. Nurse received a call from treatment nurse that she had spotted the resident and the resident ran into a coffee shop, and that all other staff arrived at the coffee shop to assist with resident. CNA F wrote a statement, undated, and stated, I was on my break, sitting outside the main entrance when I heard continuous banging by a window to the left, at 3:15 AM. I was on my way back into the building, when I heard a crash of glass and saw a female jump out of the window and ran down into the street. I met with the nurses on Floor 1, who came out and tried to find the resident. Ad Hoc QAPI meeting, dated 11/01/24, reflected the ADM, DON, MD, ADON A, and RN G met on 11/01/24 to discuss the followed summary, which stated, 11/01/24 At 2:30 AM resident observed asleep in bed by staff, at approximately 3:20 AM; resident broke her window and left running. Resident left running down the street. CNA tried to follow resident down the street but lost sight of resident and unable to find resident. Police was called, ADON and management were contacted. CNAs started driving around to see if they can find resident. Physician, RP and family notified. Resident was located by staff about 2 blocks from facility. EMS and police was activated. Resident was taken to hospital in 4-point restraint and multiple seat belts as she was refusing to go to the hospital. RP and Physician notified with the update. Resident transported to Hospital ED for evaluation/treatment via EMS. Facility notified of the resident's schizophrenia and bi diagnosis by ED staff. IDT reviewed medical records, conclusion that the resident experienced a psychiatric episode due to aphasia secondary to cerebrovascular accident. Resident unable to communicate frustration/fear of persecution. IDT determined not reportable based on provider letter content. Elopement protocol/procedure re-education with staff initiated. During an interview on 11/06/24 at 9:29 AM, the MS stated a female resident [Resident #1] broke the window in her room. The MS stated he didn't know how the female resident broke the window in her room. The MS stated he couldn't recall the date when the female resident broke the window in her room, but believed the incident happened early in the morning before 7:00 AM or possibly 6:30 AM. The MS stated he got a call on 11/01/24 at 5:14 AM to come early to the facility to repair a window. The MS stated staff didn't tell him what happened and how the window broke other than the female resident broke the window. The MS stated no one was in room when he came to the facility. The MS stated on 11/01/24, he repaired the window, which was the 2nd time the female resident broke the window. The MS stated the first time the female resident broke her window in her room happened during the week of 11/01/24. The MS stated he and the other maintenance staff member repaired the window on 11/01/24 at 7:00 AM. An observation of the outside of Resident #1's room on 11/06/24 at 9:35 AM reflected there were still pieces of broken glass on the ground. Resident #1's window was repaired. Resident #1 wasn't in her room. During an interview on 11/06/24 at 9:42 AM, the MSA stated two weeks ago, a window broke. The MSA stated a couple days later, the same window broke a second time in the early morning. The MSA stated the first time was during the day the window broke. The MSA stated he cleaned up all the glass in the room. The MSA stated the second time was in the morning when the window broke and when he came to help repair it. The MSA stated when he got there, he was told the female resident [Resident #1] broke the window. The MSA stated he didn't know how the female resident broke her window and wasn't told how the female resident broke window. The MSA stated he didn't know why the female resident broke the window. The MSA stated he helped repair the window the same way as the first time. The MSA stated the first time the female resident broke her window, he had a replacement window and the second time the female resident broke the window, he had to have a company come out to replace the window. The MSA stated the window wasn't repaired any different than the first time he repaired the window. During an interview on 11/06/24 at 10:03 AM, the DON stated Resident #1 was in the hospital. The DON stated on 10/29/24, Resident #1 had a nervous breakdown and broke her window. The DON stated Resident #1's incident happened the week before Tuesday (10/29/24). The DON stated she was not sure if it was Tuesday, but believed it was 2 weeks ago on Thursday or Friday (10/24/24 or 10/25/24) when Resident #1's incident happened. The DON stated last Tuesday (10/29/24), Resident #1 broke the window the first time. The DON stated that around 6:00 am, Resident #1 had a delusion, saw that someone was trying to come through her window, and she broke the window. The DON stated she was out of the facility when Resident #1 broke the window. The DON stated she sent Resident #1 out to the hospital because she sustained a laceration and came back same day (10/29/24). The DON stated Resident #1 didn't go out the window the first time. The DON stated staff monitored Resident #1 every shift and psychiatric services visited Resident #1 after the incident. The DON stated Resident #1 was also put on medication (Ativan) after the incident. The DON stated she didn't know if staff documented monitoring Resident #1 every shift. The DON stated she tried to move Resident #1 to another room, but Resident #1 insisted to stay in the same room. The DON stated two days later (10/31/24), Thursday or Friday (10/31/24 or 11/01/24), Resident #1 broke the window again and left the facility. The DON stated the incident happened around 3:00 AM. The DON stated LVN H and CNA I saw Resident #1 and followed her to a coffee shop. The DON stated there were also staff in their cars who followed Resident #1. The DON stated she didn't know how long the LVN H and CNA I followed Resident #1 for. The DON stated Resident #1 sustained a laceration from the incident. The DON stated Resident #1 refused to let staff approach her during the incident. The DON stated Resident #1 had a nervous breakdown and was delusional. The DON stated she called EMS and they took Resident #1 to the hospital after the incident. The DON stated she was also not working the second time Resident #1 broke the window. The DON stated she didn't know why Resident #1 broke the window. The DON stated she answered her phone around 4:00 AM. The DON stated the ADM handled and managed Resident #1's incident. An attempt to contact Resident #1 was made on 11/06/24 at 10:!5 AM. A voicemail and call back number was left. Resident #1 didn't return the call before exit. An attempt to contact Resident #1's RP was made on 11/06/24 at 10:16 AM. A voicemail and call back number was left. Resident #1's RP didn't return the call before exit. An attempt to contact Resident #1's family was made on 11/06/24 at 10:17 AM. voicemail and call back number was left. Resident #1's family didn't return the call before exit. During an interview on 11/06/24 at 10:25 AM, the ADM stated Resident #1 was a [AGE] year old female who had a stroke and left sided weakness. The ADM stated on 10/29/24 at 6:00 AM, Resident #1 broke the window twice. The ADM stated last week, Resident #1 broke her room window. The ADM stated Resident #1 told him that she saw a man, was afraid, and broke her window. The ADM stated Resident #1 didn't leave after she broke the window, staff responded to the incident, and staff repaired window. The ADM stated the staff did medication changes and sent a psychiatric referral for Resident #1. The ADM stated staff didn't repair Resident #1's window any differently after her incident. The ADM stated Resident #1 used an object to break the window. The ADM didn't describe what the object was that Resident #1 used to break the window. The ADM stated staff heard glass breaking and LVN C was working during the time. The ADM stated on 11/01/24 in the early morning, Resident #1 broke the window. The ADM stated ADON J, who was notified by LVN B, who was notified by CNA I that CNA I heard glass break and observed Resident #1 climb out the window. The ADM stated a nurse, who was outside the facility, also observed Resident #1 climb out the window. The ADM stated Resident #1 outran staff and disappeared passed the funeral home. The ADM stated staff conducted a call tree and were unable to locate Resident #1 until an hour later. The ADM stated Resident #1 was found on the street in her panties and a shirt. The ADM stated Resident #1's pants were found on a fence. The ADM stated RN E observed Resident #1 running into traffic and into a 24 hour coffee shop. The ADM stated staff held Resident #1 at the coffee shop. The ADM stated he notified the police department and EMS. The ADM stated Resident #1 vigorously fought the police department and EMS. The ADM stated the hospital notified staff that Resident #1 had schizophrenia and bipolar disorder, which the facility didn't know. The ADM stated the police department was familiar with Resident #1. The ADM stated Resident #1 used paper towels and assumed she broke the window with her hands. The ADM stated Resident #1 cut her arm along a fence that she hopped and hid in someone's backyard. The ADM stated staff only observed Resident #1 observed fence cut on her arm and no cuts anywhere else. The ADM stated Resident #1 told him that she broke the window because she was afraid. The ADM stated ST and IDT interviewed Resident #1 and all Resident #1 wrote was scary on a piece of paper. The ADM stated he didn't know when ST and IDT interviewed Resident #1. The ADM stated he didn't get to interview Resident #1. The ADM stated he didn't know Resident #1 had a history of schizophrenia and was not on a normal medication regimen for the diagnosis. The ADM stated he didn't report the incident to the SA because it didn't meet the reporting criteria and because Resident #1 was seen leaving by staff, knew where Resident #1 went, and never stopped looking for Resident #1. The ADM stated Resident #1 didn't elope, had a psychotic break, had a case of psychosis, and that her incident didn't meet definition of elopement. The ADM stated had he felt it was a reportable incident, he would've called it in to SA. The ADM stated the fact staff saw Resident #1 leave, reviewed Resident #1's incident, did AD-HOC (a meeting scheduled outside normal schedule) QAPI, looked at multiple areas, and did an investigation and timeline, he believed Resident #1's incident wasn't reportable and staff responded appropriately. The ADM stated to report elopement, it would be within 24 hours or immediately and if the incident involved serious injury. The ADM stated according to the latest provider letter, the facility had 24 hours to report the incident to the SA. The ADM stated residents couldn't be impacted if their incidents were not reported to SA. The ADM stated he didn't consider Resident #1 to have been a missing resident during the incident. An attempt to contact LVN C was made on 11/06/24 at 11:06 AM. A voicemail and call back number was left. LVN C didn't return the call before exit. An attempt to contact RN K, who worked on Resident #1's hall on 10/31/24, was made on 11/06/24 at 11:29 AM. A voicemail and call back number was left. RN K didn't return the call before exit. During an interview on 11/06/24 at 11:31 AM, NA L stated he observed Resident #1 was restless on 10/31/24 from 2:00 PM through 10:00 PM. NA L stated he believed Resident #1 was restless because she kept coming in and out of her room. NA L stated he wasn't sure, but he believed LVN C was working with him on 10/31/24. NA L stated he didn't work on 11/01/24. NA L stated he came back to work at the facility on 11/02/24, but Resident #1 wasn't at the facility. NA L stated he signed an in-service betw [TRUNCATED]

Based on interview and record review the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1) reviewed for accidents and hazards. The facility failed to identify Resident #1 as an elopement risk from his admission paperwork or complete a wandering/elopement assessment within 24 hours of admission. On 02/08/24 he eloped from the facility for approximately three hours and was located 1-2 miles from the facility at a busy intersection of a street and a highway. The noncompliance was identified as PNC. The IJ began on 02/08/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, and hospitalization . Findings include: Review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified dementia, abnormalities of gait and mobility, type II diabetes, essential hypertension (high blood pressure), and cognitive communication deficit. He was discharged from the facility on 03/11/24. Review of Resident #1's admission MDS assessment, dated 02/14/24, reflected a BIMS of 4, which indicated a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected he utilized a wheelchair. Section P (Restraints and Alarms) reflected he required a wander/elopement alarm. Review of Resident #1's care plan, revised 02/08/24, reflected he was an elopement risk/wanderer related to history of attempts to leave the facility unattended with interventions of 1:1 monitor location and a wander guard in place on right ankle. Review of Resident #1's admission paperwork, dated 01/13/24, reflected the following nursing progress notes from his previous facility: [Resident #1] was noted off-site by [BOM] . This nurse assisted [BOM] with bringing [Resident #1] back into facility. Police were present at this time Review of Resident #1's admission paperwork, dated 01/13/24, reflected the following nursing progress notes from his previous facility: [Resident #1] was brought over to memory care after an elopement Review of Resident #1's admission paperwork, dated 01/13/24, reflected the following nursing progress notes from his previous facility: [Resident #1] just left via facility van . [Resident #1] transferring to (psychiatric hospital) for behaviors and elopement Review of Resident #1's nursing progress notes in his EMR, dated 02/08/24 at 12:50 PM and documented by RN A, reflected the following: Reported by family that [Resident #1] has left facility to sightsee and is waiting on someone to pick him back to the building. [Resident #1] was interviewed upon being brought back to the facility. [Resident #1] stated that he wanted to get out of the facility to go look around and he planned to return to the facility. Stated he did not see anything wrong with it . He then proceeded to say that he sat where he could watch the door and waited till someone went through the door and followed them outside . 1:1 initiated for close monitoring. Social services, psych referral initiated and PT/Speech eval (evaluation) obtained Review of Resident #1's Pre-Restraint Assessment/Screening, dated 02/08/24, reflected the following: Wander guard to right lower leg to alert staff due to [Resident #1] wandering outside facility related to confusion and not apprehending safety measures secondary to Dementia. Review of Resident #1's Wandering Evaluation, dated 02/08/24, reflected he was at moderate risk of wandering/eloping. During an interview on 03/25/24 at 1:25 PM, the DON stated she was in the morning meeting on 02/08/24 when the ADMC called and informed her she received a text message from Resident #1's FM B saying he was on (street name) and did not know how to get back to the facility. She stated they went and located him and brought him back. She stated when he was interviewed, he told the ADM he saw people coming and going so he tried to open the door and a nurse told him he could not leave. She stated he told the ADM, I'm going to show her I can leave. She stated he apparently waited for the nurse to be busy and then followed someone out. She stated the wandering/elopement assessment had not been done prior to the elopement. She stated it was SW C's responsibility and they should be completed within 24 hours of admission. She stated SW C was immediately suspended and then she voluntarily quit. She stated she knew he was at risk of elopement but thought the memory care unit was too restrictive for him so she placed his room on the second floor. She stated after the elopement, a wander guard was put on him and he had 1:1 supervision. She stated a negative outcome of not completing a wandering/elopement assessment in the timeframe would be exactly what happened with Resident #1. During an interview on 03/27/24 at 8:50 AM, the Receptionist stated when residents wanted to leave or had an appointment, they signed out at the nurses' station and the nurses would either call her to inform her or would walk the residents down themselves. She stated Resident #1 left the faciity on [DATE] before she had arrived at 8:00 AM for her shift. She stated FM B called her sometime after 9:00 AM to inform her Resident #1 had texted them. She stated she went upstairs and told the Administration staff immediately. She stated after that elopement, in-services were done with all staff regarding elopement and wandering risks. During an interview on 03/27/24 at 9:08 AM with the ISW, she stated she was filling in to assist SW D with social work duties and had been for around two weeks. She stated she was primarily doing the MDS assessments and the BIMS. She stated SW D was doing the wandering assessments but she completed some if he was not available. She stated after Resident #1's elopement, all staff were in-serviced on elopement, monitoring residents that were near the front door, and what to do after an elopement occurred. She stated wandering assessments were important in order to identify if a resident had exit-seeking behaviors. She stated if a resident was high risk, interventions could be put in place such as 1:1, redirection, and finding activities, they liked to keep them occupied. During an interview on 03/27/24 at 9:19 AM, SW D stated he was responsible for the first floor's residents social work assessments, wandering UDAs, discharge planning, and smoking contracts. He stated wandering assessments were to be completed within the first 24 hours of admission in order to get a baseline on the resident's behaviors. He stated if the resident was a high risk, precautions needed to be put into place to ensure there was no elopement. He stated Resident #1 had not been his resident as he had resided on the second floor. He stated there was an Elopement Binder at both nurses' stations and the Receptionist's desk with pictures and face sheets of residents with a high risk of elopement. He stated those helped nurses to ensure they knew which residents they needed to monitor more closely. During a telephone interview on 03/27/24 at 9:26 AM, LVN E stated she worked 10 PM - 6 AM on the first floor. She stated she saw Resident #1 on 02/08/24 attempting to go out the front door and she told him he could not go out. She stated it must have been between 6 AM - 7 AM as she was waiting for the next shift's nurse to relieve her. She stated she called the nurses' station upstairs but there was no answer. She stated she went down the hall to get her belongings and when she returned, he was not there anymore. She stated she believed he had gone back upstairs. She stated she assumed he understood he was not able to leave. She stated after his elopement they were in-serviced on elopement risks, what to look for, and if you did not know the resident to ensure you reach the nurse upstairs. During an interview on 03/27/24 at 9:33 AM, RN A stated she worked on 02/08/24 and Resident #1 was one of her residents. She stated she did her initial rounds around 5:50 AM and he appeared to be in bed asleep but she did not physically go and look. She stated when he was admitted he had a history of elopement but did not know that until after the incident. She stated if the initial wandering/elopement assessment was completed, she would have put in interventions and would have notified the CNAs. She stated she was in-serviced on the elopement policy and physically seeing each resident at the beginning of each shift. During an interview on 03/27/24 at 9:56 AM, the ADMC stated she was responsible for marketing and admitting residents to the facility. She stated the DON was responsible for going over the clinicals for potential new admissions and would decide to either accept or deny them. She stated when she received the clinicals for Resident #1 the first time, there was no mention of elopement. They thought Resident #1 was a female (because of the name) and there were no female beds available so she assumed the clinicals were thrown out. She stated when they found out Resident #1 was a male, the DON approved his admission. She stated the second set of clinicals (which mentioned elopement) was sent to them the day before he was admitted and she and the DON thought it would contain the same information as the first set of clinicals. She stated she did not review the second set of clinicals and was not sure if the DON had. During an interview on 03/27/24 at 10:17 AM, the DON stated she was responsible for reviewing clinical records for a potential new admission. She stated after she reviewed Resident #1's first set of clinicals, she did not believe there was enough documentation. She stated there was only two pages of nursing notes and his History and Physical. She stated they also though Resident #1 was a female and they did not have a female bed available. She stated she shredded the clinicals and asked the ADMC to go to the facility he was residing at to assess him for a potential future admission. She stated the ADMC assessed him and relayed that he was just a grumpy old man, he was not agitated, and he was talking and laughing with the staff. She stated from the ADMC's assessment and the fact his first set of clinicals were not that bad, she approved the admission. She stated they requested his clinicals again and they received them the day before he was admitted . She stated she did not review them that time because she thought they would be the same as the first set. She stated because she knew Resident #1 liked to move around, she made sure he was placed on the second floor. Attempted interviews with SW C on 03/27/24 at 9:50 AM and 1:15 PM were unsuccessful. Review of a written witness statement by LVN E, dated 02/08/24, reflected the following: As this writer was in the nurse station noticed a resident from the second floor by the exit door which go to the receptionist area. [Resident #1] was tapping on the door window. This writer pass [sic] by resident get some paperwork which this writer had printed. This writer told [Resident #1] the receptionist wasn't there yet also that resident's [sic] weren't able to sign out yet. [Resident #1] looked at this writer then looked away. This writer had to gone [sic] down the hall and when this writer returned [Resident #1] was no longer there. Review of an Investigation Statement completed by RN A, dated 02/08/24, reflected the following: 1. When did you last care for the resident? 2/8/24 around 5:50 AM on my morning round 2. In what capacity were you care for this resident? Charge nurse 3. Did you witness the incident? No 4. How did you become aware of the incident? I was notified by ADON that [Resident #1] cannot be found and was not in the facility. 5. What did you see concerning the incident? [Resident #1] exited the building without signing out. 6. What did you hear about the time of the incident? I was notified that the family member called the facility that [Resident #1] out of facility. 7. What immediate action did you take? Went to check [Resident #1]'s room and instructed the team to do a head count and check exit door. . 12. What, if anything, is our knowledge of the resident? [Resident #1] is cooperative, follows commands, nurse did not observe any exit seeking behavior. Review of an Investigation Statement completed by LVN F, dated 02/08/24, reflected the following: 1. When did you last care for the resident? N/A 2. In what capacity were you care for this resident? N/A 3. Did you witness the incident? No 4. How did you become aware of the incident? Was made aware by staff member that [Resident #1] could not be located 5. What did you see concerning the incident? N/A 6. What did you hear about the time of the incident? N/A 7. What immediate action did you take? Assisted in the search of [Resident #1] and ensured all other residents were accounted for. . 12. What, if anything, is our knowledge of the resident? Prior to this incident, [Resident #1] had informed this writer that he would escape this facility; relayed message to [SW C ] Review of an Investigation Statement completed by SW C, dated 02/08/24, reflected the following: 1. When did you last care for the resident? N/A 2. In what capacity were you care for this resident? N/A 3. Did you witness the incident? No 4. How did you become aware of the incident? [LVN F] informed [SW C] on 2/7/24 that [Resident #1] told her that he was going to break the window and get out of here. [LVN F] stated that [Resident #1] went to the dining area window and started to hit it . 5. What did you see concerning the incident? Nothing - [Resident #1] has been in the facility for a week today and has not presented any wandering or elopement risk until [SW C] was told yesterday about what was said. [SW C] did not see [Resident #1] hit any windows or try to leave the facility. . 7. What immediate action did you take? I did not take any action because I did not think that [Resident #1] was going to leave the building. [Resident #1] has not presented any actions of leaving or wanting to leave until yesterday. . 12. What, if anything, is our knowledge of the resident? [Resident #1] has dementia with behaviors. [Resident #1] is oriented but has some cognition impairment. He is quiet, comes out of his room and hands out in the dining room area. 13. What additional information do you have that has not already been discussed regarding the incident? [SW C] asked [LVN F] this morning (2/8/24) if she documented what [Resident #1] told her so [SW C] can inform the managers in meeting. [LVN F] said, it's no need to document it because he has a history of elopement and the facility should have placed him in the unit when he got here. So now the ADM And DON are looking for him on [major highway]. Review of the facility's Ad-Hoc QAPI agenda, dated 02/09/24, reflected the ADM, DON, SW D, SW C, MAINTD, AD and MD were in attendance. They discussed ensuring facility practices were in line with elopement policy and procedures and social workers were to complete an audit of elopement assessments. Review of an in-service entitled Elopement and Wandering residents, dated 02/09/24, reflected staff from all shifts were reeducated on the facility's elopement policy. Review of an in-service entitled Walking Rounds/Resident Accountability, dated 02/10/24, reflected all nursing staff from all shifts were reeducated on the following: On-coming Nurse will do walking rounds and ensure all residents are in-house and/or accounted for. Review of Elopement Policy Post Training/Education Quizzes, from 02/08/24 - 02/12/24, reflected all staff completed and passed the quiz. Review of SW C's Counseling Report, dated 02/12/24, reflected the following: Substandard Job Performance - Failure to ensure that an accurate assessment of a new admission did not have a completed elopement assessment for [Resident #1]. The policy and procedure state that admission assessments are completed within 48 hours of admission to the policy. The failure to ensure timely and accurate completion of the admission assessments have the potential to result in inaccurate information for a resident. Review of the facility's investigation regarding Resident #1's elopement, dated 02/15/24, reflected the following: Incident: On 02/08/24 at approximately 9:15 AM, [FM B] of [Resident #1] reported that he had left the building and was on (major highway) sightseeing and waiting on someone from the facility to come pick him up and bring him back. Upon notification, the facility began to execute its elopement procedures in order to find the resident. [Resident #1] was located not far from the facility about 30 minutes later by the ADM and DON and brought back to the building. He was interviewed upon being brought back to the facility and stated that he wanted to get out of the facility to go look around and he planned to return. He also stated that he did not see anything wrong with it, as he was safe crossing the streets, looking both ways at each intersection. Facility Action: - Executed elopement procedures. - Located [Resident #1]. - RP notified. - Doctor notified. - Head to toe assessment completed. - Wander guard issued. - 1-on-1 monitoring initiated. - Psych referral initiated. - Therapy eval (evaluation) completed. - Report submitted to HHSC. - Staff in-serviced on elopement procedures. In review all of the information provided to the incident, it was determined that no specific individual was at fault for [Resident #1]'s elopement, however the facility could have been more diligent in assessing the resident as a high risk for elopement upon admission and put the proper interventions in place such as a wander guard, which would have immediately alerted the staff when he exited the building. Review of the facility's Elopements and Wandering Residents Policy, dated 11/21/22, reflected the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. . Policy Explanation and Compliance Guidelines: . 4. Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay bye the interdisciplinary care plan team. The noncompliance was identified as PNC. The IJ began on 02/08/24 and ended on 02/15/24. The facility had corrected the noncompliance before the survey began.

Based on observations interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for one resident (Resident #1) out of five residents reviewed; and that each resident (Resident #1) received adequate supervision and assistance devices which would have prevented accidents. The facility failed to ensure that Resident #1 did not have access to an open stairwell in her environment where she fell down the stairs in her wheelchair, suffered an abrasion to her right knee which had scabbed, and complained of pain. This failure could result in acute or permanent injury or death for residents who are wheelchair dependent or unable to navigate the stairs safely. Findings included: Record review of Resident #1 face sheet dated 11/1/2023 reflected a [AGE] year-old female resident initially admitted on [DATE]. Record review of Resident #1 face sheet reflected diagnoses of cerebral infarction, major depressive disorder, anxiety disorder, delusional disorder, psychotic disorder with delusions, history of falling, and vascular dementia among other diagnoses. Record review of Resident #1 face sheet dated 11/1/2023 reflected that resident had bilateral cataracts, presbyopia, and myopia (conditions which can affect the vision). Record review of Resident #1 MDS (a Medicare resident assessment tool) dated 9/4/2023 reflected a BIMS (a scoring system to determine cognitive impairment) score of 3 out of 15 which indicated a severe cognitive impairment. Record review of Resident #1 MDS dated [DATE] reflected that wandering behavior was not exhibited. Record review of Resident #1 MDS dated [DATE] reflected that Resident #1 required extensive assistance with locomotion on and off unit. Record review of Resident #1 MDS dated [DATE] reflected that a manual wheelchair was the mobility device that was normally used by Resident #1. Record review of Resident #1 MDS dated [DATE] reflected that Resident #1 was non-ambulatory. Record review of Resident #1 MDS dated [DATE] reflected that Resident #1's vision was moderately impaired in adequate lighting circumstances. Record review of Resident #1 care plan reflected that wandering was initiated as a problem on 6/16/2018 and was revised on 10/11/2023. Record review of Resident #1 care plan revealed that revision done on 10/11/2023 included the intervention of moving resident to the MCU. Record review of Resident #1 care plan reflected that impaired cognition was initiated as a problem on 5/25/2018 and that Resident #1 required cues, reorientation, and supervision. Record review of Resident #1 care plan reflected that Resident #1 was at risk for falls as initiated on 7/6/2019. Record review of Resident #1 care plan reflected that the problem of risk for falls was initiated to care plan on 07/06/2019 and was revised on 03/27/2023. Record review of Resident #1 care plan interventions for falls included the following statement: The resident needs a safe environment with even floors . Record review of Resident #1 fall risk evaluations completed from 10/8/2021 through 10/08/2023, a total of 14 evaluations, indicated that resident was a high fall risk on all evaluations except one (01/25/2023, low risk). Record review of Wandering Evaluations completed by nursing staff five times between 08/18/2022 and 10/09/2023 indicated that Resident #1 was at Moderate to High Risk for Wandering. The Wandering Evaluations were done quarterly prior to and after Resident #1 fall incident on 10/08/2023. Record review of nurse's progress note dated 10/8/2023 at 2:07 PM by RN A reflected that nurse had been called to 2300 hall for Resident #1. Resident #1 had left through an emergency exit door on the second floor of the building, had gone down a set of stairs, and was found as she lie on a staircase landing on her left side. Notes reflected that her wheelchair was on its side near her; injuries reflected an abrasion to the right knee with a scant amount of blood. RN A note dated 10/8/2023 at 2:07 PM reflected that exit alarm had not sounded at time of incident. Nurses note dated 10/8/2023 at 2:07 PM indicated that 911 was called and emergency services personnel had taken over care of Resident #1 when they arrived, that DON, ADON, physician were notified of incident, and that resident was transported to Acute Care Hospital. Record review of nurse's progress note dated 10/8/2023 at 2:07 PM by RN A stated: .door exit alarm was not working at time of incident. Record review of nurse's progress note dated 10/8/2023 at 2:59 PM by RN A stated: Exit alarm on 2300 hall was not working at time of (Resident #1 fall) incident, this RN (RN A) not aware; nursing progress note of 10/8/2023 at 2:59 PM reflected that ADON A and ADON B were notified immediately upon the fall incident and realization that door safety implements had not been working. Record review of Acute Care Hospital X-ray report dated 10/8/2023 indicated that there was no fracture or dislocation to Resident #1 right knee. Record review of discharge summary from Acute Care Hospital dated 10/8/2023 reflect that discharge diagnoses from Acute Care Hospital were inclusive of dementia and abrasion. Record review of Nurse Practitioner progress note dated 10/11/2023 12:17 PM reflected that resident had fallen down some stairs and there was no acute injury. Nurse practitioner progress note dated 10/11/2023 at 12:17 PM indicated that resident was transferred to MCU so that she could be monitored closely due to wandering, confusion, and dementia. Record review of Electronic and Engineering Service company receipt dated 10/10/2023 was reviewed. Receipt reflected that functional service tests were performed on eight exit doors and electronic mechanisms (alarm, delayed egress, key-pad access for staff to enter and exit the stairwell) to ensure door security were working correctly. Interview with ADM on 10/31/2023 at 4:48 PM revealed that this incident was the first time something like this had happened in the seven years he had been at the facility. ADM stated that he did not know how Resident #1 had obtained access through the door that normally required a key-pad entry code and had an alarm. ADM stated that doors were checked daily by the Maintenance Director and a software system was which documented these door checks. ADM stated that he and the corporate offices have accessed the software program and have reviewed when the maintenance duties were done. ADM stated that an Electronic and Engineering Service company was consulted after the incident and came to the facility on [DATE]. 8 doors and alarms were checked, the doors and alarms which allowed access to the stairwells. It was found by Electronic and Engineering Service company that they all worked properly and ADM provided documentation of this. Interview with ADM on 10/31/2023 at 4:48 PM revealed that in addition to the interventions enacted in Performance improvement Plan, a second alarm was also installed to each facility door which served as a back-up if first alarm failed. An interview was conducted with the DON on 10/31/2023 at 2:00 PM. DON stated that she had no idea how Resident #1 got through the door without sounding an alarm on 10/8/2023. DON stated that service workers had been in the facility the day before. The DON stated that the service workers had checked the sprinkler heads and they may have left the door unlocked. The DON stated that since the incident, two nurses are required to sign a log at each change of shift which indicated that the doors have been checked for proper security function and the narcotics have been counted. An interview and observation was conducted with Resident #1 on 10/31/2023 beginning at 12:00 PM. CNA A and ADON B worked in MCU on 10/31/2023 at 12:00 PM and were apparent in the MCU as they supervised residents in the dining room. CNA A located Resident #1 promptly for interview. Resident #1 stated during interview on 10/31/2023 at 12:00 PM that she had fallen approximately five stairs on unknown date and that she was trying to get out of the building. Resident #1 stated that the incident caused pain when it initially happened; she denied pain at time of interview. Resident #1 was asked if she had gotten hurt when she went down the stairs in her wheelchair; Resident #1 lifted her pants leg and showed a small scab on her knee. Resident #1 stated during interview that she felt safe at the facility. Resident #1 did not provide further information during the interview, and interview was ended when Resident #1 indicated that she wanted lie down. An access code, entered per an electronic wall-mounted key-pad, was used to enter and exit the MCU. The MCU door remained locked until the key-pad access code was entered, and then the door would unlock for seconds to allow for entrance/exit. The MCU was located on the first floor of the two-story building. An interview was conducted by telephone with RN A on 11/02/2023 at 8:23 AM. RN A stated that she did not remember the date of Resident #1 fall but she remembered the event. RN A stated that Resident #1 had gone in to a stair well door on a different second floor hall than the one she resided on. It was not recalled which hall stairwell that Resident #1 was found in during interview of RN A. RN A stated that staff did not see Resident #1 exit the second floor. RN A stated that a resident had alerted staff when he heard the fall; RN A did not remember which resident had alerted staff. RN A stated that she was alerted by other facility staff that Resident #1 had fallen while in her wheelchair, in a stairwell. RN A stated that Resident #1 was found as she lay on her left side with her wheelchair close by, also turned on its side. Resident #1 had fallen to the first landing in the stairwell. RN A stated that Resident #1 was awake and alert. RN A stated that Resident #1 had hit her knee and obtained an abrasion. RN A stated that she responded and observed that the door alarm had not activated when Resident #1 got through the door and into the stairwell. RN A stated that she informed ADON A and ADON B immediately after the incident that the door lock and alarm mechanism had failed when Resident #1 entered the stairwell prior to the fall. Observations on 10/31/2023 at the facility included four doors on the second floor which led to a stairwell down to the first floor. Four doors were also located on the first floor which led to the same stairwells. A key-pad access code (a code which, when input into a wall-mounted key pad, allowed the stairwell door to be opened for a few seconds) was required to enter the stairwell from the first or second floor. Observations on 10/31/2023 indicated that if a key pad access code was not entered and the door was attempted, a delayed egress mechanism was enabled and an alarm sounded. Observations were done intermittently on 10/31/2023 from 9:30 AM to 5:30 PM. Staff were observed entering a passcode per an electronic key-pad next to the individual door that they needed to open. The key-pad was mounted at approximately 5' in height on the wall next to each door. There were no observed postings of the code which opened the door as observed on 10/31/2023. Observations of residents on 10/31/2023 indicated that there is a facility elevator located near the central nurse's station for residents to be transportation between first and second floors. Entrance to and from the elevator and transportation between first and second floors in the elevator was observed to be readily accessible to all. No coded access or security feature was identified and residents were observed as they used it between 9:30 AM and 5:30 PM on 10/31/2023. Residents were not observed entering the stairwells or opening stairwell doors on 10/31/2023, when intermittently observed on first and second floors between 9:30 AM and 5:30 PM. Observations on the first floor indicated that residents, visitors, and staff who entered and exited the resident care areas and the resident common areas from the front entrance lobby were required to enter a key-pad access code first. Fall Prevention Program (Facility) Policy dated 8/15/2022 stated that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk. Fall Prevention program Policy dated 8/15/2022 indicated that a fall risk assessment would be completed every 90 days and as indicated when there is a change in resident condition. Fall prevention Program Policy dated 8/15/2022 indicated that interventions would be provided to address unique resident risk factors, and that those interventions would be monitored for effectiveness after implementation. The facility implemented the following interventions: Record review of an Ad Hoc QAPI meeting, convened after Resident #1 fell in the stairwell, held on 10/8/2023 with the ADM, DON, Medical Director, Social Worker A and Social Worker B, Maintenance Director in attendance was done. Record review of a Performance Improvement Plan was done and included doors checked by outside Electronics and Engineering Service company on 10/10/2023. Record review of Performance Improvement Plan indicated that all facility exit doors were immediately checked after the fall incident, by a weekend supervisor. Performance Improvement Plan indicated that staff were in-serviced immediately after incident; record review indicated that during this in-service, staff were instructed to monitor exit doors during resident rounds every two hours and ensure that the safety mechanisms which prevented resident exit were intact. Record review of Performance Improvement Plan indicated that social services department was designated to ensure that assessments were conducted on residents who wandered, residents who returned from emergency room , and on any other residents if it was indicated that they wandered; this was initiated on 10/08/2023 and was ongoing. Social Services department staff performed evaluation of any resident(s) who wandered for consideration of appropriate placement in the MCU and this intervention is ongoing. Care Plan Meetings were scheduled by social services with each resident's family after a wandering/exit-seeking behavior(s) had been identified and this intervention is ongoing. Nursing staff were designated to maintain updated care plans on exit-seeking behavior and the appropriate interventions enacted; this intervention is ongoing. ADM ensured that the proper process for door alarm activation/deactivation was posted and maintained in an area that would be readily accessible to staff. ADM ensured that signage on doors was upgraded which increased awareness of resident safety. In-services were held which re-educated the staff on Abuse, Neglect, Exploitation Policy, Setting/Re-setting door alarms, Reporting Improperly Working Doors, Initiating frequent/continuous Resident Monitoring when residents were noted to be exit seeking. In-service sign-in sheets and content were provided by the ADM. Per interview with ADM on 10/31/2023 at 4:48 PM, a second alarm had been added to all eight facility exit doors for instances of alarm #1 failure and two nurses are assigned to complete door checks and sign off on the Door Check Log on each hall during each change of shift. Written documentation logs were kept/stored, and the Maintenance Director had conducted daily alarm and door security checks on all facility exit doors (eight) which ensured that the locking mechanism was working correctly and that the alarms had sounded if the door was opened when the locking mechanism was by-passed or when this was attempted. Maintenance Director provided documentation of daily door security checks in online software program linked to ADM and corporate offices ; ADM stated that he had checked this daily for maintenance compliance. Record review was conducted on 10/31/2023, with ADM, which indicated that this documentation had been done daily. Record review was done on 10/31/2023 of completed facility logs which documented that two nurses had checked door security of all doors at each change of shift. This was reviewed to have been initiated on 10/08/2023, had been done at each change of shift, and was ongoing. Record review of the form which had been created to document these door checks done at change of shift was done; form was noted to have required two nurse signatures per shift change for each hall.

Based on interviews and record review, the facility failed to immediately consult with the resident's physician when there was a worsening in the resident's physical condition and a need to initiate prompt treatment for one (1) of three (3) residents reviewed for physician notification (Resident #1). The facility failed to notify the physician of all of Resident #1's symptoms including muscle rigidity, lethargy, leg pain and poor appetite for two (2) days prior to her admission to the hospital on [DATE]. Resident #1 was hospitalized with [DIAGNOSES REDACTED]. This deficient practice placed the 90 residents who resided on the second floor of the facility at risk for illness and hospital admission due to delays in notifying the physician of a change in physical condition. Findings include: Review of Resident #1's face sheet dated 02/06/14 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) quarterly review dated 11/11/13 revealed the following findings: Resident #1 had active [DIAGNOSES REDACTED]. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 (severe impairment). Resident #1 required oversight, encouragement or cueing for eating and personal hygiene activities. Review of the physician progress notes [REDACTED]. The progress note dated 01/17/14 included the following findings: Resident #1 had lost eight pounds since September 2013. Resident #1 had general malaise and chills. Resident #1 had a temperature of 98.5 degrees Fahrenheit, blood pressure reading of 132/ (unreadable) and pulse of 78 beats per minute, and 16 respirations per minute. Resident #1's blood pressure was noted to be elevated. Interventions included vital signs one time daily for one week, consultation with a registered dietician, and an appetite-enhancing drug. Review of the physician's orders [REDACTED]. Interview with CNA O on 02/10/14 at 8:50 a.m. revealed Resident #1 had a poor appetite several days prior to her hospital admission on 01/23/14. CNA O stated Resident #1's muscles were stiff, and she did not want to get out of bed. CNA O stated she notified the nurse of Resident #1's change in condition. Nurses Notes dated 01/21/14 (no time documented) read in part: "Res (resident) refused her supper stated, I stay sleepy all the time and don't feel good, listless. V/S (vital signs) 114/82 (blood pressure) 94 (pulse) 22 (respirations) O2 sat 94% (oxygen saturation level) T 98.4 (temperature). Will monitor" Nurses Notes dated 01/22/14 and timed 11:10 a.m. read in part: "This date (Resident #1) holding head hyper-flexed back. Called FNP-C (Certified Family Nurse Practitioner) for (Physician M) to inform MD of recent behaviors/medical issues" The note was signed by LVN P. There was no further assessment. Nurses Notes dated 01/22/14, timed 3:15 p.m., and signed by LVN P reflected Resident #1 was extremely lethargic, complained of pain in her legs. The Nurses Notes also indicated that the physician was notified. Interview with LVN P on 02/10/14 at 12:50 p.m. revealed she documented that Resident #1's physician was notified of Resident #1's change in condition on 01/22/14 at 3:15 p.m.; however, she never talked with the physician or the nurse practitioner. LVN P stated she called the physician's office and left a message. LVN P stated she obtained Resident #1's vital signs on 01/22/14; however, she failed to document the vital signs. LVN P stated she should have documented Resident #1's vital signs in the Nurses Notes, and she should have called the physician on his cell phone. Interview with the DON on 02/10/14 at 12:55 p.m. revealed LVN P should have documented Resident #1 ' s vital signs in the Nurses Notes. When asked about the Nurses Notes dated 01/22/14 and timed 11:10 a.m. that read " This date (Resident #1) holding head hyper-flexed back " the DON reported she did not assess Resident #1 ' s neck. The DON reported that she did not notify the physician or the nurse practitioner of the resident ' s symptoms. Review of the Nurses Notes dated 01/21/14 and 01/22/14 revealed the DON was not aware of all of the symptoms exhibited by Resident #1 during this time. The DON stated the physician should have been notified immediately of Resident #1 ' s symptoms of muscle rigidity, lethargy, leg pain and poor appetite. Review of the Nurses Notes dated 01/21/14 and 01/22/14 revealed the DON was not aware of the Resident's symptoms of muscle rigidity, lethargy, leg pain and poor appetite. The DON stated the physician should have been notified immediatley of Resident #1's symptoms of muscle rigidity, lethargy, leg pain and poor appetite. Nurses Notes dated 01/22/14, timed 9:00 p.m., and signed by LVN H, read in part: "Resident reported by CNA's to be declining in strength and unable to perform ADL's (Activities of Daily Living) Requires assistance with most ADL's Contacted on-call service for Dr. ____ (Physician M). Received call-back from ____ FNP-C (Nurse Practitioner N) who stated to try contacting physician during the day tomorrow. Resident in bed sleeping." Interview with LVN H by telephone on 02/10/14 at 1:35 p.m. revealed he worked during the 2:00 p.m. to 10:00 p.m. shift on 01/22/14. LVN H stated Resident #1 was not feeling well, so he called the physician's on-call service. The nurse practitioner (Nurse Practitioner N) called him back and told him to call Dr. ____ (Physician M) the following day. LVN H stated he was unaware of the resident's symptoms of muscle rigidity, lethargy, leg pain and poor appetite earlier in the day on 01/22/14. Interview with Nurse Practitioner N by telephone on 02/10/14 at approximately 9:10 a.m. revealed the facility called her on the evening of 01/22/14. Nurse Practitioner N stated that Resident #1's vital signs were within normal limits, and she determined Resident #1 had no emergent symptoms. Nurse Practitioner N stated she told the nurse to call Dr. ____ (Physician M) the following day. Nurse Practitioner N stated she was unaware of the resident's symptoms of muscle rigidity, lethargy, leg pain and poor appetite on 01/22/14. Interview with LVN K by telephone on 02/10/14 at 2:05 p.m. revealed she worked during the 10:00 p.m. to 6:00 a.m. shift beginning on 01/22/14 and ending on 01/23/14. LVN K stated she received report from LVN H that Resident #1 was not feeling well. LVN K stated she observed Resident #1 to be pale and weak at the beginning of the shift, and the resident slept on and off during the night. LVN K stated she was unaware of the resident's symptoms of muscle rigidity, lethargy, leg pain and poor appetite on 01/22/14. Review of the Nurses Notes for the 10 p.m. to 6:00 a.m. shift beginning on 01/22/14 and ending on 01/23/14 revealed there was no documentation of the resident's condition. Resident #1's Nurses Notes dated 01/21/14 and 01/22/14 were reviewed with the DON on 02/10/14 at 12:56 p.m. The DON stated she was unaware of Resident #1's symptoms of muscle rigidity, lethargy and poor appetite on 01/22/14. The DON stated the physician should have been notified immediately of Resident #1's symptoms of muscle rigidity, lethargy, leg pain and poor appetite. Review of the Resident Transfer Form dated 01/23/14 and signed by LVN P revealed Resident #1 was "rigid" and had a change in mental status. The transfer form reflected that "911" was called on 01/23/14 (no time documented). Review of the physician's orders [REDACTED].D. (emergency department) for eval & treat (evaluation and treatment)/ possible stroke." Interview with Resident #1's physician (Physician M) by telephone on 02/10/14 at approximately 9:20 a.m. revealed he was unaware of the resident's symptoms (muscle rigidity, lethargy, leg pain and poor appetite) for the period beginning on 01/21/14 and ending on 01/23/14, when Resident #1 was transferred to the hospital. The physician stated that the nurses had his cell phone number, and they should have called him immediately to report Resident #1's symptoms. The physician stated he would have sent the resident to the hospital for evaluation. Review of the hospital Nurses Clinical Report dated 01/23/14 revealed Resident #1 was admitted to the hospital on [DATE] at 8:33 a.m. with chief complaint of altered mental status and confusion. Physical assessment revealed Resident #1 had decreased awareness (drowsy), generalized weakness, pale skin and dry mouth and oral cavity. Review of the hospital History and Physical dated 01/23/14 revealed Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. On 02/10/14, the DON provided the facility policy titled "Change in a Resident's Condition or Status" (no date). The policy read in part: "A facility should immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is...A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications)...A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment)...." The resident roster dated 02/10/14 revealed 90 residents resided on the second floor of the facility.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for 3 of 4 residents (Resident s #9, #12, and #16) reviewed for supervision with smoking. Residents # 9, #12, and #16 deemed as unsafe smokers were left unsupervised during there smoking times and had possession of smoking tobacco, matches, lighters and other smoking paraphernalia. This deficient practice resulted in an Immediate Jeopardy (IJ) on 02/26/2012 at 9:12 PM. While the IJ was removed on 02/27/2012 at 4:15 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice to ensure adequate supervision and modify interventions allowed Resident #'s 9, 12, and 16 to smoke unsupervised with a potential for harm, and placed 27 other residents identified as unsafe smokers at risk for blisters, burns, fire and potential harm. Findings Include: Review of the facility Abuse/Neglect/Misappropriation Policy dated 06/10 reflected: It is the facility's policy to use reasonable efforts under the circumstances to prevent resident abuse and implement systems to educate each resident's families and facility staff on reporting related concerns, incidents or grievances without the fear of retribution, provide feedback regarding such matters, and identify, correct and intervene in situations where abuse, neglect or exploitation has or is alleged to have occurred. Under general circumstances, the facility Quality Assurance Team should consider the following factors in reviewing the overall facility environment and whether facility policies are achieving goals of preventing abuse: 1. Inspection of physical environment, such as secluded areas, that may increase the occurrence of abuse and/or neglect. 2. Review of staff ratios and assignment sheets for accuracy and sufficient numbers to meet the resident's needs. 3. Review of staff supervision to identify inappropriate behaviors of staff members that may be signs of potential abuse. 4. Review of resident records to determine if resident behaviors have been addressed in care plans. Under the Component IV: Identification, the facility policy reflected: The facility should use reasonable efforts to develop systems to identify events, occurrences, patterns and trends that may constitute or may be a precursor to abuse, neglect or exploitation to help minimize the threat or occurrence of abuse. Although the policy reflected abuse in most instances, in an interview on 02/29/2012 at 11:00 AM the Administration stated the policy is designated for Abuse, Neglect and Exploitation. Review of the facility smoking policy dated 02/07 reflected: 1. Smoking tobacco, matches, lighters or other smoking paraphernalia will be kept be staff. 2. The facility will designate a specific outdoor location for smoking. 3. a. Residents who are deemed safe smokers will be allowed to smoke in the designated areas. b. Residents who are deemed unsafe smokers will be assisted by staff at the times designated by the facility. 4. Smoking inside the facility is expressly prohibited. Review of the facility policy addendum dated 3/01/2007 reflected: Policy Interpretation and Implementation 1. Smoking tobacco, matches, lighters or other smoking paraphernalia will be kept by staff. 2. The facility will designate specific outdoor location for smoking. 3. All residents residing at the facility will be required to smoke only during designated smoking times. A smoking schedule will be posted in the facility. 4. The facility will provide staff available to be present during designated smoking times. 5. Smoking inside the facility, and other areas as posted, is expressly prohibited. Review of the facility policy regarding Items Not allowed in Resident's Personal Possession or Room Environment While in Facility dated 05/11 reflected: The following articles are not permitted because they are controlled by codes, regulations, standards or because the presence and/or use of such articles have been interpreted by TDH to have an adverse effect on the health and safety of the residents. K. Smoking tobacco, matches, lighters or other smoking paraphernalia, or illegal substances. A) Review of Resident # 16's Face Sheet reflected the resident is a [AGE] year old male, admitted to the facility on [DATE], with diagnosis' of [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS], Reflux Esophagitis, [MEDICAL CONDITION], Constipation, and [MEDICAL CONDITION]. Review of Resident # 16's quarterly Minimum Data Set (MDS) assessment dated [DATE] Reflected the resident is cognitively intact. Resident # 16 scored 13 of 15 possible points for the Brief Interview for Mental Status (BIMS) assessment. Review of Resident # 16's Smoking Tobacco assessment dated [DATE] reflected the resident was deemed as unsafe. This document also reflected dates of 09/23/2011 and 07/08/2011 where Resident # 16 was deemed as an unsafe smoker. The document reflected Resident # 16 drops cigarettes, butts or matches on floor, furniture, self or others; picks up cigarette butts from floor/ground; [MEDICAL CONDITION]/clothing. Review of Resident # 16's Care Plan dated 08/10/2011 reflected the resident is at risk for injury because he is a smoker and unsafe to smoke unsupervised. The approaches reflected Resident # 16 will smoke supervised in designated smoking areas. Cigarettes and paraphernalia will be kept for resident's own safety. Resident # 16 will only smoke during designated smoking times. Verbal reminders and education was also addressed in the Care Plan. Observation made on 02/26/2012 at 4:20 PM revealed Resident # 16 using the elevator to get to the first floor. Resident # 16 had multiple holes and burn marks down the front of his sweatshirt. Several of the holes holes were round and had rugged brown edges that appeared to [MEDICAL CONDITION] the shirt, surrounding the hole. Other tears in the shirt were approximately one inch long with brown, rugged edges, where it appeared a cigarette had dropped while lit on Resident # 16's shirt. Resident # 16 was observed going out into the smoking area where another resident was smoking unsupervised. Observation made on 02/26/2012 between 6:15 PM and 6:25 PM revealed Resident # 16 was in the smoking area, smoking unsupervised. Resident # 16 was observed retrieving a partially smoked cigarette from the ash tray in the smoking area when Resident # 30 lit the cigarette for him. Resident # 16 smoked the cigarette from 6:20 until 6:25 PM, unsupervised. In an interview on 02/26/2012 at 6:30 PM Resident # 16 stated he knew he was not supposed to smoke unsupervised but did it anyway. In an interview on 02/26/2012 at 6:55 PM the Administrator stated residents are prohibited from keeping smoking paraphernalia with them and the smoking paraphernalia is kept in a box at the nurse's station. The Administrator stated residents deemed as safe smokers are allowed to go to the nurse's station, retrieve the cigarettes and lighters and go to the smoking area to smoke. Residents deemed as unsafe smokers have to be supervised at all times while smoking and smoking times are posted and announced. The Administrator stated prohibiting residents from keeping smoking paraphernalia with them is a difficult task to enforce. B) Review of Resident # 9's Face Sheet reflected the resident is a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident # 9's quarterly MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired when she scored 8 of 15 for the BIMS assessment. Review of Resident # 9's Smoking/Tobacco assessment dated [DATE], 11/21/2011 and 12/27/2011 reflected the resident is unsafe to smoke without supervision. The assessment reflected Resident # 9 drops cigarettes, butts or matches on floor, furniture, self or others; picks up cigarette butts from floor/ground; [MEDICAL CONDITION]/clothing. The document further reflected Resident # 9 is unable to remain alert/awake during course of smoking and the resident does not extinguish smoking materials safely. Review of Resident # 9's Care Plan dated 11/21/2011 reflected the resident smokes and is not compliant with smoking policies of the facility, is not a safe smoker and is at risk for injury. The approaches for Resident # 9's smoking issue included educate resident regarding facility smoking policies and possible adverse health effects due to smoking, monitor for injury due to smoking/report injury to charge nurse, encourage the resident to smoke only during authorized times and store cigarettes in designated area. Observation made on 02/26/2012 between 6:15 PM and 6:25 PM revealed Resident # 9 was in the smoking area, smoking unsupervised. Resident # 9 was observed taking a cigarette out of her purse from a package of cigarettes that had 17 cigarettes in the pack. Resident # 32 was observed lighting Resident # 9's cigarette with his own lighter. An unidentified stated to Resident # 9 "you shouldn't be smoking unsupervised, you know better because you have been told". In an interview on 02/26/2012 at 6:20 Resident # 9 stated she had her cigarettes in her purse that was with her. The resident stated she keeps her cigarettes with her. In an interview on 02/26/2012 at 6:19 PM Resident # 32, who lit Resident # 9's cigarette, stated he keeps his lighter in his jacket pocket in his room he shares with his mother. Both Resident # 32 and his mother live on the Generations Unit (a locked unit for residents with dementia, exhibit elopement risk or have a highter quality of life with less stimulation). Resident # 32 stated at times he gives his lighter away and sometimes the facility takes it away and he goes and gets another one from the store. In an interview on 02/26/2012 at 6:35 PM, Registered Nurse (RN) V, a nurse for the Generations Unit stated he did not know who was safe or not safe to smoke. C) Review of Resident # 12's Face Sheet reflected the resident is a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident # 12's quarterly MDS assessment dated [DATE] reflected the resident is cognitively intact. Resident # 12 scored 15 of a possible 15 for the BIMS assessment. Review of Resident # 12's Smoking/Tobacco assessment dated [DATE] reflected the resident unsafe to smoke unsupervised because he does not follow the facility smoking policy. Observation on 02/26/2012 at 9:30 PM revealed Resident # 12 smoking outside in front of the facility approximately 25 feet from the entrance door. Resident # 12 was not supervised. In an interview with the Administrator on 02/26/2012 at 9:35 PM he stated Resident # 12 signed himself out of the facility and was to go off of facility grounds to smoke. In an interview on 02/26/2012 at 8:45 PM Social Worker (SW) S stated the SW Department evaluates residents for smoking safety. SW S stated the Social Worker Department gives the list of safe and unsafe smoking residents to the Activity Director (AD)who is responsible for smoking times and ensuring the list is provided to all staff who supervise smoking and hand out smoking paraphernalia. In an interview on 02/26/2012 at 8:50 PM the AD stated the list that is obtained for the SW Department is kept in the cigarette box for staff to be aware of who can smoke safely and who cannot smoke safely. Residents are required to obtain smoking paraphernalia from the cigarette box at the nurses station. Those safe to smoke can go out to the smoking area and smoke unsupervised. Those unsafe to smoke have to have supervision. Review of the undated smoking schedule reflected smoke times are as follows: Daily 09:00 - 09:15 AM 11:30 - 11:45 AM 02:30 - 02:45 PM 05:30 - 05:45 PM 07:00 - 07:15 PM 10:00 - 10:15 PM 12:00 - 12:15 AM Observation made on 02/26/2012 at 8:45 PM revealed Certified Nurse Aide (CNA) T was in the smoking area with the box of cigarettes to hand to residents who wanted to smoke. There was no list of unsafe or safe residents in the box. The AD was in attendance during this observation and stated the list should be in the cigarette box. Observation made on 02/26/2012 at 8:53 with the AD revealed the list of safe and unsafe smokers that was in her office had not been updated to the current list compiled by the SW Department. The AD confirmed the list was not up to date. Review of the undated current list of unsafe smokers provided by the SW Department revealed 30 residents unsafe to smoke unsupervised. Review of the list of unsafe smokers provided by the AD revealed 20 residents unsafe to smoke unsupervised. In an interview on 02/26/2012 at 8:46 PM CNA T stated he did not know who was safe to smoke unsupervised and who had to be supervised when smoking. In an interview on 02/26/2012 at 9:00 PM CNA U stated he supervises smoking sessions at times. CNA U stated he had not been trained, nor did he know, who is safe to smoke without supervision and who needs supervision to smoke. Observation made on 02/26/2012 at 9:09 PM revealed staff retrieved 20 packages of cigarettes and 8 lighters from residents within the facility. On 02/26/2012 at 9:12 PM, the Administrator was informed that an Immediate Jeopardy existed due to unsafe residents smoking unsupervised and residents had smoking paraphernalia on their person. On 02/27/2012 at 4:00 PM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Those residents found to be affected were immediately searched and paraphernalia confiscated. 2. Effective immediately, all smoking on facility grounds will be supervised. 3. The facility will immediately post staff on the smoking patio for 10-6 to ensure all residents, assessed as safe or unsafe remain in compliance. A schedule has been created for 24 hour coverage until further measures can be taken. All residents will be directed to the scheduled smoking times for compliance. 4. Residents identified as both safe and unsafe will be listed categorically and printed to be retained in the cigarette boxes for identification purposes. 5. Residents identified as both safe and unsafe will be listed categorically, and printed to be retained in the front of all ADL books for identification purposes. 6. Cigarette boxes will be kept locked in the Medication Room for safe keeping to ensure residents do not attempt to access without staff knowledge. 7 All residents identified as smokers will be searched for cigarettes, lighters and smoking related paraphernalia on both their person and their property. 8. The Social Worker will call all families of residents known to smoke, to inform them that any supplies will be provided to staff, not the residents, for safe keeping. 9. All staff will be in-serviced to confiscate any and all material related to smoking upon discovery. Social Services, Director of Nursing and Administrator to be notified. 10. Smoking grounds will be cleaned of cigarette remains after every break to ensure items will no be reused. 11. Rounds will be made periodically throughout the day to ensure paraphernalia is not being retained by residents. The survey team confirmed the facility had started to implement the plan of removal; completed a sweep of the facility to confiscate smoking paraphernalia, a person was posted at the smoking area door upon each observation, residents were supervised during scheduled smoking times observed. The in-services were approximately 70 percent complete and confirmed by staff interviews and review of the inservice sign in sheets. The Plan of Removal was accepted on 02/27/2012 at 4:15 PM. While the IJ was removed on 02/27/2012 at 4:15 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. The facility identified 30 residents unsafe to smoke without supervision.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect of residents for 3 of 4 residents (Resident s #9, #12, and #16) reviewed for supervision with smoking. Residents # 9, #12, and #16 deemed as unsafe smokers were left unsupervised during there smoking times and had possession of smoking tobacco, matches, lighters and other smoking paraphernalia. This deficient practice resulted in an Immediate Jeopardy (IJ) on 02/26/2012. While the IJ was removed on 02/27/2012, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice to ensure adequate supervision and modify interventions allowed Resident #'s 9, 12, and 16 to smoke unsupervised with a potential for harm, and placed 27 other residents identified as unsafe smokers at risk for blisters, burns, fire and potential harm. Findings Include: Review of the facility Abuse/Neglect/Misappropriation Policy dated 06/10 reflected: It is the facility's policy to use reasonable efforts under the circumstances to prevent resident abuse and implement systems to educate each resident's families and facility staff on reporting related concerns, incidents or grievances without the fear of retribution, provide feedback regarding such matters, and identify, correct and intervene in situations where abuse, neglect or exploitation has or is alleged to have occurred. Under general circumstances, the facility Quality Assurance Team should consider the following factors in reviewing the overall facility environment and whether facility policies are achieving goals of preventing abuse: 1. Inspection of physical environment, such as secluded areas, that may increase the occurrence of abuse and/or neglect. 2. Review of staff ratios and assignment sheets for accuracy and sufficient numbers to meet the resident's needs. 3. Review of staff supervision to identify inappropriate behaviors of staff members that may be signs of potential abuse. 4. Review of resident records to determine if resident behaviors have been addressed in care plans. Under the Component IV: Identification, the facility policy reflected: The facility should use reasonable efforts to develop systems to identify events, occurrences, patterns and trends that may constitute or may be a precursor to abuse, neglect or exploitation to help minimize the threat or occurrence of abuse. Although the policy reflected abuse in most instances, in an interview on 02/29/2012 at 11:00 AM the Administration stated the policy is designated for Abuse, Neglect and Exploitation. Review of the facility smoking policy dated 02/07 reflected: 1. Smoking tobacco, matches, lighters or other smoking paraphernalia will be kept be staff. 2. The facility will designate a specific outdoor location for smoking. 3. a. Residents who are deemed safe smokers will be allowed to smoke in the designated areas. b. Residents who are deemed unsafe smokers will be assisted by staff at the times designated by the facility. 4. Smoking inside the facility is expressly prohibited. Review of the facility policy addendum dated 3/01/2007 reflected: Policy Interpretation and Implementation 1. Smoking tobacco, matches, lighters or other smoking paraphernalia will be kept by staff. 2. The facility will designate specific outdoor location for smoking. 3. All residents residing at the facility will be required to smoke only during designated smoking times. A smoking schedule will be posted in the facility. 4. The facility will provide staff available to be present during designated smoking times. 5. Smoking inside the facility, and other areas as posted, is expressly prohibited. Review of the facility policy regarding Items Not allowed in Resident's Personal Possession or Room Environment While in Facility dated 05/11 reflected: The following articles are not permitted because they are controlled by codes, regulations, standards or because the presence and/or use of such articles have been interpreted by TDH to have an adverse effect on the health and safety of the residents. K. Smoking tobacco, matches, lighters or other smoking paraphernalia, or illegal substances. A) Review of Resident # 16's Face Sheet reflected the resident is a [AGE] year old male, admitted to the facility on [DATE], with diagnosis' of [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS], Reflux Esophagitis, [MEDICAL CONDITION], Constipation, and [MEDICAL CONDITION]. Review of Resident # 16's quarterly Minimum Data Set (MDS) assessment dated [DATE] Reflected the resident is cognitively intact. Resident # 16 scored 13 of 15 possible points for the Brief Interview for Mental Status (BIMS) assessment. Review of Resident # 16's Smoking Tobacco assessment dated [DATE] reflected the resident was deemed as unsafe. This document also reflected dates of 09/23/2011 and 07/08/2011 where Resident # 16 was deemed as an unsafe smoker. The document reflected Resident # 16 drops cigarettes, butts or matches on floor, furniture, self or others; picks up cigarette butts from floor/ground; [MEDICAL CONDITION]/clothing. Review of Resident # 16's Care Plan dated 08/10/2011 reflected the resident is at risk for injury because he is a smoker and unsafe to smoke unsupervised. The approaches reflected Resident # 16 will smoke supervised in designated smoking areas. Cigarettes and paraphernalia will be kept for resident's own safety. Resident # 16 will only smoke during designated smoking times. Verbal reminders and education was also addressed in the Care Plan. Observation made on 02/26/2012 at 4:20 PM revealed Resident # 16 using the elevator to get to the first floor. Resident # 16 had multiple holes and burn marks down the front of his sweatshirt. Several of the holes holes were round and had rugged brown edges that appeared to [MEDICAL CONDITION] the shirt, surrounding the hole. Other tears in the shirt were approximately one inch long with brown, rugged edges, where it appeared a cigarette had dropped while lit on Resident # 16's shirt. Resident # 16 was observed going out into the smoking area where another resident was smoking unsupervised. Observation made on 02/26/2012 between 6:15 PM and 6:25 PM revealed Resident # 16 was in the smoking area, smoking unsupervised. Resident # 16 was observed retrieving a partially smoked cigarette from the ash tray in the smoking area when Resident # 30 lit the cigarette for him. Resident # 16 smoked the cigarette from 6:20 until 6:25 PM, unsupervised. In an interview on 02/26/2012 at 6:30 PM Resident # 16 stated he knew he was not supposed to smoke unsupervised but did it anyway. In an interview on 02/26/2012 at 6:55 PM the Administrator stated residents are prohibited from keeping smoking paraphernalia with them and the smoking paraphernalia is kept in a box at the nurse's station. The Administrator stated residents deemed as safe smokers are allowed to go to the nurse's station, retrieve the cigarettes and lighters and go to the smoking area to smoke. Residents deemed as unsafe smokers have to be supervised at all times while smoking and smoking times are posted and announced. The Administrator stated prohibiting residents from keeping smoking paraphernalia with them is a difficult task to enforce. B) Review of Resident # 9's Face Sheet reflected the resident is a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident # 9's quarterly MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired when she scored 8 of 15 for the BIMS assessment. Review of Resident # 9's Smoking/Tobacco assessment dated [DATE], 11/21/2011 and 12/27/2011 reflected the resident is unsafe to smoke without supervision. The assessment reflected Resident # 9 drops cigarettes, butts or matches on floor, furniture, self or others; picks up cigarette butts from floor/ground; [MEDICAL CONDITION]/clothing. The document further reflected Resident # 9 is unable to remain alert/awake during course of smoking and the resident does not extinguish smoking materials safely. Review of Resident # 9's Care Plan dated 11/21/2011 reflected the resident smokes and is not compliant with smoking policies of the facility, is not a safe smoker and is at risk for injury. The approaches for Resident # 9's smoking issue included educate resident regarding facility smoking policies and possible adverse health effects due to smoking, monitor for injury due to smoking/report injury to charge nurse, encourage the resident to smoke only during authorized times and store cigarettes in designated area. Observation made on 02/26/2012 between 6:15 PM and 6:25 PM revealed Resident # 9 was in the smoking area, smoking unsupervised. Resident # 9 was observed taking a cigarette out of her purse from a package of cigarettes that had 17 cigarettes in the pack. Resident # 32 was observed lighting Resident # 9's cigarette with his own lighter. An unidentified stated to Resident # 9 "you shouldn't be smoking unsupervised, you know better because you have been told". In an interview on 02/26/2012 at 6:20 Resident # 9 stated she had her cigarettes in her purse that was with her. The resident stated she keeps her cigarettes with her. In an interview on 02/26/2012 at 6:19 PM Resident # 32, who lit Resident # 9's cigarette, stated he keeps his lighter in his jacket pocket in his room he shares with his mother. Both Resident # 32 and his mother live on the Generations Unit (a locked unit for residents with dementia). Resident # 32 stated at times he gives his lighter away and sometimes the facility takes it away and he goes and gets another one from the store. In an interview on 02/26/2012 at 6:35 PM, Registered Nurse (RN) V, a nurse for the Generations Unit stated he did not know who was safe or not safe to smoke. C) Review of Resident # 12's Face Sheet reflected the resident is a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident # 12's quarterly MDS assessment dated [DATE] reflected the resident is cognitively intact. Resident # 12 scored 15 of a possible 15 for the BIMS assessment. Review of Resident # 12's Smoking/Tobacco assessment dated [DATE] reflected the resident unsafe to smoke unsupervised because he does not follow the facility smoking policy. Observation on 02/26/2012 at 9:30 PM revealed Resident # 12 smoking outside in front of the facility approximately 25 feet from the entrance door. Resident # 12 was not supervised. In an interview with the Administrator on 02/26/2012 at 9:35 PM he stated Resident # 12 signed himself out of the facility and was to go off of facility grounds to smoke. In an interview on 02/26/2012 at 8:45 PM Social Worker (SW) S stated the SW Department evaluates residents for smoking safety. SW S stated the Social Worker Department gives the list of safe and unsafe smoking residents to the Activity Director (AD)who is responsible for smoking times and ensuring the list is provided to all staff who supervise smoking and hand out smoking paraphernalia. In an interview on 02/26/2012 at 8:50 PM the AD stated the list that is obtained for the SW Department is kept in the cigarette box for staff to be aware of who can smoke safely and who cannot smoke safely. Residents are required to obtain smoking paraphernalia from the cigarette box at the nurses station. Those safe to smoke can go out to the smoking area and smoke unsupervised. Those unsafe to smoke have to have supervision. Review of the undated smoking schedule reflected smoke times are as follows: Daily 09:00 - 09:15 AM 11:30 - 11:45 AM 02:30 - 02:45 PM 05:30 - 05:45 PM 07:00 - 07:15 PM 10:00 - 10:15 PM 12:00 - 12:15 AM Observation made on 02/26/2012 at 8:45 PM revealed Certified Nurse Aide (CNA) T was in the smoking area with the box of cigarettes to hand to residents who wanted to smoke. There was no list of unsafe or safe residents in the box. The AD was in attendance during this observation and stated the list should be in the cigarette box. The AD and this surveyor went to the AD's office, the AD gave this surveyor the unsafe smoker list, the list that was supposed to be in the cigarette box, that had not been updated. The list of unsafe smokers provided by the AD revealed 20 residents that were unsafe to smoke unsupervised. Review of the undated current list of unsafe smokers provided by the SW Department revealed 30 residents unsafe to smoke unsuperviised. In an interview on 02/26/2012 at 8:46 PM CNA T stated he did not know who was safe to smoke unsupervised and who had to be supervised when smoking. In an interview on 02/26/2012 at 9:00 PM CNA U stated he supervises smoking sessions at times. CNA U stated he had not been trained, nor did he know, who is safe to smoke without supervision and who needs supervision to smoke. Observation made on 02/26/2012 at 9:09 PM revealed staff retrieved 20 packages of cigarettes and 8 lighters from residents within the facility. On 02/26/2012 at 9:12 PM, the Administrator was informed that an Immediate Jeopardy existed due to unsafe residents smoking unsupervised and residents had smoking paraphernalia on their person.The administrator provided the first draft of the facility's Plan of Removal on 02/26/2012 at 10:30PM On 02/27/2012 at 4:00 PM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Those residents found to be affected were immediately searched and paraphernalia confiscated. 2. Effective immediately, all smoking on facility grounds will be supervised. 3. The facility will immediately post staff on the smoking patio for 10-6 to ensure all residents, assessed as safe or unsafe remain in compliance. A schedule has been created for 24 hour coverage until further measures can be taken. All residents will be directed to the scheduled smoking times for compliance. 4. Residents identified as both safe and unsafe will be listed categorically and printed to be retained in the cigarette boxes for identification purposes. 5. Residents identified as both safe and unsafe will be listed categorically, and printed to be retained in the front of all ADL books for identification purposes. 6. Cigarette boxes will be kept locked in the Medication Room for safe keeping to ensure residents do not attempt to access without staff knowledge. 7 All residents identified as smokers will be searched for cigarettes, lighters and smoking related paraphernalia on both their person and their property. 8. The Social Worker will call all families of residents known to smoke, to inform them that any supplies will be provided to staff, not the residents, for safe keeping. 9. All staff will be in-serviced to confiscate any and all material related to smoking upon discovery. Social Services, Director of Nursing and Administrator to be notified. 10. Smoking grounds will be cleaned of cigarette remains after every break to ensure items will no be reused. 11. Rounds will be made periodically throughout the day to ensure paraphernalia is not being retained by residents. The survey team confirmed the facility had started to implement the plan of removal; completed a sweep of the facility to confiscate smoking paraphernalia, a person was posted at the smoking area door upon each observation, residents were supervised during scheduled smoking times observed. The in-services were approximately 70 percent complete and confirmed by staff interviews and review of the inservice sign in sheets. The Plan of Removal was accepted on 02/27/2012 at 4:15 PM. While the IJ was removed on 02/27/2012 at 4:15 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. The facility identified 30 residents unsafe to smoke without supervision.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent potential accidents for 3 of 4 residents (Residents #9, #12, and #16) reviewed for supervision with smoking. Residents # 9, #12, and #16 were deemed as unsafe smokers and were left unsupervised during their smoking times by staff. These Residents also had possession of smoking tobacco, matches, lighters and other smoking paraphernalia. Resident #9 had multiple burn holes in the front of his sweatshrt. Also, Resident #32 was observed lighting other residents cigarettes using a lighter in his possession. This deficient practice resulted in an Immediate Jeopardy (IJ) on 02/26/2012. While the IJ was removed on 02/27/2012, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice placed 30 residents identified as unsafe smokers at risk for blisters, burns, fire and potential harm. Findings Include: A) Review of Resident # 16's Face Sheet reflected the resident is a [AGE] year old male, admitted to the facility on [DATE], with diagnosis' of Psychosis, Schizophrenia, Hypertension, Seizures, Anemia, Reflux Esophagitis, Insomnia, Constipation, and Osteoporosis. Review of Resident # 16's quarterly Minimum Data Set (MDS) assessment dated [DATE] Reflected the resident is cognitively intact. Resident # 16 scored 13 of 15 possible points for the Brief Interview for Mental Status (BIMS) assessment. Review of Resident # 16's Smoking Tobacco assessment dated [DATE] reflected the resident was deemed as unsafe. This document also reflected dates of 09/23/2011 and 07/08/2011 where Resident # 16 was deemed as an unsafe smoker. The document reflected Resident # 16 drops cigarettes, butts or matches on floor, furniture, self or others; picks up cigarette butts from floor/ground; and burns fingertips/clothing. Review of Resident # 16's Care Plan dated 08/10/2011 reflected the resident is at risk for injury because he is a smoker and unsafe to smoke unsupervised. The approaches reflected Resident # 16 will smoke supervised in designated smoking areas. Cigarettes and paraphernalia will be kept for resident's own safety. Resident # 16 will only smoke during designated smoking times. Verbal reminders and education was also addressed in the Care Plan. Observation made on 02/26/2012 at 4:20 PM revealed Resident # 16 using the elevator to get to the first floor. Resident # 16 had multiple holes and burn marks down the front of his sweatshirt. Several of the holes holes were round and had rugged brown edges that appeared to be burns in the shirt, surrounding the hole. Other tears in the shirt were approximately one inch long with brown, rugged edges, where it appeared a cigarette had dropped while lit on Resident # 16's shirt. Resident # 16 was observed going out into the smoking area where another resident was smoking unsupervised. Observation made on 02/26/2012 between 6:15 PM and 6:25 PM revealed Resident # 16 was in the smoking area, smoking unsupervised. Resident # 16 was observed retrieving a partially smoked cigarette from the ash tray in the smoking area when Resident # 30 lit the cigarette for him. Resident # 16 smoked the cigarette from 6:20 until 6:25 PM, unsupervised. In an interview on 02/26/2012 at 6:30 PM Resident # 16 stated he knew he was not supposed to smoke unsupervised but did it anyway. In an interview on 02/26/2012 at 6:55 PM the Administrator stated residents are prohibited from keeping smoking paraphernalia with them and the smoking paraphernalia is kept in a box at the nurse's station. The Administrator stated residents deemed as safe smokers are allowed to go to the nurse's station, retrieve the cigarettes and lighters and go to the smoking area to smoke. Residents deemed as unsafe smokers have to be supervised at all times while smoking and smoking times are posted and announced. The Administrator stated prohibiting residents from keeping smoking paraphernalia with them is a difficult task to enforce. B) Review of Resident # 9's Face Sheet reflected the resident is a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident # 9's quarterly MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired when she scored 8 of 15 for the BIMS assessment. Review of Resident # 9's Smoking/Tobacco assessment dated [DATE], 11/21/2011 and 12/27/2011 reflected the resident is unsafe to smoke without supervision. The assessment reflected Resident # 9 drops cigarettes, butts or matches on floor, furniture, self or others; picks up cigarette butts from floor/ground; and burns fingertips/clothing. The document further reflected Resident # 9 is unable to remain alert/awake during course of smoking and the resident does not extinguish smoking materials safely. Review of Resident # 9's Care Plan dated 11/21/2011 reflected the resident smokes and is not compliant with smoking policies of the facility, is not a safe smoker and is at risk for injury. The approaches for Resident # 9's smoking issue included educate resident regarding facility smoking policies and possible adverse health effects due to smoking, monitor for injury due to smoking/report injury to charge nurse, encourage the resident to smoke only during authorized times and store cigarettes in designated area. Observation made on 02/26/2012 between 6:15 PM and 6:25 PM revealed Resident # 9 was in the smoking area, smoking unsupervised. Resident # 9 was observed taking a cigarette out of her purse from a package of cigarettes that had 17 cigarettes in the pack. Resident # 32 was observed lighting Resident # 9's cigarette with his own lighter. An unidentified stated to Resident # 9 "you shouldn't be smoking unsupervised, you know better because you have been told". In an interview on 02/26/2012 at 6:20 Resident # 9 stated she had her cigarettes in her purse that was with her. The resident stated she keeps her cigarettes with her. In an interview on 02/26/2012 at 6:19 PM Resident # 32, who lit Resident # 9's cigarette, stated he keeps his lighter in his jacket pocket in his room he shares with his mother. Both Resident # 32 and his mother live on the Generations Unit (a locked unit for residents with dementia). Resident # 32 stated at times he gives his lighter away and sometimes the facility takes it away and he goes and gets another one from the store. In an interview on 02/26/2012 at 6:35 PM, Registered Nurse (RN) V, a nurse for the Generations Unit stated he did not know who was safe or not safe to smoke. C) Review of Resident # 12's Face Sheet reflected the resident is a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident # 12's quarterly MDS assessment dated [DATE] reflected the resident is cognitively intact. Resident # 12 scored 15 of a possible 15 for the BIMS assessment. Review of Resident # 12's Smoking/Tobacco assessment dated [DATE] reflected the resident unsafe to smoke unsupervised because he does not follow the facility smoking policy. Observation on 02/26/2012 at 9:30 PM revealed Resident # 12 smoking outside in front of the facility approximately 25 feet from the entrance door. Resident # 12 was not supervised. In an interview with the Administrator on 02/26/2012 at 9:35 PM he stated Resident # 12 signed himself out of the facility and was to go off of facility grounds to smoke. In an interview on 02/26/2012 at 8:45 PM Social Worker (SW) S stated the SW Department evaluates residents for smoking safety. SW S stated the Social Worker Department gives the list of safe and unsafe smoking residents to the Activity Director (AD) who is responsible for smoking times and ensuring the list is provided to all staff who supervise smoking and hand out smoking paraphernalia. In an interview on 02/26/2012 at 8:50 PM the AD stated the list that is obtained for the SW Department is kept in the cigarette box for staff to be aware of who can smoke safely and who cannot smoke safely. Residents are required to obtain smoking paraphernalia from the cigarette box at the nurses station. Those safe to smoke can go out to the smoking area and smoke unsupervised. Those unsafe to smoke have to have supervision. Review of the undated smoking schedule reflected smoke times are as follows: Daily 09:00 - 09:15 AM 11:30 - 11:45 AM 02:30 - 02:45 PM 05:30 - 05:45 PM 07:00 - 07:15 PM 10:00 - 10:15 PM 12:00 - 12:15 AM Observation made on 02/26/2012 at 8:45 PM revealed Certified Nurse Aide (CNA) T was in the smoking area with the box of cigarettes to hand to residents who wanted to smoke. There was no list of unsafe or safe residents in the box. The AD was in attendance during this observation and stated the list should be in the cigarette box. The AD and the surveyor went to the AD's office, the AD provided the surveyor the unsafe smoker list, and this list was determined to be outdated. This outdated list should have been in the cigarrette box. This list of unsafe smokers provided by the AD revealed 20 residents that were unsafe to smoke unsupervised.. Review of the current list of unsafe smokers provided by the SW Department revealed 30 residents unsafe to smoke unsupervised. In an interview on 02/26/2012 at 8:46 PM, CNA T stated he did not know who was safe to smoke unsupervised and who had to be supervised when smoking. In an interview on 02/26/2012 at 9:00 PM CNA U stated he supervises smoking sessions at times. CNA U stated he had not been trained, nor did he know, who is safe to smoke without supervision and who needs supervision to smoke. Observation on 02/26/2012 at 2:30 PM revealed Resident # 33 coming off of the elevator to the second floor with a cigarette case in her lap. Inside the cigarette case was an empty package of cigarettes and a lighter. In an interview on 02/26/2012 at 3:00 PM Resident # 33, an unsampled resident, stated those are hers and it's nobody's business where she got them. Observation made on 02/26/2012 at 9:09 PM revealed staff had entered resident rooms to search for smoking paraphernalia. Staff had 2 sacks that contained 20 packages of cigarettes and 8 lighters. In an interview on 02/26/2012 at 9:10 PM the AD stated the cigarette paraphernalia in the two sacks were obtained from resident rooms. Review of the facility smoking policy dated 02/07 reflected: 1. Smoking tobacco, matches, lighters or other smoking paraphernalia will be kept be staff. 2. The facility will designate a specific outdoor location for smoking. 3. a. Residents who are deemed safe smokers will be allowed to smoke in the designated areas. b. Residents who are deemed unsafe smokers will be assisted by staff at the times designated by the facility. 4. Smoking inside the facility is expressly prohibited. Review of the facility policy addendum dated 3/01/2007 reflected: Policy Interpretation and Implementation 1. Smoking tobacco, matches, lighters or other smoking paraphernalia will be kept by staff. 2. The facility will designate specific outdoor location for smoking. 3. All residents residing at the facility will be required to smoke only during designated smoking times. A smoking schedule will be posted in the facility. 4. The facility will provide staff available to be present during designated smoking times. 5. Smoking inside the facility, and other areas as posted, is expressly prohibited. Review of the facility policy regarding Items Not allowed in Resident's Personal Possession or Room Environment While in Facility dated 05/11 reflected: The following articles are not permitted because they are controlled by codes, regulations, standards or because the presence and/or use of such articles have been interpreted by TDH to have an adverse effect on the health and safety of the residents. K. Smoking tobacco, matches, lighters or other smoking paraphernalia, or illegal substances. On 02/26/2012 at 9:12 PM, the Administrator was informed that an Immediate Jeopardy existed due to unsafe residents smoking unsupervised and residents had smoking paraphernalia on their person. The Administrator provided the first draft of the facility's Plan of Removal on 02/26/2012 at 10:30 PM which was not acceptable.. On 02/27/2012 at 4:00 PM, the facility Administrator provided the survey team with a second written plan of removal, which reflected the following: 1. Those residents found to be affected were immediately searched and paraphernalia confiscated. 2. Effective immediately, all smoking on facility grounds will be supervised. 3. The facility will immediately post staff on the smoking patio for 10-6 to ensure all residents, assessed as safe or unsafe remain in compliance. A schedule has been created for 24 hour coverage until further measures can be taken. All residents will be directed to the scheduled smoking times for compliance. 4. Residents identified as both safe and unsafe will be listed categorically and printed to be retained in the cigarette boxes for identification purposes. 5. Residents identified as both safe and unsafe will be listed categorically, and printed to be retained in the front of all ADL books for identification purposes. 6. Cigarette boxes will be kept locked in the Medication Room for safe keeping to ensure residents do not attempt to access without staff knowledge. 7 All residents identified as smokers will be searched for cigarettes, lighters and smoking related paraphernalia on both their person and their property. 8. The Social Worker will call all families of residents known to smoke, to inform them that any supplies will be provided to staff, not the residents, for safe keeping. 9. All staff will be in-serviced to confiscate any and all material related to smoking upon discovery. Social Services, Director of Nursing and Administrator to be notified. 10. Smoking grounds will be cleaned of cigarette remains after every break to ensure items will no be reused. 11. Rounds will be made periodically throughout the day to ensure paraphernalia is not being retained by residents. The survey team confirmed the facility had started to implement the plan of removal; completed a sweep of the facility to confiscate smoking paraphernalia, a person was posted at the smoking area door upon each observation, residents were supervised during scheduled smoking times observed. The in-services were approximately 70 percent complete and confirmed by staff interviews and review of the inservice sign in sheets. The Plan of Removal was accepted on 02/27/2012 at 4:15 PM. While the IJ was removed on 02/27/2012 at 4:15 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. The facility identified 30 residents unsafe to smoke without supervision.

Based on observation, interview and record review the facility failed to distribute and serve food under sanitary conditions for 24 of 51 of residents, including 1of 1 immunosupressed resident (Resident #14), reviewed for receiving regular and mechanical soft diets on 1 of 2 floors (second floor kitchen) of the facility when: One (1) of 18 dietary staff members (Dietary Aide K) served a potentially hazardous food (chilled pasta salad) that was held in the temperature danger zone (41-135 degrees Fahrenheit) to 24 residents. Twenty-two (22) of the residents consumed this food. This deficient practice placed 24 residents, 1 with an immune-deficient disease, and could have placed an additional 27 residents, at risk for contracting foodborne illness resulting in severe illness and even death. This deficient practice resulted in an Immediate Jeopardy (IJ) on 02/26/12 at 9:10 PM. While the IJ was removed on 02/27/12 at 3:53 PM, the facility remained out of compliance at severity level or potential for more than minimal harm with a scope identified as widespread that is not IJ because all staff had not been in-serviced on food temperatures and residents were still being monitored for symptoms of foodborne illness. Findings include: Observation on 2/26/12 at 6:05 p.m. in the second floor kitchen revealed Dietary Aide K was preparing to serve dinner. A 12x20 inch steam table pan of chilled pasta salad was held on the steam table. During an interview and record review on 2/26/12 at 6:05 p.m. Dietary Aide K stated she had already taken the temperature of the food. Dietary Aide K pointed to the record of the Upstairs Temperature Food Log, dated 2/27/12 which she documented the temperature at 40 degrees. Review of the facility ' s recipe for " Pasta Salad " dated 2011 reflected " Ingredients to yield 12 servings: Macaroni ? pound, Water ? gallon, Pickle Relish 7 tablespoons, Eggs 5 total, Celery ? pound, Mayonnaise 1 cup. " " Production method: 1. Cook Macaroni until tender. Drain. Cook eggs. Peel and dice. 2. Chop celery finely. 3. (marked CCP for Critical Control Point) Combine macaroni, relish, celery, eggs, and mayonnaise. Toss lightly and chill in shallow pans at 41 degrees or below. Hold at 41 degrees or below for meal service. (Hold over ice). 4. (marked as CCP for Critical Control Point) Store leftovers according to the HACCP (Hazard Analysis Critical Control Point- a systematic preventive approach to food safety and pharmaceutical safety that addresses physical, chemical, and biological hazards.) flow chart. Cover, label and date and store in shallow pans at 41 degrees or below. " During observation and interview on 2/26/12 at 6:05 in the second floor kitchen the surveyor asked Dietary Aide K to check the temperature of the pasta salad. Dietary Aide K cleaned the thermometer and inserted the thermometer into the pasta salad. The temperature reading was 58 degrees. Dietary Aide K further stated, " Have to serve it " ; she further stated " what else " was she " going to do " . Dietary Aide K asked the surveyor what she should do (referring to the pasta salad). Continued observations on 2/26/12 between 6:05 and 6:20 PM, revealed Dietary Aide K scooped pasta salad onto paper plates. During an interview on 2/26/12 at 6:20 PM, Dietary Aide K stated when she arrived at the facility on 2/26/12 the first thing she did was to come upstairs and turn on the steam table. Dietary Aide K stated she obtained the pasta salad from the first floor refrigerator. Dietary Aide K stated she brought the food upstairs on the cart. Dietary Aide K stated she took the temperature of the pasta salad upstairs and she recorded the temperature on the log. Dietary Aide K stated she saw the steam table was too warm for the pasta salad so she added ice. Dietary Aide K stated she had to serve the food. Observation on 02/26/12 at 6:22 PM, the surveyor asked Dietary Aide K to lift the pasta salad from the steam table. There was no evidence of ice in the steam table compartment. Six inches of water was in the compartment. Observation on 2/26/12 at 6:20 PM revealed the food cart left the kitchen by Dietary Aide K with the pasta salad on the cart on paper plates. The food cart went out to the residents in the assisted dining room. During an interview on 02/26/12 at 6:25 PM, the Dietary Supervisor was informed by Dietary Aide K that she had served the pasta salad at 58 degrees, the Dietary Supervisor stated that no, she could not serve the pasta salad at that temperature. Observation on 2/26/12 at 6:25 PM the Dietary Supervisor removed the pasta salad and covered it with saran wrap. She stated she would bring another salad to serve the residents. Observation on 2/26/12 at 6:30 PM revealed residents in the assisted dining room had already received their trays with the pasta salad that reached a 58 degree temperature at 6:05 PM. During an interview on 2/26/12 at 6:30 PM Certified Nurse Aide (CNA) O stated he was not informed about whether the pasta salad should be served. CNA O had not been advised about any concerns of the temperature for the pasta salad. Continued observation on 2/26/12 at 6:30 PM in the assisted dining room revealed Residents #28 and #29 eating the pasta salad. Observation on 2/26/12 at 6:45 PM revealed Dietary Aide K serving a tossed salad with ranch dressing in the second floor kitchen. Surveyor asked Dietary Aide K to check the temperature, the temperature read 50 degrees. During interview on 2/26/12 at 6:50 PM, the Director of Nurses (DON) stated that trays were to be returned to the kitchen immediately with the tossed salad if it also was not at the correct temperature. Observation on 02/26/12 at 7:02 PM, Dietary Aide K took the temperature of a new pan of tossed salad. The temperature read 35 degrees Fahrenheit. During an interview on 2/26/12 at 7:30 PM Dietary Aide K stated she had worked at the facility for one year. Dietary Aide K stated the pasta salad should have been at 40 degrees. When asked why she served the pasta salad, Dietary Aide K stated she was very behind, and the residents were waiting. When asked what was she trained to do in situations when the food temperature was high, Dietary Aide K stated she could have called the cook. During an interview on 2/26/12 at 7:31 PM the Dietary Supervisor stated the dietary aide should have stopped the line, and called her. The Dietary Supervisor further stated she trained her staff constantly. Review of the dietary in-service dated 01/09/12 reflected " Topic: Temp Logs, Food Temps, Sanitations. " " Contents or Summary of Training Session: To ensure staff are educated on proper procedures and policies. " The in-service was presented by the Dietary Manager. A total of 16 of the 18 dietary staff members (including the Dietary Manager) signed as attended, including Dietary Aide K. During an interview on 2/26/12 at 8:35 PM the Wound Care Nurse F stated she was calling up the resident ' s doctors and families to inform them about the concern about the food. When asked were there any resident ' s that were immune-compromised (not able to fight an infection), Wound Nurse F stated Resident #14 was immuno-compromised.. During an interview on 2/26/12 at 8:35 PM with LVN I she stated Resident #14 was fed by CNA J. She stated CNA J told her the resident ate everything. During an interview on 2/26/12 at 8:36 PM CNA J he stated Resident #14 had a sandwich, soup and pasta salad. CNA J stated he ate everything on his plate. Review of Resident #14 ' s face sheet dated 2/27/12 revealed the resident was admitted from the hospital on [DATE] with a suppressed immune system and Diabetes (high blood sugar). Review of the facility ' s undated policy on " Food Prep, Serving and Storing " reflected: " Cold Hold: potentially hazardous foods must be held at 41 degrees or below. Hold on line for serving by placing container of food in a larger and deeper container. Container holding the food must be completely surrounded by ice or ice water to maintain temperature. Stir frequently while serving. During a telephone interview on 03/06/12 at 3:46 PM, A Quality Assurance Officer with the Texas Food Establishment Department with Texas Department of State Health Services stated that with eggs added to the above recipe if increases the risk that the final product of the recipe is potentially hazardous. The Quality Assurance Officer stated the only way to tell is to actually measure the pH of the recipe with a pH meter or to know what the water activity level is. The Quality Assurance Officer stated she would recommend keeping it a temperature below 41 degrees since the pH level or water activity is unknown. The Texas Food Establishment Rules defines Potentially Hazardous Foods as "a food that requires times and temperature control for safety to limit pathogen growth or toxin production." Review of facility ' s undated policy on HACCP Information (Hazard Analysis and Critical Control Point) reflected " Critical Control Points: Holding 1.Cold food should be held below 41 degrees Fahrenheit. 4. Temperatures should be taken every ? hour. 5. Food should be discarded if temperature is taken between 41 degrees and 140 degrees. " Review of the dietary in-service dated 01/16/12 reflected " Contents or Summary of Training Session: Food Temperatures. " This in-service was presented by the Dietary Manager. A total of 14 of the 18 dietary staff members (including the Dietary Manager) signed as attended, including Dietary Aide K. The facility Administrator, DON, and three corporate Administrators were notified on 02/26/12 at 9:10 PM that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator submitted the facility's Plan of Removal on 02/27/2012 at 3:00 PM. The facility's Plan of Removal was accepted on 02/27/2012 at 3:45 PM. The facility presented a plan of removal included the following: " A. The facility identified all residents who received food with an elevated temperature. B. The facility stopped immediately further service of food plates to residents in the dining room. The dietary managers served alternate food to residents in the dining room. C.The dietary manager was in-serviced on maintaining appropriate food temperatures before its service to residents. D. Temperature log will be monitored by the Administrator or designee for food temperatures prior to serving residents. E. All residents who consumed the referenced meal were assessed by charge nursing for symptoms of food poisoning F. Dietary food supervisor was in-serviced on the appropriate technique on keeping food temperature at acceptable levels. G. Dietary staff was educated on the technique on maintaining food at the proper temperature prior to serving to residents, and possible adverse effect on residents. H. Nursing staff were in-serviced on recognizing the symptoms of food poisoning. I. Each resident who received the food serving primary care physician was notified. J. All resident ' s responsible parties were notified of above occurrence. K. All residents were placed on the 24 hour nurse monitoring for symptoms of food poisoning for the next 24 hours. L. Required food temperatures were posted by the entrance of the kitchen and the serving areas on the second floor. The surveyor confirmed that the facility did the following: Review of Resident #14 ' s Nursing Assessment and Nurses Notes on Potential Food Poisoning dated 2/26/12, and 2/27/12 revealed the resident ' s temperature was 98.6, and 98.0 (normal) and the resident did not show any signs or symptoms of potential food poisoning. Review of Resident #14 ' s History and Physical dated 2/27/12 revealed the resident had been exposed to abnormal temperatures of pasta salad and was without any symptoms. Observation on 2/27/12 at 12:10 in the second floor kitchen revealed DA P and DAQ took the food temperatures from the steam table. They were: pork chops 160 degrees, steamed cabbage 168 degrees, puree beans 162 degrees, puree meat 158 degrees, mechanical soft meat 158 degree. Alternatives: fried chicken 150 degrees, peas 208 degrees served without liquid/strained, chicken nuggets 160 degrees, and milk 40 degrees. Review of the new " Food Temperature Monitoring Log " dated 02/26/12 reflected signatures by the facility Administrator for each meal following the dinner meal where the IJ was identified. Review of the in-service dated 02/26/12 at 10:45 PM reflected an in-service given by the Administrator to the Dietary Manager on correct serving temperatures. Review of the in-service dated 02/26/12, as part of the Plan of Removal, reflected an in-service given to dietary staff on food temperatures and temperatures logs. Six (6) of the 18 dietary staff members signed that they were in attendance. On 02/27/12 at 3:53 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service staff and monitor residents for foodborne illness. The facility Administrator reported 51 residents resided on the 2nd floor of the facility and received a regular or mechanical soft diet that did or could have included the pasta salad dish.

Based on observation,interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents when 1 of 12 residents reviewed for transfers and falls was injured during a transfer. Resident #3 sustained an injury to her right knee during a transfer causing swelling and increased pain when the Certified Nurses Assistant failed to identify the risks and hazard of performing an inappropriate transfer. This deficient practice has the potential to cause an avoidable accident to any resident requiring assistance and supervision with a transfer in the facility. The findings include: Review of Resident #3's face sheet reflected a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS (Minimum Data Set) dated 08/23/10 documented Cognitive Skills: 2 Moderately impaired. Review of Resident #3's Plan of Care documented 05/24/10: Resident requires total assist with two persons, with transfers due to partial weight-bearing related to CVA (Cerebral vascular accident) with right hemiparesis. She is at risk for decline. Goal: Will show minimal-no injuries related to transfer within 90 days (11/24/10) Approaches:Give verbal cues during transfer as needed. Monitor for injury after transfers, if noted report injury to charge nurse. Review of Resident #3's Fall Risk assessment dated [DATE] indicated a score of 12. (10 or above represents High Risk.) During an interview on 11/10/10 at 4:15 PM, Resident #3 stated she called for assistance to go to the bathroom. "The girl was going to take me, she had no one to help her. she couldn't lift me by herself and I fell on the floor. She let me go slowly and I landed on my right knee. I felt like a pulling in my knee. She went to get help and they got me up. She did not put my shoes on." When Resident #3 was asked by the Surveyor if CNA I used a gait belt she replied "no" "My leg was hurting real bad, I had 4 days of pain. Review of Resident Accident or Incident Report documented date 10/25/10 at 8:00 AM, Resident #3 reported to staff she had a fall on the 2:00 to 10:00 PM shift during a transfer on 10/24/10. No fall reported to Night Nurse. Assess no trauma injury noted. Complaint of pain to right leg. APAP given for pain. Director of Nurses notified and investigation in progress. Final outcome: 10/28/10 4:00 PM Resident continues to complain of pain to right knee, ice packs and pain medication administered as ordered. X-ray results no fractures noted. Continuing to monitor. Review of Witness Statements: CNA H "I went in the room to get Resident #3 up and she made a face like she was in pain, when I moved her leg. I asked her what was wrong and she said that the aide dropped her the night before. I immediately reported it to the nurse." CNA I "On Sunday, October 24 th,2010, while I was transferring Resident #3 from her chair to her bedside commode, I had to sit her on the floor. I did not put her shoes on while transferring and she slid on the floor. I told Resident #3 I would have to put her on the floor which I did and I called immediately my co-worker for help." CNA J "As I was helping (another resident) the CNA I came into the room asking for help and telling me that she had tried to help Resident #3 to the commode. When I went into the room she was in a sitting position on the floor. I asked what happened she said "when I picked her up she started to slide so I gently put her on the floor." So I told CNA I okay, lets get her in her chair. So CNA I and I got her into her chair. Then I went back to work and failed to report the incident to the nurse. Review of a facility Accident Investigation Report dated 10/25/10 documented: Nature of injury-eased down on the floor. Comments from resident: "at the first time interview, Resident stated that CNA (Certified Nurses Assistant) tried to get her up and she fell . Then she called another CNA to get her up. On the second interview when Resident was asked if the CNA made her fall or eased her down, she stated eased me down. Recommended Inservices: Inservice staff about need to follow and use proper transfer technique on Residents' according to their ADL (Activity Daily Living) sheet and the need to notify Charge Nurse immediately if resident had a fall or eased down on the floor. Outcome of investigation: Resident reported that she had a fall the day before. CNA on that shift were interviewed and CNA tried to transfer resident X 1 but she couldn't do it and eased Resident on the floor, didn't notify charge nurse because she eased her on the floor, she didn't fall. X-ray negative. Review of Resident #3's ADL Flowsheet dated 10/10 documented transfers TC (=total care-resident did absolutely nothing for self, staff did everything. Number of staff required =2. During an interview on 11/10/10 at 9:45 AM, the DON (Director of Nurses) stated CNA I informed her she had eased Resident #3 to the floor, she did not drop her. The DON stated CNA I was suspended for 1 day following the incident and pending investigation. The DON stated she would expect a CNA to report any accidents to the Charge Nurse immediately. The DON stated the transfer status of a resident is listed on the ADL (Activities of Daily Living) sheets. The DON stated CNA I did not review the ADL sheet for Resident #3. During an interview on 11/10/10 at 2:10 PM CNA J.stated her and CNA I went to get Resident #3 onto the commode. CNA J stated she had to answer another call light going off, she told CNA I to wait for her because Resident #3 was a 2 person transfer. CNA I came to her and told her she tried to transfer Resident #3, could not hold her, so she slid her to the floor. CNA J stated this was the first time CNA I transferred Resident #3. CNA J stated she neglected to report the incident to the nurse because it slipped her mind. CNA J stated the transfer mode of a resident is documented in the ADL sheets. CNA J stated she did not think CNA I looked at the sheet, she does not usually work as a CNA, she generally works an a Medication Aide. During an interview on 11/10/10 at 2:25 PM, CNA I stated she did not put Resident #3's shoes on and when she tried to transfer her, she started to slide. When asked by the Surveyor if she knew Resident #3 was a 2 person transfer, she replied "no, this is the first time I have worked with her. Her roommate can stand, I heard that she could too. CNA I stated she did not report the incident. A review of CNA I personnel file did not reveal any training. On 11/11/10, the DON provided an CNA Orientation Skills Check off list dated 10/05/08 and an inservice sheet dated 10/25/10 including a title Lifting, Transferring and Body Mechanics. The in-service sheet was attended and signed by CNA I. There were no other training forms provided. A review of an Employee Counseling Report dated 10/25/10 documented CNA I failure to report to charge nurse that a resident was eased onto the floor. Failure to follow correctly what ADL or Care Plan indicated about resident's transfer which cna put resident in danger. The report was signed by CNA I. A review of a facility policy dated 08/10 Transferring a Resident, Bed to Chair, Chair to Bed documented the following: Preparation: Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure: Note: Verify the amount of assistance that the resident requires prior to performing this procedure. f. Assist with or dress the resident (Note: unless otherwise indicated, this includes socks and shoes.) g.If the resident cannot stand alone, two persons (one on each side) should apply belt, hold it firmly, gently stand and turn the resident, and sit him in the chair. Review of a facility policy (undated) Accidents and Incidents-Investigating and Reporting documented the following: 1. Reporting of Accidents/Incidents: a. The nurse supervisor/charge nurse should be immediately informed of accidents or incidents so that medical attention can be provided. b. An employee witnessing an accident or incident involving a resident should report such occurrence to his or her immediate supervisor as soon as practical. c. Regardless of how minor an accident or incident may be, including injuries of an unknown source, it should be reported to the department supervisor as soon as such accident/incident is discovered ore when information such incident is learned. The facility census was 193 per Administrator.