Every finding on record at Laughlin Health Care Center

Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal service for 4 residents (Residents #27, # 13, #39, and #25) on 1 of 2 units observed for meal tray distribution. The facility also failed to provide separate laundry entrance/exits to sort dirty laundry, in a manner to prevent cross contamination and the spread of infectious agents. The findings include: Review of the facility's undated policy titled, Hand Hygiene, revealed .perform proper hand hygiene .to prevent the spread of infections to .residents . Review of the facility's undated policy titled, Infection Prevention and Control Program, revealed .facility has established .infection prevention and control program .to provide a safe .sanitary .comfortable environment .to help prevent .infections .Linens .Laundry .staff shall handle .process .linens to prevent spread of infection .clean linen shall be separated form soiled linen at all time . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Hypertension, and Heart Failure. Review of a comprehensive care plan revised 4/3/2026, revealed Resident #27 .requires assistance with ADLS [Activities of Daily Living] .will have adl needs met .with appropriate assistance . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident required set up or clean-up assistance with ADL's. During an observation on 7/6/2026 at 12:29 PM, Certified Nurse Assistant (CNA) A delivered the meal service to Resident #27. CNA A set up meal for Resident #27 and failed to offer hand hygiene to the resident. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. Review of the comprehensive care plan for Resident #13 dated 11/12/2025, revealed .requires assistance with ADLS R/T [related to] .muscle weakness and COPD [Chronic Obstructive Pulmonary Disease] . Review of a quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident was independent with ADL's. During an observation on 7/6/2026 at 12:30 PM, CNA A delivered the meal service to Resident #13. CNA A set up meal for Resident #13 and failed to offer hand hygiene to the resident. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Anxiety, Diabetes Mellitus, and Hypertension. Review of the admission MDS assessment dated [DATE], revealed Resident #39 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident required set up or clean-up assistance with ADL's. Review of the comprehensive care plan for Resident #39 dated 6/18/2026, revealed .requires assist with ADLS .will have adl needs met . During an observation on 7/6/2026 at 12:31 PM, CNA A delivered the meal service to Resident #39. CNA A set up meal for Resident #39 and failed to offer hand hygiene to the resident. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Diabetes Mellitus, and Hypertension. Review of the 5 day MDS assessment dated [DATE], revealed Resident #25 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident required set up or clean-up assistance with ADL's. Review of the comprehensive care plan for Resident #25 revised 7/6/2026, revealed .requires assist with ADLS .R/T Alzheimer's disease .dementia .will have adl needs met . During an observation on 7/6/2026 at 12:33 PM, CNA A delivered the meal service to Resident #25. CNA A set up meal for Resident #25 and failed to offer hand hygiene to the resident. During an interview on 7/6/2026 at 12:36 PM, CNA A confirmed she had not offered hand hygiene while passing the meal service to Residents #27, #13, #39, and #25. During an interview on 7/7/2026 at 2:25 PM, the Infection Preventionist (IP) confirmed hand hygiene was to be offered to the residents prior to meals. During an interview on 7/7/2026 at 2:36 PM, the Director of Nursing confirmed hand hygiene was to be offered to the residents prior to meals. During a laundry room tour on 7/8/2026 at 8:55 AM, with the Laundry Supervisor, revealed a single-entry door, for both the clean and dirty laundry rooms. The single-entry door opened from the hallway and directly into the clean laundry area, which contained 1 washer, 1 dryer, clean laundry baskets, and residents' clean personal clothes. Soiled/dirty laundry was brought into the single-entry door and through the clean laundry room. The Laundry Supervisor confirmed there was only one entrance/exit door and both clean and dirty laundry was brought in through the clean laundry area/room. She stated, I don't know. It would make sense to have separate doors. During an interview on 7/8/2026 at 11:11 AM, the Administrator confirmed there was a single-entry door to the laundry, for both the clean and dirty rooms. The Administrator confirmed there should be an entry for soiled linen and entry for clean linen.

Based on facility policy review, facility investigation documentation review, medical record review, and interviews, the facility failed to protect the resident's right to be free from verbal abuse for 1 resident (Resident #55) of 12 residents reviewed for abuse. The facility was cited at F-600 as Past Non-Compliance. No further corrective actions are required. Non-compliance began 12/7/2025 and ended 12/11/2025.The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .The facility will .prohibit and prevent abuse, neglect, and exploitation of residents . Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Acute Cystitis, Type II Diabetes, and Dementia with Mood Disturbance. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. Review of an undated signed statement by Registered Nurse (RN) A, revealed .on 12/7/2025 around 4 am, res [resident #55] was walking around .2 CNAs [Certified Nursing Assistants] and nurses asked her to return to her room .but she kept refusing .calling [CNA B] a 'man,' to which [CNA B] responds aggressively, by raising her arm up at the res [Resident #55] .then proceeding to point in the res [Resident #55's] face using foul language such as 'damn' .[CNA B] also threatened res [Resident #55] stating 'How old are you?' . the res [Resident #55] replied '87' and [CNA B] responds w/ [with] 'if you want to live to see 88 you will not call me a man again' . Review of a Progress Note for Resident #55 dated 12/7/2025, revealed .No injuries noted .when resident was questioned about the incident .she [Resident #55] said 'I have no idea of what you are talking about' . Review of a Separation Notice for CNA B dated 12/8/2025, revealed .Terminated due to allegations of verbal abuse to a resident . Review of an Abuse Allegation Summary dated 12/19/2025, revealed .Staff reported allegations of verbal abuse between a CNA and a resident on 12/7/25 at approximately 1800 [6:00 PM] to ADON/DON [Assistant Director of Nursing/Director of Nursing] .The incident occurred on 12/7/2025 @ 0400 [4:00 AM] .A resident statement was attempted but the resident didn't remember the incident d/t [due to] dementia .skin assessment was negative for injury .CNA was terminated for policy violation and alleged verbal abuse on 12/8/25 . During an interview on 7/7/2026 at 7:45 AM, CNA C stated she was present at the time of the incident and further stated she heard CNA B ask Resident #55 How old are you? and heard CNA B state Well if you want to live to be 88, you'll go around the other way. CNA C stated she felt like the situation was escalating and felt like CNA B was threatening Resident #55. During an interview on 7/7/2026 at 8:15 AM, LPN A stated she was present at the time of the incident and witnessed CNA B ask Resident #55 how old she was and whether she wanted to make it to her next birthday. LPN A further stated CNA B did not hurt Resident #55 physically but lashed out verbally because she was angry. During an interview on 7/7/2026 at 8:21 AM, CNA B stated she remembered the incident, and further stated Resident #55 was confused and called her a man. CNA B further stated Resident #55 was going to fall, and she [CNA B] asked Resident #55 how old she was and told her if she wanted to live, she shouldn't be walking around the hallways because the resident was unsteady on her feet and had stumbled. CNA B further stated she did not intend this to be a threat. During an interview on 7/8/2026 at 9:30 AM, the Administrator stated she could see how in some circumstances the statement made by CNA B could be taken as a threat. The facility's corrective action plans were reviewed, verified, and validated on site by Surveyor from 7/6/2026 - 7/8/2026. A plan of correction was developed from 12/8/2025-12/11/2025 to address the deficient practice identified. The corrective actions were verified on-site by the surveyor through interviews and review of facility documents from 7/6/2026 - 7/8/2026. The facility's Plan of Correction included the following: 1.) All active residents with a BIMS score of 11 or higher were interviewed on 12/8/2025. 2.) All active residents with a BIMS score of 10 or less had skin assessments completed on 12/9/2025. 3.) The Administrator and Director of Nursing (DON) were educated by the Regional Director of Operations on reporting of alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment on 12/9/2025. 4.) Beginning 12/9/2025, the Administrator and Director of Nursing completed 5 resident interviews and 5 resident skin assessments weekly for 4 weeks, then every other week for 6 weeks, then monthly for 2 months. 5.) Beginning 12/11/2025, the Regional Director Operations reviewed all grievances and results of skin assessments with the Administrator weekly for 4 weeks, then every other week for 6 weeks, then monthly for 2 months. 6.) All facility staff were educated from 12/8/2025 to 12/11/2025 on reporting of alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment. To ensure education was retained, a post-test was required with 100% compliance. If 100% compliance was not achieved, staff members were reeducated and required to re-test until 100% compliance was achieved. Education was completed for all staff on 12/11/2025. Surveyor verified the following onsite: 1.) Reviewed and validated record of residents interviewed on 12/8/2025. 2.) Reviewed and validated record of residents on whom skin assessments were performed on 12/9/2025. 3.) Reviewed and validated documentation of Administrator and Director of Nursing having received education on reporting of alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment on 12/9/2025. Multiple interviews with multiple members of staff from various departments, including nursing staff verified they had received education on abuse, neglect, exploitation, and mistreatment and the appropriate procedures for reporting such allegations. Staff were knowledgeable about the facility's policies related to abuse and neglect. The deficient practice was cited as past non-compliance for F-609 and the facility is not required to submit a plan of correction. Non-compliance began on 12/8/2025 and ended on 12/11/2025.

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of staff to resident verbal abuse for 1 resident (Resident #55) of 12 residents reviewed for abuse. The facility was cited at F-609 as Past Non-Compliance. No further corrective actions are required. Non-Compliance began 12/7/2025 and ended 12/11/2025. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation revealed, .Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies as is required .Immediately . Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Acute Cystitis, Type II Diabetes, and Dementia with Mood Disturbance. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. Review of an Employee Counseling Statement for CNA B dated 12/8/2025, revealed .It was alleged by several staff members that you [CNA B] were yelling at resident [Resident #55], using foul language and pointing your finger in her [Resident #55's] face .we advised due to alleged verbal abuse .she [CNA B] is terminated immediately . Review of a State of Tennessee Department of Human Services Submission dated 12/8/2025, revealed facility reported the allegation to the State Agency at 7:37 PM (date of incident was 12/7/2026 at 4:00 AM). Review of a local Police Department report dated 12/8/2025, revealed the facility reported the allegation to law enforcement at 7:42 PM. Review of an email to the Area Agency on Aging and Disability dated 12/8/2025, revealed the facility reported the allegation at 7:44 PM. Review of an Employee Counseling Statement for the Administrator dated 12/9/2025, revealed .failure to report allegations of abuse timely . Review of a document titled At-Risk Quality Assurance Performance Improvement Meeting dated 12/11/2025, revealed .a CNA made inappropriate comments to a resident .witnesses did not report the incident timely according to our policy, which delayed the facility in reporting . Review of an Abuse Allegation Summary for Resident #55 dated 12/19/2025, revealed .Staff reported allegations of verbal abuse between a CNA [Certified Nursing Assistant] and a resident on 12/7/25 [12/07/2025] at approximately 1800 [6:00 PM] to ADON/DON [Assistant Director of Nursing/Director of Nursing] .The incident occurred on 12/7/2025 @ 0400 [4:00 AM] .A resident statement was attempted but the resident didn't remember the incident d/t [due to] dementia .skin assessment was negative for injury .CNA was terminated for policy violation and alleged verbal abuse on 12/8/25 . During an interview on 7/8/2026 at 9:30 AM, the Administrator stated it is her expectation that allegations of abuse are reported immediately and confirmed this allegation was not reported immediately. A plan of correction was developed from 12/8/2025-12/11/2025 to address the deficient practice identified. The corrective actions were verified on-site by the surveyor through interviews and review of facility documents from 7/6/2026 - 7/8/2026. The facility's Plan of Correction included the following: 1.) All active residents with a BIMS score of 11 or higher were interviewed on 12/8/2025. 2.) All active residents with a BIMS score of 10 or less had skin assessments completed on 12/9/2025. 3.) The Administrator and Director of Nursing (DON) were educated by the Regional Director of Operations on reporting of alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment on 12/9/2025. 4.) Beginning 12/9/2025, the Administrator and Director of Nursing completed 5 resident interviews and 5 resident skin assessments weekly for 4 weeks, then every other week for 6 weeks, then monthly for 2 months. 5.) Beginning 12/11/2025, the Regional Director Operations reviewed all grievances and results of skin assessments with the Administrator weekly for 4 weeks, then every other week for 6 weeks, then monthly for 2 months. 6.) All facility staff were educated from 12/8/2025 to 12/11/2025 on reporting of alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment. To ensure education was retained, a post-test was required with 100% compliance. If 100% compliance was not achieved, staff members were reeducated and required to re-test until 100% compliance was achieved. Education was completed for all staff on 12/11/2025. Surveyor verified the following onsite: 1.) Reviewed and validated record of residents interviewed on 12/8/2025. 2.) Reviewed and validated record of residents on whom skin assessments were performed on 12/9/2025. 3.) Reviewed and validated documentation of Administrator and Director of Nursing having received education on reporting of alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment on 12/9/2025. Multiple interviews with multiple members of staff from various departments, including nursing staff verified they had received education on abuse, neglect, exploitation, and mistreatment and the appropriate procedures for reporting such allegations. Staff were knowledgeable about the facility's policies related to abuse and neglect. The deficient practice was cited as past non-compliance for F-609 and the facility is not required to submit a plan of correction. Non-compliance began on 12/8/2025 and ended on 12/11/2025.

Based on facility policy review, medical record review, and interviews, the facility failed to develop a comprehensive care plan for Post -Traumatic Stress Disorder (PTSD) for 1 resident (Resident #4) of 25 residents reviewed for care plans.The findings include: Review of the facility policy undated titled, Comprehensive Care Plans, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Acquired Absence of Left Leg Above the Knee, Major Depressive Disorder, Generalized Anxiety Disorder, and Chronic Post-Traumatic Stress Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident had a diagnosis of PTSD. Review of the comprehensive Care Plan for Resident #4 revised 5/4/2026, revealed no documentation of the PTSD or specific triggers on the Care Plan. During an interview and medical record review with the MDS Coordinator on 7/7/2026 at 2:10 PM, the MDS Coordinator confirmed Resident #4 had not been care planned for PTSD to include specific triggers. During an interview with the Director of Nursing (DON) on 7/7/2026 at 2:38 PM, the DON confirmed the facility policy for Comprehensive Care Plans was not followed and the PTSD diagnosis for Resident #4 had not been developed and implemented on the care plan.

Based on facility policy review, medical record review, facility post fall investigation review, and interviews, the facility failed to revise the comprehensive care plan related to falls for 3 residents (Resident #14, #15, and #17) of 3 residents reviewed for falls which resulted in actual harm to Resident #14 when the resident fell and sustained a laceration to the left eye and required the area to have steri strips (wound closure tape) placed to close the wound, failed to revise the comprehensive care plan related to a wound for Resident #14 of 2 residents reviewed for wounds, failed to revise the comprehensive care plan related to a wander guard (a safety device used for high elopement risk) for 2 residents (Resident #15 and #17), failed to revise the comprehensive care plan for new diagnoses for 1 resident (Resident #15), and failed to revise the comprehensive care plan for a functional decline and restraint use for 1 resident (Resident #17) of 12 care plans reviewed. The findings include: Review of the facility policy titled, Fall Risks, revised 8/4/2023, showed .PURPOSE .To assist .in identifying residents at risk for falls and implementing appropriate interventions .Interventions are implemented for fall prevention, decreasing the risk of falls and harm from falls .Each fall will be evaluated .with interventions developed to reduce risk of recurrent fall (s) .determine what interventions should be to be implemented and update the resident's care plan . Review of the facility policy titled, Care Plan/Comprehensive Assessment, revised 11/4/2022, showed .To define the process for assessing and developing an individualized .plan of care of each resident .Review and revise care plans . Resident #14 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact, required 1-person assistance with transfers, had previously fallen, was at risk for pressure ulcers, and had no current wounds. Review of a Post Fall Observation report dated 5/30/2023, showed the report had been completed by Licensed Practical Nurse (LPN) #1 .Location of Fall .Resident Room .Resident stated she was going to put her blanket in the chair across the room .Medical Care Provided Post Fall .No Care Necessary .measures to be taken to prevent further falls .unable to stay in her room in chair by herself . Review of a nursing Progress Note dated 5/30/2023, showed LPN #1 documented .residents alarm sounded followed by her [Resident #14] yelling out .was sitting in the floor with no injuries .said she [Resident #14] was going to put .blanket in a chair .replaced in .chair and taken out to the front hall . Review of a Post Fall Observation report dated 7/30/2023, showed the report had been completed by LPN #1 .Location of Fall .Resident Room .Describe .resident was in floor out of her chair .Medical Care Provided Post Fall .Basic First Aid .cleaned and dried with NS [Normal Saline] and Steri strips applied and cover dressing .resident stated she was going to walk out to the garden . Review of a nursing Progress Note dated 7/30/2023, showed LPN #1 documented .Heard alarm went into residents room she was lying in the floor on her left side crying lying in small amt [amount] of blood coming from above her eye at her eyebrow .she [Resident #14] stated she was going out to the garden .cleaned and dried her laceration applied steri strips and a cover dressing .notified hospice of incident .hospice will be here [at facility] .to see if steri strips will be enough without stitches . Review of Resident #14's annual MDS assessment dated [DATE], showed a BIMS score of 8 which indicated the resident had moderate cognitive impairment, required 2-person assistance with transfers, had 2 or more falls, 1 with injury, was at risk for pressure ulcers, and had no current wounds. Review of Resident #14's Physician's Order dated 8/21/2023, showed .Stage I Ulcer and .SDTI [suspected deep tissue injury] .clean areas with Normal Saline, dry, apply foam heel dressing and change every other day .R [right] heel . Review of a Wound Report dated 8/29/2023, showed .[Resident #14 .SDTI .R heel .Onset Date .8/21/2023 .healing . Review of the comprehensive care plan revised 10/2/2023, showed .Fall .Resident will remain free of fall related injury . Further review showed the care plan had not been revised to reflect a fall intervention when Resident #14 sustained a fall on 5/30/2023 (no injury). Continued review showed no fall intervention was initiated after the resident sustained a fall on 7/30/2023, and the care plan had not been revised to reflect a SDTI to Resident #14's right heel which was identified on 8/21/2023. Review of Resident #14's medical record showed the resident had not sustained a fall since the 7/30/2023 fall. During an interview on 10/2/2023 at 11:05 AM, Certified Nursing Assistant (CNA) #1 stated she was familiar with Resident #14 and cared for the resident routinely. Resident #14 was a high fall risk, had multiple fall interventions in place to include, if the resident was up in the broda chair (a wheelchair which provides supportive positioning), the resident was not left alone in the resident's room. CNA #1 was on duty when Resident #14 sustained a fall on 7/30/2023. The chair (broda chair) alarm sounded, CNA #1 stated she checked on the resident immediately, the resident was in her room, the resident had removed the self-release belt, was observed in the floor, and was bleeding from a cut on her eye (unable to recall which eye). Resident #14 had attended a church activity .someone from the church must have brought her [Resident #14] back to the room and did not know [Resident #14] should not be left alone in the room . During an interview on 10/2/2023 at 11:12 AM, LPN #1 stated she was familiar with Resident #14 and was the resident's routine nurse. The resident was a high fall risk with multiple interventions in place to include not left in the room alone when up in the broda chair. The LPN was on duty 7/30/2023 when Resident #14 sustained a fall. The resident had attended a church service at the facility, staff heard the chair alarm sound, checked on the resident immediately, the resident had removed the self-release lap belt, and was observed lying on the floor in a small amount of blood with a laceration to her left eye, above the eyebrow. LPN #1 cleansed the wound, applied steri strips, and notified hospice; the hospice nurse evaluated the resident and determined the resident would not require stitches. LPN #1 also stated .a church member must have brought her [Resident #14] back to her room and left her alone, we [facility staff] know not to leave her alone when she is up in the broda chair . During an interview on 10/4/2023 at 8:21 AM, the wound care nurse stated Resident #14 had a SDTI identified on 8/21/2023. The physician was notified, and wound care orders were received. She also stated the wound to Resident #14's right heel had improved and nearly healed. During an interview on 10/4/2023 at 2:13 PM, the Director of Nursing (DON) stated Resident #14 sustained a fall on 5/30/2023. The new fall intervention was for the resident not to be left in her room alone when the resident was up in the broda chair. The DON confirmed Resident #14's care plan had not been revised to reflect the new intervention. During an interview on 10/4/2023 at 2:17 PM, the DON stated Resident #14 sustained a fall on 7/30/2023. The resident was left alone in her room in the broda chair, the resident received a laceration to the left eyebrow, and the area required steri strip placement to close the wound. The DON confirmed the facility failed to revise and implement a fall intervention from 5/30/2023 which caused harm to Resident #14 when she sustained a fall with injury on 7/30/2023. The DON also confirmed a new fall intervention was not implemented after the resident fell on [DATE], and the resident had not sustained any further falls. During an interview on 10/5/2023 at 2:39 PM, the DON confirmed Resident #14's care plan had not been revised to reflect the SDTI to the resident's right heel identified on 8/21/2023. 41291 Resident #15 was admitted to the facility on [DATE] with diagnoses including Alcoholic Cirrhosis of Liver, Palliative Care, Depressive Disorders, Hallucinations, Chronic Pain, and Muscle Weakness. Review of the quarterly MDS assessment dated [DATE], showed Resident #15 had severe cognitive impairment, used a bed and chair alarm daily, used a wander guard alarm daily (the resident did not have a wander guard system in use), and did not reflect a diagnosis of hallucinations. Review of a Post Fall Observation Report dated 9/10/2023, showed Resident #15 had an unwitnessed fall from the chair with no injuries. The fall intervention was to place the chair alarm out of sight due to the resident had turned the chair alarm off. Review of a Post Fall Observation Report dated 9/23/2023, showed Resident #15 had an unwitnessed fall from the bed. The resident was observed lying on his back in the floor, the resident had turned the bed alarm off, and complained of back and shoulder pain. The resident was sent to the emergency room for evaluation and returned to the facility with no injuries. The fall intervention placed after the fall was to place a bolster mattress (a specialty mattress with foam sides to reduce the risk of rolling off the bed) to the bed. Review of the comprehensive care plan revised 9/25/2023, showed Resident #15's care plan had not been revised to include the fall intervention from 9/10/2023 to place the chair alarm out of sight, and the hallucination diagnosis. Further review showed the resident had a care plan for a wander guard. During an observation on 10/2/2023 at 11:45 AM, showed Resident #15 lying in bed with a bolster mattress, and no wander guard in use. During an observation on 10/3/2023 at 9:04 AM, showed Resident #15 lying in bed with a bolster mattress, and no wander guard in use. During an observation on 10/4/2023 at 10:34 AM, showed Resident #15 lying in bed with a bolster mattress, and no wander guard in use. Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a Post Fall Observation Report dated 5/8/2023, showed Resident #17 had an unwitnessed fall in her room with no injury. The fall intervention placed after the fall was for the resident to be in a highly visible area when up in chair. Review of a Psychiatric Nurse Practitioner note dated 8/2/2023, showed .diagnosis .depression .insomnia .delusions .psychosis . Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making, was totally dependent on 2 persons for bed mobility, dressing, toileting, personal hygiene, bathing, and required extensive assistance of 2 persons with transfers. Further review showed the MDS did not reflect Resident #17 had the following diagnoses: Alzheimers Disease, Depression, Insomnia, Delusions, or Psychosis. The resident used a bed, chair alarm, and wander guard daily. Further review showed a restraint was not used. Review of the comprehensive care plan dated 9/7/2023, showed Resident #17 had decreased Activities of Daily Living (ADL) ability related to weakness and required 1 person staff assistance with bathing, hygiene, dressing, grooming, toileting, transfers, and had a wander guard to the lower extremity. Further review showed the resident was care planned for falls and the care plan had not been revised to reflect the fall intervention on 5/8/2023 for the resident to be in a highly visible area when up in chair. Continued review showed the care plan had not been revised to include diagnoses of Alzheimer's Disease, Depression, Insomnia, Delusions, or Psychosis, and the use of a restraint. During an observation on 10/2/2023 at 3:52 PM, showed Resident #17 seated in a broda chair in the hallway, reclined back, with a click seat belt, and chair alarm in use. Resident #17 attempted to release the click seat belt but was unable; no wander guard in use. During an observation on 10/3/2023 at 9:02 AM, showed Resident #17 seated in a broda chair in the hallway, with a click seat belt, and chair alarm in use; no wander guard in use. During an interview on 10/3/2023 at 4:05 PM, the DON confirmed Resident #15's care plan had not been revised to include the fall intervention from 9/10/2023 to place the chair alarm out of sight, and the hallucination diagnosis and Resident #15 did not have a wander guard in place. Further interview confirmed Resident #17 used a click seat belt, the resident could not release the seat belt, and it was considered a restraint. She also confirmed Resident #17 had a functional decline, required more assistance from staff, and the care plan had not been revised to reflect the decline. Continued interview confirmed Resident #17's care plan had not been revised to include a fall intervention after the resident sustained a fall on 5/8/2023, and after Resident #17 had recieved the diagnoses of Alzheimer's, Depression, Insomnia, Delusions, and Psychosis. The DON confirmed Resident #17's care plan showed the resident had a wander guard to the lower extremity (Resident #17 did not have a wander guard in use), and Resident #17's care plan did not reflect the resident's current care status. During an interview on 10/4/2023 at 3:20 PM, the MDS Coordinator confirmed she had not revised Resident #15 and #17's care plan to reflect the resident's current status. Refer to tag F-689

Based on facility policy review, medical record review, facility post fall review, and interviews, the facility failed to prevent accidents related to falls for 1 resident (Resident #14) of 3 residents reviewed for falls when a new fall intervention was not implemented which resulted in actual harm to Resident #14 when the resident fell and sustained a laceration to the left eye and required steri strips (wound closure tape) to close the wound, and failed to complete thorough fall investigations for 1 resident (Resident #17) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Fall Risks, revised 8/4/2023, showed .PURPOSE .To assist .in identifying residents at risk for falls and implementing appropriate interventions .Interventions are implemented for fall prevention, decreasing the risk of falls and harm from falls .Each fall will be evaluated .with interventions developed to reduce risk of recurrent fall (s) . Review of the facility policy titled, Care Plan/Comprehensive Assessment, revised 11/4/2022, showed .To define the process for assessing and developing an individualized .plan of care of each resident .Review and revise care plans . Resident #14 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact, required 1-person assistance with transfers, and had previously fallen. Review of a Post Fall Observation report dated 5/30/2023, showed the report had been completed by Licensed Practical Nurse (LPN) #1 .Location of Fall .Resident Room .Resident stated she was going to put her blanket in the chair across the room .Medical Care Provided Post Fall .No Care Necessary .measures to be taken to prevent further falls .unable to stay in her room in chair by herself . Review of a nursing Progress Note dated 5/30/2023, showed LPN #1 documented .residents alarm sounded followed by her [Resident #14] yelling out .was sitting in the floor with no injuries .said she [Resident #14] was going to put .blanket in a chair .replaced in .chair and taken out to the front hall . Review of a Post Fall Observation report dated 7/30/2023, showed the report had been completed by LPN #1 .Location of Fall .Resident Room .Describe .resident was in floor out of her chair .Medical Care Provided Post Fall .Basic First Aid .cleaned and dried with NS [Normal Saline] and Steri strips applied and cover dressing .resident stated she was going to walk out to the garden . Review of a nursing Progress Note dated 7/30/2023, showed LPN #1 documented .Heard alarm went into residents room she was lying in the floor on her left side crying lying in small amt [amount] of blood coming from above her eye at her eyebrow .she [Resident #14] stated she was going out to the garden .cleaned and dried her laceration applied steri strips and a cover dressing .notified hospice of incident .hospice will be here [at facility] .to see if steri strips will be enough without stitches . Review of an annual MDS assessment dated [DATE], showed a BIMS score of 8 which indicated the resident had moderate cognitive impairment, required 2-person assistance with transfers, and had 2 or more falls, 1 with injury. Review of the comprehensive care plan revised 10/2/2023, showed .Falls .Resident will remain free of fall related injury . Further review showed the care plan had not been revised to reflect the fall intervention after Resident #14 sustained a fall on 5/30/2023 (no injury) and 7/30/2023. Review of Resident #14's medical record showed the resident had not sustained a fall since 7/30/2023. During an observation on 10/2/2023 at 11:00 AM, showed Resident #14 lying in a low bed, bed mat in place, bed alarm in place, and one side of the bed against the wall. Further observation showed the resident had a broda chair in the room with a self-release belt, and chair alarm attached midway down the back of the chair. During an interview on 10/2/2023 at 11:05 AM, Certified Nursing Assistant (CNA) #1 stated she was familiar with Resident #14 and cared for the resident routinely. Resident #14 was a high fall risk, had multiple fall interventions in place to include, if the resident was up in the broda chair (a wheelchair which provides supportive positioning), the resident was not left alone in the resident's room. CNA #1 was on duty when Resident #14 sustained a fall on 7/30/2023. The chair alarm sounded, CNA #1 stated she checked on the resident immediately, the resident was in her room, the resident had removed the self-release belt, was observed in the floor, and was bleeding from a cut on her eye (unable to recall which eye). Resident #14 had attended a church activity .someone from the church must have brought her [Resident #14] back to the room and did not know [Resident #14] should not be left alone in the room . During an interview on 10/2/2023 at 11:12 AM, LPN #1 stated she was familiar with Resident #14 and was the resident's routine nurse. The resident was a high fall risk with multiple interventions in place to include not left in the room alone when up in the broda chair. The LPN was on duty 7/30/2023 when Resident #14 sustained a fall. The resident had attended a church service at the facility, staff heard the chair alarm sound, checked on the resident immediately, the resident had removed the self-release lap belt, and was observed lying on the floor in a small amount of blood with a laceration to her left eye, above the eyebrow. LPN #1 cleansed the wound, applied steri strips, and notified hospice; the hospice nurse evaluated the resident and determined the resident would not require stitches. LPN #1 also stated .a church member must have brought her [Resident #14] back to her room and left her alone, we [facility staff] know not to leave her alone when she is up in the broda chair . During an observation on 10/3/2023 at 8:30 AM, showed Resident #14 seated in a broda chair near the nurse's station with a self-release belt and chair alarm in place, alarm out of her reach. During an observation on 10/3/2023 at 2:07 PM, Resident #14 was seated in a broda chair in the hallway with a self-release belt, the chair alarm was in place, and out of the residents reach. During an observation on 10/4/2023 at 7:40 AM, Resident #14 was seated in a broda chair in the dining room with a self-release belt in place with an alarm to the back of the chair out of reach. During an interview on 10/4/2023 at 2:13 PM, the Director of Nursing (DON) stated Resident #14 sustained a fall on 5/30/2023. The new fall intervention was for the resident not to be left in her room alone when the resident was up in the broda chair. The DON confirmed Resident #14's care plan had not been revised to reflect the new intervention. During an interview on 10/4/2023 at 2:17 PM, the DON stated Resident #14 sustained a fall on 7/30/2023. The resident was left alone in her room in the broda chair, the resident received a laceration to the left eyebrow, and the area required steri strip placement to close the wound. The DON confirmed the facility failed to revise and implement a fall intervention from 5/30/2023 which caused harm to Resident #14 when she sustained a fall with injury on 7/30/2023. The DON also confirmed a new fall intervention was not implemented after the resident fell on [DATE], and the resident had not sustained any further falls. 41291 Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a Post Fall Observation report dated 4/16/2023, showed .nurse was charting at nursing station when heard a bed alarm going off .she [ Resident #17 ] was standing at the air conditioner .Resident heard this nurse and tried to turn around when she fell against the wall and hit her left forearm on the bed side table. Resident slid to her bottom .Scrape noted to left forearm .No other injuries .measures to be taken to prevent further fall .continue plan of care . Further review showed no new fall intervention was placed after the fall and the fall investigation was not complete and thorough. Review of a Post Fall Observation report dated 5/8/2023, showed .[Resident #17 ] unbuckled Geri chair (a specialized chair for individuals with limited mobility) buckle and was found on the floor .heard moaning from room as staff entered room .Geri-chair was found in the middle of the room and resident was found lying on the floor in front of it .Medical Care Provided .No Care Necessary .measures to be taken to prevent further falls .Resident in highly visible area when up in chair . Review of a Post Fall Observation report dated 5/11/2023, showed .found on floor next to chair in .resident's room .What was resident's location prior to the fall .Bed .Medical Care Provided Post Fall .emergency room Visit .Evidence that resident hit left side of head .Describe measures to be taken to prevent further falls .[blank] . Further review showed no new fall intervention was placed after the fall and the fall investigation was not complete and thorough. Record review showed Resident #17's CT (Computed Tomography/a diagnostic imaging procedure) scan performed on 5/11/2023, was negative and the resident returned to the facility, and Resident #17 had not sustained a fall since 5/11/2023. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making, required extensive assistance of 1 person with bed mobility, locomotion, and personal hygiene; required extensive assistance of 2 persons with transfers, dressing, toileting, and bathing. The resident had sustained falls since the last assessment. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making, was totally dependent on 2 persons for bed mobility, dressing, toileting, personal hygiene, bathing, and required extensive assistance of 2 person with transfers. Review of the comprehensive care plan last reviewed 9/7/2023, showed Resident #17 was care planned for falls and the care plan had not been revised to reflect the fall intervention on 5/8/2023 for the resident to be in a highly visible area when up in chair. During an observation on 10/2/2023 at 3:52 PM, showed Resident #17 seated in a broda chair in the hallway, reclined back, with a click seat belt, and chair alarm in use. During an observation on 10/3/2023 at 9:02 AM, showed Resident #17 seated in a broda chair in the hallway, with a click seat belt, and chair alarm in use. During an interview on 10/4/2023 at 8:53 AM, the DON confirmed the fall investigations for Resident #17 for 4/16/2023 and 5/11/2023 were not complete and thorough. The DON also confirmed a new fall intervention had not been placed after the resident sustained a fall on 4/16/2023 and 5/11/2023. Refer to F-657

Based on facility policy review, observations, and interviews, the facility failed to maintain sanitary kitchen equipment and failed to replace damaged kitchen equipment that had not been maintained in a good working condition, which had the potential to affect 27 of 27 residents. The findings include: Review of the facility's policy titled, Cleaning of Food and Nonfood Contact Surfaces, dated 1/2023, showed .The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil .Nonfood contact surfaces of utensils and equipment must be made of materials that are safe, corrosion resistant .smooth and easily cleanable, and maintained in good condition. Nonfood contact surfaces of equipment, such as handles .gaskets .exterior .shall be cleaned .to keep the equipment free of accumulation of dust, dirt, food particles, and other debris . Observation of the kitchen with the Food Services Lead Aide (FSLA) on 10/2/2023 at 10:15 AM, showed the following: Convection ovens (top and bottom oven) had dark-brown, crusty debris on 4 of 4 of the temperature control dials. Temperature control dial #2 on the convection oven was broken on both sides. 2 metal inserts for shallow pans had been stored in the clean dish rack with dried food debris on the outer edges. Insulated gasket on the plate warmer had cracks and holes throughout the parameter which had caused an ineffective seal. Garbage disposal power switch had a thick, black greasy film that covered the switch. Gas cooking range temperature control dials had a thick, black greasy film. Metal food preparation table beside the gas stove had dried food debris and presence of a greasy-brown residue in the crevices. Deep fryer had a greasy, brownish-black residue with food debris on the outer edge of the fryer. Fryer oil in the deep fryer was thick, dark brown in color with floating food debris. Metal can opener had the presence of crusty, brownish-black corrosion. During an interview on 10/2/2023 at 11:15 AM, the Food Services Director (FSD) confirmed the convection oven and gas cooking range temperature dials, deep fryer, fryer cooking oil, metal food preparation table, garbage disposal, and metal pan inserts x (times) 2 had not been maintained in a sanitary condition. Further interview confirmed the convection oven temperature dial #2, the metal can opener, and the insulated gasket on the plate warmer needed to be replaced and had not been maintained in a good working condition.

Based on facility policy review, observation, and interview, the facility failed to ensure staff performed proper hand hygiene while delivering meal trays and during meal assistance in dining room. The findings include: Review of the facility policy titled, Hand Hygiene, revised 12/3/2021, showed .To outline indications for hand hygiene and correct procedure for performing hand hygiene in order to assist in preventing healthcare associated infections .When to perform hand hygiene .Hands must be washed with soap and water or alcohol hand gel used .after having direct contact with patients or their surroundings .After contact with inanimate objects .in the vicinity of the patient . During an observation of dining on 10/2/2023 from 12:17 PM-12:23 PM, showed the Wound Care Nurse retrieved a meal tray from the meal cart, served the tray to Resident #4, walked into the dining room to a wooden cabinet, opened the drawer, and retrieved a packet of coffee creamer. Further observation showed the Wound Care Nurse walked back to the food cart, reached in, retrieved a coffee cup, poured a cup of coffee, served the coffee to the resident on the resident's meal tray, and did not wash or sanitize the hands. Continued observation showed the Wound Care Nurse retrieved another meal tray from the meal cart, walked down the hallway to Resident #13's room, set the meal tray on the bedside table, removed the lid, and Resident #13 did not require further assistance. The Wound Care Nurse exited the room, touched the door handle, closed the door on her way out of the room, and did not wash or sanitize the hands. The Wound Care Nurse walked to the nurse's desk, touched the vital sign machine, picked up the telephone receiver, placed a call to the kitchen to request more coffee cups, and did not wash or sanitize the hands. She proceeded to the meal cart, retrieved another meal tray, walked into the dining room, placed the tray in front of Resident #12, touched and readjusted the clothing protector, opened the straw with bare hands, placed the straw into a cup, and assisted the resident with the drink. Further observation showed the Wound Care Nurse readjusted Resident #12's blanket in her lap, opened the lid to the meal tray, removed a clear plastic wrap covering from a cookie, and did not wash or sanitize the hands. During an interview on 10/2/2023 at 12:25 PM, the Wound Care Nurse stated she was to perform hand hygiene before and after resident care and direct contact which included passing meal trays. The Wound Care Nurse confirmed she failed to perform hand hygiene during dining observation when she delivered meal trays to Residents #4, #13, and #12. During an observation on 10/2/2023 at 12:26 PM, in the dining room, showed 3 CNAs and 7 residents seated at a round table. CNA #2 was observed seated on a rolling chair between Resident #1 and Resident #22. The CNA assisted both residents simultaneously with the lunch meal without washing or sanitizing the hands. During an observation on 10/2/2023 at 12:30 PM, in the dining room, showed CNA #3 was observed seated in a chair between Resident #7 and Resident #14. The CNA assisted both residents simultaneously with the lunch meal without washing or sanitizing the hands. During an interview on 10/3/2023 at 9:36 AM, the Director of Nursing confirmed the facility failed to follow the hand hygiene policy and the Wound Care Nurse, CNA #2, and CNA #3 failed to perform hand hygiene during dining observation.

Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 4 residents (Residents #5, #7, #15, and #17) of 12 residents reviewed for MDS assessments. The findings include: Review of the RAI Manual 3.0 dated 10/2019, showed .The MDS contains items that reflect the acuity level of the resident, including diagnoses, treatments, and an evaluation of the resident's functional status .The RAI process .require that .the assessment accurately reflects the resident's status .an accurate assessment requires collecting information from multiple sources .Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable . Resident #5 was admitted to the facility on [DATE] with diagnoses to include Dysphagia, Vascular Dementia, Hemiplegia and Hemiparesis, Neuromuscular Dysfunction of the Bladder, and Type 2 Diabetes Mellitus. Review of a quarterly MDS assessment dated [DATE] for Resident #5 did not reflect he had a diabetic foot ulcer and neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problem). Review of the current comprehensive care plan revised 10/4/2023, showed Resident #5 had a urinary catheter for elimination and a diabetic foot ulcer to right heel initiated on 5/9/2023. Review of a Physician's Order dated 10/4/2023, for Resident #5 showed clean right heel twice weekly with Normal Saline, apply Calmoseptine (medication is used to treat and prevent minor skin irritations), and cover with foam cover dressing. Foley catheter care every shift, place catheter bag in a dignity pouch, change foley catheter as needed, and observe foley catheter every shift for problems. During an interview on 10/3/2023 at 9:05 AM, the Physical Therapist stated the wound on Resident #5's right heel was not consistent with a pressure ulcer and due to his contractures of his bilateral lower extremities his heels do not have direct contact or pressure on the area with the wound. During an interview on 10/3/2023 at 9:31 AM, the Wound Care Nurse stated the wound on Resident #5's right foot was not related to pressure and was slow healing due to his poor circulation and diabetes. During an interview on 10/3/2023 at 9:45 AM, the MDS Coordinator confirmed the quarterly MDS completed on 9/13/2023 for Resident #5 was not accurate and did not include diagnoses for neurogenic bladder and diabetic foot ulcer. During an interview on 10/4/2023 at 3:47 PM, the Podiatrist stated she had evaluated Resident #5's right heel wound and determined it was a diabetic foot ulcer; not pressure. Resident #7 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Spastic Hemiplegic Cerebral Palsy, Quadriplegia, and Contracture of Muscle, multiple sites. Review of a quarterly MDS assessment dated [DATE], showed Resident #7 required total dependence with bed mobility, transfers, dressing, eating, toileting, personal hygiene, bathing, and restraints were not used. During an observation on 10/2/2023 at 11:45 AM, showed Resident #7 seated in wheelchair with click seat belt in place. During an interview on 10/2/2023 at 12:10 PM, Certified Nursing Assistant (CNA) #3 stated Resident #7 had a click seat belt on his wheelchair for safety and to keep him from falling out of his chair. She stated the resident could not release the click seat belt himself due to his bilateral hand contracture. During an interview on 10/3/2023 at 10:00 AM, Licensed Practical Nurse (LPN) #1 stated Resident #7 had a click seat belt to help him maintain his position while in the wheelchair and he could not release it due to his cognition and bilateral hand contractures. During an observation on 10/3/2023 at 1:05 PM, showed Resident #7 seated in a wheelchair with click seat belt in place. During an interview on 10/3/2023 at 2:30 PM, the Administrator stated Resident # 7's click seat belt was used for positioning and not as a restraint. During an interview on 10/3/2023 at 4:39 PM, Resident #7's responsible party stated he (Resident #7) used the seat belt on his wheelchair as a restraint to keep him from falling out of the wheelchair. During an interview on 10/4/2023 at 7:45 AM, the Director of Nursing (DON) confirmed Resident #7 did not have an accurate MDS assessment to reflect the use of the click seat belt as a restraint. 41291 Resident #15 was admitted to the facility on [DATE] with diagnoses including Alcoholic Cirrhosis of Liver, Palliative Care, Depressive Disorders, Hallucinations, Chronic Pain, and Muscle Weakness. Review of Psychotherapy Progress Notes dated 5/24/2023 -9/27/2023, showed Resident #15 had a diagnosis of Hallucinations. Review of the quarterly MDS assessment dated [DATE], showed Resident #15 did not have an active diagnosis of Psychiatric Disorder or Hallucinations. The resident used a wander guard (a safety device used for high elopment risk) daily. Review of Resident #15's comprehensive care plan revised 9/25/2023, showed the daughter had requested a wander guard (5/29/2023). The care plan did not reflect Resident #15 had a diagnosis of hallucinations. Review of Resident #15's current Physician Orders showed no order for a wander guard. During an observation on 10/3/2023 at 9:04 AM, showed Resident #15 lying in bed with no wander guard in use. During an observation and interview on 10/4/2023 at 10:34 AM, showed Resident #15 lying in bed with no wander guard in use. CNA #5 stated Resident #15 did not have a wander guard in use and was not an elopement risk. During an interview on 10/4/2023 at 3:20 PM, the MDS Coordinator stated Resident #15 had a .wander guard on at one time, if he didn't have it on now, then the MDS was incorrect . The MDS corrdinator confirmed she had not captured the diagnosis of Hallucinations. During an interview on 10/4/2023 at 3:36 PM, the Administrator (ADM) confirmed Resident #15's MDS dated [DATE] was inaccurate and showed the resident used a wander guard daily and did not have a diagnosis of Hallucinations. Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a Physician's Order dated 3/27/2023, showed .click type seat belt while up in chair . Review of a Psychiatric Evaluation dated 8/2/2023, showed Resident #17 was being treated with psychiatric medications for Depression, Insomnia, Delusions, and Psychosis. Review of the quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making and was totally dependent on 2 persons with bed mobility, dressing, toileting, personal hygiene, and bathing; required extensive assistance of 2 persons with transfers; totally dependent on 1 person for locomotion; and required limited assistance of 1 person with eating. Further review showed Resident #17 did not have a diagnoses of Alzheimer's Disease, Depression, Insomnia, Delusions, or Psychosis. Restraints were not use, and a wander guard was used daily. Review of the comprehensive care plan reviewed 9/7/2023, showed Resident #17 had a clip belt with an alarm when up in chair and a personal alarm when in bed. During an observation on 10/2/2023 at 11:04 AM, showed Resident #17 seated in a reclined Broda chair (a type of wheelchair used for positioning) with a click seat belt in use. Further observation showed the resident was unable to unfasten the click seat belt, and a wander guard was not in use. During an observation on 10/2/2023 at 3:52 PM, showed Resident #17 seated in a reclined Broda chair with a click seat belt in use. Further observation showed the resident was unable to unfasten the click seat belt, and a wander guard was not in use. During an observation on 10/3/2023 at 9:02 AM, showed Resident #17 seated in a Broda chair in hallway outside of her room with click seat belt in use. The resident had her hands on the latch of the click seat belt, was unable to release the belt, and a wander guard was not in use. During an interview on 10/3/2023 at 4:05 PM, the DON confirmed Resident #17's MDS assessment dated [DATE] was not accurate and did not reflect the resident's current care status. The MDS did not show the diagnoses of Alzheimer's, Depression, Insomnia, Delusions, and Psychosis. Resident #17 used a click seat belt, the resident could not release the seat belt, it was considered a restraint, and the resident did not have a wander guard in use. During an interview on 10/4/2023 at 8:30 AM, CNAs #4 and #5 stated Resident # 17 did not have a wander guard in use and did not exit seek. During an observation on 10/4/2023 at 8:38 AM, showed Resident #17 seated in a Broda chair in the dining room with a click seat belt in use, and no wander guard in use.

Based on facility policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect during dining observation when 2 Certified Nursing Assistants (CNAs) assisted 4 residents (Residents #1, #7, #14, and #22) simultaneously (at the same time) of 7 residents observed for assistance with dining. The findings include: Review of the facility policy titled, Feeding The Resident, revised 5/2014, showed .Identify residents that need assist with eating or need encouragement .Feed residents who are unable to feed selves . Review of the facility policy titled, Resident Rights & [And] Responsibilities, revised 7/9/2021, showed .You [Resident] have the right to .be treated with dignity and respect . Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychotic Disturbance, Anxiety, and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 was rarely/never understood and was totally dependent on staff for eating. Resident #7 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Quadraplegia, Epilepsy, and Physical Debility. Review of a quarterly MDS assessment dated [DATE], showed Resident #7 was rarely/never understood and was totally dependent on staff for eating. Resident #14 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease. Review of an annual MDS assessment dated [DATE], showed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment and required supervision with eating. Resident #22 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, Psychotic Disturbance, and Hypothyroidism. Review of a quarterly MDS assessment dated [DATE], showed Resident #22 was rarely/never understood and was totally dependent on staff for eating. During an observation on 10/2/2023 at 12:26 PM, in the dining room, showed 3 CNAs and 7 residents seated at a round table. CNA #2 was observed seated on a rolling chair between Resident #1 and Resident #22. The CNA assisted both residents simultaneously with the lunch meal. During an observation on 10/2/2023 at 12:30 PM, in the dining room, showed CNA #3 was observed seated in a chair between Resident #7 and Resident #14. The CNA assisted both residents simultaneously with the lunch meal. During an observation on 10/2/2023 at 12:35 PM, showed a total of 3 CNAs in the dining room to assist the dependent residents with dining. Further observation showed 1 Licensed Practical Nurse (LPN) and 1 Registered Nurse (RN) available to assist with dining if needed. During an interview on 10/2/2023 at 12:45 PM, CNA #2 stated multiple residents are assisted simultaneously during dining .there isn't enough staff to feed all the residents . She also stated she had not requested assistance from the LPN and RN with dining today. During an interview on 10/2/2023 at 12:52 PM, CNA #3 stated she assisted multiple residents simultaneously during dining .not enough staff to feed all of them [residents] . She also stated she had not requested assistance from the LPN and RN with dining today. During an interview on 10/2/2023 at 12:56 PM, CNA #1 stated she routinely assisted residents simultaneously during dining .not enough staff . The CNA assisted 1 resident with the lunch meal today and she had not requested assistance from the LPN and RN with dining today. CNA #1 stated .the nurses will help if we ask . Review of an assisted dining list dated 10/3/2023, showed the facility had 4 residents who were totally dependent on staff for eating, and 3 residents who required supervision with eating. During an interview on 10/3/2023 at 10:00 AM, the Director of Nursing (DON) stated the facility had sufficient staff to assist dependent residents with eating. The facility had 4 residents who were totally dependent on staff for eating and 3 residents who required supervision with eating. The facility typically had 2-3 CNAs scheduled, on shift, and the nurses assisted with dining when needed. The DON confirmed the facility failed to maintain dignity during dining for Residents #1, #7, #14, and #22 during meal observation on 10/2/2023.

Based on review of the facility's Resident Fund Statement, medical record review, and interview, the facility failed to ensure the trust fund accounts for 2 residents (Residents #14 and #24) of 7 residents with trust fund accounts reviewed did not exceed the $2000.00 Supplemental Security Income (SSI) resource limit. The findings include: Resident #14 was admitted to the facility on [DATE]. Review of the facility's Resident Fund Statement report dated 7/31/2023 - 9/30/2023 revealed Resident #14 had a current balance of $3,008.48. Resident #24 was admitted to the facility on [DATE]. Review of the facility's Resident Fund Statement report dated 7/31/2023 - 9/30/2023 revealed Resident #24 had a current balance of $6,220.60. During an interview on 10/05/23 at 11:34 AM, the Corporate Business Office Account Representative (CBOAR) confirmed the Resident Trust Funds are to be maintained with a balance of less than $2000.00 and Residents #14 and #24 exceeded the balance.

Based on facility policy review, medical record review, and interview the facility failed to follow the policy for restraints for 2 residents (Resident #7 and #17) of 5 residents reviewed for restraints. The findings include: The facility policy titled, Restraints, revised 8/5/2022, showed .Physical Restraint: is defined as any manual method, physical or mechanical device/equipment that .Cannot be removed easily by the resident .Restricts the resident's freedom or movement or normal access to his/her body .The assessment is documented and use of the device is added to the plan of care .Restraints are discontinued as early as possible based on an individualized resident assessment and re-evaluation. Consideration whether to implement a restraint should weigh the risks of using a restraint against the risks presented by the resident's behavior. Reduction of risks associated with restraint use will be accomplished through preventative strategies, innovative alternatives, process improvement, planning, education, and allocation of resources .Resident care team members who are appropriately trained will assess and monitor a resident's condition on an ongoing basis to ensure that the resident is released from restraint at the earliest possible time .Resident Assessment .should include a physical assessment .Prior to the application of restraints, less restrictive alternatives should be attempted and documented. These alternatives may include but are not limited to .bed and personal safety alarms will be reviewed in order to determine whether they are to be categorized as a restraint .Order and Documentation Requirements for Restraint Use .When alternative interventions are unsuccessful in treating the medical symptom and restraints are deemed necessary a provider's order is required. The order shall include .Date/Time .Reason for use .Type of restraint .Anticipated length of use .Release parameters .Determine if the restraint is to be continued and re-certified at appropriate intervals but no less often than every thirty (30) days. Documentation shall include .Pre-assessment screening .Interdisciplinary care planning .Interventions attempted .Medical symptoms/conditions .Re-evaluations should be completed quarterly if continued use is documented .Obtain consent from the resident/resident representative that includes type of restraint and the risk and benefits .Types of Approved Physical Restraints .Lap Belt .Seat Belt and Personal Safety Alarms .Care of the Patient in Restraint .Perform ongoing assessments and monitoring of the resident's condition to ensure restraints are utilized in support of the plan of care and discontinued at the earliest possible time .The plan of care will be updated by the Registered Nurse (RN) to reflect the use of restraints .Residents in restraints .Will be checked every thirty (30) minutes .Every two (2) hours .Release the restraints .Reposition and exercise .Offer toileting and more frequently when requested by the resident .Documentation will include .Reasons for continuing restraints .Alternatives/interventions attempted .Justification for continued use . Resident #7 was admitted to the facility on [DATE] with diagnoses including Spastic Hemiplegic Cerebral Palsy, Quadriplegia, Epilepsy, and Age-Related Physical Debility. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had severe cognitive impairment for daily decision making, required total dependence of 2 people with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing; restraints were not used. Review of Resident #7's current comprehensive care plan showed a restraint was not use. Review of Resident #7's Physician's Orders dated 9/4/2023- 10/4/2023 showed no order for a restraint or restraint monitoring. Review of the medical record showed Resident #7 had no restraint consent, assessment, or ongoing re-assessments for the click seat belt. During an observation on 10/2/2023 at 11:45 AM, showed Resident #7 seated in a wheelchair with click seat belt in place. Resident #7 was unable to demonstrate or release the seatbelt. During an interview on 10/2/2023 at 12:10 PM, Certified Nursing Assistant (CNA) #3 stated Resident #7 had a seat belt on his wheelchair for safety and to keep him from falling out of his chair. She also stated the resident used the seat belt when up in his wheelchair, and could not release the seat belt himself due to bilateral hand contractures. During an interview on 10/3/2023 at 10:00 AM, Licensed Practical Nurse (LPN) #1 stated Resident #7 had a seat belt to help him maintain his position while in the wheelchair and he could not release it due to his cognition and bilateral hand contractures. During an observation on 10/3/2023 at 1:05 PM, showed Resident #7 seated in a wheelchair with a click seat belt in place, and unable to release the click seat belt. During an interview on 10/3/2023 at 2:30 PM, the Administrator stated Resident # 7's seatbelt was used for positioning and not as a restraint. During an interview on 10/3/2023 at 4:39 PM, Resident #7's responsible party stated he (Resident #7) was using the click seat belt on his wheelchair as a restraint to keep him from falling out of the wheelchair. During an interview on 10/4/2023 at 7:45 AM, the Director of Nursing (DON) stated when restraints are used it was her expectation the medical record should have an order, signed consent, an initial assessment, an ongoing assessment, and routine monitoring. She expected the MDS assessment to capture the use of restraints and the resident's care plan to reflect the use of restraints. The DON stated based on the definition of a restraint, Resident # 7's click seat belt on the wheelchair would be consistent with a restraint. The DON confirmed Resident #7 did not have an order, signed consent, an initial assessment or ongoing assessments, an accurate MDS assessment, a comprehensive care plan developed, or routine monitoring in the medical record for restraint use. 41291 Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a Physician's Order dated 3/27/2023, showed .click type seat belt while up in chair . The Physician's Order did not reflect reason or monitoring of the click seat belt. Review of the quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment for daily decision making, was totally dependent of 2 persons with bed mobility, dressing, toileting, personal hygiene, and bathing; required extensive assistance of 2 persons with transfers; and totally dependent on 1 person for locomotion; and restraints were not used. Review of the comprehensive care plan last reviewed 9/7/2023, showed Resident #17 had .Clip belt with alarm when up . Review of the medical record showed Resident #17 had no consent, assessment, or ongoing re-assessments for the click seat belt. During an observation on 10/2/2023 at 11:04 AM, showed Resident #17 seated in a reclined Broda chair (a type of wheelchair used for positioning) with a click seat belt in use. The resident was unable to unfasten the click seat belt. During an observation on 10/2/2023 at 3:52 PM, showed Resident #17seated in a reclined Broda chair with a click seat belt in use. The resident was unable to unfasten the click seat belt. During an observation on 10/3/2023 at 9:02 AM, showed Resident #17 seated in a Broda chair in hallway outside of her room with a click seat belt in use. The resident had her hands on the latch of the click seat belt and was unable to unfasten. During an interview on 10/3/2023 at 4:05 PM, the DON confirmed the click seat belt was considered a restraint and Resident #17 could not release the click seat belt on her own. She also confirmed Resident #17 did not have a signed consent, an initial assessment or ongoing assessments, an accurate MDS assessment, a revised care plan, or routine monitoring in the medical record for restraint use.

Based on facility policy review, record review, observation, and interviews, the facility failed to develop a comprehensive care plan to address restraint usage for 1 resident (Resident #7) out of 12 residents reviewed for comprehensive care plans. The findings include: Review of the facility's policy titled, Restraints, dated 5/5/2022, showed .defined as any manual method, physical or mechanical device .cannot be removed easily by the resident .restricts the resident's freedom of movement .use of the device is added to the plan of care . Review of the facility's policy titled, Care Plan/ Comprehensive Assessment, dated 11/4/2022, showed .Residents will have a comprehensive assessment that determines their functional status .comprehensive care plan will be developed that includes objectives, measurable goals and timetables to meet their medical, mental, and psychosocial needs that are identified in the comprehensive assessment . Resident #7 was admitted to the facility on [DATE] with diagnoses including Spastic Hemiplegic Cerebral Palsy, Quadriplegia, and Epilepsy. Review of the comprehensive care plan revised on 5/30/2023, showed Resident #7 had Self-Care Deficit related to Cerebral Palsy and was at risk for falls. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had severe impairment for daily decision making, required total dependence of 2 staff with bed mobility and transfers, and restraints had not been in use. Review of the Physician's Orders dated 10/2/2023, showed Resident #7 had no current order for restraint usage or restraint monitoring. During an observation on 10/2/2023 at 11:45 AM, showed Resident # 7 seated in a wheelchair with click seat belt in place. Resident # 7 was unable to open or release the seatbelt. During an interview on 10/2/2023 at 12:10 PM, Certified Nursing Assistant (CNA) #3 stated Resident #7 used a click seat belt to keep him from falling out of the wheelchair. The resident could not release the click seat due to his bilateral hand contractures. During an interview on 10/3/2023 at 10:00 AM, Licensed Practical Nurse (LPN) #1 stated Resident #7 used a click seat belt when sitting in the wheelchair. During an interview on 10/3/2023 at 4:39 PM, Resident #7's Responsible Party (RP) stated the resident used the click seat belt on the wheelchair as a restraint to keep him from falling out of the wheelchair. The RP also stated Resident #7 had used the restraint on his wheelchair since he was admitted to the facility on [DATE]. During an interview on 10/4/2023 at 7:45 AM, the Director of Nursing (DON) stated when restraints are utilized, the facility must develop a comprehensive care plan. Based on the definition of a restraint, Resident #7's click seat belt on the wheelchair would be consistent with restraint usage. The DON confirmed Resident #7 did not have a comprehensive care plan developed for restraint use.

Based on medical record review, observation, and interview, the facility failed to provide services to prevent further decline in functional status for 1 resident (Resident #17) of 17 residents reviewed for Activities of Daily Living (ADL). The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #17 required extensive assistance of 1 person with bed mobility, locomotion, and personal hygiene; required extensive assistance of 2 persons with transfers, dressing, toileting, and bathing; and required supervision with eating. Resident #17 did not receive therapy services. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 was severely cognitively impaired for daily decision making, required total dependence of 2 persons with bed mobility, dressing, toileting, personal hygiene, and bathing; required extensive assistance of 2 persons with transfers; and required limited assistance of 1 person with eating. Resident #17 did not receive therapy services. Review of the comprehensive care plan revised 9/7/2023, showed Resident #17 had .Activities of Daily Living (ADL) Functional Status/Rehabilitation Potential .Decreased ADL ability related to (r/t) weakness .Staff assist [assistance] x [times] 1 for bathing/hygiene. Staff assist x 1 for dressing/grooming. Staff assist x 1 for eating. Staff assist x 1 for toileting. Staff assist x 1 for ambulation. Staff assist x 1 for transfers. Wheelchair (W/C) for locomotion .Range of Motion (ROM) as indicated . Staff assist with ADL's . ADLs Functional Status/Rehabilitation Potential Decreased ADL ability r/t Diagnosis (Dx) of Dementia .Consult Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) as indicated . During an interview on 10/3/2023 at 4:05 PM, the Director of Nursing (DON) stated the current MDS assessment for Resident #17 showed a decline in ADL function. The DON confirmed Resident #17 had a functional decline with her ADLs and had not been referred to therapy services.

Based on medical record review and interview, the facility failed to provide an evaluation and rationale for the continued use of a PRN (as needed) antianxiety medication beyond 14 days for 1 resident (Resident #17) of 5 residents reviewed for unnecessary medications. The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses including Anxiety and Muscle Weakness. Review of a pharmacy recommendation note dated 8/15/2023, showed .Phase 2 limits PRN psychotropic medications to 14 days, unless the prescriber believes it is appropriate to extend the order .must document the following required information .if the PRN psychotropic medication is continued .Why the medication is needed on a PRN basis .What is the benefit of the PRN medication .Duration of PRN continuation/ reevaluation of medication . Further review showed the Medical Director had disagreed with the recommendations with no rationale documented. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #17 was severely cognitively impaired of cognitive skills for daily decision making and had an active diagnosis of anxiety disorder. Further review showed Resident #17 had taken an antianxiety medication. Review of the Physician Order Report dated 9/4/2023-10/4/2023, showed Lorazepam (an antianxiety medication) 0.5 milligrams (mg) twice a day PRN had been ordered on 6/6/2023 without a stop date. Review of the comprehensive care plan reviewed on 9/7/2023, showed Resident #17 had .Psychotropic Drug Use .Assess for signs and symptoms of adverse reactions to medication use .Assess target behaviors .Consult with Mental Health Services .monitor and document mood .Medication as ordered . During an interview on 10/3/2023 at 4:05 PM, the Director of Nursing (DON) confirmed the Lorazepam PRN medication ordered on 6/6/2023 for Resident #17 did not have a stop dated and the physician had not given an indication as to why the medication was needed or the benefit of the PRN medication usage.

Based on medical record review and interview, the facility failed to ensure laboratory (lab) tests were obtained for 1 resident (Resident #20) of 5 residents reviewed for laboratory services. The findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Vitamin D Deficiency, and Hypothyroidism. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment and had an active diagnosis of Diabetes Mellitus. Review of the comprehensive care plan revised 10/4/2023, showed Resident #20 had problems of Hypothyroidism and Diabetes with interventions to monitor lab work as ordered. Review of a Physician's Order dated 9/8/2022, showed Resident #20 had lab orders for TSH (a lab test to measure thyroid function and medication levels), Hemoglobin (Hgb) A1C (a lab test to measure how well blood glucose levels had been controlled), Vitamin D level (a lab test to measure a vitamin deficiency and to monitor medication levels), on 3/2023 and 9/2023. Review of Resident #20 lab results revealed there were no documented lab results for the month of 9/2023. During an interview on 10/3/2023 at 3:45 PM, Licensed Practical Nurse (LPN) #1 stated she cared for Resident #20 and was aware the resident had routine lab orders for TSH, Hgb A1C, and Vitamin D level due September 1, 2023. LPN #1 stated the lab results were not in the medical record and was unsure if they had been obtained. During an interview on 10/4/2023 at 12:46 PM, the Director of Nursing (DON) confirmed the TSH, Hgb A1C, and Vitamin D level due on 9/1/2023 had not been obtained for Resident #20.

Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 2 of 3 dumpsters (dumpster #1 and #2) and in the grease trap receptacle. The findings include: Review of the facility's policy titled, Solid Waste Disposal, dated 1/2023, showed .Garbage containers are clean .covered at all times .Place trash and garbage directly into designated receptacles .Keep lids closed on all outside trash receptacles . During an observation on 10/2/2023 at 10:43 AM, with the Food Services Lead Aide (FSLA) showed the outside dumpster area had 3 dumpsters present. 2 dumpsters (dumpster #1 and #2) for waste disposal and 1 dumpster (dumpster #3) for cardboard disposal. The area around dumpsters #1 and #2 had plastic pieces, used disposable gloves, and trash debris on the ground surrounding the dumpster area. The grease trap was 1/3 full, had one glove with presence of brownish-black, greasy debris located on the top of the receptacle, and the grease trap lid was fully open to air and elements. During an interview on 10/2/2023 at 10:45 AM, the FSLA stated the grease trap lid needed to be closed at all times and the trash debris, which included used disposable gloves, should not be present on the ground around the dumpster area. During an interview on 10/2/2023 at 11:30 AM, the Food Services Director (FSD) confirmed the outside dumpster area and the grease trap receptacle had not been maintained in a sanitary condition.

Based on facility policy review, medical record review and interview the facility failed to ensure pneumococcal vaccinations were administered to 2 residents (Resident #11 and #14) of 5 residents reviewed for vaccinations. The findings include: Review of the facility policy titled, Immunizations-Influenza and Pneumococcal, revised 11/4/22, showed .pneumococcal immunizations will be offered to all residents .unless medically contraindicated .provide immunization .Residents over the age of sixty-five .years or older are encouraged to receive the vaccine . Resident #11 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. Review of a Physician Services form undated, showed .I hereby grant permission for inoculation [immunize] with the pneumonia vaccine . Further review showed the form was signed by Resident #11's Power of Attorney (POA). Review of Resident #11's immunization record showed the pneumococcal vaccine had not been administered. Resident #14 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease. Review of a Physician Services form dated 5/8/2017, showed .I hereby grant permission for inoculation with the pneumonia vaccine . Further review showed the form was signed by Resident #14. Review of Resident #14's immunization record showed the pneumococcal vaccine had not been administered. During an interview on 10/4/2023 at 10:10 AM, the Infection Preventionist confirmed the facility failed to administer Resident #11 and Resident #14 the pneumococcal vaccination.

Based on policy review, observation, and interview, the facility failed to ensure infection control practices were followed to prevent the potential spread of infection for 1 resident ( #11) of 4 residents observed during medication administration. The findings include: Review of the facility Oral Medication, undated, .place pills/capsules in the medication cup using aseptic (Asepsis is a condition in which no living disease-causing microorganisms are present. Asepsis covers all those procedures designed to reduce the risk of bacterial, fungal or [MEDICAL CONDITION] contamination including the gloved 'no touch') technique . Observations on 1/7/20 at 9:08 AM, at the East Hall Medication Cart, revealed LPN #1 removed an Iron 325 mg (milligram) tablet from the medication cart for Resident #11, dropped the tablet onto the medication cart, picked up the tablet with her bare hands, placed the tablet into the resident's medication cup, entered the resident's room, and administered the medication to Resident #11. Interview with the Director of Nursing (DON) on 1/8/20 at 9:47 AM, in the DON's office, confirmed the facility failed to follow their infection control practices for medication administration. The DON stated the nurse should have disposed of the dropped pill, and ordered a new medication from the pharmacy for Resident #11.

Based on facility policy review, observation, and interview the facility failed to properly label and date foods available for resident consumption, and failed to ensure employee and resident foods were stored separately in 2 of 2 nourishment refrigerators. The findings include: Review of the facility policy, .PANTRY ORDERS ., dated (MONTH) 2001, and revised (MONTH) 2006, revealed .If no date, put date on the product .Nursing department is responsible for cleaning pantry refrigerators . Interview and observation of the East wing nourishment refrigerator with the Dietary Supervisor and Registered Nurse (RN) Unit Manager #1 on 12/19/18 at 9:47 AM, in the East wing nourishment room revealed, 1 - 8 ounce opened, undated, and unlabeled chocolate milk, and 2 frozen meals unlabeled. Further interview confirmed nourishment refrigerators are used for employee and resident use, and the above items were available for resident use. Interview and observation of the West wing nourishment refrigerator with the Dietary Supervisor and RN Unit Manager #2 on 12/19/18 at 9:57 AM, in the West wing nourishment room revealed, 1 - 8 ounce opened, undated, unlabeled milk; 1 - 33 ounce undated, unlabeled box of zap a snack; 18 unlabeled, undated popsicles; and 1 - 1.5 quart opened, undated, and unlabeled carton of vanilla ice cream. Further interview confirmed nourishment refrigerators are used for employee and resident use, and the above items were available for resident use. Interview with the Director of Nursing (DON) on 12/19/18 at 10:08 AM, in the conference room, confirmed the facility failed to properly label and date foods available for resident consumption, and ensure staff and resident foods were stored separately in the nourishment refrigerators.

Based on review of facility policies, review of the wander guard manufacturer's recommendations, medical record review, review of a facility investigation, interview, and observation, the facility failed to provide adequate supervision to prevent an accident for 1 resident (#1) of 16 residents reviewed for elopement risk and failed to properly secure wander guards (device worn by residents that triggers an alarm when the resident attempts to exit the facility) to the ankle of 5 residents (#4, #5, #7, #11, and #14) of 16 residents reviewed for elopement risk. The facility's failure to provide supervision resulted in Resident #1 exiting the building, falling down an embankment, sustaining an injury, and placing Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F689 at a scope and severity of J which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective 7/3/18 and is ongoing. The findings included: Review of facility policy Elopement of Resident last revised on 1/2007, revealed .locate as quickly as possible, prevent serious injury or exposure, to any resident that may have wandered away from the facility .Charge nurses and CNAs (Certified Nursing Assistants) on each station must be aware of those residents assigned to each (staff member) .notice that you haven't seen a resident for a while, start searching immediately in that area . Review of facility policy Incident/Accident Report dated 2/2008, revealed .Purpose: to document the events of an incident or accident . Review of Manufacturer's recommendations Compliance Information Statement (wander guards) dated 3/20/15, revealed .place the strap around the resident's ankle .to ensure proper operation of the Transmitter, it must be in an upright or vertical position on the ankle . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan, last updated 11/18/17, last reviewed on 11/22/17, revealed .Episodes of exit seeking. Episode of wandering when anxious .Wander guard to prevent from exiting building without anyone knowing . Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Further review revealed the resident needed supervision for transfers and personal hygiene with 1 person assist and was independent with ambulation. Medical record review of Resident #1's quarterly Elopement Risk evaluation dated 5/30/18 revealed the resident was at risk for elopement and required continued use of a wander guard alarm bracelet. Review of a facility investigation of an incident that occurred on 7/3/18 at 9:15 AM revealed Resident #1 exited the facility through the front entrance alongside contracted landscapers. Further review revealed the resident fell in the parking lot, got back up, proceeded to walk toward a wooded embankment area, and then fell down the embankment. Continued review of a hand written statement by the facility receptionist dated 7/3/18 revealed .around 9:20 AM I heard the alarm at the front door go off. I immediately went out and turned the alarm off and glanced out the doors. I did not see anyone outside so I returned to my desk. Within a couple of minutes two workers from (contracted landscaping company) came to the front window to report they thought a man was trying to get away .the workers proceeded to tell me the man went into the woods. I rushed to the edge of the woods and found (Resident #1) sitting on the ground . Further review of a hand written statement by Landscape Contract Worker #1 dated 7/3/18 at 9:30 AM revealed .I was leaving the nursing home after doing some landscaping work in the courtyard and a man followed me out the door before the door locked. He fell in the road next to the door. (He) got up went across the road almost fell again .got to the woods fell into the woods. Notified the (receptionist) . Continued review of a hand written statement by the facility Staffing Coordinator dated 7/3/18 revealed .Worker from (landscaping company) .stated there was a man that fell .the worker stated the resident fell off the curb .he helped him (Resident #1) up and watched him .(Resident #1) proceeded to woods on far side of parking lot .when we (Staffing Coordinator and Receptionist) got to edge of woods the (landscape) workers went down to resident, which had fallen down over bank .I proceeded down over the hill to assist . Medical record review of an acute care hospital Emergency Department (ED) physician's History and Physical dated 7/3/18 at 10:29 AM revealed .presents with a complaint of fall/right hand injuries .pt (patient) escaped from the NH (Nursing Home) and found in the woods in back .some scratches to hands and abrasion to rt (right) knee. No MS (Mental Status) changes .Physical Exam .Extremities .abrasions to rt hand and knee (bandage) dressed by EMS (Emergency Medical Services) .neurovasc (neurovascular) intact .Patient Disposition .Primary Impression: Hand Abrasion . Interview with the Receptionist on 7/11/18 at 10:30 AM, in the conference room, revealed .I saw a group of people pass by out of the corner of my eye .the alarm sounded .I walked around from my desk, out into the hallway, down to the doors. I looked through the doors and window and didn't see anyone so I reset the alarm .I did not go outside . Interview with Licensed Practical Nurse (LPN) #1 on 7/11/18 at 1:25PM, at the West Nurses' Station, revealed .(Resident #1) would go to the front door and it would lock and alarm .he would just walk up and look out the doors .would tell us he wanted to go home .(Resident #1) easy to redirect . Interview with LPN #2 on 7/11/18 at 1:35 PM, at the West Nurses' Station, revealed .(Resident #1) was oriented to some degree .he could find his way from his room to the dining room and back .he would talk about going home .I never had to go to the front and get him . Interview with CNA #5 on 7/11/18 at 2:05 PM, on the East Wing Hallway, revealed .if I responded to an alarm at the front door, I would go outside and look to see if I saw a resident .if I didn't see anyone I would report it to my nurse or the nearest one that could take care of it . Interview with Registered Nurse (RN) #3 on 7/11/18 at 2:15 PM, in the East Wing Nurses' Station, revealed .if someone reported the door alarm had sounded and no one was seen I would go outside and look for a resident myself and then I would page for both wings (units) to complete a head count of all residents . Interview with the Director of Nursing (DON) on 7/11/18 at 2:45 PM, in her office, revealed .talked to the workers (landscapers) they said they didn't hear the alarm .we have signs on the doors to always make sure the doors closed behind them (visitors) and not let anyone out they don't know .he (Resident #1) must have caught the door before it closed .really don't know what else we could have put in place . Interview with the Administrator on 7/11/18 at 3:00 PM, in the Administrator's office, revealed .we have annual in-services for our employees and contract workers .we try to get as many contract workers to come as possible .no I don't think the landscape workers attended .we have signs on the doors telling our visitors to not let anyone out they don't know .she (Receptionist) saw a few people pass by then the alarm went off .she looked around and didn't see anything .turned the alarm off .no she did not go outside .probably been better if she had . Interview with the Receptionist on 7/12/18 at 2:00 PM, in the front office, revealed .if the alarm sounds I respond .it's usually just a CNA pushing someone out or a family member, or therapy taking someone for a home evaluation, never had an elopement .no one ever told me to go outside and look around but looking back I should have . Observation and Interview with the Facility Maintenance Director and the Receptionist on 7/17/18 at 9:00 AM, in the facility parking lot, confirmed the distance from the facility entrance/exit doors to the beginning of the woods/embankment was 157 feet and the embankment drop off was 15.3 feet. Interview with the Administrator on 7/17/18 at 1:15 PM, in the conference room, revealed .not sure we have covered that (to check outside when alarm sounds) in the annual in-service .not sure if the annual in-service is for specific procedures for code orange (elopement) . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed Resident #4 had a BIMS score of 9 (moderate cognitive impairment). Continued review revealed the resident required supervision for ambulation. Medical record review of Resident #4's annual Elopement Risk assessment dated [DATE] revealed the resident was identified at risk for elopement and required the continued use of a wander guard. Medical record review of Resident #4's care plan revised date 5/25/18 revealed .can become anxious/agitated .pace and wander in her wheelchair . Observation of Resident #4 on 7/11/18 at 12:15 PM, in the dining room, revealed a wander guard alarm was attached to Resident #4's wheelchair and was not on the resident's ankle. Interview with RN #2 on 7/17/18 at 10:15 AM, in the conference room, confirmed Resident #4 .is at risk for elopement .someone would need to hold the door for her, but she would go out . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident had a BIMS score of 11 (cognitively intact). Continued review revealed the resident required supervision for locomotion with the use of a wheelchair. Medical record review of Resident #5's care plan, last revised 6/6/18 revealed the resident was identified with wandering behaviors in the past and the wander guard alarm was implemented. Observation of Resident #5 on 7/12/18 at 12:15 PM, in her room, revealed a wander guard alarm was on the resident's wheelchair and was not attached to the resident's ankle. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long term memory loss, was severely impaired for daily decision making, and required limited assist for locomotion off the unit in a wheelchair with 1 person to assist. Medical record review of Resident #7's quarterly Elopement Risk assessment dated [DATE] revealed the resident was identified at risk for elopement and required the continued use of a wander guard alarm. Observation of Resident #7 on 7/17/18 at 8:15 AM, in his room, revealed the wander guard was attached to the resident's wheelchair and was not attached to the resident's ankle. Interview with RN #2 on 7/17/18 at 10:25 AM, in the conference room, revealed .he (Resident #7) could get out if someone opened the door for him . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS for Resident #11 dated 7/1/18 revealed a BIMS score of 5 (severe cognitive impairment). Continued review revealed the resident required limited assistance for mobility with the use of a wheelchair and 1 person assist. Medical record review of Resident #11's comprehensive care plan dated 7/4/18 revealed Resident #11 was at risk for elopement and the intervention included the use of a wander guard. Observation of Resident #11 on 7/20/18 at 10:55 AM, in her room, revealed the wander guard was attached to the resident's wheelchair and was not attached to the resident's ankle. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #14's 14 day MDS dated [DATE] revealed the resident had a BIMS score of 4 (severe cognitive impairment). Continued review revealed the resident required extensive assist with locomotion using a wheelchair with 1 person physical assist. Medical record review of the Resident #14's Care Plan dated 6/4/18 revealed the use of a wander guard alarm. Observation of Resident #14 on 7/20/18 at 11:15 AM, in the front hallway, revealed the wander guard was attached to the resident's wheelchair and was not attached to the resident's ankle. Interview with Certified Nurse Assistant (CNA) #4 on 7/11/18 at 2:00 PM, on the East Wing Hallway, revealed . I have been working here since (MONTH) (YEAR) .I don't know if they (residents) have a wander guard bracelet unless I see it on the chair or their leg . Interview with the Director of Nursing on 7/21/18 at 11:30 AM, in the conference room, confirmed the facility failed to follow the manufacturer's recommendations for placement of the wander guards for Resident #4, #5, #7, #11, and #14.

Based on review of facility policy, medical record review, review of facility investigation, educational training review, and interviews, the facility's Administrator failed to ensure all staff and contractors received education on procedures for resident elopement and wander guards. The Administrator's failure resulted in the elopement of 1 resident (#1) of 16 residents reviewed with exit seeking behaviors when Resident #1 eloped and sustained an injury. The Administrator's failure resulted in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 7/3/18 and is ongoing. The findings included: Review of facility policy Elopement of Resident last revised 1/2007, revealed .an elopement assessment will be done on every resident upon admission .if the assessment indicated a high risk potential .initiate placement of a secure care bracelet (wander guard) .secure care bracelets should be attached to the resident .Charge Nurses and CNAs (Certified Nursing Assistants) on each station must be aware of those residents assigned to each group .notice that you haven't seen a resident for a while, start searching immediately in that area .if you are unable to find the resident, broaden your search .the charge nurse will designate someone to make a search of the grounds .when trying to find a resident who has wandered, look everywhere possible . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan last updated 11/18/17 and last reviewed on 11/22/17 revealed .Episodes of exit seeking. Episode of wandering when anxious .Wander guard to prevent from exiting building without anyone knowing . Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Continued review revealed the resident needed supervision for transfers and personal hygiene with 1 person assist, and was independent with ambulation. Medical record review of Resident #1's quarterly Elopement Risk evaluation dated 5/30/18 revealed the resident was at risk for elopement and required continued use of a wander guard alarm bracelet. Review of a facility investigation of Resident #1's elopement on 7/3/18 revealed Resident #1 exited the facility through the front doors alongside contracted landscapers. Continued review revealed the resident was wearing a wander guard and the alarm sounded as he exited the front doors. Further review revealed the Receptionist heard the alarm, left her desk and walked to the front lobby, looked out through the doors without exiting the building and because she did not see anyone, reset the alarm, and returned to her desk. Continued review revealed one of the landscapers returned to the receptionist desk and reported he thought a resident had gotten out of a facility and had fallen down the embankment into the woods. Review of the annual in-service document dated 10/26/17 - 10/27/17 revealed the elopement of a resident and management of the wander guard system were not included in the topics discussed. Interview with the Receptionist on 7/11/18 at 10:20 AM, in the front hallway, revealed .I peeped through the doors and didn't see anyone so I reset the alarm . Interview with the Administrator on 7/11/18 at 3:00 PM, in the Administrator's office, revealed .we have annual in-services for our employees and contract workers .we try to get as many contract workers to come as possible .no I don't think the landscape workers attended .we have signs on the doors telling our visitors to not let anyone out they don't know .she (Receptionist) saw a few people pass by then the alarm went off .she looked around and didn't see anything .turned the alarm off .no she did not go outside .probably been better if she had . Interview with the Receptionist on 7/12/18 at 2:00 PM, in the front office, revealed .if the alarm sounds I respond to it .no one ever told me to go outside and look around .but looking back I should have (gone outside) . Interview with the Administrator on 7/17/18 at 1:15 PM, in the conference room, revealed .not sure we have covered that (to check outside when alarm sounds) in the annual in-service . Telephone interview with the Administrator on 7/18/18 at 3:30 PM revealed .yes we tell them to check the area where the alarm sounds and to go outside if they do not see anyone .not sure that is in writing anywhere . Interview with CNA #8 on 7/20/18 at 11:45 AM, in the West Wing Nurses' Station, revealed .during a Code Orange .they usually take one of our residents and hide them in (DON) office .have never gone outside to look for someone .usually by the time I know anything is going on (Administrator) is coming around to have us sign the paper (code orange participation log) .no additional information is shared at that time. Just sign the paper . In summary, the Administrator failed to ensure all employees and contractors were trained/in-serviced on the supervision of residents at risk for elopement and failed to ensure the staff properly responded to the wander guard alarm when a resident eloped. Refer to F-689

Based on facility policy review, medical record review, review of facility investigation, review of Quality Assurance and Performance Improvement (QAPI) Committee meeting documentation, and interview, the QAPI committee failed to identify and correct quality deficiencies resulting in an avoidable elopement in which Resident #1 exited the facility, while wearing a wander guard, fell down an embankment and received injuries to his body. The QAPI Committee's failure placed 1 resident (#1) of 16 residents reviewed for exit seeking behaviors in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 7/3/18 and is ongoing. The findings included: Review of the facility policy, Performance Improvement Plan dated 1/2002, revealed .Provide for a facility wide program that assure the facility designs processes well and systematically measures, assesses and improves its performance to achieve optimal resident health outcomes in a collaborative, cross-departmental, interdisciplinary approach. These processes include mechanisms to assess the needs and expectations of the residents and their families, staff and other. Assure that the improvement process is organizationwide (organization wide), monitoring, assessing and evaluating the quality and appropriateness of resident care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events . Review of the facility policy, Elopement of Resident revised date 1/2007, revealed .Purpose: To locate as quickly as possible, prevent serious injury or exposure, to any resident that may have wandered away from the facility. To assess residents for the possibility of wandering beyond safe environment and need to wear secure care bracelet (wander guard alarm bracelet) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan last updated 11/18/17 and last reviewed on 11/22/17 revealed .Episodes of exit seeking. Episode of wandering when anxious .Wander guard to prevent from exiting building without anyone knowing . Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Continued review revealed the resident needed supervision for transfers and personal hygiene with 1 person assist, and was independent with ambulation. Medical record review of Resident #1's Quarterly Elopement Risk evaluation dated 5/30/18 revealed the resident was at risk for elopement and required continued use of a wander guard alarm bracelet. Review of a facility investigation of an incident that occurred on 7/3/18 revealed Resident #1 exited the facility through the front doors of the facility alongside 2 contracted landscapers. Further review revealed Resident #1 was wearing a wander guard, causing the alarm to sound as the resident exited the facility. Continued review revealed the Receptionist heard the alarm, left her desk and walked to the front lobby, looked out through the doors without exiting the building and because she did not see anyone, reset the alarm, and returned to her desk. Further review revealed one of the landscapers returned to the receptionist desk and reported he thought a resident had gotten out of a facility and had fallen down the embankment into the woods. Interview with the Receptionist on 7/11/18 at 10:20 AM, in the front hallway, revealed .I peeped through the doors and didn't see anyone so I reset the alarm . Interview with Unit Clerk #1 on 7/11/18 at 11:00 AM, in the conference room, revealed .we have a half a dozen or so (residents) on the east wing that wear wander guards .no one is actively exit seeking .most are just confused and might accidently go out the door .(Resident #2) goes to the door often and looks out .I try to keep a close eye on her . Interview with East Wing Manager (Registered Nurse) on 7/11/18 at 11:15AM, in the conference room, revealed .residents are at risk of elopement if they are actively exit seeking . Interview with the Administrator on 7/11/18 at 3:00 PM, in the Administrator's office, revealed .we have annual in-services for our employees and contract workers .we try to get as many contract workers to come as possible .no I don't think the landscape workers attended .we have signs on the doors telling our visitors to not let anyone out they don't know .she (Receptionist) saw a few people pass by then the alarm went off .she looked around and didn't see anything .turned the alarm off .no she did not go outside .probably been better if she had . Interview with the Director of Nursing (DON) on 7/12/18 at 1:00 PM, in the DON's office, revealed .we put new employees with a mentor in their department for 3-4 weeks until the new employee feels comfortable .a mentor is the person in each department that has worked here the longest .no formal orientation .the wing manager completes a checklist after 90 days for the nurses .Certified Nurse Assistants (CNA) train CNAs .have annual in-service .or if something comes up we may have a meeting . Interview with the Receptionist on 7/12/18 at 2:00 PM, in the front office, revealed .if the alarm sounds I respond .it's usually just a CNA pushing someone out or a family member, or therapy taking someone for a home evaluation, never had an elopement .no one ever told me to go outside and look around but looking back I should have . Interview with the Administrator on 7/17/18 at 1:15 PM, in the conference room, revealed .not sure we have covered that (to check outside when alarm sounds) in the annual in-service . Telephone interview with the Social Services Assistant on 7/18/18 at 3:25 PM revealed she conducted the Patient Rights/Ethics/Abuse in-service in (YEAR), but the in-service did not include training on resident elopement (Code Orange). Telephone interview with the Administrator on 7/18/18 at 3:30 PM revealed .yes we tell them to check the area where the alarm sounds and to go outside if they do not see anyone .not sure that is in writing anywhere . Interview with Unit Clerk #2 on 7/20/18 at 11:15 AM, in the West Wing Nurses' Station, revealed .have worked here [AGE] years .if they don't get up and walk but are at risk of elopement we put it (wander guard alarm) on the wheelchair . Interview with CNA #8 on 7/20/18 at 11:45 AM, in the West Wing Nurses' Station, revealed .during a Code Orange .they usually take one of our residents and hide them in (DON) office .have never gone outside to look for someone .usually by the time I know anything is going on (Administrator) is coming around to have us sign the paper (code orange participation log) .no additional information is shared at that time. Just sign the paper . Interview with the DON on 7/21/18 at 1:30 PM, in the conference room, confirmed the QAPI committee failed to ensure all staff were educated on the assessment of residents at risk for elopement and failed to recognize wander guards were utilized incorrectly for residents at risk of elopement. Refer to F-689