Every finding on record at Hessmer Nursing and Rehabilitation Center

Based on observations, interviews and record review, the facility failed to ensure support personnel were competent to safely and effectively carry out the functions of the food and nutrition service. This deficient practice had the potential to affect the 75 residents who were prepared and served meals from the kitchen. Findings: Review of the facility's undated policy entitled Dietary Daily Functions revealed, in part . dietary staff preparing meal trays to be served to residents are to check all menu items to determine the correct serving utensil. Dietary staff are to monitor and record the parts per million (ppm) of sanitizer solution in the 3-part sink. 200ppm is desired. Observation on 02/03/2025 at 10:59 a.m. revealed S9 DS incorrectly monitoring ppm of sanitizing solution by inserting the testing strip into the sink used for washing, rather than into the sink used for sanitization. Interview with S8 DM on 02/03/2025 at 11:42 a.m. revealed S9 DS was responsible for monitoring ppm of sanitizing solution. Review of sanitization log on 02/03/2025 at 11:55 a.m. revealed ppm of sanitization solution in sanitization sink had been recorded three times per day since 01/01/2025. S8 DM confirmed the ppm of the sanitization solution had been documented below the acceptable concentration for every entry in the sanitization log. S8 DM confirmed sanitization solution should be at least 200ppm to safely and correctly sanitize dishes. Review of employee training records for S8 DM, S9 DS, S11 DS, and S12 DS revealed no documentation of training specific to tasks performed by dietary staff to ensure they can safely and effectively carry out the functions of the food and nutrition service. Observation on 02/05/2025 at 10:45 a.m. revealed three entries in the sanitization log on 02/04/2025 and one entry on 02/05/2025. All four entries documented sanitization solution ppm below the acceptable range for dishes to be safely and correctly sanitized. Interview on 02/05/2025 at 12:00 p.m. S8 DM confirmed the sanitization log reveals there was unacceptable sanitization solution in the sanitization sink on 02/04/2025 and 02/05/2025. S8 DM confirmed there is no established or documented training process to ensure dietary staff are competent. S8 DM confirmed there is no established or documented training process to ensure dietary staff can safely and effectively carry out the functions of the food and nutrition service. Interview on 02/03/2025 at 11:36 a.m. with S9 DS revealed the scoop size for each menu item served was whatever she chose. S9 DS confirmed she did not refer to the menu when selecting the scoop sizes for serving food to residents. S9 DS confirmed she did not know if she was serving each resident 3 ounces of sausage. S9 DS confirmed she was not serving each resident the same amount of sausage. Interview on 02/03/2025 at 11:36 a.m., S8 DM confirmed incorrect serving utensil size was used to serve pureed peas, and sausage to residents for the 02/03/2025 lunch meal service.

Based on observations, interviews, and record review, the facility failed to provide each resident with a nourishing diet that met his or her daily nutritional needs. This deficient practice had the potential to affect the 75 residents who were prepared and served meals from the kitchen. Findings: Review of the facility's undated policy entitled Diet Orders revealed, in part .The facility will serve diets as ordered by the physician. A regular diet contains all food groups and is planned to provide all then nutrients necessary to provide and maintain proper nutrition. For a pureed diet, foods are processed in a food processor. Procedures have been developed to puree food to provide correct and adequate portions equivalent to portions used on regular diets. Review of the facility's undated policy entitled Portion Control revealed, in part .Ladles are sized according to their capacity: 1/4 cup = 2 ounces, 1/2 cup = 4 ounces, 3/4 cup = 6 ounces, and 1 cup = 8 ounces. Scoops are sized by the number: 6 = 2/3 cup, 8 = 1/2 cup, 10 = 2/5 cup, 12 = 1/3 cup, and 16 = 1/4 cup. Observation on 02/03/2025 at 10:34 a.m. revealed the facility was currently on Monday, Week 2 of the approved dietary menu. Review of the menu revealed, in part . Regular Diet and Regular Soft Diet - Lunch serving size 3 ounces, sausage. Regular Pureed Diet - Lunch serving size 1/3 cup sausage, and 1/2 cup peas. Mechanical Soft Diet - Lunch serving size 1/3 cup sausage. Observation on 02/03/2025 at 11:27 a.m. revealed S9 DS used a 1/3 cup green-handled scoop to serve pureed peas when she prepared trays for residents with a pureed diet. S9 DS used tongs to serve 6 to 10 round slices of sausage when she prepared trays for residents with regular or soft diets. Interview on 02/03/2025 at 11:36 a.m. with S9 DS revealed the scoop size for each menu item served was whatever she chose. S9 DS confirmed she did not refer to the menu when selecting scoop sizes prior to serving and preparing meal trays. S9 DS confirmed she did not know if she was serving each resident 3 ounces of sausage. S9 DS confirmed she was not serving each resident the same amount of sausage. Interview on 02/03/2025 at 11:36 a.m., S8 DM confirmed incorrect portion sizes of pureed peas, and sausage were prepared and served to residents for the 02/03/2025 lunch meal service.

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. This deficient practice had the potential to affect 75 residents who were prepared and served meals from the kitchen. Findings: Review of the facility's undated policy entitled Storage: Freezer revealed, in part .label and date all items. Review of the facility's undated policy entitled Storage: Dry Food revealed, in part .keep all containers tightly closed. Observation on 02/03/2025 at 8:48 a.m. revealed a Ziploc bag of thawed sausage links dated 12/26/2024 in the refrigerator. Three grey pans, each containing 4 undated bags of thawed chicken pieces, were in the refrigerator. Thin red liquid was in the bottom of one grey pan. Interview on 02/03/2025 at 8:55 a.m. with S8 DM revealed she had taken the Ziploc bag of sausage and the 12 bags of chicken pieces from the freezer on 02/01/2025 and placed them into the refrigerator to thaw. S8 DM stated when food is removed from freezer and placed into the refrigerator it should be labeled with the date. S8 DM confirmed she did not date the bag of sausage or the 12 bags of chicken pieces when they were removed from the freezer and placed into the refrigerator, but should have. Observation of the facility Dry Storage room on 02/03/2025 at 9:02 a.m. revealed the following items on the shelves for use: An unopened bag of cookies dated 10/17 with a best by date of 06/17/2024 An unopened bag of flake coconut with a best by date of 09/27/2024 Unopened bags of gelatin dated 10/20 with no expiration date or best by date Opened box of prune juice containing (91) 4-ounce cups dated 08/07/2024 with a best by date of 12/04/2024 Opened jar of Italian Dressing dated 1/29/2025. Label read Refrigerate after opening. Opened 10-pound bag of raisins dated 03/13/2024. Opened bag of breadcrumbs dated 01/19. Interview conducted on 02/03/2024 at 9:18 a.m. with S8 DM revealed unused food is discarded on the expiration or best by date. S8 DM revealed food items are dated when received, and when opened. She stated any opened, unused items are thrown away 7 days after they are opened S8 DM stated if an item does not have an expiration date or a best by date, it should be discarded 2 years after the date it was received. Interview with S8 DM on 02/03/2025 at 9:21 a.m. while in the facility Dry Storage room revealed S8 DM confirmed the cookies and flake coconut should have been discarded, but had not been. S8 DM confirmed the dates on the cookies, gelatin and breadcrumbs were incomplete and should include the year, but did not. S8 DM confirmed the jar of Italian Dressing was not labeled with the date it was opened, but should have been. S8 DM confirmed the jar of Italian Dressing was not refrigerated, but should have been. S8 DM confirmed the bag of raisins was not tightly closed, but should have been. S8 DM confirmed the raisins were not discarded 7 days after the bag was opened, but should have been.

Based on interview and record review the facility failed to ensure a resident's right to be free from abuse by another resident, for 1 (#72) of 3 (#28, #35, and #72) residents reviewed for abuse. The facility failed to ensure Resident #72 was not physically abused by Resident #35. Findings: Review of the facility policy titled: Abuse Prevention and Investigation, undated read in part . The facility defines resident abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes hitting, slapping, pinching, and kicking. f. Residents-to-resident abuse allegations will be reviewed and the safety of residents will be ensured. Resident #72 Review of Resident #72's medical record revealed an admitted [DATE]. Resident #72 had diagnoses that included in part . Cerebral Infarction, Muscle Wasting and Atrophy, Generalized Muscle Weakness, Abnormalities of Gait and Mobility, Schizophrenia, and Bipolar Disorder. Review of Resident #72's Quarterly MDS with an ARD of 01/28/2025, revealed a BIMS of 14, indicating intact cognition. Review of Resident #72's Care Plan dated 09/11/2024 revealed in part . A problem of Potential for alteration in psychosocial status. Intervention included: 07/19/2024 at 10:27 p.m. Another resident was hitting this resident with his cane after he became upset with resident over the use of bathroom shared by both residents. Review of Resident #72's Nursing Notes read as follows in part . 07/19/2024 at 10:27 p.m., S4 LPN documented: This nurse noted hollering and cursing from Room A area. When this nurse passed Room A, noted Resident #35 in wheelchair, in doorway of bathroom. Noted Resident #35 with cane raised in right hand, and slowly lowering it as he backed out of the bathroom doorway. Resident #72 then walked out of Room A and reported you need to do something with him! He (Resident #35) hit me with his cane on my shoulder! Resident #72 indicated his top of right shoulder area was hit with cane. Resident #72 assessed for injury with no redness, bruising, or swelling noted. Resident #72 denies complaints of pain and denies hitting head. When asked what had happened, Resident #72 stated I was using the toilet when he (Resident #35) came in. I told him to leave because I was using the bathroom. He started talking at me, but I couldn't understand him. Then he started hitting me on my shoulder with his cane. That's when I came out and told you what happened. Interview with Resident #72 on 02/03/2025 at 10:47 a.m. revealed, in 07/2024 he shared a restroom with Resident #35. Resident #72 stated that he was on the toilet in the restroom when Resident #35 came into the restroom and just looked at him. Resident #72 stated that he told Resident #35 to get out, and asked him what he was doing. Resident #35 did not respond. Resident #72 stated that he cleaned himself and got off the toilet. Resident #72 stated he walked past Resident #35, who was in the doorway of the bathroom, with a cane in his hand. Resident #72 stated that once he was past the doorway, Resident #35 turned around, and hit him (Resident #72) on his shoulder with the cane. Resident #72 revealed that Resident # 35 used a wheelchair, and that he was not using the cane to walk with, but as a weapon. Resident #72 stated that staff heard him say, He in here hitting people with this cane, and came in to see what happened. Resident #72 stated that he had a little pain, but it did not last long, and he refused to go to the hospital to be checked out. Resident #72 stated, I was not hurt. Resident #35 Review of Resident #35's medical record revealed an admitted [DATE]. Resident #35 had diagnoses that included in part . Major Depressive Disorder, Problem related to Social Environment, Problem related to Unspecified Psychosocial Circumstances, Bipolar Disorder, Impulse Disorder, Dementia, and Psychotic Disorder with Delusions due to Known Physiological Condition. Review of Resident #35's Quarterly MDS with an ARD of 12/16/2024, revealed the following: A BIMS of 08, indicating moderate cognitive impairment. Resident #35 had verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others that occurred 1 to 3 days, during the assessment period. Resident #35 had a behavior of rejecting care that occurred 1-3 days, during the assessment period. Resident #35 used a manual wheelchair for mobility. Resident #35 required partial/moderate assistance with toileting hygiene, and required Supervision or touching assistance for changing from sitting to standing position. Review of Resident #35's Care Plan dated 09/13/2024 revealed in part . A problem of History of combative behavior, with interventions that included: 07/19/2024 at 10:27 p.m., Resident #35 was hitting another resident with his cane after he became upset with Resident #72 over the use of bathroom shared by both residents. Review of Resident #35's Nursing Notes revealed the following in part . 07/19/2024 at 10:27p.m., S4 LPN documented: When asked what had happened, Resident #35 shook his head and denied having hit resident #72. Resident #35 became upset with staff, and fussed at, and cursed at staff. Residents separated and cane removed. Physician notified at this time of incident. New order noted at this time to move Resident #35 to empty bed on secured unit, and monitor one-on-one until psych placement. Resident #35 assisted with move to Room B, and started one-on-one monitoring. On 07/20/2024 at 2:07 p.m.: L/E 7/20/24 - Resident #35 being transferred to behavioral hospital via behavioral hospital transportation. Resident #35 was transferred at 11:30 a.m. Interview on 02/05/2025 at 9:30 a.m. with S2 DON, revealed Resident #35 had a history of behaviors, and confirmed that on 07/19/2024, Resident #35 hit Resident #72 with his cane. Resident #35 was moved to the secure unit and placed on one-on-one monitoring until he was transferred to the behavioral hospital at 11:30 a.m. on 07/20/2024. Interview with S2 DON on 02/05/2025 at 5:50 p.m., confirmed the facility substantiated Resident to Resident Abuse related to the 07/19/2024 incident between Resident #35 and Resident #72.

Based on record review and interview, the facility failed to ensure an allegation of resident to resident abuse was thoroughly investigated for 2 (Resident #72 and Resident #35) of 3 (Resident #28, Resident #35 and Resident #72) residents reviewed for abuse. Findings Review of the facility's undated policy, titled Abuse Prevention and Investigation, revealed the following in part . f. Residents-to-resident abuse allegations will be reviewed, and the safety of the residents will be ensured. Resident # 72 Review of Resident #72's medical record revealed an admitted [DATE]. Resident #72 had diagnoses that included in part . Cerebral Infarction, Muscle Wasting and Atrophy, Generalized Muscle Weakness, Abnormalities of Gait and Mobility, Schizophrenia, and Bipolar Disorder. Review of Resident #72's Quarterly MDS with an ARD of 01/28/2025, revealed a BIMS of 14, indicating intact cognition. Review of Resident #72's Care Plan dated 09/11/2024 revealed in part . A problem of Potential for alteration in psychosocial status. Intervention included: 07/19/2024 at 10:27 p.m. Another resident was hitting this resident with his cane after he became upset with resident over the use of bathroom shared by both residents. Review of Resident #72's Nursing Notes read as follows in part . 07/19/2024 at 10:27 p.m., S4 LPN documented: This nurse noted hollering and cursing from Room A area. When this nurse passed Room A, noted Resident #35 in wheelchair, in doorway of bathroom. Noted Resident #35 with cane raised in right hand, and slowly lowering it as he backed out of the bathroom doorway. Resident #72 then walked out of Room A and reported you need to do something with him! He (Resident #35) hit me with his cane on my shoulder! Resident #72 indicated his top of right shoulder area was hit with cane. Resident #72 assessed for injury with no redness, bruising, or swelling noted. Resident #72 denies complaints of pain and denies hitting head. When asked what had happened, Resident #72 stated I was using the toilet when he (Resident #35) came in. I told him to leave because I was using the bathroom. He started talking at me, but I couldn't understand him. Then he started hitting me on my shoulder with his cane. That's when I came out and told you what happened. Interview with Resident #72 on 02/03/2025 at 10:47 a.m. revealed, in 07/2024 he shared a restroom with Resident #35. Resident #72 stated that he was on the toilet in the restroom when Resident #35 came into the restroom and just looked at him. Resident #72 stated that he told Resident #35 to get out, and asked him what he was doing. Resident #35 did not respond. Resident #72 stated that he cleaned himself and got off the toilet. Resident #72 stated he walked past Resident #35, who was in the doorway of the bathroom, with a cane in his hand. Resident #72 stated that once he was past the doorway, Resident #35 turned around, and hit him (Resident #72) on his shoulder with the cane. Resident #72 revealed that Resident # 35 used a wheelchair, and that he was not using the cane to walk with, but as a weapon. Resident #72 stated that staff heard him say, He in here hitting people with this cane, and came in to see what happened. Resident #72 stated that he had a little pain but it did not last long and he refused to go to the hospital to be checked out. Resident #72 stated, I was not hurt. Resident #35 Review of Resident #35's medical record revealed an admitted [DATE]. Resident #35 had diagnoses that included in part . Major Depressive Disorder, Problem related to Social Environment, Problem related to Unspecified Psychosocial Circumstances, Bipolar Disorder, Impulse Disorder, Dementia, and Psychotic Disorder with Delusions due to Known Physiological Condition. Review of Resident #35's Quarterly MDS with an ARD of 12/16/2024, revealed the following: A BIMS of 08, indicating moderate cognitive impairment. Resident #35 had verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others that occurred 1 to 3 days, during the assessment period. Resident #35 had a Behavior of rejecting care that occurred 1-3 days, during the assessment period. Resident #35 used a manual wheelchair for mobility. Resident #35 required partial/moderate assistance with toileting hygiene, and required Supervision or touching assistance for changing from sitting to standing position. Review of Resident #35's Care Plan dated 09/13/2024 revealed in part . A problem of History of combative behavior, with interventions that included: 07/19/2024 at 10:27 p.m., Resident #35 was hitting another resident with his cane after he became upset with Resident #72 over the use of bathroom shared by both residents. Review of Resident #35's Nursing Notes revealed the following in part . 07/19/2024 at 10:27p.m., S4 LPN documented: When asked what had happened, Resident #35 shook his head and denied having hit resident #72. Resident #35 became upset with staff, and fussed at, and cursed at staff. Residents separated and cane removed. Physician notified at this time of incident. New order noted at this time to move Resident #35 to empty bed on secured unit, and monitor one-on-one until psych placement. Interview with S2 DON on 02/05/2025 at 09:30 a.m., revealed the facility had substantiated resident to resident physical abuse of Resident #72 by Resident #35, that occurred on 07/19/2024. Interview with S2 DON on 02/05/2025 at 5:50 p.m., revealed that monitoring and interviewing of other residents was not completed as part of the alleged abuse investigation, and should have been, to ensure the safety of other residents. S2 DON confirmed other residents were not monitored for Resident to Resident Abuse.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of a hearing aid for 1 (Resident #48) of 42 sampled residents. Findings: Record review of Resident #48 revealed an admitted [DATE]. Review of Resident #48's Quarterly MDS with ARD 12/02/2024 revealed, in part . Section B: difficulty hearing in some environments, Hearing Aid: No. Section C: BIMS score of 15, indicating intact cognition. An interview was conducted with Resident #48 on 02/03/2025 at 02:26 p.m. Resident #48 stated she had difficulty hearing because the batteries were dead in her hearing aids. An interview was conducted with Resident #48 on 02/05/2025 at 02:16 p.m. Resident #48 stated the batteries were replaced in her hearing aids on 02/04/2025. Resident #48 reported having hearing aids for approximately 1 year. An interview was conducted with S15 MDS and S16 MDS on 02/05/2025 at 4:15 p.m. S15 MDS and S16 MDS stated they were responsible for completion of MDS assessments for residents. S15 MDS and S16 MDS confirmed they were not aware Resident #48 had hearing aids. S15 MDS and S16 MDS confirmed hearing aid should be indicated in Section B of the MDS if the resident has a hearing aid. S15 MDS and S16 MDS confirmed Resident #48's MDS should have been indicated for hearing aid, but was not. An interview of S3 Social Services Director on 02/05/2025 at 4:32 p.m. revealed Resident #48 had received hearing aids on 08/03/2023.

Based on interviews and record review, the facility failed to implement a care plan for hearing aid for 1 (Resident #48) of 42 sampled residents. Findings: Record review for Resident #48 revealed an admitted [DATE]. Review of Resident #48's Quarterly MDS with ARD of 12/02/2024 revealed, in part . Section B: difficulty hearing in some environments, Hearing Aid: No. Section C: BIMS score of 15, indicating intact cognition. Review of Care Plan for Resident #48 revealed there was no care plan related to hearing aids. During an interview conducted on 02/03/2025 at 2:26 p.m., Resident #48 stated she had difficulty hearing because the batteries were dead in her hearing aids. An interview was conducted with Resident #48 on 02/05/2025 at 2:16 p.m. Resident #48 confirmed the batteries were replaced in her hearing aids on 02/04/2025. Resident #48 reported having hearing aids for approximately 1 year. During an interview conducted on 02/05/2025 at 4:15 p.m., S15 MDS and S16 MDS stated they were responsible for completion of MDS assessments. S15 MDS and S16 MDS confirmed they were not aware Resident #48 had hearing aids. S15 MDS and S16 MDS confirmed hearing aid should be indicated in Section B of the MDS if the resident has a hearing aid. S15 MDS and S16 MDS confirmed Resident #48's MDS should have been indicated for hearing aid, and placed on the plan of care, and was not. An interview of S3 Social Services Director on 02/05/2025 at 4:32 p.m. revealed Resident #48 had received hearing aids on 08/03/2023.

Based on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The facility failed to provide documentation of a clinical rationale to continue use of psychotropic medications for 1 (#26) of 5 (#13, #22, #25, #26, and #35) sampled resident's reviewed for psychotropic medication usage. Findings: Review of Resident #26's medical record revealed an admitted [DATE] with diagnoses that included in part . Cognitive Communication Deficit, Generalized Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, Unspecified Dementia, Delusional Disorders, and Hallucinations. Review of Resident #26's Annual MDS with an ARD of 12/03/2024 revealed Resident #26 had a BIMS of 01 (Severe Cognitive Impairment). Resident #26 received Antipsychotic, Antianxiety and Antidepressant medications. Review of Resident #26's 01/2025 Physicians Orders revealed in part . Trazodone (antidepressant) 50mg, Give 0.5 tablet via g-tube one time a day for depression Trazodone (antidepressant) 50mg, Give 25mg via g-tube at bedtime for depression Trazodone(antidepressant) 50mg, Give 12.5mg via g-tube one time a day for depression Clonazepam (antianxiety) 0.5mg, Give 1 tablet via g-tube one time a day for anxiety Clonazepam (antianxiety) 1mg, Give 1 tablet via g-tube one time a day for anxiety Clonazepam (antianxiety) 5mg, Give 1 tablet via g-tube at bedtime for anxiety Olanzapine (antipsychotic) 5mg, Give 1 tablet via g-tube at bedtime for depression Olanzapine (antipsychotic) 2.5mg, Give 1 tablet via g-tube one time a day for increased mood behaviors Review of Resident #26's Pharmaceutical Consultant Report dated 09/23/2024 revealed the consultant pharmacist requested the physician to evaluate the use of the following psychotropic medications and to consider a dose reduction; Clonazepam, 1mg daily, Clonazepam 0.5mg daily, Olanzapine 5mg at night, Olanzapine 2.5mg daily, Trazodone 25mg daily, Trazodone 12.5mg daily, and Trazodone 25mg at night. The report read if a dose reduction is not desired, CMS regulations require a clinical rationale as to why a dose reduction is contraindicated, and to provide the clinical rationale as indicated on the form. Review of the Pharmaceutical Consultant Report revealed there was no documentation of clinical rationale provided by physician for continuance of the medications. Interview on 02/05/2025 at 6:10 p.m. with S2 DON confirmed the physician should have provided a documented rationale for continuing Resident #26's psychotropic medications on the 09/23/2024 Pharmaceutical Consultant Report.

Based on observation and interview, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, comfortable and home-like environment by failing to ensure: 1.Residents' room (Room A) maintained in good condition 2.Residents' assistive devices were maintained in good condition for 4 (Resident #25, Resident #52, Resident #64 and Resident #74) of 29 residents sampled for environment. Findings: Resident #52 Review of Resident #52's medical record revealed an admitted [DATE] with diagnoses that included Cerebral Infarction, Type 2 DM, Generalized Muscle Weakness, Abnormalities of Gait and Mobility, Altered Mental Status, Encephalopathy, Cognitive Communication Deficit and Malignant Neoplasm of Left Kidney. Review of Resident #52's Significant Change in Status Assessment MDS with ARD of 11/24/2023 revealed a BIMS of score of 11 indicative of moderate cognitive impairment. Resident required assistance with bathing, bed mobility, transfers and toileting. Observation on 01/30/2024 at 2:45 p.m. in Resident #52's room revealed residents' over-bed table top broken with particle board exposed and pieces of particle board flaking off of the edges. Interview at this time of observation with S6 CNA confirmed the broken over-bed table top with exposed particle board and with a strip of neon green tape raveled and coming off on the edges of the over-bed table. S6 CNA stated all of Resident #52 meals are served in her room and on her over-bed table. S6 CNA noted resident's belongings (cell phone, TV remote, water pitcher, peppermints and a bible) on her over-bed table within her reach. Interview on 01/30/2024 at 3:10 p.m. with S4 LPN revealed Resident #52 is served all of her meals in her room and placed on her bedside table for her to eat. S4 LPN confirmed the above findings and stated he would call maintenance to have the broken top over-bed table removed from her room. Interview on 01/30/2024 at 3:25 p.m. in Resident's room with S7 CNA revealed Resident #52 takes her meals in her room and uses her over-bed table for her tray and to eat her meals. S7 CNA verified resident's belongings, cell phone, TV remote control, water pitcher, individually wrapped peppermint candy and a bible on top of Residents over-bed table within Resident's reach. S7 CNA confirmed Resident's broken table top with exposed particle board pieces flaking off of the edges with a strip of neon green tape over one edge of the over-bed table. Resident #74 Review of Resident #74's medical record with an admitted [DATE] with diagnoses that included: Diffuse Traumatic Brain Injury with Loss of Consciousness of Unspecified Duration, Hemiplegia following Cerebrovascular Disease affecting Left Non-dominant side, Generalized Muscle Weakness, Contracture of Muscle, Left Shoulder and Attention and Concentration Deficit. Review of Resident #74's Quarterly MDS Assessment with an ARD of 11/27/2023 revealed a BIMS score of 05 indicative of severely impaired cognition. Resident with upper extremity impairment on one side and required assistance with bed mobility and dependent with toileting and transfers. Observation on 01/30/2024 at 2:41 p.m. of Resident #74 awake sitting up in bed with head of bed elevated with over-bed table at bedside. Observation of over-bed table top broken around the edges with particle board exposed and with pieces of particle board flaking off of the edges. Interview at this time in Resident's room with S6 CNA confirmed the over-bed table top with exposed particle board around the edges and pieces of particle board chipped and coming off along the edges of the over-bed table. Observation on 01/30/2024 at 3:15 p.m. in Resident #74's room with S4 LPN confirmed the above findings of Resident's broken over-bed table top with exposed particle board all along the edges. S4 LPN stated he would have Maintenance replace resident's over-bed table. Resident #64 Review of Resident #64's medical record revealed an admitted [DATE] with diagnoses that included Vascular Dementia, Severe with Behavioral Disturbances, Acute Kidney Failure, Generalized Muscle Weakness, Cognitive Communication Deficit, Unsteadiness on Feet, Abnormalities of Gait and Mobility and Hypertensive Heart Disease. Review of Resident #64's Quarterly MDS with an ARD of 01/02/2024 revealed a BIMS score of 00 indicative of severely impaired cognition. Resident required assistance with bed mobility and dependent with transfers. Observation on 01/30/24 at 2:35 p.m. of Resident #64 lying in bed with eyes closed. Observation of over-bed table top with particle board exposed around the edges with pieces of particle board chipped. Interview at this time in Resident #62's room with S6 CNA confirmed the broken over-bed table top with exposed particle board on the edges with pieces of particle board chipped on the edges. Interview on 01/30/2024 at 3:20 p.m. with S4 LPN in Resident #64's's room confirmed the above findings. Observation of S4 LPN removed resident's broken over-bed table top with exposed particle board and pieces chipped on the edges to maintenance to replace. Interview on 01/30/2024 at 4:00 p.m. with S5 Maintenance confirmed the broken over-bed table tops with exposed particle board and pieces of particle board chipped off along the edges. S5 Maintenance stated he had removed 17 broken over-bed tables throughout the facility in the same condition that needed to be repaired or replaced. Interview on 01/30/2024 at 4:30 p.m. with S2 DON confirmed the above findings of the broken over-bed table tops with exposed particle board and pieces of particle board chipped on the edges. S2 DON revealed her staff removed 17 over-bed tables in the same condition throughout the facility that were in need of repair or replacement. 31206 Observation of Room A on 01/30/2024 at 1:30 p.m., was occupied by 2 residents. The floor tiles had a large zigzag pattern crack from the door entrance to the window approximately 18-20 feet with cracked and broken tiles near and underneath the residents' beds. Observation on 01/30/2024 at 1:45 p.m. accompanied by S1 Administrator stated she was not aware of the condition of the floor in Room A. S1 Administrator confirmed the flooring in Room A was in need of repairs and/or replacement. Resident #25 Review of Resident # 25's Medical Record revealed she was admitted to the facility on [DATE], admitting diagnoses included Major Depressive disorder, recurrent severe with psychosis symptoms, Hallucinations, Anxiety, and Delusional Disorder. Review of Resident #25's 01/2024 Physician orders revealed an order for up in wheel chair with chair alarm. Review of Resident #25's Annual MDS with an ARD of 12/14/2023 revealed a BIMS of 6 (severely impaired cognition), upper/lower extremity impairment on one side with use of wheel chair. Observation on 01/30/2024 at 1:32 p.m. revealed Resident #25's wheelchair was observed with multiple tears to the right and left arm rest. Interview on 01/30/2024 at 1:35 p.m. with S3 CNA stated the wheel chair is used by Resident #25 for outside appointments and while getting out of bed. Interview with S1 Administrator on 01/30/2024 at 1:45 p.m. confirmed the wheel chair was used by the CNAs to get the resident up and it was in need of repair and/or replacement.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1. Store dishes and utensils under sanitary conditions 2. Ensure food preparation equipment was clean 3. Ensure the kitchen was maintained in sanitary conditions 4. Ensure food, dish washer, and 3 compartment sink, temperatures were performed and recorded. This deficient practice had the potential to affect the 77 residents that received meals prepared in the kitchen. Findings: Observation of the kitchen accompanied by S8 Dietary Manager on 01/29/2024 at 8:10 a.m. revealed: An upright mini 2 compartment refrigerator was noted to have a large amount of dark substance on the top and bottom door gasket, dark rusty film on the upper vents, and door latches with thick caked on bluish/green substance. The following items were noted in the refrigerator: (1) 64 oz. silk almond milk- open undated (1) 32 oz. (ounces) vanilla coffee creamer- open undated (1) 15 oz. bottle ranch salad dressing - open undated (4) sandwiches wrapped in saranwrap undated 12 foot, 2 tier stainless-steel table located next to the steam line was observed to have large amount of trash scattered on the bottom tier, a plastic pitcher, an open box of saltine crackers (undated), yellow tip food thermometer, (2 )12 in. (inch) serving pans sacked inside one another stored wet, (1) 12 in. serving pan with dried brown strings of substances, (3) 7 in. serving pan stacked inside one another with films of white substances inside of each pan, (1) 4 in. square serving pan stored with brown crumbs, (1) 12 in serving pan stored with brown and white crumbs. (1) large gray plastic storage container contained a torn large white trash bag filled with clean white dish towels, was noted to have large amount of toasted bread crumbs in the bottom of the container. (3) tier plastic carts in the dishwashing area was observed to have dark black and brown substance caked in all corners on which clean plates were stored. Ice machine was observed with dark black substance around on door gasket. Ice scoop stored in a dated plastic bag inside of a blue plastic wall mounted container with approximately 12 oz. of dark greenish colored water. 2 tier wooden table with manual can opener attached, bottom tier with large amount of trash, leaves and sticks. Small counter top can opener with greasy film on top surface and lever. Tilt table with large amount of dark black drippings on the sides and back. Dutch oven with large amount of dark thick gel substance on the outside rim, top and bottom doors and handles. Microwave with dried yellow, brown, and white substances on top and bottom surfaces, side panels, and inside door. Large amount of trash on the floor between the stove and behind the oven. Red hose connected to the steam table in a drain covered with paper, gloves, molded bread and packets of single serve butter spread. Red hose in drain near 3 compartment sink was filled with wet pinkish substance and paper wrappings. Review of the temperature and dishwashing log revealed on 01/26/2024 & 01/27/2024 the logs were blank. There were no documented evidences that the food temperatures, dishwasher temperature, and sanitizer were performed. S8 Dietary Manager confirmed the above findings. S8 Dietary Manager stated he had no way of knowing if the temperature checks were performed on 01/26/2024 and 01/27/2024. S8 Dietary Manager confirmed the food and dish temperatures should have been documented and had not been.

Based on record review, observation, and interview the facility failed to ensure residents received adequate supervision to prevent elopement, and failed to supervise an unsafe smoker, for 1 (#1) of 5 (#1#2, #3, #4, #5) residents reviewed for elopement. This deficient practice resulted in an immediate jeopardy situation on 03/13/2023 at 3:26 p.m., when Resident #1 who had a history of exit seeking behaviors, had been identified as a high elopement risk, and was placed on a secured unit, was left unsupervised while outside smoking. Resident #1 wandered off the facility grounds through an unlocked courtyard gate unnoticed by staff. Resident #1 was found by S1 Admin in a field, behind the facility 1/4 of a mile away, and returned, uninjured, to the facility at approximately 3:43 p.m. on 03/13/2023. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility's policy titled Elopement Risk - Resident read in part .the facility will make every attempt to provide adequate supervision to all residents. However, even when all precautions are taken, a resident who is independently mobile may be able to leave the facility grounds without being observed by the staff. 1. Residents are assessed upon admission and at least quarterly for potential elopement risk. 2. If a resident is found to be at risk, the facility will closely monitor the resident's locations and document a visual check at least every 2 hours, in addition the resident may be provided with a security soft bracelet that will identify him or her as a resident of the facility in the event the resident becomes lost. 3. The facility may maintain locked doors so that a code is required to release the doors. Such a system is automatically unlocked in the event of a fire. 4. At the direction of the Administrator, the facility may post, in an inconspicuous yet known to staff location, a list of residents who need to be watched closely for potential elopement. This watch list would also be available in the nurse's stations. Review of the facilities Elopement - Missing Residents policy read in part . As soon as a resident is determined to be missing, the charge nurse will immediately do the following: 1. Assign all available staff to systematically search the entire premises, both inside and outside, patient rooms, bathrooms, closets, kitchen, lobby, and offices. 2. Notify the Administrator and /or Director of Nursing. 3. Assign staff to search around the facility a radius of one mile during the first 30 minutes. This should include searched by vehicle and on foot. When the resident is located, contact an ambulance if injuries are apparent, or if the resident has been exposed to extreme heat or cold weather. Otherwise, return the resident to the facility where the charge nurse will: 1. Examine the resident and provide first aide or request medical attention as needed. 2. Completed and file an incident report; and 3. Document the incident in the resident's medical record 4. Documentation must be concise and reflect the actual facts as they relate to the incident including: a. Times b. Persons contacted c. Condition of resident upon return to the facility d. Physician notified e. Physician orders f. Treatment indicated g. Any other pertinent information. 8. The Administrator will be responsible to review the safety procedures of the facility for needed changes. Resident #1 Review of the medical record for Resident #1 revealed an admitted [DATE], with diagnoses that included: Alcohol Dependence with Alcohol Induced Persisting Dementia, Nicotine Dependence, Vascular Dementia, Psychotic Disturbances, Mood Disturbance, Impulse Disorder, Wandering, Delusional Disorder, Psychotic Disorder with Delusions, Hypertensive Heart Disease and Peripheral Vascular Disease. Review of the facility's Elopement Risk assessment dated [DATE] revealed: Resident #1's contributory factors include poor safety judgement, Dementia, memory impairment, and decline in cognitive skills. Resident #1's potential elopement risk factors included: expressed desire to go home, wanders aimlessly, wanders/seeks to find family members and ambulates independently without assistive device; therefore, Resident #1 is considered at high risk for elopement. Review of Safe Smoking Assessment completed on 03/09/2023 revealed in part .Resident #1 required constant staff supervision while smoking due to a diagnosis of Alcohol Induced Dementia and potential for elopement. Review of Resident #1's Quarterly MDS with an ARD date of 02/08/2023 revealed a BIMS score of 03, which indicated he has severely impaired cognition. The MDS revealed Resident #1 required limited assistance with bed mobility, transferring, and locomotion on the unit, and extensive assistance with locomotion off the unit, dressing and personal hygiene. The MDS assessment revealed Resident #1 had wandering behavior that occurred 1-3 days during the review. Review of Resident #1's physician's orders dated 05/2023 revealed in part . 02/01/2023 - May admit to the secured care unit 02/01/2023 - Resident is considered to be an unsafe smoker an requires staff supervision at all times while smoking. 03/15/2023 - Census check every hour related to elopement. 03/29/2023 - Trazadone 50mg tablet 1 by mouth at bedtime. Diagnosis: Insomnia with behaviors of sleeplessness and pacing. 04/25/2023 - Chlorpromazine 25mg tablet 1 by mouth at bedtime. Diagnosis: Ineffective Impulse Control and Delusional Disorder with behaviors of constant wandering. Review of Resident #1's care plan with a target date of 05/28/2023, revealed Resident #1 needed close supervision due to the following: a diagnosis of Alcohol Induced Dementia with a history of wandering, sleeplessness, pacing, and exit seeking behaviors stating he wants to go home while pushing on exit doors. Interventions included: Secured unit, census check every hour, Id Bracelet for safety in case of elopement, Supervision with smoking at all times while outside and secured/coded exit doors. Review of a nurse's note written by S3 LPN on 03/12/2023 revealed Resident #1 was up until 1:00 a.m. wandering, pacing by the exit doors, asking to go home and trying to go into other resident's rooms. Resident refused to fall asleep in his bed, and eventually fell asleep in his recliner. An interview on 06/05/2023 at 8:20 a.m. with S1 ADM revealed the facility hired carpenters to work on the showers on the secure unit on 03/13/2023. S1 ADM revealed that she gave a key fob to the gate near the secured unit, to construction workers for easy access in and out of the unit after educating them to ensure the gates and doors were closed and locked at all times. S1 ADM stated the carpenters did not close the gate properly while working in the utility trailer right outside the facility gate. Resident #1, who was left smoking unsupervised outside in the courtyard, eloped through the unlocked gate. S1 ADM stated that she was notified by staff that Resident #1 was missing and all staff began to search. She stated that she located Resident #1 in a field, behind the facility, 1/4 of a mile away. S1 ADM stated Resident #1 was uninjured, and told her that he was going to his mom's house in another town. S1 ADM stated Resident #1 has been on the locked unit since being admitted to the facility due to health issues and risk for elopement. An interview on 06/05/2023 at 11:30 a.m. with S2 DON revealed that she was in the office with S1 Admin when S5 CNA notified them via telephone that Resident #1 was missing. S2 DON stated staff checked the courtyard gate and it was not locked. S2 DON stated she was notified at 3:43 p.m. by S1 ADM that she located the resident in a nearby field. S2 DON stated Resident #1 was assessed after he was returned to the building and was noted unharmed. S2 DON stated she and S1 ADM reviewed the facility cameras and noted that Resident #1 was taken outside to smoke by S5 CNA at 3:15p.m. At 3:24 p.m., S4 LPN observed Resident #1 outside alone, finishing smoking his cigarette. S2 DON stated at 3:26 p.m. S5 CNA went back to check on Resident #1, and he was not in the courtyard area. At 3:28 p.m. S1 ADM and S2 DON were notified that Resident #1 was missing and the search began. At 3:43 p.m. Resident #1 was brought back to the building after being located in a field 1/4 of a mile away. An interview on 06/05/2023 at 9:28 a.m. with S4 LPN revealed that she was the nurse on duty for the secure unit the day the incident occurred. S4 LPN stated S5 CNA escorted Resident #1 out to smoke in the courtyard area while S5 CNA sat inside the door watching the residents smoke. S4 LPN stated she notified S5 CNA that Resident #1 was not finished smoking, then went back onto the halls. S4 LPN stated a few minutes later, S5 CNA noted that Resident #1 was not in the courtyard, then called the S2 DON and notified all staff to start looking for Resident #1. An interview on 06/05/2023 at 12:40 p.m. with S5 CNA revealed that she let Resident #1 out to smoke by the back door unsupervised. S5 CNA stated that she sat in an area in the dining room where she could see the smokers outside and residents in the dining room. S5 CNA stated when S4 LPN came back from med pass, she notified S5 CNA that Resident #1 was still outside smoking. S5 CNA stated after helping another resident in the dining room, she went to the door to let Resident #1 inside, and he was not there. S4 LPN stated she looked around for Resident #1 and couldn't find him inside or in the courtyard area, then noticed the gate was open. S4 LPN stated she immediately called S2 DON and all staff began searching. Review of a statement written on 3/13/23 by S4 LPN read on part .At 3:15 p.m. Resident #1 was let out to smoke. Resident #2 knocked on the door to come back inside. Resident #1 was sitting on chair with his back against window. At 3:29 p.m. Resident #1 reported missing from yard - noted gate was opened (per construction workers). Resident was noted leaving the yard at 3:28 p.m. by surveillance cameras. Resident was located and returned to NH at 3:45 p.m. Family made aware. 2 scratches noted to right lower leg. No broken skin. Review of a statement written by S5 CNA on 3/13/23 read in part .I let Resident #1 out to smoke around 3:10 p.m. When I went back to check on him and yelled his name 5 times, then realized the back gate was open. I alerted the nurse immediately and called the DON. Observation on 06/05/23 9:20 a.m. revealed the door to secure unit was locked. Surveyor was let in the door by staff member using a key fob. The door to the courtyard area was locked. Staff member observed opening door using key fob. The gate in the courtyard area was locked with a sign stating gate is only to be used for emergencies. Observation on 06/05/2023 1:00 p.m. revealed S6 CNA checked the outside gate, then went to the nurses station to get residents' cigarettes and lighter. S6 CNA signed Resident #1 and Resident #2 out on the smokers' sign out log. S6 CNA was observed applying Resident #2 smokers apron, then brought Resident #1 and Resident #2 outside to the gazebo area. S6 CNA was observed in the gazebo the entire time Resident #1 and Resident #2 were smoking. An interview on 06/05/2023 at 1:05 p.m. with S7 CNA revealed that while caring for Resident#1, she has observed him standing by the exit doors of the secure unit pushing them to try to get out. S7 CNA stated she is aware that Resident #1 is not to go outside by himself. S7 CNA stated since the elopement with Resident #1, she checks the courtyard gate and signs prior to taking Resident #1 outside. S7 CNA stated she was in-serviced on elopement which included ensuring gates and doors are locked, and safe smoking practices. An interview on 06/05/2023 at 2:52 p.m. with S8 CNA revealed that she is an agency CNA, and has worked at the facility numerous times including the locked unit. S8 CNA revealed that she worked the secured unit the day the elopement took place. S8 CNA stated that she was in-serviced on elopement and safe smoking practices. S8 CNA stated that she was made aware of which residents are high risk for elopement and unsafe smokers by the off going nurse and aides during report. An interview on 06/06/2023 at 8:15 a.m. with S9 HSK revealed that she provides housekeeping on and off the locked unit. S9 HSK revealed that the door is always locked and she has to use the key fob every time she wanted to come on and off the unit. S9 HSK revealed that she has to go outside of the locked unit and clean the gazebo area, and denied seeing a resident outside the locked unit by themselves, recalling that there is always a staff member present. An Interview on 06/06/2023 at 10:10 a.m. with the facility's NP revealed that Resident #1 has a diagnosis of Alcohol Dependence with Alcohol Induced Persisting Dementia, with behaviors of aggression, insomnia, exit seeking to find family members, and wandering into other resident's rooms. The NP stated after several medication adjustments, she feels like Resident #1's behaviors are better managed with the current regimen that is in place at this time. The NP stated that Resident #1 is the most stable that he has been since admission. The NP stated he will wander during the day, but is able to be redirected and is sleeping better at night at this current time. An interview on 06/06/23 at 9:45 a.m. with S10 Maintenance Supervisor revealed he was present on the day Resident #1 eloped. S10 Maintenance Supervisor stated he assessed the gates the day after the elopement, and found no issues. S10 Maintenance Supervisor stated after the elopement, he is responsible for monitoring the gates twice daily to ensure they are closed, and the magnetic hinges are working properly. S10 Maintenance Supervisor stated that he added a top hinge and a resistance hinge on the gate so that the gate would spring closed once it has been opened. S10 Maintenance Supervisor stated that a gate company installed the magnetic security system on the gate, and will maintenance the gates if there are issues that arise that the facility cannot fix. S10 Maintenance Supervisor stated if the electricity goes out, the generator kicks in and will supply electricity to the courtyard gates. An interview on 06/07/2023 at 11:10 a.m. with S2 DON revealed she counseled and gave S4 LPN and S5 CNA a formal write up for bringing Resident #1out to smoke and leaving them outside unsupervised, after the elopement incident was investigated. An interview on 06/07/2023 at 12:10 p.m. with S11 Corporate ADM revealed she came the day after the elopement incident, and did a walkthrough of what occurred, a root cause analysis, and what we could do to move forward. S11 Corporate ADM stated that giving a vendor a key fob was not in the best interest of the residents especially on the secured unit. S11 Corporate ADM stated she discussed with S1 ADM that from now on all vendors were to go through front door, and should not be given a key fob. An interview on 06/07/2023 at 11:35 a.m. with S1 ADM revealed that management staff have a daily QA where they monitor the smoking log and locked gate log ensuring it being done daily. S1 ADM revealed that a performance improvement project was started regarding elopement immediately after Resident #1 was returned to the facility. S1 ADM stated the first formal QAPI meeting was on 5/29/23 where they continue to assess and ensure elopement and safe smoking practices are being followed and are effective. The facility has implemented the following actions to correct the deficient practice: 1. Immediately got key fob to facility's gates and doors back from Carpenters on 03/13/2023. 2. All gates and doors were immediately assessed to ensure that they were locked and functioning. 3. Resident #1 was assessed after located on 03/13/2023, and placed back on the secure unit. Resident #1 had 2 small scratches to right lower leg. 4. Inservices were immediately started and all staff were in-serviced and reeducated on risk for elopement and safe smoking policy. 5. Risk assessments on all 12 residents who are identified as at risk for elopement were updated to include identifying who these residents are by placing a binder at each nurse's station with a face sheet and picture of the resident. 6. 8 residents at risk for elopement reside on the secure unit. 4 residents at risk for elopement live in the general population. Residents who are high risk for elopement in the general population have hourly census checks. 7. ID bracelets were applied to residents at high risk for elopement. 8. All new employees and agency staff to be in serviced upon hire for risk of elopement and safe smoking practices. 9. Re-educate the staff on Code Pink for missing person. 10. Maintenance director is responsible for daily checks of the gates to ensure it is closed and locked. The checks were monitored 2x daily, once in morning on arrival and again midday for 8 weeks and then daily thereafter. The Administrator is responsible for making sure that the maintenance director has signed each time he checked the gate at the beginning of their shift, and the oncoming nurse was responsible at the beginning of her shift. 11. The nurse will continue to monitor the courtyard gate and document/initial that the gate is locked at the beginning of her shift on the weekends in a log stored in the secured unit's nurses station. The weekend RN will continue to monitor the binder to ensure it is being done. This is an ongoing process with no completion date. 12. A new unsafe smokers monitoring tool for residents on the secured unit was created where staff must sign resident out to take them to smoke. CNAs will continue to check the gate prior to taking any residents out to smoke to ensure that the gate is locked and secured. Residents who smoke are to be signed out at the nurse's station prior to going out to smoke. Staff have been educated that they are not to leave residents unattended outside while smoking. 13. All staff were re-in serviced on 5/31/23 on the elopement and safe smoking policy. 14. Daily QA meetings discussing any behaviors noted for general population residents that may put them at a higher risk for elopement. 15. QA committee will continue with daily QA and Quarterly meeting where they will continue to assess and ensure elopement and safe smoking practices are being followed and are effective. 16. Corporate ADM visits every other week where she goes around to ensure the gates and doors are functional and locked appropriately. QAPI initiated 03/13/2023. The ADM received verbal counseling regarding the elopement incident involving Resident #1. As of 03/17/2023 and once the above interventions were all implemented, the past noncompliance was considered to be corrected.

Based on observation, record review and interview, the facility failed to implement a person-centered care plan for 1 (#11) of 35 sampled residents. The facility failed to administer oxygen therapy as ordered for Resident #11. The total facility census was 89 residents. Findings: Review of Resident #11's Face Sheet revealed diagnoses to include Depression, muscle weakness, Anxiety and COPD. Review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS of 14. Review of Resident #11's Physician's Orders dated 02/2023 revealed in part .an order for oxygen at 3 liters per nasal cannula continuously per concentrator. The order had a start date of 11/12/2022. Review of Resident #11's Care Plan, with a review date of 03/24/2023, revealed the resident required oxygen via nasal cannula continuously due to diagnosis of COPD and Emphysema. Interventions included in part . to administer oxygen as ordered. Review of Resident #11's EMAR dated 02/2023 revealed an entry for Oxygen at 3 liters per nasal cannula continuously per concentrator. The entry was timed to be initialed at 6:30 a.m. and again at 6:30 p.m. The EMAR was initialed daily (02/01/2023 - 02/14/2023) at 6:30 a.m. and 6:30 p.m. and on 02/15/2023 at 6:30 a.m. Observation of Resident #11 on 02/13/2023 at 10:29 a.m. revealed the resident was receiving oxygen at 5 liters per nasal cannula continuously per concentrator. Observation of Resident #11 on 02/14/2023 at 11:27 a.m. revealed the resident was receiving oxygen at 5 liters per nasal cannula continuously per concentrator. Observation of Resident #11 on 02/14/2023 at 2:00 p.m. revealed the resident was seated in the dining room playing bingo with her oxygen concentrator and nasal cannula in place. Resident #11's oxygen concentrator was by her side and was set on 5 liters per minute. Observation of Resident #11 on 02/15/2023 at 8:44 a.m. revealed the resident was receiving oxygen at 5 liters per nasal cannula continuously per concentrator. Observation and interview with S3 LPN on 02/15/2023 at 8:46 a.m. confirmed Resident #11 was receiving oxygen at 5 liters per nasal cannula continuously per concentrator. S3 LPN stated she did not recall how much oxygen the resident was ordered to receive, and she would have to look at her chart. Observation on 02/15/2023 at 8:50 a.m. revealed S1 DON and S3 LPN entered Resident #11's room. S1 DON told Resident #11 that she could not adjust the rate of her oxygen, and that she needed to leave it alone. Interview with S1 DON on 02/15/2023 at 8:51 a.m. revealed she stated the resident should have been receiving 3 liters of oxygen per nasal cannula instead of 5 liters per nasal cannula. S1 DON stated the resident would independently adjust her oxygen per concentrator. During an interview with Resident #11 on 02/15/2023 at 9:00 a.m., the resident was asked if she ever adjusted her oxygen concentrator, and she stated no. Resident #11 stated she wouldn't know where to adjust it or what to turn. Review of Resident #11's Care Plan and Progress Notes dated 02/2023 revealed there was no documentation that she adjusted the flow of her oxygen on the concentrator. Interview with S1 DON on 02/15/2023 at 9:55 a.m. confirmed the resident had a current order for oxygen at 3 liters per nasal cannula continuously per concentrator. S1 DON confirmed the resident's EMAR was initialed twice daily in 02/2023 by nursing staff to reveal the resident was receiving oxygen at 3 liters per nasal cannula. S1 DON confirmed when nurses initial the EMAR, they should ensure the resident was receiving the correct amount of oxygen as ordered.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to properly prevent the development and transmission of COVID-19 for 3 residents (Resident #31, Resident #71, and Resident #81) out of a total sample of 35. Findings: Review of the facility's policy titled Coronavirus Prevention and Response revealed in part . Policy: This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus. 13. IPC practices when caring for residents with suspected or confirmed SARS-CoV-2 infection: b. For asymptomatic residents following close contact with someone with SARS-CoV-2 infection: i. Asymptomatic residents do not require empiric use of transmission-based precautions while being evaluated for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection. The resident should still wear source control and those who have not recovered from SARS-CoV-2 infection in the prior 30 days should be tested as per the testing policy. 14. Resident placement considerations: a. Residents with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room with the door kept closed, if safe to do so, and a dedicated bathroom if possible. i. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. 20. Managing a resident who has been treated for SARS-CoV-2 infection: b. Utilize Symptom-based strategy for discontinuing transmission-based precautions based on severity of symptoms and presence of immunocompromising condition except in rare situations where the test-based strategy is to be considered. Discontinuation of transmission-based precautions on SARS-CoV-2 infection is as follows: i. Symptom Based Strategy: A. Residents with mild to moderate illness who are not moderately to severely immunocompromised: a) At least 10 days have passed since symptoms first appeared and b) At least 24 hours have passed since last fever without the use of fever-reducing medications and c) Symptoms (e.g. cough, shortness of breath) have improved ii. Test-Based Strategy A. Residents who are symptomatic: a) Resolution of fever without the use of fever-reducing medications and b) Symptoms (e.g., cough, shortness of breath) have improved, and c) Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. Documentation of Testing c. The facility will document resident test results in the medical record in accordance with standard for protected health information. Review of the BinaxNOW COVID-19 Ag Procedure Card revealed in part A positive specimen will give two pink/purple colored lines. This means that COVID-19 antigen was detected. Specimens with low levels may give a faint Sample Line. Any visible pink/purple colored line is positive. Resident #31 and Resident #81 Review of Resident #31's POC Test Result Reporting revealed Resident #31's last COVID-19 test was completed on 02/05/2023 with a negative result and Resident #31 had a positive COVID-19 test on 12/27/2022. Review of Resident #81's Departmental Notes revealed in part . 02/11/2023 2:09 p.m. Resident is COVID positive .Contact Precautions due to COVID positive. Review of Resident #81's POC Test Result Reporting revealed Resident #81 tested positive for COVID-19 on 02/11/2023. Interview on 02/13/2023 at 11:12 a.m. with S1 DON revealed she was the Infection Preventionist for the facility. S1 DON reported Resident #81 tested positive for COVID-19 on 02/11/2023 and was placed on transmission-based precautions (TBP) at that time. S1 DON stated Resident #81 remained in the room with Resident #31. S1 DON reported Resident #31 had COVID-19 less than 30 days ago. S1 DON stated Resident #31 tested positive for COVID-19 on 12/27/2022. Observation on 02/13/2023 at 11:31 a.m. outside of Resident #81 and Resident #31's room revealed isolation precaution signs and PPE. The door to Resident #81 and Resident #31's room was open approximately 80 degrees, and both residents were observed in the room eating lunch. Interview on 02/13/2023 at 11:45 a.m. with S2 LPN revealed Resident #81 was on TBP for COVID-19. S2 LPN reported Resident #81 tested positive for COVID-19 on 02/11/2023. S2 LPN stated Resident #81 was is the room with Resident #31. S2 LPN stated Resident #31 tested positive for COVID-19 on 12/27/2022. S2 LPN reported her understanding was that Resident #31 already had COVID-19 in 12/2022, she can test positive within 90 days and that she was already exposed because she was in the room with Resident #81; therefore, she could remain in the room with Resident #81. S2 LPN confirmed the door to Resident #31 and Resident #81's room was open but should not have been due to TBP. Interview on 02/13/2023 at 1:25 p.m. with S1 DON revealed Resident #81 tested positive for COVID-19 on 02/11/2023 and Resident #31 was her roommate at the time. S1 DON stated Resident #31 was not tested after her roommate, Resident #81 tested positive. S1 DON reported Resident #31 remained in the room with Resident #81 because she tested positive for COVID-19 on 12/27/2022. S1 DON stated if it had been any other resident, she would have moved them from the room. Interview on 02/13/2023 at 3:45 p.m. with S1 DON confirmed Resident #31 should have been tested for COVID-19 after Resident #81 tested positive for COVID-19 and moved to a different room. Resident #71 Review of Resident #71's Departmental Notes revealed in part . 02/05/2023 10:52 a.m.Resident's face was flushed with a temperature of 99.6 temporally and thick green mucus noted to night shirt . 02/05/2023 4:50 p.m. Resident tested positive for COVID-19 Isolation Protocol put in place. 02/13/2023 6:17 p.m. Late Entry 02/12/2023 Resident tested negative for COVID-19. 02/13/2023 9:32 p.m. Late Entry for 02/12/2023 10:00 a.m. Notified resident family that resident's COVID swab results are showing a light line on last line of swab. Hard to read for sure. Will leave resident in isolation until the morning and have treatment nurse to swab in the morning to reassure results are negative . Review of Resident #71's POC Test Result Reporting revealed Resident #71 tested positive for COVID-19 on 02/05/2023. Observation on 02/13/2023 at 10:00 a.m. revealed no isolation precautions on Resident #71's door. Interview at that time with S4 Administrator revealed Resident #71 was taken off of isolation precautions 02/13/2023 because Resident #71 tested negative for COVID-19 on 02/13/2023. Interview on 02/13/2023 at 3:45 p.m. with S1 DON revealed on 02/05/2023, Resident #71 had symptoms of COVID-19. S1 DON reported Resident #71 tested positive for COVID-19 and was then placed on TBP on 02/05/2023. S1 DON stated Resident #71 should have been retested on [DATE] and 02/12/2023 but she did not see any documentation of the testing in the Nurses' Progress notes or anywhere else. Observation on 02/13/2023 at 3:55 p.m. of Resident #71's room accompanied by S1 DON revealed Resident #71 was not on isolation for COVID-19. S1 DON reported Resident #71 was taken off of TBP this morning 02/13/2023 after Resident #71 had two consecutive negative COVID-19 tests 48 hours apart. S1 DON stated they were using the Test-Based Strategy of their policy. S1 DON reported Resident #71 was tested [DATE] by S5 Treatment Nurse and was negative. S1 DON stated S5 Treatment Nurse tested Resident #71 on 02/10/2023 and S3 LPN tested him on 02/12/2023 with negative results. S1 DON confirmed there was no documentation of Resident #71's COVID-19 testing on 02/10/2023, 02/12/2023, and 02/13/2023 in his medical record, but there should have been. Interview on 02/14/2023 at 8:50 a.m. with S5 Treatment Nurse revealed the facility was using BinaxNOW COVID-19 Ag Cards for COVID-19 testing. S5 Treatment Nurse confirmed any visible pink/purple colored line on the sample line was considered positive. Telephone interview on 02/14/2023 at 9:08 a.m. with S6 LPN revealed he performed a rapid COVID-19 test on Resident #71 on 02/12/2023 around lunch time, and the result was positive. S6 LPN stated that there was a faint line on the sample line of the test, so he considered this as a positive. S6 LPN further stated he left Resident #71 in isolation. S6 LPN reported if a nurse performs a COVID-19 test, they document the results in a nursing note. S6 LPN stated he did not document Resident #71's test results on 02/12/2023 in the nursing notes until yesterday 02/13/2023. Interview on 02/14/2023 at 10:41 a.m. with S1 DON, regarding the late entry note in Resident #71's Departmental Notes on 02/13/2023 at 9:23 p.m. where it stated the results showed a light line on the last line of the swab, S1 DON stated any line in the sample should be considered positive. S1 DON confirmed Resident #71 should not have been removed from TBP on 02/13/2023 and should have remained on TBP for ten days from 02/05/2023 when he tested positive for COVID-19.

Based on interview and record review, the facility failed to ensure that an alleged violation of misappropriation was thoroughly investigated for 18 ( #3, #5, #14, #25, #33, #40, #47, #53, #56, #63, #65, #66, #68, #73, #77, #81, #232 and #233) of 21( #3, #5, #14, #25, #33, #40, #47, #48, #53, #56, #63, #65, #66, #68, #73, #77, #79, #81, #232 and #233) residents sampled for having narcotic prn pain medications. Findings: Review of a Facility SIMS report dated 03/18/2022 revealed an incident involving S4 LPN possible diverting Resident #48's Schedule 2 narcotics. S4 LPN was placed on suspension on 03/18/2022 and remained on suspension pending complete investigation. Interview on 03/28/2022 at 1:40 p.m. with S2 DON revealed she did not have a Facility Investigation Report on the above SIMS reported incident. She further revealed she had not developed any new policies or procedures or initiated a QA monitoring system to prevent further incidents related to prn narcotics. She further revealed she had no documentation to ensure that the incident did not happen again. Interview on 03/28/2022 at 3:48 p.m. with S2 DON revealed she had been able to obtain documents for Residents #13 and #79 from the shred box. She stated she had been able to piece these together and found that there were issues with these resident's narcotic count sheets. She confirmed at this time there were more residents than these 3 on prn medications. Interview on 03/29/2022 at 9:40 a.m. with S6 LPN revealed that all LPN's rotate care areas every 2 weeks. She stated all LPNs work all areas of the nursing home. Review of documentation provided by S2 DON revealed a total of 21 resident who were prescribed prn pain medications and she had only investigated 3 of the 21. 1. Review of Resident #3's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 01/12/2022 - [MEDICATION(S)] 100 mg/5 ml give 0.25 ml SL q 2 hours prn air hunger or pain 01/27/2022 - [MEDICATION(S)]-Acetamin 7.5 mg/325 mg give 1 po q 6 hours prn pain. 2. Review of Resident #5's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 12/06/2021 - Tylenol #3 1 po q 4 hours prn pain. 3. Review of Resident #13's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 04/24/2020 - [MEDICATION(S)] 50 mg 1 po q 6 hours prn pain, moderate pain 06/27/2021 - [MEDICATION(S)]-Acetamin 5-325 mg 1 po q 6 hours prn pain Review of Resident #13's 3/2022 e-MAR revealed S4 LPN administered [MEDICATION(S)]-Acetamin on the following dates and times: 03/04/2022 at 7:46 a.m., 03/07/2022 at 7:30 p.m., 03/09/2022 at 7:54 a.m. and 03/17/2022 at 12:07 a.m. 4. Review of Resident #14's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 08/22/2019 - [MEDICATION(S)] 50 mg 2 po TID prn pain. 5. Review of Resident #25's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 06/24/2021 - [MEDICATION(S)] HCl 50 mg tablet 1 po q 8 hours prn pain. 6. Review of Resident #33's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 12/17/2021 - [MEDICATION(S)] HCl 50 mg tablet 1 po q 8 hours prn pain. 7. Review of Resident #40's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 09/14/2021 - [MEDICATION(S)] 20 mg/ml give 0.25 ml SL q 2 hours prn air hunger or severe pain. 8. Review of Resident #47's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 02/16/2022 - [MEDICATION(S)] 5-325 mg tablet 1 po q 8 hours prn pain. Review of Resident #47's 03/2022 e-MAR revealed that S4 LPN had given the above medication on the following dates and times: 03/04/2022 at 11:42 a.m., 03/06/2022 at 1:21 p.m., 03/09/2022 at 7:13 a.m. & 5:02 p.m. and 03/16/2022 at 7:28 p.m. 9. Review of Resident #48's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 01/10/2021 - [MEDICATION(S)]/Acetaminophen 10 mg/325 mg 1 po q 4 hours prn pain. Review of Resident #48's 03/2022 e-MAR revealed that S4 LPN had given the above medication on the following dates and times: 03/14/2022 at 4:30 p.m. and 03/16/2022 at 8:40 p.m. 10. Review of Resident #53's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 04/12/2021 - [MEDICATION(S)] HCl 50 mg tablet 1 po q 6 hours prn mild pain. 11. Review of Resident #56's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 12/03/2021 - [MEDICATION(S)] 5-325 tablet give 1 po TID prn moderate pain. 12. Review of Resident #63's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 12/18/2021 - [MEDICATION(S)] 5-325 tablet give 1 q 24 hours prn severe pain. Review of Resident #63's 03/2022 e-MAR revealed S4 LPN had given the above medication on 03/15/2022 at 8:22 a.m. 13. Review of Resident #65's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 04/12/2021 - [MEDICATION(S)] HCl 50 mg po q 8 hours prn pain. Review of Resident #65's 03/2022 e-MAR revealed S4 LPN had administered the above medication on 03/10/2022 at 8:13 p.m. 14. Review of Resident #66's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 12/29/2021 - [MEDICATION(S)]-Acetamin 5-325 mg give 1 po BID 15. Review of Resident #68's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 11/29/2021 - [MEDICATION(S)] 50 mg - 2 po q 6 hours prn pain. Review of Resident # 68's 03/2022 e-MAR revealed S4 LPN had administered the above medication on 03/07/2022 at 7:04 p.m. 16. Review of Resident #73's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 02/22/2022 - [MEDICATION(S)] 20 mg/ml give 0.25 ml SL 17. Review of Resident #77's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 02/01/2022 - [MEDICATION(S)] 50 mg 2 po q 6 hours prn pain 02/01/2022 - [MEDICATION(S)] 7.5-325 mg give 1 po q 8 hours prn moderate pain. Review of Resident #77's 03/2022 e-Mar revealed S4 LPN administered [MEDICATION(S)] on 03/18/2021 at 8:40 a.m. 18. Review of Resident #79's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 03/03/2022 - [MEDICATION(S)]-Acetamin 5-325 mg 1 po q 6 hours prn pain. Review of Resident #79's 03/2022 e-MAR revealed S4 LPN administered [MEDICATION(S)]-Acetamin on 03/04/2022 at 8:36 a.m. 19. Review of Resident #81's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 01/05/2022 - [MEDICATION(S)] HCl 50 mg give 1 po q day prn pain 20. Review of Resident #232's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 03/12/ - [MEDICATION(S)] 20mg/ml solution-Give 0.25mls sublingual Q2hrs prn SOB, Air Hunger, or Pain. 21. Review of Resident #233's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 03/17/2022- [MEDICATION(S)] 10-325mg tablet. Give 1 tablet po every 6 hours prn pain.

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 3 ( #13, #48 and #79) of 21 ( #3, #5, #13, #14, #25, #33, #40, #47, #48, #53, #56, #63, # 65, #66, #68, #73, #77, #79, #81, #232, and #233) residents reviewed for misappropriation of prn narcotic medications. Findings: Review of a Facility SIMS report revealed an incident involving S4 LPN possible diverting Resident #48's Schedule 2 narcotics. S4 LPN was placed on suspension on 03/18/2022 and remained on suspension pending complete investigation. Interview on 03/28/2022 at 3:48 p.m. with S2 DON revealed she was notified by S5 LPN that there had been a new narcotic log sheet for Resident #48 placed in the Narcotic Log Book and it should not have been. S2 DON stated S5 LPN ask her for the old narcotic log sheet and S2 DON was unable to locate the sheet. S2 DON stated she texted S4 LPN and asked her where she had put the old narcotic sheet. S2 DON stated all completely filled narcotics sheets were to be given to her. S4 LPN stated she would locate the sheet when she returned to work. S2 DON stated S4 LPN did not find Resident #48's old narcotic sheet when she returned. S2 DON stated she watched camera footage of S4 LPN in the medication room. S2 DON stated S4 LPN appeared nervous and was frequently going to the shred box. S2 DON stated she was able to obtain and piece together Resident #48's narcotic log sheet. S2 DON stated that Resident #48 had 90+ narcotic medications on his log sheet, she stated she had issued 90 pills on 03/14/2022. The narcotic count S4 LPN had transferred over to Resident #48's new narcotic log sheet was 70. She further revealed she was able to find 4 other residents with the same issue. S2 DON stated she was unsure of how long the issue had been going on because the shredder company picked up monthly. 1. Interview on 03/29/2022 at 9:29 a.m. with Resident #48 revealed he could not remember the last time he had asked for pain medication. Review of Resident #48's Quarterly MDS with ARD of 02/21/2022 revealed the resident had a BIMS of 12 (mildly impaired). Review of Resident #48's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 01/10/2021 - [MEDICATION(S)]/Acetaminophen 10 mg/325 mg 1 po q 4 hours prn pain. Review of Resident #48's 03/2022 e-MAR revealed the resident received [MEDICATION(S)]-Acetaminophen 10 mg/325 mg on the following dates and times by S4 LPN: 03/14/2022 at 4:30 p.m. and 03/16/2022 at 8:40 p.m. Interview on 03/29/2022 at 11:07 a.m. with S5 LPN revealed she reported the suspected narcotic issue pertaining to Resident #48 on Wednesday (03/16/2021). She stated she had worked on Sunday (03/13/2021) and when she reported to work on Wednesday, she knew there was something wrong with Resident #48's narcotic count sheet. She stated she notified S2 DON of the issue. S5 LPN was unable to remember the exact numbers on the narcotic log sheet, but she stated that Resident #48 should not have had a new narcotic log sheet because his was only half full when she left on Sunday. She stated a new narcotic log sheet was started only if the present one was completely full. Interview on 03/28/2022 at 3:48 p.m. with S2 DON revealed she had been able to obtain documents for Residents #13 and #79 from the shred box. She stated she had been able to piece these together and found that there were discrepancies with Resident's #13 and #79's narcotic count sheets as well. 2. Review of Resident #13's 03/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 04/24/2020 - [MEDICATION(S)] 50 mg 1 po q 6 hours prn pain 06/27/2021 - [MEDICATION(S)]-Acetamin 5-325 mg 1 po q 6 hours prn pain. Review of Resident #13's 03/2022 e-Mar revealed the resident received [MEDICATION(S)]-Acetaminophen 5-325 mg on the following dates and times by S4 LPN: 03/04/2022 at 7:46 a.m., 03/07/2022 at 7:20 p.m., 03/09/2022 at 7:54 a.m., and 03/17/2022 at 12:07 a.m. 3. Review of Resident #79's 03/2022 MD Orders revealed the following including: 03/03/2022 - [MEDICATION(S)]/Acetaminophen 5-325 mg 1 po q 6 hours prn pain. Review of Resident #79's 03/2022 e-MAR revealed the resident received [MEDICATION(S)]-Acetaminophen 5-325 mg on the following dates and times by S4 LPN: 03/04/2022 at 8:36 a.m. Interview on 03/29/2022 at 1:28 p.m. with S2 DON revealed she suspected S4 LPN of diverting medications. S2 DON stated S4 LPN reported to work on 03/18/2022 but was sent home after discussions were held concerning Resident #48's prn pain medication with S4 LPN admitting to the allegations.

Based on interview and record review the facility failed to develop and implement appropriate plans of action to correct identified deficiencies following identified incidents of misappropriation of prn narcotic medications. Findings: Interview on 03/29/2022 at 1:28 p.m. with S2 DON revealed she had not initiated or implemented a plan to monitor/correct the allegation of misappropriation of medications that was identified on 03/18/2022 in the Facility's SIMS report. She stated she planned on QA'ing the issue, but was still piecing everything together.

Based on record review and interview the facility failed to properly prevent and/or contain COVID-19 by failing to ensure all staff had obtained an exemption or were fully vaccinated for COVID-19 before providing care or services to residents. Findings: Review of the facility's COVID-19 Staff Vaccination for Providers revealed there were 82 total staff members. 55 of the 82 staff members had been completely vaccinated. 26 employees had been granted an exemption and there was 1 partially vaccinated employee. Review of the facility's employee religious exemption forms revealed there was no signed exemption form for S3 Dietary. Interview on 03/27/2022 at 4:53 p.m. with S2 DON confirmed there was no exemption on file for S3 Dietary nor had she been fully vaccinated. She stated the hire date for S3 Dietary was 03/07/2022.

Based on observation, record review, and interview the facility failed to ensure residents were free from physical restraints by failing to ensure pre-restraint assessments and on-going assessments were conducted prior to the use of side rails as a restraint (#66) and the use of a seat belt (#92) to determine if the devices added increased risks to the resident's safety for 2 of 2 residents reviewed for restraints (#92, #66) out of a total of 21 Stage 2 sampled residents. According to the Resident Census and Conditions of Residents form provided by the facility, the facility's total resident census was 90, of which 4 residents were physically restrained. Findings: 1. Observation of resident #66 on 3/22/2017 at 8:00 a.m. revealed he was sitting in a Geri chair in the day/dining area with a lap tray in place. Observation of resident #66's room on 3/20/2017 at 12:23 p.m. revealed his bed was in a low position with both upper 1/2 side rails in the up position. A fall matt was observed on the floor next to his bed. Review of the Face Sheet revealed an admission date of [DATE] with an admission [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of a physician's letter dated 1/17/17 revealed the resident's family and physician agreed that bilateral side rails (upper and lower) with padding while in bed was in the best interest of the resident for his functional and medical well-being due to repeated falls. Review of Physical Restraint Consent dated 1/30/2017 revealed bilateral 1/2 side rails per family request due to history of frequent falls and resident safety. Further review of the Physical Restraint Consent revealed Medical reason for restraint usage was per family request due to history of frequent falls and residents safety. Review of the physician orders [REDACTED]. Review of notes documented by S3 ADON dated 2/1/17 revealed a meeting was held with the resident's family to discuss concerns related to his falls and the use of bilateral upper and lower side rails for his safety. The notes revealed that on 1/30/17 the physician ordered the use of bilateral upper and lower side rails with padding at all times while in bed per family's request. Review of the Significant Change MDS with ARD date of 2/25/2017 revealed the resident was coded for the use of bilateral 1/2 side rails daily as a restraint. Review of the clinical record revealed the facility had assessed the resident for the use of a geri-chair with a lap tray as a physical restraint; however, there were no assessments documented for the use of the side rails as a physical restraint. Review of the care plan with a goal date of 4/6/2017 revealed a problem of need for bilateral 1/2 upper and lower side rails with padding at all times while in bed (coded as a restraint). Further review of care plan with a goal date of 4/6/17 revealed a problem of high risk for falls related to limited mobility, [MEDICAL CONDITION] drug use, history of fall with subdura hematoma, [MEDICAL CONDITION] and general muscle weakness. The care plan further revealed that on 2/15/2017 the resident's bed alarm was sounding. The resident was found kneeling on soft fall matt, leaning on bed, with the side rails in the up position. The Care Plan revealed no injuries were noted due to the fall. Review of current Nurse Interventions dated from 3/1/17 to 3/21/17 revealed May apply upper and lower 1/2 side rails bilaterally with padding at all times while in bed to aid with repositioning and safety d/t impaired mobility and cognition Family Request. The intervention was initialed by the nurse twice daily. Review of the facility's policy and procedures for application of Physical Restraints revealed the purpose was to assure that each resident was adequately assessed in aspects of well-being prior to use of physical restraining devices in order to identify the least restrictive intervention. The procedure revealed all residents upon admission and prior to application or change in restraint being used will have a Pre-restraining Assessment done. Review of resident #66's medical record revealed there was no documented evidence to indicate a Pre-Restraining Assessment had been conducted to determine the resident's ability to transfer between positions, and if the raised bed rails added risks to the resident's ability to transfer. Further review revealed there was no documented evidence to indicate on-going assessments were conducted related to reduction in the use of side rails as a restraint. Interview on 3/21/2017 at 1:55 p.m. with S5 CNA revealed resident #66 was ambulatory; however, he was very unsteady on his feet. Interview with S5 CNA revealed that when resident #66 was put to bed, the 4 side rails were placed in the up position with the cushion wedged between the rails to prevent the resident from getting out of bed. S5 CNA further stated that the side rails and cushion did not prevent the resident from getting out of bed because he was still noted to climb over the rails and cushion. Interview on 3/22/2017 at 10:07 a.m. with S2 DON confirmed that resident #66 had not received a Pre-restraint Assessment and on-going assessments (per the facility's policy and procedure) for the use of bilateral upper and lower 1/2 side rails with a cushion in place. S2 DON stated the resident should have been assessed by the floor nurse (for the use of side rails as a restraint) with a Pre-restraint Assessment completed prior to placement of the restraint. S2 DON state that resident #66's restraints were applied per family request to keep him from falling out of bed. S2 DON confirmed there was no documentation of a Pre-restraining Assessment and on-going assessment for the use of side rails for resident #66. 2. Observation of resident #92 on 3/20/17 at 10:15 a.m. revealed the resident was seated in a w/c in the day/dining area of the SCU. Further observation revealed the resident to have a self-releasing seatbelt in place. Observation of the resident on 3/21/17 at 1:40 p.m. revealed she was seated in the day/dining area of the SCU. The resident was calm and with a normal affect; exhibiting no behaviors. Further observation revealed the resident with a self-releasing seatbelt in place. Further observation of the resident on 3/22/17 at 7:45 a.m. revealed she as seated at the dining table in the SCU. The resident was in good spirits; smiling and talking. The resident was exhibiting no mood indicators. Further observation revealed the resident to have a self-releasing seatbelt in place. The resident was observed to later be ambulating (wandering), propelling herself per w/c about the day area with the self-releasing seatbelt in place. Review of the Face Sheet for resident #92 revealed [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders revealed an order dated 1/4/17 as follows: May use w/c BID with self-releasing belt with alarm and maintain safety tips on back of w/c to prevent resident from tipping w/c at all times q shift monitor. Review of February and March 2017 MARs revealed the following order was initialed as completed daily: 1/4/17 - May use w/c BID with self-releasing belt with alarm and maintain safety tips on back of w/c to prevent resident from tipping w/c at all times. Monitor q shift. Review of a Pre-Restraining Assessment for the resident revealed the form was blank, had a line drawn through it with NA written on it. Review of the most recent MDS assessment (Quarterly) dated 2/5/17 revealed the resident was coded as not having a restraint device in place. Further review of the MDS assessment revealed the resident's Brief Interview of Mental Status was not scored due to the resident's inability to complete the interview. The resident was assessed to have cognitive deficits as evidenced by the inability to repeat and recall words, and the inability to report the correct year, month and day of the week. The resident was also assessed to have short-term and long-term memory problems, moderately impaired daily decision-making skills, inattention, and disorganized thinking. Review of the January 2017 Nurses' Notes revealed no documentation to indicate the resident was capable of self-releasing the seatbelt. Further reviewed revealed an entry dated 1/4/17 at 11:00 a.m. revealing a new order was received from the physician that the resident may use a w/c BID with a self-releasing belt with alarm. Further review of the entry revealed no documentation of a rationale/medical necessity for the initiation of the device. Further review of the January 2017 Nurses' Notes, and review of the December 2016 Nurses' Notes revealed no documentation of an assessment of the resident for the use of a self-releasing seatbelt prior to the initiation of the device. Interview on 3/22/17 at 10:09 a.m. with S2 DON revealed she thought the resident may have been able to release the seatbelt and that the resident may have released the seatbelt in the past. Interview confirmed a pre-restraint assessment was not done, but should have been completed on the resident prior to placement/initiation of the self-releasing seatbelt. S2 DON stated it was the floor nurses' responsibility to complete the pre-restraint assessments prior to placement of restraints. Further interview confirmed there was also no documentation to include rationale for initiating the self-releasing seatbelt. She stated she would go and check the I&A report and see if there was documentation there. Interview on 3/22/17 at 10:48 a.m. with S6 LPN confirmed she was the nurse who received the order for the self-releasing seatbelt on 1/4/17, and that there was no documentation of an assessment. She confirmed she should have completed the pre-restraining assessment prior to initiating the device. Observation on 3/22/17 at 10:50 a.m. of the resident with S6 LPN revealed the resident was verbally prompted several times by the nurse to release the seatbelt. Further observation revealed the resident not able to release the seatbelt. S6 LPN requested that another attempt be made at a later time. She was instructed at that time to inform the surveyor when she was ready to make another attempt. The nurse never came back to inform the surveyor she was ready to make another attempt.

Based on observation, interview, and record review the facility failed to ensure each residents' drug regimen was free from unnecessary drugs by failing to perform ordered drug dose reductions in a timely manner for 2 (#91, #49) of 5 (#37, #49, #66, #91 and #92) residents reviewed for unnecessary medications out of a total Stage 2 sample of 21 residents. According to the Resident Census and Conditions of Residents form provided by the facility, and dated 3/20/17 the current census was 90, of which 59 residents were receiving psychoactive medications. Findings: 1. Review of resident #91's Face Sheet revealed an admitted [DATE] and [DIAGNOSES REDACTED]. Review of the resident's Additional [DIAGNOSES REDACTED]. Observation on 3/20/17 at 2:00 p.m. revealed the resident awake/alert, sitting on the side of her bed watching television. There were no behavior issues observed. Observation on 3/22/17 at 7:50 a.m. revealed the resident awake/alert sitting, on the side of her bed talking on her cell phone and exhibiting no signs of distress or behavior issues. Review of the resident's Care Plans with a target date of 5/28/17 revealed a plan for Altered Mood State with need the for [MEDICAL CONDITION] Medications, and Risk for side effects of Antipsychotic Drug Use. The approaches included administer antipsychotic medication as ordered and pharmacist to review medications monthly/make recommendations for gradual dose reduction as deemed necessary. Review of a Pharmacy Consultation Report for resident #91, dated 1/4/17 revealed a recommendation for a gradual drug reduction of the medications [MEDICATION NAME] (Antidepressant medication), [MEDICATION NAME] (Antidepressant medication), and [MEDICATION NAME] (Antianxiety medication). The report revealed a handwritten note at the bottom of the letter noting the following: was sent 1/19/17, was returned unsigned, and letter resent on 2/9/17. Further review of a second Pharmacy Consultation report regarding these recommended reductions dated 1/4/17 revealed the reduction was accepted/signed by the MD on 2/27/17 with a new order to reduce [MEDICATION NAME] to 10 mg. Review of the resident's January 2017 physician's orders [REDACTED]. 6/15/16 - [MEDICATION NAME] 20 mg one po daily. Review of the resident's March 2017 physician's orders [REDACTED]. 6/15/16 - [MEDICATION NAME] 20 mg one po daily. 3/21/17 - Reduce [MEDICATION NAME] to 10 mg po daily (Handwritten). Review of the resident's January, February and March 2017 MARs/TARs dated through 3/21/17 revealed the resident was still receiving [MEDICATION NAME] 20 mg one po daily. Review of the resident's February and March 2017 Nurses' Notes revealed the resident was monitored for abnormal behavior and no behavior issues had been documented. Interview on 3/21/17 at 2:30 p.m. with S4 LPN QA nurse revealed gradual dose reductions signed by the MD were picked up from the doctors' offices every Tuesday and Thursday, brought to the facility, and placed on her desk. She confirmed the drug reduction for the resident's [MEDICATION NAME] from 20 mg daily to 10 mg daily was signed by the MD on 2/27/17 and was received in the facility on 3/16/17, but had not been implemented yet. Further interview with S4 LPN QA nurse revealed she would write the new order today (3/21/17) reducing the resident's [MEDICATION NAME] from 20 mg to 10 mg daily after surveyor intervention. Interview on 3/22/17 at 2:15 p.m. with S1 Administrator and S2 DON revealed that according to their Policy on Medication and Treatment Orders, as soon as the facility received a signed drug reduction order from the doctor, the order was to be implemented. 2. Observation and interview with resident #49 on 3/21/17 at 1:45 p.m. revealed the resident was sitting at the dining table in the day area of SCU. The resident voiced no concerns, and was in a good mood. The resident stated she had a good night and day, and had slept well. Further observation revealed the resident's affect was normal and she carried normal conversation with confusion noted. Observation of the resident on 3/22/17 at 7:45 a.m. revealed the resident was seated at the dining table in the SCU. The resident was calm and alert, and exhibited no behaviors. Review of the March 2017 physician's orders [REDACTED]. Review of Pharmacy Consultation Reports revealed a copy of a GDR request dated 1/4/17 for [MEDICATION NAME] 0.5 mg QHS and [MEDICATION NAME] 50 mg daily for delusional d/o. Review of the consultation report revealed handwritten documentation on the letter noting it was sent to the physician on 1/19/17. Further review of the handwritten documentation on the bottom of the form revealed the letter was returned unsigned and was resent to the physician on 2/9/17. Review of the original GDR Pharmacy Consultation Report dated 1/4/17 revealed the physician agreed to the dosage reduction of [MEDICATION NAME] to 25 mg q day. The form had a physician's signature date of 2/28/17. Further review of the form revealed handwritten documentation dated 3/22/17 that the consult report was received with new orders noted to decrease the [MEDICATION NAME] to 25 mg po daily. Review of the February 2017 and March 2017 Nurses' Notes revealed no documentation that the Consultation Report of 1/4/17 was addressed by the facility until on 3/22/17 at 1:50 p.m. The documentation revealed the consult report was received from the physician with an order to decreased the dosage of [MEDICATION NAME] to 25 mg po daily. Review of February and March 2017 MAR indicated [REDACTED]. The resident continued to receive the medication at the 50 mg QHS dosage until 3/22/17. Interview on 3/22/17 at 1:45 p.m. with S4 LPN/QA Nurse confirmed the above. Interview revealed that once the pharmacist completed his monthly reviews, they were given to the DON. She stated the DON would then give them to her and they would go over them, which took about 3 days. She stated the letters were then sent out to the physician's. She stated the process took about 3 weeks normally. She confirmed the consultation report GDR dated 2/28/17 by the physician was received sometime the prior, but she was unable to give an exact date. She stated she just had not gotten to the order to make the change, but would do so this date (3/22/17). Review of the facility's Policy on Medication and Treatment Orders revealed the following: 2. Medication orders and treatment will be administered by nursing service personnel as soon as the order has been received. Interview on 3/22/17 at 2:15 p.m. with S1 Administrator and S2 DON revealed that according to their Policy on Medication and Treatment Orders, as soon as the facility received a signed drug reduction order from the doctor the order was to be implemented.

Based on observation, record review, and interview the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status of a resident, by failing to code a restraint for a resident who was observed to have a self-releasing seatbelt in place, and was unable to release the belt for 1 (#92) of 2 residents reviewed for restraints (#92, #66) out of a total of 21 Stage 2 sampled residents reviewed. According to the Resident Census and Conditions of Residents form provided by the facility, and dated 3/20/17, the facility's total resident census was 90, of which 4 residents were physically restrained. Findings: Observation of resident #92 on 3/20/17 at 10:15 a.m. revealed the resident was seated in a w/c in the day/dining area of the SCU. Further observation revealed the resident to have a self-releasing seatbelt in place. Observation of the resident on 3/21/17 at 1:40 p.m. revealed she was seated in the day/dining area of the SCU. The resident was calm and with a normal affect; exhibiting no behaviors. Further observation revealed the resident with a self-releasing seatbelt in place. Further observation of the resident on 3/22/17 at 7:45 a.m. revealed she as seated at the dining table in the SCU. The resident was in good spirits; smiling and talking. The resident was exhibiting no mood indicators. Further observation revealed the resident to have a self-releasing seatbelt in place. The resident was observed to later be ambulating (wandering), propelling herself per w/c about the day area with the self-releasing seatbelt in place. Review of the Face Sheet for resident #92 revealed [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders revealed an order dated 1/4/17 as follows: May use w/c BID with self-releasing belt with alarm and maintain safety tips on back of w/c to prevent resident from tipping w/c at all times q shift monitor. Review of February and March 2017 MARs revealed the following order was initialed as completed daily: 1/4/17 - May use w/c BID with self-releasing belt with alarm and maintain safety tips on back of w/c to prevent resident from tipping w/c at all times. Monitor q shift. Review of a Pre-Restraining Assessment for the resident revealed the form was blank, had a line drawn through it with NA written on it. Review of the most recent MDS assessment (Quarterly) dated 2/5/17 revealed the resident was coded as not having a restraint device in place. Further review of the MDS assessment revealed the resident's Brief Interview of Mental Status was not scored due to the resident's inability to complete the interview. The resident was assessed to have cognitive deficits as evidenced by the inability to repeat and recall words, and the inability to report the correct year, month and day of the week. The resident was also assessed to have short-term and long-term memory problems, moderately impaired daily decision-making skills, inattention, and disorganized thinking. Review of the Nurses' Notes for December 2016 through January 2017 revealed no documentation of an assessment of the resident for the use of a self-releasing seatbelt prior to the initiation of the device. Review of the January 2017 Nurses' Notes revealed no documentation to indicate the resident was capable of self-releasing the seatbelt. Further reviewed revealed an entry dated 1/4/17 at 11:00 a.m. revealing a new order was received from the physician that the resident may use a w/c BID with a self-releasing belt with alarm. Further review of the entry revealed no documentation of a rationale/medical necessity for the initiation of the device. Interview on 3/22/17 at 10:09 a.m. with S2 DON revealed she thought the resident may have been able to release the seatbelt and that the resident may have released the seatbelt in the past. Interview confirmed a pre-restraint assessment was not done, but should have been completed on the resident prior to placement/initiation of the self-releasing seatbelt. S2 DON stated it was the floor nurses' responsibility to complete the pre-restraint assessments prior to placement of restraints. Further interview confirmed there was also no documentation to include rationale for initiating the self-releasing seatbelt. She stated she would go and check the I&A report and see if there was documentation there. Interview on 3/22/17 at 10:48 a.m. with S6 LPN confirmed she was the nurse who received the order for the self-releasing seatbelt on 1/4/17, and that there was no documentation of an assessment. She confirmed she should have completed the pre-restraining assessment prior to initiating the device. Observation on 3/22/17 at 10:50 a.m. of the resident with S6 LPN revealed the resident was verbally prompted several times by the nurse to release the seatbelt. Further observation revealed the resident not able to release the seatbelt. S6 LPN requested that another attempt be made at a later time. She was instructed at that time to inform the surveyor when she was ready to make another attempt. The nurse never came back to inform the surveyor she was ready to make another attempt. Interview on 3/22/17 at 11:00 a.m. with S7 RN/MDS Coordinator revealed she was responsible for completing the resident's most recent MDS with an ARD of 2/5/17. She stated she did not code the resident's seatbelt as a restraint, because it was self-releasing. She stated that if the device was self-releasing the facility did not code a restraint on the MDS, and that the resident was able to release the device, and she had witnessed her do so. Further interview with S7 RN/MDS Coordinator confirmed she had not documented an assessment of the resident's ability to self-release the seatbelt, and that there should have been some documentation indicating the resident's ability to self-release the seatbelt. Further interview on 3/22/17 at 11:41 a.m. with S7 RN/MDS Coordinator confirmed no documentation of an assessment of the resident's ability to self-release the seatbelt. When questioned as to what she used as her rationale for coding the MDS for no restraint, she stated used her observations of the resident self-releasing the seatbelt to code no restraint on the MDS. Further interview confirmed she did not document any of her observations of the resident self-releasing the device.