Every finding on record at Indigo Manor

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service. Proper food handling and sanitation are essential in healthcare environments serving nursing home residents. Failure to adhere to safe food handling practices may expose all residents consuming food prepared in the kitchen to potential pathogenic risks.The findings include:On 8/19/2026 at 10:41 AM, a tour of the facility's kitchen was conducted with the Culinary Director. The following conditions were observed: A double compartment sink was present, with one compartment covered by a large pan, obstructing use. A spray hose was attached to the sink; the Culinary Director stated it was used by staff to spray dishes. No pedal operated garbage can was present in the immediate handwashing area. The Culinary Director stated the pedal type can was located on the opposite side of the kitchen. The Culinary Director lifted the lid of a large garbage bin next to the sink and confirmed this was the method used by staff during handwashing. The Culinary Director reported ongoing issues with the garbage disposal in the covered sink compartment as well as the disposal in the back of the kitchen.The tour proceeded to the food storage areas, including the walk in freezer and refrigerator: Multiple undated food items were present (cookies, cake slices, covered cups containing a thick substance). (Photographic evidence obtained) Small pools of dark red liquid were noted beneath boxes labeled Italian Style Seasoned Cooked Beef with Seasoned [NAME] Rice and Fresh Prepared Salads. Several outdated food items were stored:- Butterscotch dated 8/11/26- Peas dated 8/9/26- Tuna salad dated 9/9/26- Peaches dated 8/9/26- Pudding dated 7/20/26 Food debris was present under shelves in the refrigerator. A pool of clear liquid was observed on the floor in front of the freezer door. (Photographic evidence obtained)During an interview on 8/19/2026 at 11:05 AM, the Kitchen Manager stated responsibility for food storage, preparation, ordering, and labeling. The Manager confirmed cookies and cakes should have been dated, including unlabeled cups of pureed items. The Manager stated Dietary Aides perform daily cleaning and labeling but acknowledged these tasks had not been completed.At 11:10 AM, the Culinary Director was notified of outdated items and confirmed open food must be labeled. The Director stated foods are labeled for three days, stored for up to seven, then discarded; however, she acknowledged no system exists to prevent use after three days. The Director reported the freezer issue had not occurred that morning, planned to notify maintenance, and stated a prior maintenance request had been submitted in June.A review of the facility's Food Safety/Sanitation Policy (implemented 3/1/20) revealed staff are required to maintain cleanliness and sanitation through adherence to a written, comprehensive cleaning schedule.A review of the Kitchen Sanitation Policy (implemented 3/11/2026) revealed staff are required to maintain kitchen cleaning and sanitation in accordance with a written, comprehensive cleaning schedule.

Based on observations, interviews, and record review the facility failed to ensure that all essential equipment in the kitchen was maintained in a safe operating condition, by failing to clear ice in freezer (on plastic flaps, on floor, and hanging from ceiling and conduits coils); failing to keep garbage disposal from leaking/keeping clean; and failing to have covered drains, unbroken floorboards, and unbroken tiles throughout the kitchen.The findings include:On 8/19/2026 at 10:41 AM, a tour of the facility's kitchen was conducted with the Culinary Director. The following observations were made: A double compartment sink was present, with one compartment covered by a large pan, obstructing intended use. A spray hose was attached to the sink; the Culinary Director stated staff used it to spray dishes. The Culinary Director directed the surveyor to a smaller faucet to be used for handwashing. No pedal operated garbage can was present in the immediate handwashing area; the Culinary Director stated the pedal operated can was located across the kitchen. The Culinary Director lifted the lid of a large garbage bin next to the sink and confirmed it was used by staff during the handwashing process. The Culinary Director reported ongoing issues with garbage disposals in the covered sink compartment and in the back of the kitchen. A pool of clear liquid was present on the floor in front of the freezer door. Clear plastic flaps were covered with ice. Mounds of crushed ice were present on the floor near the door and throughout the freezer. Icicles were hanging from the ceiling and conduit coils. Vents were covered in frost. The interior temperature reading was -11 F.(Photographic evidence obtained.) Garbage disposal seals were leaking, with excess sludge visible on exterior piping. Dark sludge was noted along the rim of the disposal unit. Standing water was present in the sink above the disposal. Uncovered drains, broken floorboards, and damaged tiles were observed throughout the area.At 11:10 AM on 8/19/2026, the Culinary Director was interviewed regarding the freezer conditions. She acknowledged prior issues, confirmed the current condition had not been present earlier that morning, stated she would notify maintenance, and reported submitting a maintenance request in June.At 11:26 AM, observations were made during discussion with the Kitchen Manager: Garbage disposal seals were leaking, with sludge accumulating on exterior piping. Dark sludge remained along the rim of the disposal unit. Standing water was present in the sink above the disposal. The Kitchen Manager stated the disposal had been problematic for months, functioning inconsistently. A sink was covered with a black plastic bag, with multiple fruit flies swarming around it. Uncovered drains, broken floorboards, and broken tiles were present. The Kitchen Manager stated the sink had not been used since January 2026. Upon removal of the bag, a live roach was observed in the sink bowl. When the faucet was turned on, water sprayed from the pipe connecting the sink to the wall.(Photographic evidence obtained.)At 3:05 PM on 8/19/2026, an interview was held with the Maintenance Director. He stated repair notifications are received through the electronic system (TELS) and verbally, and turnaround time depends on the issue. When asked about kitchen maintenance concerns, he reported only one pending repair-the garbage disposal in the dish pit.In a follow up interview at 3:31 PM, after reviewing documentation, the Maintenance Director stated there were no outstanding work orders for the freezer or the garbage disposals.

Based on observations, staff interviews, and review of facility policy and procedure, the facility failed to ensure that its pest control service was effective and free of pests and rodents. Fruit flies, dead bugs, and roaches were observed in the kitchen area. An ineffective pest control program can result in the transmission of disease/infection.The findings include:On 08/19/2026 at 11:16 AM, during a tour of the kitchen, a mixing bowl was observed covered with a black plastic bag. Upon removal of the bag, multiple insect carcasses and miscellaneous food debris were observed inside the bowl.Two windows were observed in the kitchen food preparation area with signs stating, Do Not Open. The window frames and casings for both windows were incomplete, compromising the physical integrity and environmental safety of the kitchen.On 08/19/2026 at 11:26 AM, in the dish pit area, several fruit flies and water puddles were observed. Fruit flies and rust were observed on the handle of the mop stored in the dish area. Fruit flies were also observed on the walls and doors. The Kitchen Manager stated these were drain flies and attracted to bacteria. He confirmed that the area was used for washing plates, cups, and lids used for resident meal service, utilizing a high temperature dish machine.A sink in the same area was observed covered by a black plastic bag. Multiple fruit flies were present on the surrounding walls. Uncovered floor drains, broken floorboards, and broken tiles were observed throughout the kitchen. The Kitchen Manager stated the sink had not been used since beginning employment in January 2026. Upon removing the bag, a live roach was observed inside the sink basin. When the faucet was turned on, water sprayed from the pipe connecting the sink to the wall. Another live roach was observed moving across the kitchen floor and underneath the stove. Several live and deceased roaches were observed between the stove and the beverage machine.A bug zapper was observed behind a door leading to a hallway. The unit was unplugged, and a handwritten note posted near the outlet stated, Do Not Use Top Plug. The Kitchen Manager stated the bug zapper had not been used since beginning employment and was unsure if it worked. He plugged the unit into the lower outlet and the bug zapper immediately illuminated.During interview with the Culinary Director on 08/19/2026, she stated the bug zapper had not been used since beginning employment and she was unsure if it functioned. She referenced the handwritten note advising not to use the outlet. After the Kitchen Manager clarified that only the top outlet was restricted, the Culinary Director observed the bug zapper functioning when plugged into the lower outlet.Record review of the facility's Pest Control Policy, implemented 03/01/2022, revealed that the facility is required to maintain an effective pest control program that eradicates and contains household pests including roaches, ants, flies, mosquitos, mice, and rats. The observed pest activity, structural issues, and sanitation deficiencies were not consistent with the facility's policy.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to maintain sanitary conditions in the cooking area, with significant accumulation of grease buildup, food debris and residue, and heavy soilage on both floor surfaces and equipment. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:A tour of the kitchen was conducted on 2/17/26 at 10:15 am. During the tour the following unsanitary conditions were observed: food residue on equipment and cookware, grease buildup, accumulated debris, and grime on the kitchen floor in and around the cooking area. (Photographic evidence obtained)A follow-up tour of the kitchen was conducted on 2/17/26 at 3:27 pm. The same observations were made of food residue on equipment and cookware, grease buildup, accumulated debris, and grime on the kitchen floor in and around the cooking area. (Photographic evidence obtained)On 2/17/26 at 12:10 pm, an interview was conducted with Employee J, dietary aide, who reported dietary aides and cooks are responsible for stocking the dry storeroom. Employee J confirmed the facility policy around date marking food and discarding after 3 days and explained that the cooks are responsible for cleaning the kitchen and food service equipment daily or after each use. The dietary aides are responsible for cleaning the microwave and ice machine in the nourishment rooms.On 2/17/2026 at 1:47 pm, Employee B, Certified Dietary Manager (CDM) reported the cooks were responsible for cleaning the cook area. The CDM stated her goal is to schedule a deep cleaning by the end of this month; the last kitchen deep cleaning was completed in January 2025. The cleaning schedule includes a list of daily cleaning assignments and assigned deep cleaning. Deep cleaning consists of cleaning bins, cooler racks, wiping walls, and inside and out of seals. She also stated the CDM was responsible for ensuring cleaning was completed daily in the kitchen.On 2/17/26 at 3:38 pm, Employee C, dietary aide, reported the cook was responsible for cleaning their area. The Pot staff clean their area. Dietary aides clean all other areas which include the tray line, scrape carts, clean belt, and mop floor. Cleaning is completed daily. At the start of her shift, duties consist of prep; cleaning; organizing; wipe out refrigerator; scrape/empty food carts; sanitize, rinse, and dry food carts. The same cleaning routine is completed after dinner.On 2/17/26 at 3:52 pm, Employee D, cook, reported the scheduled cook was responsible for cleaning the cook area but all staff should participate and do not. When this happens, he informs the CDM. He stated he was aware that cleaning should be completed daily. A review of the facility's policy and procedure entitled Food Safety/Sanitation, dated: 3/1/2020 revealed Policy: Cleaning and Sanitation of dining and food service areas: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service area through compliance with a written, comprehensive cleaning schedule. (Copy obtained)Reference: FDA Food Code 2022, https://www.fda.gov/media/184685/download?attachment reviewed 2/23/2026, Chapter 4. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observations, interviews, record review, and policy and procedure review, the facility failed to provide fingernail care for one (Resident #3) of five residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 7 residents. The finding include:On 02/17/26 at 10:49 AM, Resident #3 was observed sitting in a wheelchair adjacent to the south unit nurse's station. Several of the resident's fingernails of both hands were observed as jagged and extended approximately 1/2 inch beyond the nail bed. When the resident was asked about his nails, he stated he did not like his nails so long but could not remember if he asked the facility staff to trim his fingernails. (Photographic evidence obtained)A review of Resident #3's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified, type II diabetes mellitus without complications, pseudobulbar affect, chronic kidney disease, stage 2 (mild), and dementia in other diseases classified elsewhere.A review of the quarterly minimum data set (MDS) assessment, dated 10/1/25, revealed the resident had a brief interview for mental status (BIMS) score of 07/15, indicating severe cognitive impairment. No psychosis or behaviors were indicated. A review of his functional status revealed he required extensive to dependent assist with activities of daily living (ADLs). A review of Resident #3's most recent care plan revealed he was care planned for ADL self-care performance deficit related to impaired cognition and functional mobility. The care plan goal noted that the resident will participate in care as able and be clean and well-groomed through next review. Care plan interventions included assisting the resident with ADL care daily including showers, transfers, incontinent care, dressing, bathing, toileting, hygiene, dining; reapproach if care is refused. The resident requires nail care as needed.personal hygiene and is dependent upon staff. The care plan did not contain information related to the resident rejecting care. On 02/17/26 at 11:42 AM, an interview was conducted with Certified Nursing Assistant (CNA) E. After observing Resident #3's fingernails, she confirmed the resident's fingernails were too long and they should have been trimmed. She further explained that resident fingernails are usually trimmed during shower days while fingernails are soft.On 02/17/26 at 12:14 PM, an interview was conducted with Licensed Practical Nurse (LPN) F. After observing Resident #3's fingernails, she confirmed that the resident's fingernails were much too long. She explained that she was familiar with the resident's care needs, which included ADL assistance. She stated that she administered medications to Resident #3 this morning but did not notice the resident's fingernails were excessively long. She further explained that the CNAs usually trim resident fingernails on shower days when the fingernails are softer and easier to trim. On 02/17/26 at 1:12 PM, a second observation was made of Resident #3's resident's fingernails. Both hands were observed as jagged and extended approximately 1/2 inch beyond the nail bed. (Photographic evidence obtained)On 02/17/26 at 1:24 PM, an interview was conducted with Licensed Practical Nurse (LPN) I/Unit manager, who explained that CNAs and nurses are permitted to file resident fingernails.On 02/17/26 at 2:22 PM, an interview was conducted with the Assistant Director of Nursing (ADON), who explained the process to trim resident fingernails. Nurses and CNAs are permitted to trim nails, but if the resident is diabetic, a nurse must trim the resident's fingernails. CNAs are instructed to document shower assistance on a shower sheet, which is kept in a binder at the nurse's station. There is an area on the shower sheet for CNAs to note whether a resident needs to have toenails trimmed, and the CNA must circle the body diagram noting fingernails need attention. A review of shower sheets for Resident #3 lacked documentation showing the resident required attention to his fingernails. A review of Activities of Daily Living (ADL), Supporting Policy (undated) revealed the following: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, and with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a) hygiene (bathing, dressing, grooming and oral care). (Photographic evidence obtained)

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure one (Resident #7) of five sampled residents' room were maintained in a safe, functional, sanitary, and comfortable environment by leaving disposable razors unattended on the resident's bedside table. The findings include:On 02/17/26 at 11:13 AM, two unused disposable razors were observed on Resident #7's bedside table. When asked about the razors, the resident reported that a certified nursing assistant (CNA) brought the razors into his room and abruptly left before providing shaving assistance. He couldn't remember the name of the CNA or whether the incident occurred during the daytime or nighttime shift.A review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, muscle weakness, type II diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, unspecified, chronic systolic (congestive) heart failure, and major depressive disorder.Further record review revealed that Resident #7 is alert and oriented to person, place and time. He communicates verbally, with clear speech and is able to understand others and be understood by others. On 02/17/26 at 12:33 PM, Registered Nurse (RN) G was observed removing two disposable razors from Resident #7's room. She said that the razors did not appear to be facility disposable razors and thought that perhaps a family member brought the disposable razor to the resident's room. She explained that residents are not permitted to keep disposable razors in their room and CNAs should remove razors after providing shaving assistance. On 02/17/26 at 12:53 PM, an interview was conducted with CNA H, who is assigned to Resident #7 and is familiar with his care needs. She explained that she provided care to the resident in his room this morning and did not notice disposable razors on the resident's bedside table. She further explained that residents are not permitted to have disposable razors unattended in their room. If she had seen the razors in his room, she would have removed the razors and reported it to her nurse. On 02/17/26 at 5:20 PM, an interview was conducted with the DON. She reported that razors are not permitted in resident rooms, as anyone could potentially wander into the resident's room and injure themselves. She has informed CNA staff that after providing shaving assistance, they must immediately remove the razor from the resident's room and dispose of the razor in a sharp's container. She makes attempts to educate residents and their families to inform facility staff when they bring personal items to resident's rooms. Facility staff conduct quarterly cleaning of resident rooms and ask families to help remove unnecessary items from resident rooms and inform them of items brought into the facility which were not listed on resident inventory sheets. CNAs have been instructed to immediately inform her if they observe items such as disposable razors in a resident's room. A review of the facility's policy titled, Needlesticks and Cuts, Revision Date: August 2013, documented All personnel must follow our facility's established procedures to help prevent injuries caused by needlesticks, sharp blades, broken glass, or other sharp instruments or devices, and to report all such incidents that occur. (Photographic evidence obtained)

Based on kitchen food service observations, staff interviews, record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to log proper temperatures for the dish machine and chemical sanitization for the 3-compartment sink, and clean food buildup stuck on the back handle and under the safety guard of the mixer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 03/10/25 at 11:07 AM. During the tour, a review of the dish machine temperature logs for January, February, and March 2025, revealed a wash temperature of 140 degrees Fahrenheit (F) and a rinse temperature of 145 degrees F, consistently. Further, a review of the 3-compartment sink, Pot/Pan temperature logs for January (29th, 30th, and 31st), February, and March 2025 revealed chemical sanitation at 190 ppm (parts per million), consistently. Dietary Aide J explained ware washing of the 3-compartment sink and stated the ppm should be 190 followed by 400. Dietary Aide J completed another sanitization test and stated the ppm reading was 200 - 400, and again at 400 - 500. When asked if he had been provided with training on ware washing at the 3-compartment sink, he replied that his last training was four years ago. [NAME] L explained ware washing of the 3-compartment sink and stated, Dishes are air dried and sanitation should be above 150. (Copy obtained) A follow-up tour of the kitchen was conducted on 03/12/25 at 11:30 AM. During the tour, the mixer located next to the oven had brownish-colored food buildup stuck on the back handle and under the safety guard of the mixer. On 3/13/25 at 10:33 AM, the same observations were made again of the mixer located next to the oven with brownish colored food buildup stuck on the back handle and under the safety guard of the mixer. (Photographic evidence obtained) An interview was conducted on 03/13/25 at 10:40 AM with Dietary Aide F. She reported that Dietary Aide staff rotated using the dish machine. She had been assigned to the dish machine for about one month. She was usually assigned to prep, work the tray line, and take resident meal orders using the tablet. Dietary Aide F reported that the dish machine was a high-temperature machine and the wash temperature should reach 104 degrees. Sanitation strips were used to test the dish machine's sanitation. The pot staff were responsible for washing dishes in the 3-compartment sink. She was not sure about the chemical sanitation or what was prepared using the mixer. She stated the mixer had not been used. An interview was conducted on 03/13/25 at 11:02 AM with [NAME] H. She stated Dietary Aides were responsible for use of the dish machine. The dish machine was a low-temperature machine and the temperature should be greater than 120 degrees. The pot washer was responsible for use of the 3-compartment sink. When asked how staff tested for proper chemical sanitation and where that was logged, she replied, Dip the strip in water but she was not sure of the ppm. When asked what was prepared using the mixer, she replied, Nothing, it has not been used since I started one year ago. [NAME] H stated she received training on the dish machine and 3-compartment sink a couple of months ago in January 2025. An interview was conducted on 03/13/25 at 11:08 AM with Dietary Aide I. She stated Dietary Aides rotated working the dish machine. The dish machine was a low-temperature machine with temperatures ranging from 120-140 degrees. Chemical sanitation using test strips should read 50 ppm. The pot washer was responsible for use of the 3-compartment sink. When asked how staff tested for proper chemical sanitation, she replied, Test strips and the ppm should be 50. When asked who was responsible for logging the temperatures on the log, she replied, Whoever is the dish washer. I logged this morning because I was the dish washer. When asked what was prepared using the mixer, she replied, cakes and cookies. She had not seen the mixer used since her employment at the facility, over approximately one month's time. Dietary Aide I stated she recently received training on the dish machine and 3-compartment sink. An interview was conducted on 03/13/25 at 11:16 AM with Dietary Aide J. He reported that Dietary Aides were responsible for the use of the dish machine. Dietary Aide J was not sure what the proper temperature should be to show that the machine was working accurately. He stated he was responsible for washing pots and pans in the 3-compartment sink. He stated he tested sanitation using the test strip and the ppm should be 200. Dietary Aide J was also responsible for cleaning the mixer. He stated meat loaf was prepared last Friday using the mixer. His last training on the dish machine and 3-compartment sink was two years ago. During an interview with the Certified Dietary Manager (CDM) on 03/13/25 at 11:23 AM, the CDM confirmed that the Dietary Aides were responsible for use of the dish machine. When asked how staff tested for sanitation of the dish machine and what the proper ppm was, the CDM replied, Staff should run the dishwasher until it gets up to temperature and test using a test strip. The ppm should be 50. The pot washer is responsible for use of the 3-compartment sink. Use a test strip to determine proper chemical sanitation by dipping the strip in the sanitation sink to compare the strip to the card; it should read 200 ppm. The CDM confirmed sanitation for ware washing was 200 ppm and sanitation for the dish machine was 50 ppm. The cook is responsible for cleaning the mixer after each use. She confirmed the mixer is not a piece of equipment Dietary use on a regular basis; it was last used about one year ago. The CDM provided a copy of the kitchen and equipment cleaning schedule but stated she did not currently have a tracking method to show duties completed. (copy obtained) A review of the facility's policy and procedure titled Procedures for Cleaning Equipment Sanitation (undated), revealed: Procedure for cleaning food mixer. Immediately after use; 1. As soon as the food has been emptied from the mixer, disconnect the electric power; 2. Remove the bowl and beaters to the dishwasher; run through the wash and rinse cycle and air dry; 3. Wash the base of the unit with warm detergent solution; rinse and air dry. Be sure to wash splash-up areas. A review of the facility's policy and procedure titled 3-Compartment Sink (dated 3/1/23), revealed: Food and nutrition services staff must be trained to properly utilize the 3-compartment sink to manually wash, rinse, and sanitize food equipment, dishes, utensils, and removable parts from equipment. Compliance Guidelines: pre-scrape all dishes before proceeding . c. utilizing the Hydrion tester dip a 1-inch piece of the strip in the sanitized water. Compare the color of the strip to the chart in the case. The sanitizer level should be 200 ppm. Record the ppm and initials on the pot and pan log provided. A review fo the facility's policy and procedure titled Low-Temp Conveyor Dish Machine (dated 3/1/23), revealed: Food and nutrition staff must be trained to properly utilize the Low-Temp Conveyor Dish Machine to wash, rinse, and sanitize food equipment, dishes, utensils, and removable parts from equipment. Compliance Guidelines: Pre-scrape all dishes before proceeding . 2. Close the dish machine door and allow the machine to run a complete cycle. Do this a minimum of 2 times to ensure the water is getting hot . 3a. Check machine's temperature gauge is operating while it is running in both the wash and rinse cycles; wash temp of min 120-150 max, rinse temp of min 120-150 max; record the temp on the dish log provided; do not move to the next step if these criteria were not met. Notify Dietary Director, Dietitian, or Kitchen Manager immediately for next step. 4. After the cycle completes test the sanitizer ppm level utilizing a chlorine test strip. 4a. touch the strip to the surface of the plate and compare to ppm chart on the bottle; approved chlorine rate is 50-100 ppm at 120-140 degrees; record the ppm on the dish log provided; do not move to the next step if these criteria were not met. Notify Dietary Director, Dietitian, or Kitchen Manager immediately for next step. (Copy obtained) Reference: FDA Food Code 2022 Page 126. https://www.fda.gov/media/164194/download?attachment (Accessed on 3/14/2025): Chapter 4 Equipment, Utensils, and Linens, 4-6 Cleaning of Equipment and Utensils; 4-601 objective; 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. .

Based on observations, interviews, and record review, the facility failed to provide toenail care for one (Resident #33) of four residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 41 residents. Resident #33's toenails extended approximately one half inch beyond the nailbed and were jagged. The findings include: An observation made on 03/10/25 at 1:43 PM, revealed that Resident #33's toenails extended approximately one half inch beyond the nail bed and were jagged on both feet. (Photographic evidence obtained) An interview was attempted with the resident, but he did not respond. On 03/11/25 at 10:44 AM, Resident #33's toenails were observed and were in the same condition as the previous day's ovservation. They extended approximately one half inch beyond the nail bed and were jagged on both feet. (Photographic evidence obtained) An interview was again attempted with the resident, but he did not respond. During an interview with Certified Nursing Assistant (CNA) B on 03/13/25 at 11:37 AM, she reported that she had been employed by the facility since July 2024 and was familiar with Resident #33 and his care needs. She stated the resident was dependent for ADLs and further explained that she considered toenails extending a half inch beyond the nailbed as too long and that they should be trimmed. She said that while she provided residents' ADL care, she made observations of their personal hygiene needs. If, during provision of care, she discovered a resident had long toenails, she would ask the resident for permission to trim the nails. She would then check the electronic medical record (EMR) to determine whether facility staff were permitted to trim the resident's toenails. If the resident was able to have their nails trimmed by staff, she would use nail clippers, which were located in the clean supply room near the nurses' station. After trimming the nails, she would document it in the task tab of the EMR. When asked if she saw Resident #33's toenails, she stated she did not look at his toes when she recently changed his brief and hospital gown. During an interview with Licensed Practical Nurse (LPN) C on 03/13/25 at 12:00 PM, she stated she had been employed by the facility for three months and was familiar with Resident #33 and his care needs. She stated she considered excessive toenail length as any growth beyond the nail bed. She said that long nails could result in snagging and scratching hazards. She stated while administering medication, if she noticed a resident had long toenails, she would ask the resident for permission to arrange for their toenails to be trimmed. She would then ask Social Services to place the resident on the list for podiatry. She stated even if a resident was not diabetic, facility staff were not permitted to trim toenails. She reported that she did not notice Resident #33's toenail length while recently administering his medication. On 03/13/25 at 12:11 PM, CNA B was accompanied to Resident #33's room to observe his toenails. She verified that his toenails were too long and could be a scratching hazard. During an interview with the Assistant Director of Social Services on 03/13/25 at 1:50 PM, she stated the nurse unit managers notified her when a resident needed to be added to the list for a podiatrist visit. Her process to arrange podiatrist visits for residents included sending an email to the podiatrist's office, and receiving confirmation of when the podiatrist would come to the facility to see the residents. After checking her records, she stated no requests were noted for trimming Resident #33's toenails, and the last time he was seen by the podiatrist was for a routine foot care visit on 05/23/24. A review of Resident #33's medical record revealed an admitted [DATE] and diagnoses including metabolic encephalopathy, diabetes mellitus, diabetic retinopathy, traumatic subdural hemorrhage, other cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia (language disorder affecting a person's ability to communicate) following cerebral infarction, diabetic polyneuropathy, tinea unguium (fungal infection of the nails), age-related cataracts bilaterally, altered mental status, contracture of left elbow, contracture of left hand, and epilepsy. A review of the Minimum Data Set (MDS) assessment for Resident #33, dated 01/17/25, revealed no brief interview of mental status (BIMS) score. The resident had no hallucinations or delusions; no verbal or physical behavioral symptoms directed toward others; and did not exhibit wandering or refusal of care. The resident had impairment on one side of the upper and lower extremities. The resident was assessed as dependent in all selfcare ADLs and received enteral nutrition. All mobility was assessed as either dependent or not applicable. A review of the resident's care plan revealed a focus area for Physical Functioning Deficit related to mobility impairment and range of motion limitations. The care plan goal documented that the resident would receive passive range of motion to the left elbow, left wrist and left hand up to seven days a week through next review. Resident will tolerate left hand and elbow splints up to seven days a week through next review. The resident will maintain his current level of physical functioning and have no complications through next review date. Initiation date was 05/10/22 and revision was 11/19/24. The target date of the care plan was documented as 01/17/25. Interventions included nail care as needed. Initiation date was 08/09/22 and revision was 11/09/22. Interventions also included personal hygiene, dependent with assistance of one. Initiation date was 08/09/22 and revision was 08/23/24. A review of the facility's policy for Activities of Daily Living (ADLs) (implemented: 01/01/2022; date reviewed/revised (blank); reviewed/revised by: (blank) revealed: Policy: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 5. The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on observations, interviews, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision to prevent accidents for one (Resident #7) of three residents reviewed for accidents, from a total survey sample of 41 residents. Resident #7 was discovered keeping smoking materials on self. The findings include: On 03/10/25 at 9:55 AM, an observation was made of Resident #7 holding a cigarette lighter while seated in his wheelchair on the elevator going to the first floor. On 03/13/25 at 10:29 AM, Resident #7 was observed in his room and was interviewed. He reported that he was a smoker and smoked during the 8:00 AM, 10:00 AM, 1:00 PM and 3:00 PM smoking breaks. He further reported that he kept his cigarette lighter in the dresser next to his bed. He became agitated and yelled that the facility could just take his lighter and take it all away. During an interview with the Assistant Director of Nursing (ADON) on 03/13/25 at 10:50 AM, the ADON explained that Resident #7 had been a cigarette smoker for a long time and often asked visitors to borrow a lighter. He would never return it and would then pocket the lighter. The ADON stated the resident often arrived to smoke breaks and produced a lighter from his pocket to light his cigarette. Facility staff continually found the resident with lighters and took them away for safe storage. The ADON further explained that the resident had been informed that he could not keep lighters on himself or in his room, as it posed a safety hazard, yet the resident continued to produce lighters during smoke breaks. During an interview with Certified Nursing Assistant (CNA) D on 03/13/25 at 11:27 AM, she reported she had been employed by the facility since April 2023 and was assigned as the smoking attendant. She explained that the Staffing Coordinator trained her on the facility's smoking policy. She stated safety precautions included only issuing residents one cigarette at a time during smoke breaks. Residents were permitted to smoke two cigarettes during the 15-minute break but they were not permitted to use lighters. She was responsible for lighting cigarettes. Facility staff kept resident lighters and cigarettes in individual plastic bags labeled with the residents' names. The bags containing resident cigarettes and lighters were stored in a bin at the receptionist area. She further explained that safety precautions included smoking bibs for residents assessed as a risk, and oxygen tanks were not permitted in the smoking area. At the end of each smoke break, she emptied ashtrays with cigarette butts in a designated red metal bin, which was not accessible to residents. She reported that if she were to see a resident produce a cigarette or lighter, she would inform the Director of Social Services. If the resident refused or was noncompliant with smoke break rules, she would inform the ADON or DON. She said she did not see Resident #7 with a cigarette lighter. During an interview with the ADON at 2:30 PM on 03/13/25, she explained that she had spoken to Resident #7 numerous times about not using lighters and that they posed a safety risk to the resident. She stated she had reviewed the resident smoking agreement with the resident several times, and the resident continued to be noncompliant with the facility's smoking policy. A review of Resident #7's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance, vascular dementia with psychotic disturbance and agitation, age-related bilateral cataracts, repeated falls, major depressive disorder, other specified persistent mood disorders, and paranoid schizophrenia. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #7 had a brief interview for mental status (BIMS) score of 7 out of 15 possible points, indicating severe cognitive impairment. Verbal behavior directed toward others occurred 4-6 days during the look-back period. The resident had no impairment in upper or lower extremity mobility; used a walker, and was independent in all self-care and mobility. He received antidepressant, antiplatelet and anticonvulsant medications. A review of Resident #7's care plan revealed a focus area for At Risk for Smoking-Related Injury related to: smokes independently during designated times under supervision of facility staff per agreed upon policy. He will keep his own smoking material and does not always adhere to smoking policy. Date focus initiated: 08/29/22. The care plan goal documented the resident was to maintain independence safely while smoking during designated times under supervision of facility staff per agreed upon policy through next review. Date goal initiated: 08/29/22; revision date: 11/29/24; target date: 02/26/25. Care plan interventions included: document any episodes of non-compliance with smoking policy. Date initiated: 02/28/23. Explain to resident danger of non-compliance, including risk for facility fire. Date initiated: 02/28/23. Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management. Date initiated: 08/29/22. Patient not to have cigarettes or smoking material on person. Date initiated: 12/03/22. Storage of smoking materials per Living Center policy. Date initiated: 08/29/22. A review of the progress notes for Resident #7 revealed no documented evidence of incidents related to smoking or possession of smoking material. A review of the facility's smoking list confirmed that Resident #7 did smoke. A review of smoke break assignment sheet revealed that staff were assigned to supervise residents during smoke breaks at 8:00 AM, 10:00 AM, 1:00 PM, 3:30 PM, 6:00 PM and 8:00 PM. It further documented that each department manager would be responsible for making sure the smoke breaks were assigned. Smoking materials could be picked up at the reception desk in the front lobby. A review of the resident smoking agreement, signed by Resident #7 on 01/03/25, and witnessed and signed by facility staff revealed: 1. Smoking times. 2. All smoking materials will be maintained by nursing staff . 11. If you do not abide by the smoking policy (e.g. smoking materials are provided directly to the resident . the plan of care may be revised to include additional safety measures. A review of Attachment D, titled Tobacco-Restrictive Policy Acknowledgement, revealed that it was the policy of the facility to discourage any smoking in the facility. However, we are also understanding of the fact that as a skilled nursing and rehabilitation facility, some of our residents may choose to smoke . Purpose . to reduce the risk of fire. Procedure: Every resident who smokes will be assessed for safety . Staff will dispense the resident's cigarettes, light the cigarette, and stay with the resident until the cigarette is properly extinguished . For qualified residents, cigarettes, lighters and any other smoking materials will be kept at the nurses' station .

Based on observation, interview, record review, and policy and procedure review, the facility failed to ensure ensure that one (Resident #137) of 39 residents receiving respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #137 was not receiving oxygen at the ordered flow rate. The findings include: On 03/10/25 at 1:51 PM, Resident #137 was observed lying in bed receiving oxygen via nasal cannula (NC). The oxygen concentrator located next to the head of her bed had a flow rate setting of 3.25-3.50 Liters per minute (L/min). (Photographic evidence obtained) On 03/13/25 at 12:50 PM, while checking the resident's oxygen flow rate, Licensed Practical Nurse (LPN) K verified that Resident #137's oxygen flow rate setting was currently set at 4 L/min, but the oxygen order was for a flow rate of 2 L/min. She stated nurses provided ongoing monitoring of the resident's oxygen therapy. Nursing was responsible for ensuring that the resident was receiving the correct oxygen flow rate per the physician's order. Correct oxygen settings were identified by checking the resident's chart on the computer. Nursing staff on the night shift were responsible for changing the resident's oxygen tubing and concentrator. Correct settings were communicated from one staff person to another through shift reports. Resident #137 would remove her nasal cannula but did not change her own flow rate settings. When Resident #137 refused oxygen therapy, nursing staff ensured her oxygen was at saturation level; she would comply when provided with an explanation of why the oxygen was needed. On 03/13/25 at 4:52 PM, the Director of Nursing confirmed that correct oxygen settings were identified by reviewing the physician's orders. A review of Resident #137's medical record revealed the following active orders: Oxygen at 2 L/min via NC as needed for oxygen saturation below 92% every shift. Place NC or mask in bag when not in use (3/11/2025). No oxygen order was located in the medical record prior to 3/11/25 when the resident was observed receiving oxygen at 3.25-3.50 L/min. Other orders related to oxygen included: Change oxygen tubing every Thursday night on 7 PM to 7 AM shift every night shift every Thursday (3/11/2025); May remove oxygen for transport and showers every shift (3/12/2025). (Photographic evidence obtained) A review of the resident's medical record revealed an admitted [DATE]. Her diagnoses included: hypertensive heart disease without heart failure; major depressive disorder; insomnia; anxiety disorder; other specified depressive episodes; dementia; and encounter for palliative care. A review of the Quarterly minimum data set (MDS) assessment, dated 02/27/25, revealed that the resident was not identified as requiring oxygen. A review of the active care plan, focus and goals revealed no care plan for oxygen therapy. A review of the Medication Administration Record (MAR) for March 2025 revealed an order for providing oxygen at 2 L/min via nasal cannula as needed for oxygen saturation below 92% every shift. Place NC or mask in bag when not in use. The date ordered by the physician was 3/11/25. (Copy obtained) A review of the facility's policy and procedure titled Medication Administration (dated: 01/01/24), revealed: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 14. Administer medication as ordered in accordance with manufacturer specifications. (Copy obtained)

Based on observations, staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that its medication error rate was not 5% or greater. Two medication errors out of 25 opportunities for error, resulted in an error rate of 8 % and involved Residents #45 and #113. The findings include: On 03/12/25 at 12:44 PM, Registered Nurse (RN) L was observed preparing Oxycodone-Acetaminophen 10/325 mg (milligrams), 1 tablet by mouth every 6 hours routinely for Resident #45 in room [ROOM NUMBER]-2. RN L was then accompanied into room [ROOM NUMBER]-1 where Resident #77 was lying in bed. RN L greeted the resident and explained that she was going to administer pain medication the resident had requested. The nurse asked Resident #77 what her pain level was and at that point, was asked to hold the medication and step outside of the resident's room. RN L was asked if she had chosen the right patient, medication, dose, time, and frequency. RN L was accompanied back to the medication cart to review Resident #45's Narcotic Reconciliation Sheet and current MAR (medication administration record). RN L acknowledged that she almost medicated the wrong resident. On 03/13/25 at 8:37 AM, Licensed Practical Nurse (LPN) M was observed preparing medication to administer to Resident #113. Among the medications pulled for administration was Docusate Sodium 100 mg. After LPN M prepared the medications she intended to administer, she was asked if she intended to administer the medications that she had prepared. She confirmed that she was going to administer them. She was asked to recheck the over-the-counter medication bottles that she poured from against the resident's MAR (medication administration record). LPN M acknowledged that the resident did not have an order for Docusate Sodium. The resident had an order for Senna 8.6 mg by mouth daily. LPN M acknowledged that she almost administered medication that had not been ordered for Resident #113. A review of the facility's policy and procedure for Medication Administration (implemented: 01/01/2024), revealed: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and compliance guidelines: 3. Identify resident by photos in the MAR (medication administration record) 10. Review MAR to identify medication to be administered 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observations, interviews, and facility policy review, the facility failed to maintain the kitchen in a safe and sanitary manner due to a ceiling area having a plastic sheet covering an opening that was dripping liquid where food is prepared, and by failing to maintain missing ceiling tiles in the dish room. The findings include: During a visit to the kitchen on 10/02/23 at 12:06 pm, the ceiling was observed with three plastic bags covering an opening. One of the areas was covered by a bag near the tray line taped with black and red duck tap. A brown liquid was observed dropping water on the floor. Water was also observed on the floor at the tray line where the carts were parked. In the dish room there were missing tiles in the ceiling. (Photographic evidence obtained) During an interview with the certified dietary manager (CDM) on 10/02/23 at 12:15 pm, she confirmed there was liquid dripping close to the tray line and there were missing tile pieces in the dish room. When asked what the status was to repair these areas, she stated the maintenance manager would have more details. An interview was conducted with the Maintenance Director on 10/02/23 at 12:48 pm. He stated the issue had been going on for the last 6 months. He explained the issue started with the duct work main on the second floor and they were waiting for the issue to be fixed first before repairing the kitchen. He added that he had contacted several companies, but they were not willing to do the job, because it was just too much. He stated that he just called another company and was waiting for their quote. When asked to provide the invoices of the inspections or communication for the companies that he had contacted without success, he said that she did not have it. He provided a list of Alternating Current (AC) repair companies names and phone number, but no information of when they were contacted or the feedback. (Copy obtained). When asked about the liquid observed dripping from the plastic bag, he said, I have been draining the water holding up on the plastic bags weekly. When asked about the missing tiles in the dish room, he said, Yes I am aware of missing tiles, I just haven't had gotten the time to fix it. On 10/03/23 at 3:00 pm, the Administrator was asked about the condition of the kitchen ceiling. He said, It was like this when I came on board about a month ago and I'm working on it. He added that there was an issue on the second floor and Occupation Safety and Health Administrator (OSHA) officials were involved and therefore they had to take care of that first. He had no updates on the status of the repair of the kitchen. He mentioned that the facility had developed a PIP for repair of the dish room tiles and resident's would be informed that they would be served on disposable utensils as the repair is done. A review of the facility's policy titled Preventative Maintenance Program reveled the following: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of safe, functional, sanitary, and comfortable environment for residents, staff and the public. Policy Explanation and Complained Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building, grounds and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shalt assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufactures' recommendations, maintenance requests, grand rounds, life safety requirements or experience. (Photographic evidence obtained)

Based on interview, record review, and review of facility policy, the facility failed to convey within 30 days upon discharge the resident's funds, and a final accounting of those funds for 2 (Residents #2 and #7) of 4 residents reviewed for personal funds; and failed to notify the resident or the resident's representative when the amount in the residents account reached $200 less than the eligibility limit for 1 (Resident #6) of 4 residents reviewed, from a total sample of 8 residents. The findings include: 1. A closed record review for Resident #2 revealed that she was admitted on [DATE] and discharged on [DATE]. A review of the discharge return not anticipated minimum data set (MDS) assessment dated [DATE] revealed that Resident #2 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Resident had a planned discharge to hospice and her daughter was listed as the power of attorney (POA). During a phone interview with Resident #2's POA on 10/2/23 at. 1:30 pm, she stated that she had contacted the facility several times and spoke with the Business Office Manager (BOM) at the facility regarding her mother's refund. She went on to say, It has been over 6 months and we had not received it. During an interview with the BOM on 10/3/23 at 10:17 am, she was asked how residents accounts were maintained and monitored. She explained that she and her assistant have access to the accounts and ensure that residents are not above the $2000 threshold. She added that she sends quarterly statements to Resident's and/or resident POA/guardian. For residents that are discharged a refund is issued within 30 days. When asked if there was a process ensuring that resident(s) do not go over the limit and refunds are issued timely. She said that she was still new to the facility, and she had not established a process yet and that the billing was conducted by a third-party company. A review of the billing statement for Resident #2, dated 9/26/23 revealed a credit balance of $510.65. (Photographic evidence obtained) 2. A review of the billing statement for Resident #7, dated 9/26/23 revealed a credit balance of $1,247.76. (Photographic evidence obtained) 3. A review of the billing statement for Resident #6, dated 9/26/23 revealed a credit balance of $2,213.13. (Photographic evidence obtained) During a follow-up interview with the BOM on 10/3/23 at 1:00 pm, she confirmed the account balances above were correct for Residents #2, #6, and #7. She also confirmed that Residents #2 and #7 had been discharged for more than 30 day and their refunds had not been issued. Resident #6 was still at the facility. When asked if Resident #6 was notified for being over the limit of $2000, she said, No. A review of the facility's policy titled Resident Personal Funds (dated 1/20/2019) revealed the following: Notice of Certain Balances: The facility must notify each resident that received Medicaid benefits; a. When the amount in the resident 's account reaches $200 less than the SSI resource limit for one person and; b. If the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person , the person may lose eligibility for Medicaid or SSI. Conveyance upon Discharge, Eviction or Death: Upon discharge, eviction or death of a resident with a personal fund deposited with the facility, the facility will convey with 30 days the resident's funds and a final account of those funds to the resident or in case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. (Photographic evidence obtained)

Based on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to ensure residents were free from neglect, by failing to provide supervision and interventions to maintain safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's neglect to provide appropriate services and interventions to prevent elopement after identifying the resident as at risk, permitted Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. The same day, at 2:15 p.m., he was assessed as an elopement risk and a Wanderguard (alarm bracelet) was to have been applied. On 2/28/23 at 6:29 a.m., the resident was noted as wandering the unit checking exit doors. An order and placement of a Wanderguard was to be obtained this AM. On 2/28/23 between 2:20 p.m. and 2:30 p.m., Resident #92 left the facility and was located wandering down a busy boulevard at approximately 2:31 p.m. He was brought back to the facility, moved to a more secure floor, and a Wanderguard was placed. The resident was identified by the facility as an elopement risk upon admission. Due to the failure of three nurses to adequately supervise Resident #92 and put safety interventions in place, the resident was able to elope and was found wandering down the busy boulevard. The resident likely could have fallen, been hit by a car, and/or have gotten lost. The facility census was 152 and there were nine residents identified as at risk for elopement as of 4/12/23. The Immediate Jeopardy (IJ) began on 2/28/2023 at 2:30 p.m. and was identified on 4/12/2023 at 11:30 a.m. The Administrator was notified of the IJ determination at 2:30 p.m. on 4/13/23, and the Immediate Jeopardy was ongoing as of the survey exit on 4/13/23. The findings include: Cross reference to F689. A record review for Resident #92 found he was admitted to the facility on [DATE]. A Clinical Admission Evaluation and corresponding nursing progress note was completed by Registered Nurse (RN) A on 2/27/23 at 2:15 p.m. She indicated Resident #92 was not alert and oriented to person, place or time. He ambulated with a steady gait and was described as confused, with disorganized thought and moderate cognitive impairment (memory loss). Resident #92 was verbal but incoherent. Narrative notes reported him wandering about the floor and that the previous nurse was to obtain a Wanderguard. Staff were to monitor him closely for wandering. (Photographic evidence was obtained.) An Elopement Evaluation completed 2/27/23 at 3:43 p.m. by RN A indicated Resident #92 had verbally expressed a desire to go home, packed his belongings to go home, or stayed near an exit door. Both goal-directed and aimless wandering were observed. Resident #92 was assessed as being recently admitted and had not accepted the situation. Wandering was likely to affect the privacy of others. Resident #92 scored a 5 and was identified as At Risk. (Photographic evidence obtained) Licensed Practical Nurse (LPN) C wrote a progress note on 2/28/23 at 6:29 a.m., indicating that Resident #92 was non-compliant with COVID-19 isolation, was wandering the unit, and was checking exit doors. Every hour checks were initiated. Resident #92 was to be checked on frequently by staff. Order and placement for Wanderguard to be obtained this morning. (Photographic evidence obtained) A 2/28/23 progress note written at 4:00 p.m. by LPN D, revealed that Resident #92 was found walking down the boulevard by staff members. He was escorted back to the facility. His room was changed to [the second floor], and a Wanderguard was placed on his left ankle to ensure his safety. (Photographic evidence obtained) Observations of the facility and surrounding areas were conducted during the survey between 4/10/23 and 4/13/23. The facility is situated on the northeast intersection of a busy four to six lane boulevard (turn lanes considered) with a speed limit of 45 miles per hour (mph). The boulevard intersects with a three lane road (speed limit 30 mph) at the northwest end of the property. The facility's front glass sliding doors face West and are approximately 200 feet from the boulevard. The doors open to a covered portico then a two-lane parking lot. Between the lot and the boulevard is a grassy treed area. The terrain is uneven, with dips and rises in its surface. A sidewalk runs parallel to the boulevard just beyond the grass. Using a step counter application and timer, the distance from the front door, across the grass to the sidewalk was calculated at 135 steps. Traversing that distance took one minute 16 seconds. The diagonal distance from the front door to the corner intersection is approximately the same distance. On admission, Resident #92's room was on the first floor on the north wing. He would have had to walk approximately 200 feet to get from his room, past the nurses' station, down another hallway, turn and pass administrative offices and the reception desk to reach the front door. (Photographic evidence was obtained of all areas described.) A review of a facility report dated 2/28/23, revealed that Resident #92 was seen walking in the hallway on the Certified unit (1st floor, 1 North) on 2/28/23. He was ambulating up and down the hallways. At approximately 2:20 p.m., staff saw him walking in the hallway on the Certified unit. At approximately 2:30 p.m., staff were unable to locate him. A possible elopement alarm was initiated and approximately one minute later, at 2:31 p.m., Resident #92 was found on the front lawn of the facility. He willingly got into a staff member's car and was transported back to the facility. He was too confused to explain what he was trying to do, but he did tell the nurse who was in the car that he was looking for a woman. The facility's report revealed that on 2/28/23, between 2:20 p.m. and 2:30 p.m., Resident #92 walked out the front lobby doors to take a walk. He was found by staff at approximately 2:31 p.m. He was too confused to provide an explanation about what he was trying to do other than he was looking for a woman. Resident #92 was identified as an elopement risk on admission and triggered At Risk on his elopement assessment. Staff statements revealed he was walking on the sidewalk in non-skid socks. Despite nurses documenting wandering and exit-seeking behavior, no Wanderguard was placed. Nursing notes on 2/28/23 at 6:29 a.m. indicated that Resident #92 was wandering the unit and checking exit doors. Every hour and frequent checks were initiated. Order and placement for Wanderguard to be obtained this a.m. This same day at 2:31 p.m., Resident #92 was found walking down the boulevard and escorted back to the facility. His room was relocated and a Wanderguard was applied. The report concluded that Resident #92 had been recognized as an elopement risk but not moved to a more secure location on the second floor. As a result, three nurses received warnings for failing to provide Resident #92 with a Wanderguard which may have prevented this elopement. The report stated staff were re-educated on elopement. (Photographic evidence obtained) An interview was conducted with LPN B on 4/12/23 at 9:13 a.m. She explained that on admission, the assigned nurse was to obtain a brief history of the resident, conduct a skin assessment, and must complete multiple additional assessments and consents. She reported it was a little much on the nurses at times. When a resident exhibited wandering behavior, staff redirected them to another location. If the behavior persisted, she presumed a Wanderguard would be placed. The devices were stored on site in central storage. The nurse was to notify the Nurse Practitioner if a patient was wandering or exit-seeking. Nurses instructed Certified Nursing Assistants (CNAs) to keep an eye on residents who wandered. An interview was conducted with Certified Nursing Assistant (CNA) G on 4/12/23 at 9:29 a.m. She explained the standard for supervision was to check on residents every two hours. For residents who wandered, checks would be every 45 minutes to an hour. If a resident was exit-seeking, she redirected them away from the door and told the nurse. The doctor decided which resident got a personal alarm, which went on the resident's ankle or wrist. There were alarms on all facility doors. In an interview with LPN E on 4/12/23 at 9:37 a.m., she explained that if a resident was observed wandering, she would notify the supervisor and get a Wanderguard. They were stored in the facility and could be obtained right away. Residents were assessed on admission using an elopement risk assessment. If a resident still tried to leave after being oriented to the facility and provided with reassurance they could call their family, they were reassessed for cognition and elopement risk. If a resident was confused, staff would place the Wanderguard. Sometimes residents who wandered or were exit-seeking could be moved upstairs, especially when there was a risk. The elevator was code-operated and only alert and oriented residents had the code. Supervision would be increased from the standard every two to three hours to hourly for more confused residents. If the need for a Wanderguard was identified, it could be placed immediately, then the nurse could contact the physician and write a telephone order for its use. LPN E stated there was an elopement book at the nurses' station for identifying residents at risk. She reviewed the book at this time and confirmed Resident #92's information was not included. An interview was conducted with the front desk receptionist on 4/12/23 at 10:02 a.m. She reported she worked Mondays through Fridays from 8:00 a.m. to 5:30 p.m. Another staff member relieved her when she went to lunch. The facility was not a locked facility. The receptionist was asked how she knew which residents were at risk for elopement and who could sign out and leave independently. She said she knew residents who wandered had the alarm (Wanderguard). The sensor is right here on the side of the wall. (She gestured to the wall flanking the reception desk.) If they went past it by themselves, she knew that was not good. When the alarm went off, staff came running. She said she kind of knows which residents could come and go, but she just started here mid-March, so was still learning. There was an elopement risk book in the drawer. She was not sure if it was up to date, but she had access to the electronic medical records. She retrieved the elopement book from the drawer and confirmed upon review that Resident #92's information was not included. LPN F was interviewed on 4/12/23 at 10:22 a.m. She was assigned to the second floor south unit where Resident #92 now resided. LPN F said all residents were assessed on admission, and if they were identified as at-risk for elopement, or if they exhibited wandering behaviors, the family and physician were called and a Wanderguard was placed. Normally, the Wanderguards were kept downstairs on the Certified unit or in central storage. When the need was identified, the device could be placed within five to ten minutes. LPN F explained that she would not want to put that off since residents could be quick on their feet when they wanted to be. It only takes a split second when you take your eye off of them. LPN F again reinforced that she wouldn't wait to place a device when needed. The other option would be to get a physician's order and put the resident on one-on-one supervision. More frequent checks would also be a suggestion, but she would check more frequently than every hour. A lot can happen in one hour. LPN F produced the elopement book for unit 2 south, and Resident #92's information was included. The second floor north wing elopement book was reviewed and found Resident #92 was on the list of residents who wore a Wanderguard, however, further review found no photograph or demographic information for him. LPN K looked through the book on 4/12/23 at 10:38 a.m. She confirmed that Resident 92's information was not in the book. Certified Nursing Assistant (CNA) I was interviewed on 4/13/23 at 10:17 a.m. She explained that she was one of the staff who found Resident #92 after his elopement. On the day of the event after the Code Indigo (elopement) was announced, she and the Assisted Living Facility (ALF) Administrator immediately drove off-campus and located Resident #92 at the north end of the property at the intersection. Resident #92 willingly got into the car and was returned to the facility. An interview was conducted with the Administrator at 12:40 p.m. on 4/13/23. When asked if the elopement book was what the receptionists used for identifying residents at risk, she confirmed it was. The facility's records were reviewed. A written statement from the Assisted Living Facility (ALF) Administrator was included, which verified on the day of the event, she and CNA I went to search for Resident #92. They rode down [boulevard name] boulevard and found Resident #92 walking along the sidewalk in non-skid socks. He stated he was looking for a woman and was unaware he had eloped. The statement was signed by the ALF Administrator on 3/3/23. The file contained the meeting sign-in sheet for the elopement training that the facility report said was provided in response. The training was conducted on 3/1/23 with 14 staff members in attendance. Only three of the staff were floor nurses; two LPNs and one registered nurse (RN). The remainder of the staff were all department heads, including but not limited to, the Maintenance Director, the Human Resources Director, Admissions Coordinator, ALF Administrator and Dietician. A review of the employee roster at the time of the survey revealed there were 211 staff members. Thirty-two (32) were licensed nurses (RNs and/or LPNs). There was no evidence any of the floor nurses had received any re-training on elopement risk identification or prevention. One elopement response drill was conducted on 2/28/23 with 24 staff members signing as having been in attendance. A review of the facility's policy on Abuse/Neglect/Exploitation (not dated) revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation . Neglect is defined as failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Under the section Prevention of Abuse, Neglect and Exploitation it read: The facility will implement its policies to prevent and prohibit neglect that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions and monitoring of resident with needs and behaviors which might lead to conflict or neglect. (Photographic evidence obtained) A review of the facility's policy titled Elopement (undated) read: The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered-plan addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. Wandering is random or repetitive locomotion that may be goal-directed (e.g., The person appears to be searching for something such as an exit) or non-goal directed or aimless. 2. Elopement occurs when a resident leaves the premises of a safe area without authorization (e.g., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Resident will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan meeting. b. The ID (Interdisciplinary) Team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior or minimize risks associated with hazard will be added to the care plan and communicated with appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopement. e. Charge nurses and UMs will monitor the implementation of interventions, response to interventions and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The section titled Tips for Prevention of Elopement included, but were not limited to: -Involve family in the prevention strategy by supervising resident during key risk times. -Room placement for easy observation . -. Involve the activities department in the prevention strategy; involve resident in small groups and activities that engage resident's attention at key risk times . -Never assume everyone knows the resident is a wanderer; make it clear to dining room aides, new staff and whoever is involved in the resident's care . -Consider color coded wristbands as an alert to staff. -Consider the use of a personal alarm for the resident . (Photographic evidence obtained) On 4/13/23 at approximately 1:00 p.m., after being advised of concerns about Resident #92's elopement and the facility's lack of response, the Administrator and Director of Nursing (DON) entered the conference room. They asked why relocating Resident #92 to a secure floor and placing a Wanderguard was not a sufficient response to his elopement. They were advised of the following investigative findings and resulting concerns: 1. Three different floor nurses failed to act appropriately and provide needed services and interventions to protect Resident #92. None placed a Wanderguard, implemented sufficient supervision, or relocated Resident #92 to a secure unit. The in-service training the facility provided in response to the incident only included three of 32 licensed floor nurses. Most training attendees did not work the floor and were not responsible for assessing risk or implementing interventions. Due to the lack of training, there was a likelihood other residents could be affected. 2. Three of four of the facility's elopement books had not been updated to contain Resident #92's information after he was assessed as at risk or since the event. 3. The facility's policy for elopement was vague and allowed for subjective decision-making by nurses related to the implementation of safeguards; and 4. Only one drill had been conducted in response to the incident with only three of 32 floor nurses in attendance. When advised that the lack of urgency and appropriate response to correct the problem contributed to a likelihood of recurrence, the Administrator and DON acknowledged the concern.

Based on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to provide supervision and implement interventions to maintain resident safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's failure to provide appropriate supervision and implement identified and/or available interventions, allowed Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. The same day, at 2:15 p.m., he was assessed as an elopement risk and a Wanderguard (alarm bracelet) was to have been applied. On 2/28/23 at 6:29 a.m., the resident was noted as wandering the unit checking exit doors. An order and placement of a Wanderguard was to be obtained this AM. On 2/28/23 between 2:20 p.m. and 2:30 p.m., Resident #92 was located wandering down a busy boulevard. He was brought back to the facility, moved to a more secure floor, and a Wanderguard was placed. The resident was identified by the facility as an elopement risk upon admission. Due to the failure of three nurses to adequately supervise Resident #92 and put safety interventions in place, the resident was able to elope and was found wandering down the busy boulevard. The resident likely could have fallen, been hit by a car, and/or have gotten lost. The facility census was 152 and there were nine residents identified as at risk for elopement as of 4/12/23. The Immediate Jeopardy (IJ) began on 2/28/2023 at 2:30 p.m. and was identified on 4/12/2023 at 11:30 a.m. The Administrator was notified of the IJ determination at 2:30 p.m. on 4/13/23, and the Immediate Jeopardy was ongoing as of the survey exit on 4/13/23. The findings include: Cross reference to F600. A record review for Resident #92 found he was admitted to the facility on [DATE]. A Clinical Admission Evaluation and corresponding nursing progress note was completed by Registered Nurse (RN) A on 2/27/23 at 2:15 p.m. She indicated Resident #92 was not alert and oriented to person, place or time. He ambulated with a steady gait and was described as confused, with disorganized thought and moderate cognitive impairment (memory loss). Resident #92 was verbal but incoherent. Narrative notes reported him wandering about the floor and that the previous nurse was to obtain a Wanderguard. Staff were to monitor him closely for wandering. (Photographic evidence obtained) An Elopement Evaluation completed 2/27/23 at 3:43 p.m. by RN A indicated Resident #92 had verbally expressed a desire to go home, packed his belongings to go home, or stayed near an exit door. Both goal-directed and aimless wandering were observed. Resident #92 was assessed as being recently admitted and had not accepted the situation. Wandering was likely to affect the privacy of others. Resident #92 scored a 5 and was identified as At Risk. (Photographic evidence obtained) Licensed Practical Nurse (LPN) C wrote a progress note on 2/28/23 at 6:29 a.m., indicating that Resident #92 was non-compliant with COVID-19 isolation, was wandering the unit, and was checking exit doors. Every hour checks were initiated. Resident #92 was to be checked on frequently by staff. Order and placement for Wanderguard to be obtained this morning. (Photographic evidence obtained) A 2/28/23 progress note written at 4:00 p.m. by LPN D, revealed that Resident #92 was found walking down the boulevard by staff members. He was escorted back to the facility. His room was changed to [the second floor], and a Wanderguard was placed on his left ankle to ensure his safety. (Photographic evidence obtained) Observations of the facility and surrounding areas were conducted during the survey between 4/10/23 and 4/13/23. The facility is situated on the northeast intersection of a busy four to six lane boulevard (turn lanes considered) with a speed limit of 45 miles per hour (mph). The boulevard intersects with a three lane road (speed limit 30 mph) at the northwest end of the property. The facility's front glass sliding doors face West and are approximately 200 feet from the boulevard. The doors open to a covered portico then a two-lane parking lot. Between the lot and the boulevard is a grassy treed area. The terrain is uneven, with dips and rises in its surface. A sidewalk runs parallel to the boulevard just beyond the grass. Using a step counter application and timer, the distance from the front door, across the grass to the sidewalk was calculated at 135 steps. Traversing that distance took one minute 16 seconds. The diagonal distance from the front door to the corner intersection is approximately the same distance. On admission, Resident #92's room was on the first floor on the north wing. He would have had to walk approximately 200 feet to get from his room, past the nurses' station, down another hallway, turn and pass administrative offices and the reception desk to reach the front door. (Photographic evidence was obtained of all areas described.) A review of a facility report dated 2/28/23, revealed that Resident #92 was seen walking in the hallway on the Certified unit (1st floor, 1 North) on 2/28/23. He was ambulating up and down the hallways. At approximately 2:20 p.m., staff saw him walking in the hallway on the Certified unit. At approximately 2:30 p.m., staff were unable to locate him. A possible elopement alarm was initiated and approximately one minute later, at 2:31 p.m., Resident #92 was found on the front lawn of the facility. He willingly got into a staff member's car and was transported back to the facility. He was too confused to explain what he was trying to do, but he did tell the nurse who was in the car that he was looking for a woman. The facility's report revealed that on 2/28/23, between 2:20 p.m. and 2:30 p.m., Resident #92 walked out the front lobby doors to take a walk. He was found by staff at approximately 2:31 p.m. He was too confused to provide an explanation about what he was trying to do other than he was looking for a woman. Resident #92 was identified as an elopement risk on admission and triggered At Risk on his elopement assessment. Staff statements revealed he was walking on the sidewalk in non-skid socks. Despite nurses documenting wandering and exit-seeking behavior, no Wanderguard was placed. Nursing notes on 2/28/23 at 6:29 a.m. indicated that Resident #92 was wandering the unit and checking exit doors. Every hour and frequent checks were initiated. Order and placement for Wanderguard to be obtained this a.m. This same day at 2:31 p.m., Resident #92 was found walking down the boulevard and escorted back to the facility. His room was relocated and a Wanderguard was applied. The report concluded that Resident #92 had been recognized as an elopement risk but not moved to a more secure location on the second floor. As a result, three nurses received warnings for failing to provide Resident #92 with a Wanderguard which may have prevented this elopement. The report stated staff were re-educated on elopement. (Photographic evidence obtained) On 4/12/23 at 9:00 a.m., the Director of Nursing (DON) was asked if this was the only elopement incident since the last survey. He stated yes, but that Resident #92 had been admitted from an assisted living facility (ALF) and simply didn't know he couldn't just go outside. He was asked for the elopement policy and procedures, Wanderguard guidelines, and anything related to elopement prevention at this time. An interview was conducted with LPN B on 4/12/23 at 9:13 a.m. She explained that on admission, the assigned nurse obtained a brief history of the resident and conducted a skin assessment. Multiple additional assessments had to be completed and consents had to be signed. LPN B said she wished the process was smoother; it was a little much on the nurses at times. Depending on the time of admission, the paperwork was expected to be completed during the same shift. If it could not be completed, the oncoming nurse had to finish it. She tried to leave as many cues as possible regarding outstanding tasks. When a resident exhibited wandering behavior, staff redirected them to another location. If the behavior persisted, she presumed a Wanderguard would be placed or the Unit Manager (UM) would be asked if a Wanderguard was appropriate. The devices were stored on site in central storage. Nurses instructed Certified Nursing Assistants (CNAs) to keep an eye on residents who wandered. Fifteen-minute checks were only used for neuros (neurological checks, implemented after a fall with potential head injury), but she would note any increased supervision for wandering in a progress note. The nurse notified the Nurse Practitioner if a patient was wandering or exit-seeking. LPN B said she had worked in the facility since November 2022 but had not participated in an elopement drill. When asked if she received training on elopement prevention and response, she said no, but she just knows what the signs are. An interview was conducted with CNA G on 4/12/23 at 9:29 a.m. She explained the standard for supervision was to check on residents every two hours. For residents who wandered, checks would be every 45 minutes to an hour. If a resident was exit-seeking, she redirected them away from the door and told the nurse. The doctor decided which residents got a personal alarm, which went on the resident's ankle or wrist. There were alarms on all facility doors. CNA G said she had elopement training when hired in October 2022, but none since. She had not participated in any elopement drills. In an interview with LPN E on 4/12/23 at 9:37 a.m., she explained that there was an elopement book at the nurses' station, and everyone had access to it. It included the names and pictures of residents at risk for elopement. If a resident was observed wandering, she would notify the supervisor and get a Wanderguard. They were stored in the facility and could be obtained right away. Residents were assessed on admission using an elopement risk assessment. If a resident still tried to leave after being oriented to the facility and provided with reassurance that they could call their family, they were reassessed for cognition and elopement risk. If a resident was confused, staff would place the Wanderguard. Sometimes residents who wandered or exit-seeked could be moved upstairs, especially when there was a risk. The elevator was code-operated and only alert and oriented residents had the code. Supervision would also be increased. Staff usually checked on residents every two to three hours but for more confused residents, they checked hourly. These frequent checks were communicated verbally but not documented except maybe in a nurse's note. The nurse's note would explain hourly rounding was being conducted due to the resident's increased confusion. It could be recorded on the medication or treatment administration records (MARs or TARs), but it would be a lot of checking off. If the need for a Wanderguard was identified, it could be placed immediately, then the nurse could contact the physician and write a telephone order for its use. Elopement training was provided quarterly, and the elopement books were updated at that time by the UM, but the nurse could do it too. The book on the certified unit was reviewed at this time but contained no photograph or identifying information for Resident #92. LPN E reviewed the book on request and confirmed that Resident #92's information was not there. LPN E said she had worked in the facility for almost two years. When asked if she had ever participated in an elopement drill, she said no, not on her shift. Perhaps they were conducted on her days off. An interview was conducted with the front desk receptionist on 4/12/23 at 10:02 a.m. She reported she worked Mondays through Fridays from 8:00 a.m. to 5:30 p.m. Another staff member relieved her when she went to lunch. The facility was not a locked facility. The receptionist was asked how she knew which residents were at risk for elopement and who could sign out and leave independently. She said she knew residents who wandered had the alarm (Wanderguard). The sensor is right here on the side of the wall. (She gestured to the wall flanking the reception desk.) If the residents went past the sensor by themselves, she knew that was not good. When the alarm went off, staff came running. She kind of knew which residents could come and go, but she just started here mid-March, so she was still learning. There was an elopement risk book in the drawer. She was not sure if it was up to date, but she had access to the electronic medical records. The receptionist retrieved the elopement book from the drawer. Upon review, it identified nine residents as at risk for elopement in the front section of the book. Resident #92's information was not included. The Receptionist was asked if she could locate Resident #92's information or photograph in the book. She reviewed the electronic medical record, then the elopement binder, explaining where his information should be. After searching the binder, the receptionist was unable to locate any photo or information for Resident #92. LPN F was interviewed on 4/12/23 at 10:22 a.m. She was working the second floor south unit, where Resident #92 now resided. LPN F said all residents were assessed on admission, and if they were identified as at-risk for elopement, or if they exhibited wandering behaviors, the family and physician were called and a Wanderguard was placed. The Nurse Practitioner could authorize the device's use. Normally, the Wanderguards were kept downstairs on the certified unit or in central storage. When the need was identified, the device could be placed within five to ten minutes. LPN F explained that she would not want to put that off since residents could be quick on their feet when they wanted to be. It only takes a split second when you take your eye off of them. LPN F again reinforced that she wouldn't wait to place a device when needed. The other option would be to get a physician's order and put the resident on one-on-one supervision. More frequent checks would be a suggestion, but she would check more frequently than every hour. A lot can happen in one hour. The UM updates the elopement books, but the nurse could probably do it too. Elopement training is done several times a year and they do drills, but she was not sure how often. She said she heard about Resident #92's elopement. Resident #92 was ambulatory with a fairly stable gait and was quick on his feet. She explained that since the incident, he had been placed on this unit and a Wanderguard was applied. LPN F produced the elopement book for 2 south, and Resident #92's information was included. The second floor north wing Elopement book was reviewed and found Resident #92 was on a list of residents who wore a Wanderguard, however, further review found no photograph or demographic information for him. LPN K looked through the book on 4/12/23 at 10:38 a.m. She confirmed Resident 92's information was not in the book. LPN K was asked how the elopement binders were used. She replied that, in all honesty, she did not use the book at all. The Director of Nursing (DON) was interviewed on 4/13/23 at 9:39 a.m. He stated elopement training was provided on hire and elopement drills were conducted every six to 12 months, or in response to an incident. He stated there were no written procedures for elopement drills or for obtaining and placing Wanderguards. CNA I was interviewed on 4/13/23 at 10:17 a.m. She explained she was one of the staff who found Resident #92 after his elopement. On the day of the event after the Code Indigo (elopement) was announced, CNA I asked who the resident was. She and the Assisted Living Facility (ALF) Administrator immediately went to her car and drove off-campus. They turned right onto the boulevard and found Resident #92 at the north end of the property at the intersection. He was standing on the corner facing North. They pulled the car up to him, and he said, I am allowed to leave. He said he was looking for a woman, so CNA I replied, Here I am, I am here! Resident #92 then willingly got into the car and was returned to the facility. An interview was conducted with the Administrator at 12:40 p.m. on 4/13/23. She was asked if there was a receptionist on duty when Resident #92 left the building on the day of the incident. She stated she did not know if the receptionist was at the desk at the time, and stated this was not a locked facility. When asked if the elopement book was what the receptionists used for identifying residents at risk, she confirmed it was. The Administrator returned to the conference room at 1:00 p.m. to report that there was a manager at the desk the day of the incident, as they were between receptionists. The facility's records were reviewed. A written statement from the Assisted Living Facility (ALF) Administrator was included, which verified on the day of the event, she and CNA I went to search for Resident #92. They rode down [boulevard name] boulevard and found Resident #92 walking along the sidewalk in non-skid socks. He stated he was looking for a woman and was unaware that he had eloped. The statement was signed by the ALF Administrator on 3/3/23. The file contained the meeting sign-in sheet for the elopement training that the facility report said was provided in response. The training was conducted on 3/1/23 with 14 staff in attendance. Only three of the staff were floor nurses; 2 LPNs and 1 registered nurse (RN). The remainder of the staff were all department heads, including but not limited to, the Maintenance Director, the Human Resources Director, Admissions Coordinator, ALF Administrator and Dietician. A review of the employee roster at the time of the survey revealed there were 211 staff members. Thirty-two (32) were licensed nurses (RNs and/or LPNs). There was no evidence any of the floor nurses had received any re-training on elopement risk identification or prevention following the event. One elopement response drill was conducted on 2/28/23 with 24 staff members signed as having been in attendance. A review of the facility's policy titled Elopement (undated) read: The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered-plan addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. Wandering is random or repetitive locomotion that may be goal-directed (e.g., The person appears to be searching for something such as an exit) or non-goal directed or aimless. 2. Elopement occurs when a resident leaves the premises of a safe area without authorization (e.g., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Resident will be assessed for risk of elopement and unsafe wandering up on admission and throughout their stay by the interdisciplinary care plan meeting. b. The ID (Interdisciplinary) Team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior or minimize risks associated with hazard will be added to the care plan and communicated with appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopement. e. Charge nurses and UMs will monitor the implementation of interventions, response to interventions and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. The section titled Tips for Prevention of Elopement included, but were not limited to: -Involve family in the prevention strategy by supervising resident during key risk times. -Room placement for easy observation . -.Involve the activities department in the prevention strategy; involve resident in small groups and activities that engage resident's attention at key risk times . -Never assume everyone knows the resident is a wanderer; make it clear to dining room aides, new staff and whoever is involved in the resident's care . -Consider color coded wristbands as an alert to staff. -Consider the use of a personal alarm for the resident . (Photographic evidence obtained) On 4/13/23 at approximately 1:00 p.m., after being advised of concerns about Resident #92's elopement and the facility's response, the Administrator and Director of Nursing entered the conference room. They asked why relocating Resident #92 to a secure floor and placing a Wanderguard was not a sufficient response to his elopement. They were advised of the following investigative findings and resulting concerns: 1. Three of four of the facility's elopement books failed to contain Resident #92's information. 2. The in-service training the facility provided in response to the incident only included three of 32 licensed floor nurses. Most training attendees did not work the floor and were not responsible for assessing risk or implementing interventions. Because three different floor nurses failed to act appropriately and either place a Wanderguard, implement sufficient supervision or relocate Resident #92 to a secure unit, there was a likelihood the mistake would be repeated if nurses were not retrained. 3. The facility policy on elopement was vague and allowed for subjective decision-making by nurses related to the implementation of interventions. There were no specific guidelines for nurses on how to respond when residents were actively exit-seeking or wandering persistently; and 4. Only one drill had been conducted in response to the incident. Fourteen out of 211 employees participated. Three (3) of 4 licensed staff interviewed during the survey had never participated in an elopement drill, including one nurse of two years. When advised the lack of urgency and appropriate response to correct the systemic problem contributed to a likelihood of recurrence, the Administrator and DON acknowledged the concern.

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety and sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure the ice machine located in the kitchen and one of three microwaves located on the 1st floor at the nursing station was clean. Food safety and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 4/12/23 at 10:50 a.m. The ice machine located next to the three-compartment sink was observed with a pink, slimy substance that was in close proximity to the ice in the internal shoot of the ice machine. (Photographic evidence obtained) During the tour, the microwave in Nourishment Room One of three located at the nursing station on the 1st floor was observed with a buildup resembling fungal growth. (Photographic evidence obtained) An interview was conducted on 4/12/23 at 2:24 p.m. with Licensed Practical Nurse (LPN) M, who confirmed that the microwave was used to reheat residents' food. An interview was conducted on 4/12/23 at 2:36 p.m. with LPN D, Unit Manager, who confirmed that the night shift staff was responsible for cleaning the microwave. She stated, They are making plans to take the microwave out. An interview was conducted on 4/13/23 at 2:24 p.m. with Dietary Aide Q, who reported she was not sure who was responsible for cleaning the ice machine and did not know how often it was cleaned. An interview was conducted on 4/13/23 at 2:47 p.m. with Certified Dietary Manager R, who confirmed that the Dietary Department staff wiped the outside of the ice machine daily and the Maintenance Department provided deep cleaning of the ice machine monthly. Nursing was responsible for cleaning the microwave, and to keep the nourishment room and area near the nursing station clean. A review of the facility's policy and procedure titled Cleaning and Sanitizing Dietary Areas and Equipment Overview (undated), revealed: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary food service that meets state and federal regulations. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 4/14/23 at 3:15 p.m.) Annex 3. Public Health Reasons/Administrative Guidelines. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 461 . Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment. Annex 4. Equipment, Utensils, and Linens. 4-602.12. Cooking and Baking Equipment. Page 129. (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 4-602.13 Nonfood-Contact Surfaces. Nonfood-Contact Surfaces of Equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments for three (Residents #31, #260, and #133) in a total sample of 52 residents. The findings include: On 4/10/23 at 12:45 p.m., a bottle of Flonase nasal spray was observed on Resident #31's bedside table in plain sight. She stated, Oh, they forgot and left it there this morning. I'll remind them when they come back. I only take it once a day. (Photographic evidence obtained) On 4/11/23 at 8:40 a.m., a bottle of Flonase nasal spray was observed on Resident #31's bedside table. (Photographic evidence obtained) On 4/12/23 at 8:28 a.m., Licensed Practical Nurse (LPN) B was observed administering medications to Resident #260. She started to administer a Trelegy Ellipta Aerosol Powder breath-activated inhaler, but the resident stopped her and said she already took that inhaler this morning. The resident pointed to a box on her bedside table which revealed several medications in plain sight. These medications included: Trelegy inhaler, Symbicort inhaler, Albuterol inhaler, ear wax removal drops, and a small see-through plastic container with nine various pills inside. LPN B asked the resident why she had the Trelegy inhaler in her room. The resident said she had it from home. The nurse did not ask about the other visible medications, nor did she ask the resident whether she had already self-administered the Trelegy inhaler. LPN B told the resident, I'll have to find out if you can keep this at bedside, but it's fine. She left the resident's room without removing any of the medications. (Photographic evidence obtained) On 4/12/23 at 8:38 a.m., LPN D was asked if medications should be left in residents' rooms. She stated, No, not unless they have an order for self-administration. She was asked to observe Resident #260's bedside table. Upon entering the room, LPN D confirmed the presence of a Trelegy inhaler, an Albuterol inhaler, a Symbicort inhaler, ear wax drops, and a small clear plastic pill box with nine unidentified pills inside. The nurse explained to the resident that she could not keep medications at her bedside unsecured. The resident became upset and stated, I do my Trelegy inhaler every morning at around 6:00 in the morning and I rinse my mouth out. I don't want to wait for the nurse because I don't know when she's coming in, and they don't give me anything to rinse my mouth out after I use it. I have my Albuterol inhaler because it's my rescue inhaler. My doctor told me I can use it for two puffs up to four times a day as needed. Yesterday I used it once after therapy. I only use it usually once or twice a day. She was asked if she told staff when she had used her inhalers. She stated, No, none has ever asked. The resident was agreeable to allowing the nurse to remove medications from her room until she was assessed for self-administration of medications. On 4/13/23 at 9:33 a.m., Resident #133 was observed sitting up in bed, awake. Medication was observed on her bedside table in her bucket, in plain sight. She was asked what the medication was. She stated, Oh, those are for if I have gas. She was asked if the staff knew she had them. She replied, I don't know, nobody has asked. They are right there; you can see them. (Photographic evidence obtained) The medication package revealed Simethicone softgels. There were 16 tablets remaining. The baggie also contained one unidentifiable oval shaped white tablet. LPN L entered the room. She was asked if she was caring for Resident #133 today. She stated yes. She was asked if she was aware that the resident had medications on her bedside table. She stated, No, I didn't know those were there. She was asked if the resident should have medications on her bedside table. She stated, As long as she has an order for them, but she is alert and oriented. She was asked if the resident had an order to have medications at the bedside. She stated, I'm not sure, I'll have to look it up. She left the resident's room, leaving the medications on the bedside table. LPN L looked the resident up on her medication cart laptop and stated, No, she doesn't have an order. She was asked what she would do now. She stated, I'll notify her provider and my unit manager. On 4/13/23 at 12:41 p.m., Resident #133 was observed in her room, sitting up in her wheelchair, watching TV. The same medications observed earlier in the day were observed on her bedside table, in her bucket, visible without moving any items. The resident was asked if any staff had asked her about the medication in her bucket. She stated no. A review of the medical record for Resident #31 revealed an order for: 3/26/23: Feluccas nasal suspension 50 mcg/act: 2 sprays in both nostrils one time daily for allergies. There was no order found for self-administration of medication. A review of the medical record for Resident #133 did not reveal an order for Simethacone. There was no order found for self-administration of medication. A review of the medical record for Resident #260 revealed an order for: 4/8/23: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 mcg/act: 1 inhalation, inhale orally one time a day for SOB/COPD, rinse mouth and spit after administering. There were no orders found for the Symbicort Inhaler, Albuterol Inhaler, ear wax drops, or self-administration of medications. A review of the facility's policy titled Self-Administration of Medications (revised 8/2020) read: Policy: In order to maintain the resident's highest level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (or equivalent) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. A review of the facility's policy titled Storage of Medications (revised 8/2020) stated: Policy: Medications and biologicals are stored safely, securely, and properly, following the manufacturers' recommendations or those of the supplier. The medication supply is accessible to the licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observations, staff interviews, and facility policy and procedure review, the facility failed to ensure process surveillance, the review of practices by staff directly related to resident care, specifically hand hygiene, for two residents (#31 and #260) from a total sample of 52 residents. The findings include: On 4/12/23 at 8:17 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #31. Gloves were not donned during this preparation. LPN B did not perform hand hygiene prior to preparing the medications, or before or after administering the medications. Gloves were not donned during this medication administration. The nurse returned to the medication cart at 8:27 a.m., and without performing hand hygiene, she proceeded to prepare medications for Resident #260. Gloves were not donned during this preparation or during medication administration. LPN B did not perform hand hygiene prior to preparing the medications, or before or after administering the medications. She returned to her medication cart at 8:35 a.m. and proceeded to prepare medications for her next resident. She was stopped and asked if she performed hand hygiene before beginning a medication pass, before handling medication, and before contact with a resident. She stated, I usually do. She was asked if anyone from management had observed her during her medication pass. She stated no. On 4/12/23 at 8:38 a.m., in an interview with LPN D, she was asked what the expectation for hand hygiene was during medication pass/administration. She stated, The nurse should be either washing with soap and water or using hand sanitizer in between each resident and whenever they are coming in or out of a resident room. They should always use soap and water if their hands are visibly soiled. She was asked if it was acceptable to pass medications to residents without performing hand hygiene between residents. She stated no. She was asked if staff were monitored for compliance with hand hygiene during medication pass. She stated, If there is a problem identified, yes. A review of the facility's policy titled Administration Procedures for All Medications (effective date 9/2018), revealed: Policy: Medications will be administered in a safe and effective manner. Procedures: Administration: 3. Cleanse hands using anti-microbial soap and water or facility approved hand sanitizer before beginning a med pass, before handling medication, and before contact with a resident. 12. When finished administering medication to each resident, wash hands with antimicrobial soap and water or facility approved hand sanitizer.

Based on a review of facility records and interviews with staff, the facility failed to provide advanced notice to two (Residents #36 and #63) of three Medicare beneficiaries reviewed when Medicare skilled services were terminating, from a total of 52 residents in the sample. The findings include: 1. A record review found that Resident #36 was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, diabetes mellitus, Parkinson's disease, malnutrition, and depression. Further review of the record found that Resident #36 was issued a Notice of Medicare Non-Coverage (NOMNC) informing her that skilled nursing services (occupational therapy/physical therapy/speech therapy (OT/PT/ST) would end on 3/9/23. The notice indicated that Resident #36's Medicare provider and/or health plan had determined Medicare would likely not pay for current skilled services after the effective date. The resident may have to pay for services received after that date. Resident #36 signed the form on 3/9/23, the day services ended. Resident #36 was also issued an Advanced Beneficiary Notice (ABN) informing her that her Medicare Part A skilled services episode, starting 2/13/23, would terminate on 3/9/23. The facility initiated a discharge from the services before Resident #36's benefit days were exhausted. Resident #36's last day of Part A services were terminating on 3/9/23. The ABN advised skilled services were ending due to the resident not meeting her therapy goals. OT and PT costs were estimated at $65.00 per therapy evaluation and $35.00 per unit. Room and board estimated costs were $270.00 per day. Section G of the form asked that the resident choose one of the following: Option 1. I want the PT and OT listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. Option 2. I want the OT and PT listed above but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. Option 3. I don't want the PT, OT listed above. I understand with this choice I am not responsible for payment and cannot appeal to see if Medicare would pay. None of the options were marked in response. In addition, the notice was signed by the resident on 3/9/23; the same day the services ended. 2. A record review for Resident #63 revealed that she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, COVID-19, heart failure and aftercare following hip joint prosthesis. Further review found that Resident #63 had a physician's order dated 1/4/23 for occupational therapy five times a week for four weeks as per the plan of care (POC) for ADLs (activities of daily living), re-education, therapeutic activities, and therapeutic exercises as appropriate. A NOMNC was issued on 2/10/23 to Resident #63 related to her skilled nursing services starting on 1/2/23. The last day of Part A services was 2/10/23. The facility initiated the discharge when Resident #63's skilled benefit days were not exhausted. The NOMNC was signed by the resident on 2/10/23, the day services ended. An ABN was also issued on 2/10/23 for PT and OT ending on 2/10/23, due to Resident #63 meeting her therapy goals. Estimated costs were listed and Resident #36 selected Option 3: I do not want the therapy listed above. She signed the form the same day, 2/10/23. An interview was conducted with the facility Social Worker (SW) on 4/13/23 at 5:14 p.m. She stated as soon as insurance sent an e-mail notification indicating that skilled services were terminating, the resident was notified in writing that same day. Sometimes insurance notified two days in advance but that was not always the case. The Admissions Coordinator (AC) was interviewed on 4/13/23 at 5:19 p.m. When asked about Resident #36's and Resident #63's termination of benefits, she explained both were long-term care residents. She stated each had skilled nursing services open back up in-house. The determination was made in advance that services would terminate when the in-house benefits ended. The facility always knew the termination date a couple of days in advance. When shown the forms and asked about Resident #36's and Resident #63's same-day notification, the AC shook her head no. She said, Unfortunately, there was always a couple days notice. The termination is discussed by the management team during the Utilization Review meetings on Wednesdays. [Residents #36 and #63] should have been given advanced notice.

Based on observations, staff interviews, and facility document and policy review, the facility failed to protect the residents' right to personal privacy and confidentiality of his or her personal/medical records for three (Residents # 26, 31, and 28) out of a total sample of 52 residents. The findings include: On 4/11/23 at 9:04 a.m., an observation was made on the 2600 hallway. Licensed Practical Nurse (LPN) B, assigned to the medication cart on this hallway, was not observed anywhere in the vicinity. Her medication cart was halfway down the residential hallway. The laptop computer on the cart was open, unlocked, and displaying Resident #26's personal health information. (Photographic evidence obtained) LPN B returned to the cart at 9:07 a.m. and began preparing medications. On 4/12/23 at 8:20 a.m. during a medication administration observation with LPN B, she left her medication cart to deliver medications to Resident #31. The medication cart laptop screen was left open with Resident #31's personal medication information visible. When LPN B returned to her medication cart five minutes later, she was asked if she had left the medication screen open with resident medical information visible. She replied, Oh, I did. I didn't mean to do that. The hallway was observed to have various staff and residents walking past the medication cart during this time who could have seen Resident #31's personal medical information. On 4/13/23 at 9:15 a.m., an observation on the 2600 hallway revealed a medication cart left unattended with the laptop computer screen open and displaying the personal medical information for Resident #28. No nurse was observed in the area. LPN E returned to the medication cart at 9:18 a.m. She was asked if she realized she had left the computer screen open and unattended with resident medical information visible. She stated, I know. I had to go get his blood pressure and I left it up. I didn't mean to. A review of Resident Rights contained in the facility's Admission Agreement (dated 9/1/22) revealed: (h) Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. A review of the facility's policy titled Administration Procedures for All Medications (effective date 9/2018) revealed: Procedures: II. Privacy: 2. Secure (cover) records containing protected health information, such as Medication Administration Records (MARs). 30969