Every finding on record at Laurelwood Health Care Center

Based on policy review, Maintenance Director Job Description review, https://weather.com review, National Library of Medicine website review, invoice review, medical record review, observation, and interview, the facility failed to ensure residents resided in a safe, clean, homelike, and comfortable environment with temperatures ranging from 71 degrees Fahrenheit (F) to 81 degrees F when resident room temperatures were measured ranging from 53 degrees F to 65 degrees F in 8 of 35 (Resident #11, #13, #14, #20, #27, #34, #40, #42, #45, #47, and #51) resident rooms observed during initial tour. The facility's failure to prevent dangerously cold room temperatures placed Residents #11, #13, #45, and #47, who were vulnerable and cognitively impaired residents, at an immediate jeopardy risk for weather induced complications. The census was 47. Immediate Jeopardy (IJ), (a situation in which the facility's noncompliance has caused or is likely to cause serious injury, serious harm, serious impairment, or death) related to its failure to provide and ensure a safe environment for residents when Resident room temperatures were measured ranging from 53 to 65 degrees F. The Administrator, Director of Nursing, and Regional Nurse Consultant were informed of this immediate jeopardy at F-584 on 1/20/2026 at 7:13 PM in the employee break room. The facility was cited Immediate Jeopardy at F-584 at a scope and severity of J, which is substandard quality of care. The Immediate Jeopardy began on 1/20/2026 through 1/22/2026 and was removed on 1/23/2026. An acceptable Removal Plan was accepted on 1/22/2026 at 2:58 PM and validated onsite on 1/22/2026 by review of education and in services, facility documents, room temperature logs, and interviews. An extended survey was conducted on 1/21/2026 through 1/22/2026. A Plan of Correction is required.The findings include: 1. Review of the undated facility policy titled, Resident Rights, revealed .The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents.The resident has the right to a dignified existence.The right to reside and receive services in the facility with reasonable accommodation of resident needs.The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of the facility policy titled, Infection Control Plan, dated 8/2017, revealed .MISCELLANEOUS-Windows without screens will not be opened under any circumstances .Any employee discovering an open, unscreened window will close the window and discuss the facility policy with the individual involved. The facility was unable to provide policies related to maintaining resident room temperatures between 71 degrees to 81 degrees F or monitoring temperatures in resident rooms. 2. Review of the Maintenance Director Job Description dated 2/28/2022, revealed .Directs the day-to-day activities of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing the facility, and to assure the facility is maintained in a safe and comfortable manner .Ensures the facility remains in compliance with all federal, state and local regulations for Life safety Code compliance . 3. Review of the weather.com internet site dated 1/19/2026 and 1/20/2026 revealed the outside overnight temperature on 1/19/2026 was 12 degrees F. The outside temperature on 1/20/2026 was 46 degrees F. 4. Review of the National Library of Medicine website, MedlinePlus article titled, Body temperature norms [usual practice or custom], dated 1/1/2025, revealed Normal body temperature varies by person, age, activity, and time of day. The average normal body temperature is generally accepted as 98.6 Fahrenheit (F). Some studies have shown that the normal body temperature can have a wide range, from 97F.to 99 F. 5. Observation on 100 Hall during initial tour on 1/20/2026 starting at 9:29 AM, revealed the 100 Hall felt cold in the hallway and in Residents' rooms. Observation on the 100 Hall on 1/20/2026 at 10:30 AM, revealed Life Safety Surveyor #1 used an air gun to measure the air temperature in residents' rooms on the 100 Hall. The temperatures were recorded as follow: a. Resident #42's room air temperature was 59.3 degrees F. b. Resident #27's room air temperature was 57.0 degrees F. c. Resident #11 and Resident #47's shared room air temperature was 65.1 degrees F. d. Resident #45's room air temperature was 60.9 degrees F. e. Resident #40's room air temperature was 60.9 degrees F. Observation on the 100 Hall on 1/20/2026 at 11:40 AM, revealed Life Safety Surveyor #1 and the Maintenance Director recorded the resident room air temperatures as follow: a. Resident #42's room air temperature was 54.2 degrees F. b. Resident #27's room air temperature was 53.0 degrees F. c. Resident #11 and #47's shared room air temperature was 62.0 degrees F. d. Resident #45's room air temperature was 58.8 degrees F. e. Resident #14 and #34's room air temperature was 60.9 degrees F. f. Resident #13's room air temperature was 57.2 degrees F. g. Resident #40's room air temperature was 56.0 degrees F. h. Resident #20 and #51's shared room air temperature was 54.8 degrees F. Observation during tour of the outside of the facility on 1/20/2026 at 12:30 PM, revealed Life Safety Surveyor #2 and the Maintenance Director found the windows opened to the outside in the following Resident rooms exposing the Residents to the outside temperature of 46 degrees F: Resident #42's room. Residents #11 and #47 shared room. Residents #14 and #34 shared room. Residents #20 and #51'sshared room. Observation on the 100 Hall on 1/20/2026 at 3:08 PM, Life Safety Surveyor #1 and the Administrator recorded the room air temperatures as follow: a. Resident #42's room air temperature was 61.2 degrees F. b. Resident #27's room air temperature was 65.8 degrees F. c. Resident #11 and #47's room air temperature was 70.2 degrees F. d. Resident #45's room air temperature was 65.1 degrees F. e. Resident #14 and #34's shared room air temperature was 70.9 degrees F f. Resident #13's room air temperature was 65.3 degrees F. g. Resident #40's room air temperature was 65.1 degrees F. h. Resident #20 and #51 share room air temperature was 69.3 degrees F. The facility failed to ensure resident's room temperatures were maintained between 71 degrees F and 81 degrees F. 6. Review of the medical record revealed Resident #11 and #47 shared a room. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Paraplegia, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Resident #11 required substantial assistance with transferring. Observation in the Resident's on 1/20/2026 at 9:13 AM, revealed Resident #11 sitting up in the chair with a coat on. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Emphysema, Depression, and Alzheimer's Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 12 on the BIMS assessment, which indicated she was moderately cognitively impaired. 7. Review of the medical record revealed Resident #13 had no roommate. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Traumatic Brain Injury, Dementia, Hypertension, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 7 on the BIMS assessment, which indicated he was severely cognitively impaired. Resident #13 was dependent on chair/bed-to-chair transfer. 8. Review of the medical record revealed Resident #14 and #34 shared a room. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Diabetes, Depression, Hypertension, and Dementia. Review of the annual MDS assessment dated [DATE], revealed Resident #14 scored a 14 on BIMS assessment, which indicated she was cognitively intact. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Schizophrenia, Diabetes, and Bipolar. Review of the admission MDS assessment dated [DATE], revealed Resident #34 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the Weights and Vitals Summary dated 1/19/2026, revealed Resident #34's temporal temperature was 97.7 degrees F. Observation in Resident #34's room on 1/20/2026 at 12:47 PM, Licensed Practical Nurse (LPN) G obtained Resident #34's temporal temperature with a reading of 96.7 degrees F. During an interview on 1/20/2026 at 1:30 PM, Resident #34 was asked about the temperature of her room this morning. Resident #34 stated, .I noticed the room being chilly this morning.I put on my house coat. 9. Review of the medical record revealed Resident #20 and #51 shared a room. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Diabetes, paranoid Schizophrenia, Depression, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #20 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Observation in Resident #20's and #51's room on 1/20/2026 at 9:34 AM and 5:34 PM, and 1/21/2026 at 8:03 AM and 10:30 AM, revealed the thermostat box that controls the temperature on the left side of the 100 Hall was opened and unlocked. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Anxiety Disorder, and Osteoarthritis. Review of the quarterly MDS assessment dated [DATE], revealed Resident #51 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. 10. Review of the medical record revealed Resident #27 did not have a roommate. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Hypertension, Dementia, Schizophrenia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #27 scored a 14 on the BIMS assessment, which indicated he was cognitively intact. During an interview in Resident #27's room on 1/20/2026 at 9:38 AM, Resident #27 was asked about the temperature in his room. Resident #14 stated, It is cold. 11. Review of the medical record revealed Resident #40 did not have a roommate. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes, and Paranoid Schizophrenia. Review of the annual MDS assessment dated [DATE], revealed Resident #40 scored a 15 on the BIMS assessment, which indicated that he was cognitively intact. Review of the Weights and Vitals Summary dated 1/19/2026, revealed Resident #40's temporal temperature 98.1 degrees F. During an interview in Resident #40's room on 1/20/2026 at 9:33 AM, revealed Resident #40 in bed with 1 blanket. Towels were lined around the bottom of the windowsill. Resident #40 was asked how he was doing. Resident #40 stated, It's cold, I asked for a blanket, but they say they don't have any. Observation in Resident #40's room on 1/20/2026 at 12:49 PM, revealed Licensed Practical Nurse (LPN) G obtained Resident #40's temporal temperature with a reading of 96.1degrees F, which was down 2 degrees from 1/19/2026. During an interview in Resident #40's room on 1/20/2026 at 1:10 PM, Resident #40 was asked how long his room had been cold. Resident #40 stated, It's been cold for about 2 weeks now . Resident #40 was asked had he reported it to anyone. Resident #40 stated, I've told many of them .I be so cold that I try not to move and when I ask for a blanket, they say they don't have any . 12. Review of the medical record revealed Resident #42 did not have a roommate. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Viral Hepatitis, Hypertension, and Schizophrenia. Review of the quarterly MDS assessment revealed Resident #42 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. 13. Review of the medical record revealed Resident #45 did not have a roommate. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Depression and Alzheimer's Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #45 scored a 4 on the BIMS assessment, which indicated she was severely cognitively impaired. 14. During an interview on 1/20/2026 at 2:30 PM, the Administrator was asked when had she been informed that the resident rooms on the 100 Hall were cold. The Administrator stated, When [Named Life Safety Surveyor #1] told me. During a telephone interview on 1/20/2026 at 3:53 PM, Certified Nursing Aide (CNA) F was asked if she worked the night of 1/19/2026) on the10:00 PM to 6:00 AM shift. CNA F stated. Yes, I did. CNA F was asked did she take care of Resident's #34 and #40, CNA F stated, Yes, I had both of them. CNA F was asked if the residents' rooms were cold. CNA stated, The hallways were cold but not the resident's rooms. CNA F was asked if she noticed any of the residents' rooms with the windows up. CNA F stated, No. During an interview on 1/21/2026 at 2:25 PM, the Maintenance Director was asked why the thermostat box in Resident #20 and #51's room would be opened and unlocked. The Maintenance Director stated, .I have no recollection of that box being open. He was asked who has keys to that box. The Maintenance Director stated, I am the only one with keys, but I can't stop the residents from tampering with it . The Maintenance Director was asked what the thermostat box in Resident #20 and #51's room controlled. The Maintenance Director stated, The left side of the 100 Hall . The Maintenance Director was asked what the regulations were for resident room temperatures. The Maintenance Director stated, .it can't be higher than 85 degrees .low I think it is 71, 70 [degrees F]. The Maintenance Director was asked about the federal regulation temperatures. He stated, I am not sure. The Maintenance Director was asked what was implemented when he was informed of the room temperatures identified by Life Safety Surveyor #1. The Maintenance Director stated, I had [named company] already coming in to do some work .I fixed my part and [Named Heating and Air Company] did their part .I had a duct that was leaking air .[Named Heating and Air Company] repaired a clogged igniter to 1 unit, they boosted the gas on another unit . when the temp dropped, when you turn the unit up it has a higher demand, the knob wasn't fully turned and needed boosting . The Maintenance Director was asked would you expect staff to notice and report a change in temperature in the halls and rooms. The Maintenance Director stated, No Ma'am, I might be hot, and you may be fine .I don't expect staff to know . The Maintenance Director was asked if it was his responsibility to check the building's heating and air units to ensure they are working properly. The Maintenance Director stated, Yes, it's my responsibility . During an interview on 1/21/2026 at 3:58 PM, the Administrator was asked when she was notified that the resident rooms were cold. The Administrator stated, It was when [Named Life Safety Surveyor #1] stopped me, it was morning, before lunch. The Administrator was asked if she expected the staff to notify her if the rooms are cold. The Administrator stated, If someone complained of being cold, yes. The Administrator was asked would you have expected the Maintenance Director to know the regulations for the room temperatures. The Administrator stated, Yes. The Administrator was asked if 3 residents on 100 Hall had complained of being cold should staff have reported that to you. The Administrator stated, Yes. The Administrator was asked how she knew the residents had opened the windows. The Administrator stated, The Maintenance Director told me. During a telephone interview on 1/22/2026 at 8:50 AM, the Named Heating and Air Company Employee was asked if the Named Heating Company had been previously scheduled to come to the facility on 1/20/2026 prior to the surveyors identifying the cold temperatures. The Named Heating and Air Company Employee stated, They were not already coming for a scheduled service, they received a call on 1/20/2026 at 11:17 AM from the [Named Facility's Maintenance Director] stating they were having heating issues. Review of the Named Heating and Air Company invoice bill dated 1/20/2026, revealed Dispatched to [Named Facility] .Dispatched to check on no Heat in 3 of the Gas fired Splits Systems in the [NAME] Mechanical Room .found the gas was shut off to the new one that [Named Company] Installed [.] Facility had a gas leak . [Another Named Company] came out and shut the gas valve off, but did not turn it back on . During an interview on 1/21/2026 at 1:55 PM the Medical Director acknowledged he was told about the temperature issue in the facility. The Medical Director stated, . 1 of the gas lines did not turn all the way on since [around Christmas] . During an interview on 1/22/2026 at 2:58 PM, CNA A was asked if she ever noticed the windows in the resident's rooms being open. CNA A stated, Yes, one of the other shifts opens the windows. CNA A was asked do you think the residents could open the windows. CNA A stated, Oh no. During an interview on 1/22/2026 at 4:46 PM, the Maintenance Director acknowledged the windows in Resident #42, #11, #47, #14, #34, #20, and #51's rooms were found open. The Maintenance Director stated, I never visually saw anyone open the windows . The facility was unable to determine who had opened the windows or how long they had been open. An acceptable Removal Plan was accepted on 1/22/2026 at 2:58 PM and validated onsite on 1/22/2026 by review of education, in services, documents, room temperature logs, and interviews. Identification of Residents Affected or Likely to be Affected: On 1/20/26, during rounding with the surveyor, the Maintenance Supervisor identified patient room windows that were cracked open in some patient rooms on the 100 Hall. The Maintenance Supervisor closed the windows with the surveyor present at that time. Life Safety Surveyors validated the windows were closed on tour with the Maintenance Director. 1/20/26 at approximately 11:00 AM the administrator was notified by the surveyor that 8 patient rooms on the 100 Hallway were below regulated temperatures. Maintenance notified Administrator that some windows were open and he had already closed the windows. Administrator immediately asked staff to hand out additional blankets to any patients in rooms and to put blankets at the bottom of each window. Surveyors validated by observation, residents that were in bed had additional blankets, and blankets placed at windowsills. Staff began relocating residents to other rooms in the building until the room temperatures were at the required temperature of 71-81[degrees Fahrenheit]. CNA staff on the hall were asked to monitor windows to ensure they were not opened again by the admistrator [Administrator]. A recheck of the rooms was completed at 12:00, revealing that temperatures remained below the required 71 degrees. All residents had been relocated out of the l?atient [Patient] rooms by 12:15 PM. Surveyors validated by observation that residents were moved out of their rooms while the facility was working on temperatures. Staff members continue to document temperatures on logs and surveyors continued to check resident rooms. Residents that were in rooms that were below the required 71 degrees were assessed by licensed nurses regarding body temperature. Residents that were able to be interviewed had no complaints of being cold. Residents' body temperatures were found to be within each individual range of regular temperatures, to include residents# [residents #] 11, 13,14, 20, 27, 34,40, 42, 45, 47, and 51. Surveyors validated resident's temperatures were taken and validated by review of documentation. The remaining rooms in the facility were assessed to ensure no other residents were affected by lower than regulated room temperatures at time of the walk through with surveyor (Named Life Safety Surveyor #1). No other rooms were identified to be lower than 71 degrees. Actions to Prevent Occurrence/Recurrence: A licensed HVAC [Heating, Ventilation and Air Conditioning] repair contractor had been called on 1/20/26 and scheduled to verify that all units were working properly. The licensed HVAC technician arrived at the building at 3:00pm [3:00 PM] on 1/20/26 and found that one unit that was controlling the temperatures on the 100 hall was repaired immediately. All other units working properly. Surveyors validated by review of invoice from licensed HVAC repair contractor and Maintenance Director interview. The administrator educated the maintenance director on 1/20/2026 that he needed to monitor all units to ensure they are working properly daily, and if any unit was not working to call an HVAC repair technician. The weekend supervisor will check the HVAC systems on the weekend by checking vents to ensure there is appropriate air flow, and by monitoring of the patient rooms with the temperature gun. Maintenance was also in serviced to monitor temperatures in Resident rooms to verify temperatures were within 71 - 81 degrees, unless patient requested the room to be different like room [ROOM NUMBER] who prefers the room temperature range to be 65-75 degrees Fahrenheit. That temperature will then be logged on to the room temperature monitoring log. Any concerns will be reported to the administrator to address immediately. Surveyors validated by interview of the Administrator, Maintenance Director and Weekend Supervisor. The affected rooms continued to be monitored hourly with the use of a temperature gun while residents were in other rooms to ensure temperature was coming up to the required temperature of 71 degrees. After the room met the required temperatures, residents were asked if they would like to return to their room. All residents choose to return to their room. Surveyors validated by review of timed room temperature log documentation. At 7:30 PM an in-service was held with all on shift staff by the Administrator regarding patient area temperatures. If it is determined that the room is not in the acceptable range, the patient will be asked to change rooms temporarily until the concern can be resolved. Staff were also educated to check windows when entering each patient room to ensure that no windows were open. Staff were issued a thermometer gun for the nurse's station, available on all shifts and weekends, and shown how to use this gun and how to appropriately monitor room temperature with written instructions provided as well. In-servicing of staff will continue until all facility staff are educated, with completion to be no later than 1/22/2026. Staff that are on FMLA, PTO or off will be in service before returning to work. Surveyors validated through interviews and review of in-service documentation. On 1/20/26 at 8:00 PM a second facility wide room check was completed by the VP [Vice President] of Clinical Reimbursement; all patient rooms were in the range of 71-81 degrees Fahrenheit. Room temperature rounds and window checks continued in the 8 patient rooms on 100 hall every 30 minutes for 12 hours with no rooms being noted below the approved temperature range beginning at 9:00pm [9:00 PM] on 1/20/2026. Then, Room temperature rounds and window checks will continue every 2 hours throughout the day shift of 1/22/26 to ensure temperatures remain within acceptable range. If rooms were out of compliance, the administrator will direct the Maintenance director to adjust the thermostat and verify that all HVAC units continue to operate correctly. On 1/12/2026, between the hours of 11:00 am and 3:00pm [3:00 PM] the maintenance director [Maintenance Director] was continually monitoring the temperature until all rooms were in compliance. The rooms will continue to be monitored every two hours until 6:00 am on 1/22/2026, utilizing the thermometer gun. If the required temperatures maintain then the monitoring will be changed to qshift [every shift]. Surveyors validated through review of room temperature logs. Affected rooms will be monitored q shift for 30 days including weekends beginning 1/22/2026 ending on 2/20/2026, by the nursing staff and/or the maintenance director. After the completion of the first month the maintenance director will monitor random patient care areas and patient rooms no less than once weekly times 4 weeks, then monthly by the maintenance director. This monitoring will be completed by the staff member or maintenance director utilizing a thermometer gun to measure the temperature in the rooms per the assigned audit schedules or with any complaints as needed. All staff, including those assigned to the affected 100 hall as well as those in all other areas of the facility have received this education as of 1/21/26 and any staff on leave will receive prior to returning. That temperature will then be logged on to the room temperature monitoring log. Any concerns will be reported to the administrator to address immediately. All patient rooms were in the acceptable range of 71-81 degrees Fahrenheit when the facility-wide round was completed and additional monitoring and directive from the Administrator will be initiated in any other areas immediately as concerns arise. All residents with a BIMS of 12 or above were educated by the Social Worker of the potential risk of opening the window during adverse weather conditions on 1/21/2026. Surveyors validated by review of questionnaires from residents and with the Social Worker interview. Random window audits will be completed by the maintenance director no less than 3x [3 times] a week for 3 months. After 3 months the maintenance director will complete room temperature audits monthly or at any time a staff, resident or family member report a concern regarding the temperature. Staff will continue to look for any windows left open after the 3-month period and close immediately when they are present in the room. Windows will be visually checked daily throughout each shift by the staff members entering resident rooms for routine care, any window open will be closed immediately and the administrator will be notified. Education will be provided to all staff no less than annually to ensure staff are aware of the regulation for temperature, use of a temperature gun, and to watch for any signs that may alter a resident room temperature such as a window being open. Surveyors validated with interview with the Administrator. All audits will be submitted to the QAPI [Quality Assurance and Performance Improvement] team monthly to ensure long term stability of the plan of correction.

Based on policy review, observation, and interview, the facility failed to provide a safe, functional, and sanitary environment for 4 of 4 (100 Hall men's and women's and 200 Hall men's and women's) communal bathrooms. The findings include: 1. Review of the undated facility policy titled, Resident Rights, revealed, .The resident has the right to a dignified existence.The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of the facility policy titled, Infection Control Plan, dated 8/2017, revealed .Ensure compliance with state and federal regulations related to infection prevention and control.Monitor risk of transmission of infection by assuring proper policies and.procedures as it related to the use of medical.equipment.Ongoing evaluation and recommendations for Hand Hygiene.The infection control program will be managed by the Administrator and Director of Nursing.The Director of Nursing or designee.delegates or performs the following.Supervises the disinfection of contaminated articles. Review of the facility policy titled, Infection Control-General Policies and Procedures, dated 8/2017, revealed .Every resident is a possible carrier of pathogenic microorganisms [bacteria]. Infections are transmitted by direct or indirect contact with pathogenic organism.Proper hand care.are required by all persons.Paper products and disposable supplies shall be used for all residents. 2. Observations in the 100 Hall men's communal bathroom on 1/20/2026 at 8:45 AM, revealed no paper towels for hand hygiene, 3 elongated streaks of a brown substance approximately 6 inches in length smeared on the wall, a trash can lid lying on the floor, and a brown residue on both toilet bowls. 3. Observations in the 100 Hall women's communal bathroom on 1/20/2026 at 9:45 AM, 11:50 AM, and 5:00 PM, revealed an unlabeled wash basin with smeared brown substance to the outside of the basin, 2 toilets with a dried brown substance around the toilet bowl, and no soap or paper towels for hand hygiene. Observation in the 100 Hall women's communal bathroom on 1/20/2026 at 4:13 PM, revealed a metal rod approximately 5 feet in length propped against the wall beside the commode in the second bathroom stall. During an observation and interview on the 100 Hall women's communal bathroom on 1/20/2026 at 5:00 PM, the Director of Nursing (DON) was asked if the bathroom was a communal bathroom. The DON stated, Yes. The DON was asked if soap and paper towels should be available for hand hygiene. The DON stated, Yes. 4. Observations in the 200 Hall women's communal bathroom on 1/20/2026 at 9:45 AM, 11:50 AM, and 4:13 PM, revealed a raised commode seat with a reddish-brown substance to both front and back legs. The first bathroom stall revealed a reddish-brown area to the left of the bathroom stall wall and brown debris approximately 2 inches in width around the base of the commode. A reddish-brown substance was noted to the inside right wall of the bathroom stall. A brown substance approximately 3 inches in width and length was observed on the base of the wall adjacent to the shower and unlabeled, unbagged wash basin containing an unknown liquid were sitting under the sink. During an observation and interview in the 200 Hall women's communal bathroom on 1/20/2026 at 4:21 PM, the Administrator acknowledged the reddish-brown substance was rust on legs and arm rails of the raised commode seats in the 200 hall bathrooms. The Administrator acknowledged the commode seats should have been removed and stated, .we have new ones . The Administrator was asked what the metal rod was in the bathroom stall. The Administrator stated, .I don't know let me get [Named Activity Director]. The Activity Director arrived in the communal bathroom and was asked what the metal rod was used for. The Activity Director stated, .It's a snake auger used to unstop the commode. The Administrator was asked if it was safe for this to be in the communal bathroom. She stated, No. The Administrator asked the Activity Director to remove the metal rod. The Administrator was asked should a wash basin be sitting unlabeled and unbagged under the sink. The Administrator acknowledged the wash basins should be bagged and labeled. The Administrator then stepped out of the bathroom and called for Certified Nursing Assistant (CNA) D to remove the wash basin under the sink. CNA D stated, .the sink is leaking that is why we keep the wash basin under the sink. The Administrator verified the sink was leaking. 5. Observations in the 200 Hall men's communal bathroom on 1/20/2026 at 10:52 AM, 11:47 AM, 4:11 PM, and 4:39 PM, revealed a raised commode seat in the bathroom stall with a reddish-brown substance extending the entire length of both front legs and a reddish-brown substance noted to both arm rails. A brown smeared substance approximately 2 inches in width and length was noted on the right-side wall in the bathroom stall. An automatic paper towel holder was noted in the communal bathroom. Observations revealed no paper towels for resident's hand hygiene. During an observation and interview on the 200 Hall men's communal bathroom on 1/20/2026 at 4:39 PM, the Administrator acknowledged the reddish-brown substance was rust on the right side of the wall of the bathroom stall. The Administrator asked Housekeeper E to come into the bathroom to clean the wall. Housekeeper E stated, Looks like BM [bowel movement] on the wall. The Administrator and Housekeeper E was asked if the residents should have paper towels for hand hygiene. Housekeeper E stated, .the battery is dead [referring to the automatic paper towel holder], I don't have any batteries to fix it. The Administrator told Housekeeper E to obtain some batteries out of her office and fix the paper towel holder. The Administrator verified paper towels should be available for hand hygiene. During an interview on 1/21/2026 at 8:30 AM, the Environmental Services Director was asked what he expected of the housekeeping staff in regard to cleaning of the communal bathrooms. The Environmental Services Director stated, .bathrooms should be cleaned daily and checked 3 times per day to make sure they are clean. During an interview on 1/21/2026 at 11:30 AM, CNA C acknowledged the nursing staff use the 100 and 200 Hall communal bathrooms for hand hygiene when needed.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 4 of 4 communal bathrooms (100 Hall women's, 100 Hall men's, 200 Hall women's and 200 Hall men's) were observed with unsecured personal items, and without hand hygiene supplies, and when 2 of 2 nurses (Licensed Practical Nurse (LPN) A and LPN B) failed to use proper infection control measures during medication administration.The findings include: 1. Review of the facility policy titled, Infection Prevention and Control, dated 1/24/2025, revealed .All reusable items and equipment.shall be cleaned in accordance with our current procedures governing the cleaning.of soiled or contaminated equipment.Reusable items potentially contaminated.shall be placed in.clear plastic bag.Label bag. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered.in accordance with professional standards of practice.in a manner to prevent contamination or infection. Review of the undated facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed .Reusable multiple-resident items .are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs .Direct care staff are responsible for cleaning single-resident equipment when visibly soiled.Multiple-resident use equipment shall be cleaned and disinfected after each use. Review of the undated facility policy titled, Hand Hygiene, revealed .The use of gloves does not replace hand hygiene .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 2. Observation in the 100 Hall women's communal bathroom on 1/20/2026 at 9:45 AM and 11:50 AM, revealed 2 unlabeled, unbagged bath basins in the shower stall, a soiled washcloth laying on the floor of the shower stall, and no hand soap or paper towels for hand hygiene. During an observation and interview in the 100 Hall women's communal bathroom on 1/20/2026 at 5:00 PM, the Director of Nursing (DON) confirmed the bathroom was a communal bathroom. The DON was asked if unlabeled bath basins should be in the shower room. The DON stated, No, they shouldn't be in here at all . The DON was asked if soap and paper towels should be in the bathroom for the residents' use. The DON stated, Yes. 3. Observations in the 200 Hall men's communal bathroom on 1/20/2026 at 10:52 AM, 11:47 AM, and 4:11 PM, revealed 4 unlabeled, unbagged bath basins and 1 unlabeled, unbagged bed pan stacked together on the floor under the sink. No paper towels were present for hand hygiene. During an observation and interview in the 200 Hall men's communal bathroom on 1/20/2026 at 4:39 PM, the Administrator acknowledged that the unlabeled, unbagged bath basins should not be in the bathroom and residents should have paper towels for hand hygiene. 4. Observations in the 200 Hall women's communal bathroom on 1/20/2026 at 11:00 AM and 12:18 PM, revealed 2 unlabeled, unbagged bath basins sitting under the sink on the floor. During an observation and interview in the 200 Hall women's communal bathroom on 1/20/2026 at 4:21 PM, the Administrator was shown the unbagged, unlabeled personal items. The Administrator was asked if unlabeled, unbagged bath basins and bedpans should be in the bathroom. The Administrator stated, No . The Administrator acknowledged that a soiled washcloth should not be on the floor of a shower stall but bagged and placed in the soiled linen cart. 5. Observations in the 100 Hall men's communal bathroom on 1/20/2026 at 11:49 AM and 4:47 PM, revealed no hand soap or paper towels for hand hygiene. During an interview on 1/21/2026 at 8:30 AM, the Environmental Service Director was asked what he would expect the housekeeping staff to do if unlabeled bath basins were found in the communal bathrooms. The Environmental Service Director stated, .the basins would need to be thrown away .without a label you don't know who the basin belongs to . During an interview on 1/21/2026 at 11:30 AM, CNA C acknowledged the nursing staff use the 100 and 200 Hall communal bathrooms for hand hygiene when needed. 6. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Dementia, and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Observation on the 100 Hall during medication administration on 1/22/2026 at 7:57 AM, revealed LPN A drew up ordered insulin and failed to recap or engage the safety shield on the insulin needle. LPN A removed a bottle of eyedrops from the medication cart with her right hand then, while holding the uncapped insulin syringe in her left hand, walked down the hall to Resident #3's room. LPN A placed the bottle of eyedrops on the nightstand without providing a barrier. LPN A then donned a gown and gloves while she continued to hold the uncapped insulin syringe. LPN A picked up the eyedrop bottle from the nightstand, went to Resident #3's bed, placed the eyedrop bottle on the over bed table without a barrier, and administered the insulin and eye drops to Resident #3. LPN A carried an uncapped, exposed needle down the hall to administer medication to Resident #3 and failed to provide a barrier for medication during medication administration. 7. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Chronic Kidney Disease, and Chronic Respiratory Failure. Review of the admission MDS assessment dated [DATE], revealed Resident #30 scored a 15 on the BIMS assessment, indicating he was cognitively intact. Observation on the 200 Hall during medication administration on 1/22/2026 at 8:30 AM, revealed LPN B prepared medication for Resident #30. LPN B removed a house stock bottle of medication, obtained the medication, and attempted to return the lid to the bottle. LPN B dropped the lid of the bottle on the floor, picked up the lid and immediately placed it on the bottle without cleaning it, then returned the bottle to the medication cart. LPN B entered Resident #30's room and placed the prepared cup of medications, a bottle of eyedrops, and an inhaler on the over bed table without a barrier, next to a half full urinal. LPN B donned gloves without performing hand hygiene and removed the urinal. LPN B removed her gloves without performing hand hygiene, took Resident #30's blood pressure, and administered the medications to Resident #30. LPN B then returned to the medication cart, laid the blood pressure cuff on the back of the cart, signed out the medications, and then stated, Ok, I'm done. LPN B failed to disinfect the blood pressure cuff after obtaining Resident #30's blood pressure. LPN B failed to clean a lid that had fallen on the floor before replacing it and returning the bottle to the medication cart, failed to use a barrier for medications, failed to perform hand hygiene before and after removing her gloves, before obtaining Resident #30's blood pressure and administering the medications and failed to clean reusable medical equipment before returning it to the medication cart. During an interview on 1/22/2026 at 4:45 PM, the DON was asked if staff should draw up insulin for medication administration and walk down the hallway with an uncapped syringe. The DON stated .They should always engage the safety or put the lid back on it .No, they shouldn't walk down the hall with it uncapped. The DON was asked if staff should replace the lid of a medication bottle after the lid had dropped onto the floor. The DON stated .No .she should have cleaned it first. The DON was asked if staff should place medications on an unclean surface during medication administration. The DON stated .They should always place a barrier. The DON was asked when staff should perform hand hygiene during medication administration. The DON stated .after they take their gloves off. The DON was asked if staff should disinfect a blood pressure cuff after it had been used on a resident. The DON stated .they should take it back to the cart and clean it before they use it on anyone else.

Based on policy review, invoice review, medical record review, a list of residents who use the 100 Hall communal bathrooms, observation, and interview, the facility failed to promote and ensure dignity and quality of life was met for 3 of 4 residents (Resident #14, #29, and #34) sampled for activities of daily living.The findings include: 1. Review of the undated facility policy titled, Resident Rights, revealed .The resident has the right to a dignified existence.The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences .The resident has the right to personal privacy .Personal privacy includes accommodations .personal care .The resident has a right to a.comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living. 2. Review of an Invoice provided by the facility dated 12/3/2025, revealed an order for 4 standard overhead braced toilet partitions (dividing wall or enclosure that separates toilets). 3. Observation in the 100 Hall women's communal bathroom on 1/20/2026 at 9:45 and 11:50 AM, revealed no lock on the door, with 2 toilets side by side with a few feet between them on the right side as you open the door. There was no wall, privacy curtain or other enclosure, and allowing full view of the toilets when the door was opened. 4. Review of the medical record revealed Resident #14 and Resident #34 were roommates. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Hypertension and Gastroparesis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she had no cognitive impairment. Resident #14 required supervision or touching assistance from staff with toileting hygiene. 5. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Hypertension and Epilepsy. Review of the admission MDS assessment dated [DATE], revealed Resident #34 scored a 14 on the BIMS assessment which indicated she had no cognitive impairment. Resident #34 required partial/moderate assistance from staff for toileting hygiene. During an interview with roommates Resident #14 and Resident #34 on 1/22/2026 at 1:35 PM, the residents were asked about using the toilets in the 100 Hall women's communal bathroom. Resident #14 stated, .we don't have any privacy in the bathroom, the stalls were never put up. Resident #34 stated, .it's a female restroom but it would be nice to have some privacy. Resident #14 and Resident #34 acknowledged it was uncomfortable for them to use the 100 Hall communal bathroom and it was the only bathroom available on their hall. 6. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Hypertension and Chronic Pain. Review of the annual MDS assessment dated [DATE], revealed Resident #29 scored a 15 on the BIMS assessment, which indicated she had no cognitive impairment. Resident #29 was independent for toileting hygiene. During an interview on 1/20/2026 at 12:17 PM, Resident #29 was asked about the use of the communal bathrooms in the 100 and 200 Halls. Resident #29 stated, .I use the employee restroom sometimes for more privacy.the 100 Hall bathroom stalls were not put back up, no curtains or anything.I know it has been like that for a month. Resident #29 acknowledged it was uncomfortable to use a bathroom without any privacy. Observation and interview in the 100 Hall women's communal bathroom on 1/20/2026 at 5:00 PM, revealed no privacy for Resident use of the toilets. The Director of Nursing (DON) was asked if the bathroom was a communal bathroom. The DON stated, Yes. The DON was asked if the residents should have privacy while using the restroom. The DON stated, Yes. During an interview on 1/22/2026 at 5:00 PM, the Regional Nurse Consultant provided a list of residents that use the 100 Hall communal bathrooms. Resident #14 and Resident #34 were on the list.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when carbon covered cookware was used in the kitchen, the dishwasher thermometer failed to reach 120 degrees during the wash cycle, sanitation solution did not measure appropriately, when residents were served with unsanitary plates and silverware, when expired foods were found in the dry storage area and in the Emergency Food Supply. The facility had a census of 53, with 51 of those resident's receiving a lunch tray from the kitchen on [DATE], and 49 receiving a breakfast tray on [DATE]. The findings included: 1. Review of the facility's undated policy titled, Dishwasher Temperatures, revealed .It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures .low temperature dishwashers .wash temperature shall be 120 degrees F [Fahrenheit] .sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse .Chemical solutions shall be maintained at the correct concentration . 2. Observation on [DATE] at 8:09 AM, and on [DATE] at 11:05 AM, revealed 2 large and 3 small pans, 1 small and 3 medium pots, 4 steam table pans, and 3 skillets with thick carbon build up. Observation on [DATE] at 11:10, revealed two containers of peanut butter with a best if used by date of [DATE], and a can of tomato juice with an expiration date of [DATE]. Observation and interview on [DATE] at 11:10 AM, revealed while the low temperature dishwasher was washing and rinsing dishes, the temperature gauge on the machine read 40 degrees and did not move the whole cycle. The Dietary Manager (DM) was asked to check the sanitation with the dishwasher test strips. The DM confirmed that the dishwasher test strips were not measuring the correct amount of chemicals during the rinse. The DM also confirmed that the thermometer was not working correctly and used a cooking thermometer to check the temperature during a wash cycle. The temperature was 112.6 Fahrenheit. Observation on [DATE] at 11:30 AM, revealed Dietary staff serving lunch on regular dishware that had been washed in the malfunctioning dishwasher. Observation on [DATE] at 7:42 AM, revealed residents being served breakfast on regular dishware that had been washed in the malfunctioning dishwasher. 3. During an observation and interview on [DATE] at 9:00 AM, the DM confirmed the facility would have to replace the broken temperature gauge, the repairman had just worked on the dishwasher machine and the machine was currently working properly. The DM used a kitchen thermometer to test the water during the wash cycle and it read 130 degrees. The dishwasher sanitation strip also tested correctly at this time. The DM was asked if the residents of the facility should have been served lunch on regular dining plates on [DATE] and breakfast on [DATE] knowing that the dishwasher temperature and the chemical sanitation was not what it should have been. The Dietary Manager confirmed he should have used disposable plates and utensils. 4. Observation and interview at the Emergency Food Supply Storage Area on [DATE] at 9:32 AM, revealed the following: a. Four containers of peanut butter with a best used by date of [DATE], and two containers of peanut butter with a best if used by date of [DATE]. b. Two cans of tomato juice with an expiration date of [DATE]. c. Three cans of Cream of Chicken Soup with an expiration date of [DATE]. d. One gallon of Apple Cider Vinegar with an expiration date of [DATE]. e. One case containing 22 cans of evaporated milk with an expiration date of [DATE]. The DM confirmed there should not be any expired food items in the Emergency Food Supply or in the kitchen and stated, .I will get rid of all of this right now . The DM was asked what should have been done for lunch on [DATE] when the dishwasher was noted to not have the right temperature and the right sanitation. The DM stated, .I should have used the paper plates and utensils . The DM was asked what he should have done for breakfast on [DATE] since the repairman had not been in yet to service the dishwasher. The DM stated, .disposable plates should have been used .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices were followed during medication administration when 1 of 3 Licensed Practical Nurse (LPN) A nurses failed to follow Enhanced Barrier Precautions (EBP) when administering PEG (percutaneous endoscopic gastrostomy) tube medications and failed to perform appropriate hand hygiene. The findings include: 1. Review of the undated facility policy titled, Enhanced Barrier Precautions, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .High-contact resident care activities include .Device care or use: .feeding tubes . Review of the undated facility policy titled, Hand Hygiene, revealed .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 2. Review of medical record revealed Resident #31 was admitted on [DATE], with diagnosis including Gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #31 was moderately cognitively impaired. Review of Physician's orders dated 4/17/2024 revealed .Enhanced barrier precautions r/t [related to] peg tube every shift . Observation in Resident's room on 1/22/2024 at 11:00 AM, revealed LPN A removed gloves, did not perform hand hygiene, cleaned stethoscope, removed medication, put on gloves .opened capsules, removed gloves, did not perform hand hygiene, administered medications per peg and did not wear a gown. During an interview on 1/22/2025 at 11:23 AM, LPN A was asked if Resident #31 was in Enhanced Barriers. She replied, No. LPN A was asked if there was a sign on the door that says enhanced barrier. She replied, Yes, but he is not sick. LPN A was asked if PPE [Personal Protective Equipment] should have been worn when providing care to a resident in Enhanced Precautions. LPN A stated, Yes. I never would have thought of that. LPN A confirmed that hand hygiene should have been performed after taking off dirty gloves and before putting on clean gloves. During an interview on 1/23/2025 at 2:50 PM, the Director of Nursing (DON) was asked if nursing staff providing care to residents should know what EBP are. The DON replied, Yes, absolutely. The DON confirmed the nurse should have worn PPE when administering peg meds to a resident in EBP. The DON confirmed that staff should perform hand hygiene after removing gloves and before putting on clean gloves.

Based on policy review, record review, and interview the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 6 of 24 (Resident #34, #40, #41, #42, #47 and #49) residents reviewed for Advance Directives. The findings include: 1. Review of the facility's undated policy titled, Resident Rights, revealed The facility will inform the resident both orally and in writing .the resident understands .The right to request, refuse, and/or discontinue treatment .and to formulate an advance directive . 2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Epilepsy, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 was rarely/never understood and cognitive skills for daily decision making were moderately impaired. Review of the facility document Advanced Directive Acknowledgement, dated 3/30/2023, revealed the document was not filled out completely. 3. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Parkinson's Disease, Paranoid Schizophrenia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 which indicated Resident #40 was moderately cognitively impaired. Review of the facility document Advanced Directive Acknowledgement, dated 9/22/2023, revealed the document was not filled out completely. 4.Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression, and Brief Psychotic Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 10 which indicated Resident #41 was moderately cognitively impaired. Review of facility document, Advance Directive Acknowledgement, dated 7/7/2023 revealed the document was not filled out completely. 5. Review of medical record revealed Resident #42 was admitted on [DATE], with diagnoses including Bipolar, Anxiety, and Idiopathic Progressive Neuropathy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #42 was cognitively intact. Review of facility document, Advance Directive Acknowledgement, dated 5/11/2023, revealed the document was not filled out completely. 6. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Adult Failure to Thrive, Anxiety, and Seizures. Review of the quarterly MDS dated [DATE], revealed Resident #47's cognitive skills for decision making were severely impaired. Review of facility document, Advance Directive Acknowledgement, dated 5/20/2024, revealed the document was not filled out completely. 7. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dementia, Chronic Liver Failure, and Schizophrenia. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 13, which indicated Resident #49 was cognitively intact. Review of facility document, Advance Directive Acknowledgement, dated 2/26/2024 revealed the document was not filled out completely. 8. During an interview on 1/22/2025 at 10:58 AM, the Administrator and Regional Director of Clinical Services confirmed the Advance Directive should be filled out completely to show education was provided to the Resident or Responsible Party (RP). 48285 49311

Based on policy review, medical record review, and interview, it was determined the facility failed to have physician orders and failed to provide pressure ulcer/injury treatments for 1 of 4 (Resident #258) sampled residents reviewed for pressure ulcer/injuries. The findings include: 1. Review of the facility's undated policy titled, Pressure Injury Prevention and Management, .This facility is committed to the prevention of avoidable pressure ulcers .and to provide treatment and services to heal the pressure ulcer/injury .and the development of additional pressure ulcers/injuries .Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission .Findings will be documented in the medical record .the attending physician will be notified of .the presence of a new pressure ulcer upon identification . 2. Review of the medical record review revealed Resident #258 was readmitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Absence of Left Leg Above the Knee, Absence of Right Toes, Gastrostomy, Alzheimer's Disease, and Peripheral Vascular Disease. Review of the care plan dated 1/13/2025, revealed Resident #258 returned from the hospital to the facility with a left Leg above the knee amputation and a right toe amputation. Review of a Progress Note dated 1/13/2025, revealed The writer conducted skin check on resident on 01/14/2025 .Resident has above the knee amputation on left leg. Right second toe amputation .resident has right gluteal would [wound] 3.5 [centimeters] x [by] 7.0 x 0.5. Coccyx wound 1.0 x 1.5 x 0.3 . Review of the Physician's Order dated 1/17/2025, revealed, Clean pressure wound to superior sacrum with wound cleanser and pat dry . Review of a Physician's Order dated 1/17/2025, revealed Clean pressure wound to inferior sacrum with wound cleanser and pat dry . Review of the Treatment Administration Record (TAR) dated 1/1/2025-1/31/2025, revealed Resident #258's treatment to the inferior and superior sacrum was not documented as performed until 1/17/2025. During an interview on 1/22/2025 at 11:11 AM, Licensed Practical Nurse (LPN) B confirmed Resident #258 was admitted to the facility on [DATE], LPN B stated she came in late that evening and assessed Resident #258 on 1/14/2025. LPN B was asked, Did you get a treatment started. LPN B confirmed she cleaned the area and put a dressing on it, LPN B confirmed a treatment for the sacrum was ordered on 1/16/2024 by the [Named treatment Company] doctor. During an interview on 1/22/2025 at 2:45 PM, the Director of Nursing (DON) was asked when a doctor's order should be obtained for a treatment. The DON stated, Immediately. The DON was asked if she knew LPN B did not get an order for the sacrum. The DON confirmed that LPN B should have written an order for the sacrum the day of the assessment on 1/14/2025.

Based on policy review, medical record review, and interview, the facility failed to take appropriate actions in accordance with the facility's policy when a fall occurred for 1 of 3 (Resident #5) reviewed for falls. The findings include: 1. Review of the facility's undated policy titled, Fall Prevention Program, revealed .When any resident experiences a fall, the facility will .Assess the resident .Complete a fall assessment .Complete an incident report .Notify physician and family .Review the resident's care plan and update as indicated .Document all assessments and actions .Obtain witness statements . 2. Review of the medical record review revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Disorganized Schizophrenia, Anxiety, Blindness, Obsessive Compulsive Disorder, and Major Depressive Disorder. Review of the Care Plan dated 1/7/2025 revealed Resident #5 is at risk for falls. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #5 was moderately cognitively impaired. Resident #5 was assessed to have highly impaired vision. Review of the Progress Notes dated 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024 and 1/21/2024, revealed Resident #5 had a witnessed fall on 1/14/2024. During an interview on 1/23/2025 at 9:18 AM, the Director of Nursing (DON) was asked for the complete investigation related to the 1/14/2025 fall. The DON confirmed she was not able to provide any documentation related to this fall. The DON was unable to provide a resident assessment after the fall, an incident report, notification of the physician or family, any assessments related to the fall, and no witness statements. The DON was asked should you have completed a fall investigation. She stated, Yes .we did look at the cameras, Resident #5 was in the dining room, she bent over and slid out of her chair.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter (a tube in the bladder that drains the urine) for 1 of 1 (Resident #258) sampled residents reviewed for indwelling catheters. The findings include: 1. Review of the undated facility policy titled Catheter Care, revealed .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift and as needed by nursing personnel .Privacy bags will be available and catheter drainage bags will be covered at all times while in use .Empty drainage bags when bag is half- full or at least each shift . 2. Review of the medical record revealed Resident #258 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Gastrostomy, Alzheimer's Disease and Peripheral Vascular Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #258 was severely cognitively impaired. Resident was always incontinent of bowel and bladder. Observation in Resident's #258's room on 1/21/2025 at 10:42 AM, revealed the foley catheter was not in a dignity bag. Observation in Resident #258's room on 1/21/2025 at 1:59 PM, 1/22/2025 at 2:02 PM, and 1/23/2025 at 4:17 PM, revealed a Foley catheter bag was wrapped in a pillowcase. Review of the medical record on 1/21/2025, revealed no physician's orders for a foley catheter and no orders for catheter care. Review of the Physician's orders dated 1/22/2025, revealed .catheter care daily and prn [as needed] with soap and water. every shift for Catheter care AND every 1 hours as needed for cath [catheter] care prn with soap and water .record output every shift for record output record output each shift .catheter .TYPE: Foley SIZE:_16 fr [French] BALLOON:__15___CC every shift for Foley catheter care Check placement and secure .Ensure catheter tubing is secured to resident's leg as tolerated, to prevent accidental dislodgement . Review of Care Plan dated 1/22/2025 revealed .Resident has incontinence of bowel .1/22/25 - order for indwelling urinary catheter . Resident has indwelling urinary catheter 16 f [French]/15cc [cubic centimeter] r/t [related to] wound . During an Interview on 1/22/2025 at 2:21 PM, the Director of Nursing (DON) was asked when Resident #258's catheter was placed. The DON stated that she came from the hospital with one and we left it in due to pressure ulcers to her buttocks. The DON confirmed that Resident #258 did not have an order for the foley catheter or the catheter care. The DON confirmed that there should be foley catheter orders and catheter care orders. The DON confirmed that catheters should be in dignity bags for privacy. The DON stated, .We have ordered some [privacy bags], I told them to put a pillowcase to cover it .

Based on policy review, medical record review, and interview, the facility failed to follow the facility's policy for monitoring weekly weights for 1 of 3 (Resident #1) sampled residents reviewed for nutritional status. The findings include: 1. Review of the facility's policy titled, Weight System, dated 3/4/2022, revealed .If weight concerns are noted/weights are not stable, notify your RD [Registered Dietician] and continue the weekly weights until stable . 2. Review of medical record revealed Resident #1 was admitted on [DATE], with diagnoses including Hypertension, Diabetes, Hyponatremia, Overweight, and Abnormality of Albumin. Review of the Physician Orders dated 3/12/2024, revealed .HOUSE SUPPLEMENT three times a day for give 6oz for increased calorie intake. end date 7/10/24 . Review of the Care Plan dated 5/24/2024, revealed .resident at nutrition risk related to diagnosis of diabetes mellitus .gradual weight loss .house supplement as ordered, regular texture diet with thin liquids .set up assist with meals .hs [hour of sleep] snack . RD [Registered Dietitian] to eval [evaluate] with recommendations as needed .Weights per facility protocol . Review of the Physician Orders dated 7/10/24, revealed .HOUSE SUPPLEMENT four times a day for give 6oz for increased calorie intake . Review of the Physician Orders dated 7/11/2024, revealed . weekly weights r/t [related to] weight loss . Review of the Weight Summary for Resident #1 dated 7/24/2024, revealed the resident weighed 180 lbs. On 1/17/2025, the resident weighed 169 pounds which is a -6.11 % Loss. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact with no symptoms of depression. Resident had no problems related to swallowing disorder, no broken or loosely fitting dentures and no difficulty with chewing. Review of the facility Weight Summary for Resident #1 revealed the facility failed to get weekly weights for the weeks of 8/5/2024, 8/19/2024, 8/26/2024, 9/9/2024, 9/16/2024, and 9/23/2024. Review of the Dietary assessment dated [DATE], revealed . resident on carbohydrate-controlled diet with thin liquids. Residents with most recent weight of 182 and ideal body weight of 172. Resident consumes 26-100% of all meals . Review of the facility Weight Summary for Resident #1 revealed the facility failed to get a weekly weight for the week of 9/31/2024. Review of the Weight Summary for Resident #1 dated 10/7/2024, revealed the resident weighed 183 lbs. On 1/17/2025, the resident weighed 169 pounds which is a -7.65 % Loss. Review of the facility Weight Summary for Resident #1 revealed the facility failed to get weekly weights for the weeks of 10/14/2024, 10/21/2024, 10/28/2024, and 11/4/2024. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #1 was cognitively intact with no symptoms of depression. Resident is independent for eating. Resident has no problems related to swallowing disorder. Resident weighed 173 pounds. Weight loss of 5% or more in the last month or more in the last 6 months and is not on a prescribed weight-loss regimen. Review of the facility Weight Summary for Resident #1 revealed the facility failed to get weekly weights for the weeks of 12/9/2024, 12/16/2024, and 12/23/2024. Review of the Dietary assessment dated [DATE], revealed .resident on carbohydrate-controlled diet with thin liquids. Resident with most recent weight of 163 lbs. with and ideal body weight of 172. Resident consumes 26-100% of all meals . Review of the Physician Orders dated 1/2/2025, revealed .Mirtazapine Tablet 15 MG Give 1 tablet by mouth at bedtime for Appetite . Review of the Interdisciplinary Team Note dated 1/7/2025, revealed .Being monitored for weight loss. He was started on Remeron for appetite (1/2/25). Appetite varies . During an interview on 1/22/2025 at 4:31 PM, the [NAME] President (VP) of Nutrition was asked if she was aware of Resident #1's significant weight loss that occurred in the last 3 months of 7.65%. She stated He was stable July through October then started going down about 10 pounds. He had been on House supplement then put on weekly weights. The VP of Nutrition was asked if she had documentation of his nutritional assessments. She replied, You can't see the orders. We put him on weekly weight his po [oral] intake was ok. The VP was asked if Resident #1 was still on weekly weights. VP of Nutrition replied, I don't think he is. Once he starts to get stable, we take him off the weekly weights. I know you look back 6 months, but I am more concerned about the last 60 days. During an interview on 1/23/2025 at 2:50 PM, the Director of Nursing (DON) confirmed that any resident with an order for weekly weights should have weights assessed weekly and documented.

AMENDED 6.10.24 Based on policy review, Occupational Safety and Health Administration (OSHA) review, medical record review, observations, and interview, the facility failed to ensure the residents' environment was free of accidents and hazards when the facility failed to develop and implement care plan interventions to prevent falls for a resident with high risk of falls, supervise a cognitively impaired Resident, failed to monitor the Resident's condition post fall, and failed to provide care and services for 1 of 10 (Resident #42) sampled residents reviewed for falls. Resident #42 is a moderately cognitively impaired Resident who was ambulatory with a walker, fell on [DATE], and had complaints of right hip pain documented on 10/19/2023. The facility failed to obtain the Xray until 10/25/2023, and failed to assess the Resident when the Resident complained of post fall pain on 10/19/2023, 10/20/2023, and 10/24/2023. Resident #42 was transferred to the hospital's emergency department (ED) 12 days after the fall and admitted for a surgical repair of a fractured hip. The facility's failure to provide supervision of cognitively impaired resident and immediately assess the Resident with complaints of right hip pain following a fall which required surgical repair, resulted in Immediate Jeopardy for Resident #42. 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) was identified related to the facility's failure to monitor and assess Resident #42, who complained of right hip pain following a fall. An extended survey was conducted from 3/25/2024 to 3/26/2024. The Administrator was notified of the Immediate Jeopardy (IJ) for F-689 on 3/25/2024 at 5:29 PM, in the Employee Break Room related to Resident #42's fall. The facility was cited Immediate Jeopardy at F-689, at a severity of J which is Substandard Quality of Care. The Immediate Jeopardy began on 10/19/2023, and is ongoing. The findings include: 1. Review of the facility policy Resident Rights dated 10/18/2022, revealed .The resident has a right to a safe .environment . Review of the facility undated policy, Abuse, Neglect, and Exploitation revealed .Establishing a safe environment . Review of the undated facility policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .When any resident experiences a fall, the facility will .Assess the resident .Complete a fall assessment .Complete an incident report .Notify physician and family .Review the resident's care plan and update as indicated .Document all assessments and actions .Obtain witness statements in the case of injury . 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia, Depression, Seizures, Auditory Hallucinations . Review of the facility's MORSE FALL SCALE for Resident #42 dated 8/16/2022, revealed Resident #42 was high risk for falls. Review of the care plan with a revision date of 8/22/2022, revealed no documentation of interventions to prevent falls for Resident #42, who was identified as high risk for falls. Review of the annual Minimum Data Set (MDS) dated [DATE], for Resident #42 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated Resident #42 is moderately cognitively impaired, and required extensive assist for most Activities of Daily Living and required assistance of a walker with ambulation. There was no documentation Resident #42's care plan was revised to reflect interventions to prevent falls. Review of the facility's MORSE FALL SCALE for Resident #42 dated 10/14/2023, revealed Resident #42 was high risk for falls. Review of the HIGH RISK EVENT - INVESTIGATION STATEMENT for Resident #42 dated 10/14/2023, revealed .Type of Incident: unwitnessed fall .Did you witness the incident .No .[staff] Walked in the room resident [Resident #42] was on the floor . Review of the Incident Report dated 10/14/2023, for Resident #42 revealed .when [staff] walking in the room she [Resident #42] was calm laying on the floor on her right side in front of the tv [television] .Injury Type .Fracture .Right Trochanter (hip) [unknown why the staff documented a hip fracture here prior to the 10/25/23 Xray report] .Injuries Report Post Incident .No Injuries Observed Post Incident .Witnesses .No Witnesses found . There was no documentation the care plan had been revised following Resident #42's fall on 10/14/2023 with interventions to prevent further falls. Review of the October 2023 Medication Administration Record (MAR) for 10/14/2023 - 10/26/2023 revealed nursing documented Resident #42's pain level as 0 (on a scale of 1 - 10 with 10 being the most severe and 0 being no pain) for the day and night shifts. Review of the Nursing Progress Notes dated 10/16/2023, revealed .Resident [Resident #42] had an unwitnessed fall [regarding the 10/14/2023 fall] . Review of the Physical Therapy (PT) Evaluation and Plan of Treatment for Resident #42 dated 10/17/2023, revealed .Multiple medical conditions, Multiple medications .Desired change in Condition of Risk Area: to prevent falls .pt had unwitnessed fall on 10/14/2023, she was not using her walker, She was found on the floor on her R [Right] side, noted skin tear to R [Right] elbow . Review of the Physical Therapy Treatment Encounter Note for Resident #42 dated 10/19/2023, revealed .pt [patient, Resident #42] c/o increased R [Right] hip pain .Pt [patient] attempted RLE [Right Lower Extremity] exercises but c/o [complained of] pain and demoed [demonstrated] decreased ROM [Range of Motion] .PTA [Physical therapy Assistant] notified NSG [nursing] on pt pain. NSG [Nursing] aware . There was no documentation of a nursing pain assessment for Resident #42's complaint of right hip pain that was reported by the therapist during the 10/19/2023 therapy session. Review of the Intern Physician's Progress Notes dated 10/20/2023, for Resident #42 revealed .Nursing Home Visit .patient [Resident #42] report R hip pain since having a fall over the last weekend 5 days ago .R hip pain .on palpation of R hip .X-ray to be ordered to assess for acute fracture .Will consider adding pain medication . There was no documentation of a nursing pain assessment for Resident #42's complaint of right hip pain reported during the physician's visit on 10/20/2023. Review of the Physician's Orders for October 2023 revealed there was no order documented on 10/20/2023 for Xray. Review of the Physical Therapy Note dated 10/24/2023, for Resident #42 revealed .right hip pain .notified nursing of patient's [Resident #42] pain . Review of the Nursing Progress Notes dated 10/24/2023, for Resident #42 revealed .therapy [PT] stated pt [Resident #42] c/o hip pain today .will cont'd [continued] to monitor as doctor stated we can get an x-ray .and notify doctor . There was no documentation the X-ray was obtained on 10/24/2023. Review of the Nursing Progress Notes dated 10/26/2023 at 1:14 PM, revealed .[Resident #42] being monitored for hip pain. Xray completed and resulted 10/25/2023. Review of the nursing progress notes revealed the physician was not notified of the STAT x-ray results from 10/25/2023 that revealed Resident #42 had a fractured hip. Review of the Nursing Progress Notes dated 10/26/2023, revealed .Resident [Resident #42] being monitored for hip pain. Xray completed and resulted 10/25/2023 .Dr [named Medical Director] in facility for visit. Reviewed x-ray .hip is broken and externally rotated .MD [Medical Director] ordered resident be sent [to the hospital] .for evaluation and possible repair . Review of the Physician's Progress Notes dated 10/26/2023 at 2:51 PM, for Resident #42, revealed .Hip Pain .injury mechanism was a fall .pain is present in the right hip .described as stabbing .pain is moderate .inability to bear weight .loss of motion .Hip joint externally rotated, Any movement causes significant pain .closed fracture of right hip with nonunion . Review of the Hospital ED medical record revealed Resident #42 presented to the ED on 10/26/2023, 12 days after the Resident fell on [DATE]. Review of the ED Triage Assessment performed on 10/26/2023 4:46 PM, revealed Resident #42 presented to the ED via Emergency Medical Service (EMS) with complaints of .Fall with R [right] hip .Severe pain . The ED Nursing assessment dated [DATE], revealed, .PAtient [Patient, Resident #42] presents from [Named Nursing Home] with c/o [complaints of] R hip pain from a fall days ago and an xray resulted 24 hours ago showing a possible fracture .Severe pain .Arm, right .Bruising . Review of the Hospital ED Nurse Practitioner note dated 10/26/2023 at 4:50 PM, for Resident #42 revealed, .Right shoulder pain; Traumatic hematoma of right upper arm; Impacted fracture of right hip; Fall .Additional history: Patient [Resident #42] presents to emergency department with complaints of right hip pain right arm pain and head pain. Patient states she had a fall approximately 1 week ago at the nursing home that was unwitnessed .At this time she is complaining of right hip pain and a large hematoma to the right upper arm. She also states she has a headache . Review of the Hospital X-ray report of the Resident #42's right hip dated 10/26/2023, revealed .Acute to subacute superiorly displaced and impacted right femoral neck fracture. No dislocation of the femoral head from the acetabulum [part of the hip bone]. Underlying moderate osteopenia. Moderate right and mild left hip DJD [Degenerative joint disease] with loss of joint space and subchondral sclerosis [bones thicken] . Review of the Hospital History & Physical dated 10/26/2023, for Resident #42, revealed .Patient [Resident #42] is a [AGE] year-old female with a past medical history of dementia, CVA [Cerebral Vascular Accident also known as a stroke], osteoarthritis, schizoaffective disorder and seizures who presents from the nursing home due to a right femur fracture .patient is alert and oriented to name only, she does not answer questions appropriately .she has had right shoulder pain and right hip pain. Right hip x-ray shows acute to subacute superior displaced and impacted right femoral neck fracture. Orthopedic surgery consulted. Right CT [computerized tomography - a detailed scan to determine/identify internal problems] shoulder shows severe DJD as well as multiple pulmonary nodules. CT brain unremarkable. CT cervical spine unremarkable . Review of the Radiology Consultation Report dated 10/26/2023, revealed Acute to subacute superiorly displaced and impacted right femoral neck fracture .Underlying moderate osteopenia. Moderate right and mild left hip DJD [degenerative joint disease] with loss of joint space and subchondral sclerosis . Resident #42 had an Arthroplasty Partial Hip (replacement of the damaged and/or worn out bone) at the hospital on 10/27/20023. Review of the Hospital Progress Note dated 11/5/2023, revealed .[Resident #42] had been up walking on 11/3/2023 but then started shouting with pain when she sat in a chair. [Resident #42] was found have acute right hip dislocation Resident #42 required a second operation while in the hospital on 11/4/2023 to repair the dislocated hip. Review of the Hospital discharge summary dated 11/14/2023, for Resident #42 revealed, Patient [Resident #42] is a [AGE] year-old female with a past medical history of dementia, CVA [stroke], osteoarthritis, schizoaffective disorder and seizures who presents from the nursing home due to a right femur fracture. On my encounter, patient is alert and oriented to name only, she does not answer questions appropriately .She underwent right hip hemiarthroplasty [replacement of the damaged or worn out bone] on 10/27 [2023] .hemoglobin was down to 6.4 [normal 12 - 15] on 10/29 [2023] .transfused [blood to improve the hemoglobin levels] .required another unit of Packed red blood cells on 10/30 when her hemoglobin was 7.5 .[Resident #42] was noted to have some coughing after eating and a video swallow eval was obtained, with the recommendation of dysphagia chopped diet with nectar thick liquids She was found have acute right hip dislocation. This was reduced in the OR [operating room] on 11/04 [2023] .As she [Resident #42] was getting ready for discharge, started to have hip pain, repeat x-ray showed recurrent right hip dislocation. She went back to OR on 11/8 [2023]for irrigation, debridement, and evacuation of large right hip hematoma and revision of hemiarthroplasty to total hip arthroplasty .Patient [Resident #42] needs to follow up for his [her] primary care provider for imaging lung nodules .Need to discuss antiplatelet therapy . Review of the medical record revealed Resident #42 was readmitted to the long term care facility on 11/14/2023, with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia, Depression, Seizures, Auditory Hallucinations and Fracture of Head and Neck of Right Femur. Review of the significant change MDS dated [DATE], revealed Resident #42 scored a 7 on the BIMS indicating the Resident is severely cognitively impaired and sustained a fall in the last month. Review of the care plan revised 11/17/2023, revealed the intervention for falls was to keep the call light in place. There was no documentation of other fall interventions to prevent further falls. During an observation in Resident #42's room on 3/18/2024 at 9:49 AM, Resident #42 was sitting in the wheelchair with her socks on. During an observation in Resident #42's room on 3/19/2024 at 8:08 AM, Resident #42 was in her wheelchair and her call light was on the floor behind the wheelchair. During an observation in Resident #42's room on 3/25/2024 7:56 AM, Resident #42 was in the bed and the call light was laying over the chair next to the hospital bed out of reach for the resident. During a telephone interview on 3/21/2024 at 4:05 PM, the Physical Therapy Director stated, We saw her [Resident #42] for a few days before she went to the hospital .I believe it was an unwitnessed fall .[Physical Therapy] reported her [Resident #42] pain to nursing a few times . During an interview on 3/25/2024 at 1:49 PM, Certified Nursing Assistant (CNA) B was asked to explain what happened the day of Resident #42's fall on 10/14/2023. CNA B stated, .she [Resident #42] was reaching for her walker and fell on her butt, she didn't hit her head [the fall was unwitnessed] and I yelled out to the charge nurse . During an interview on 3/25/2024 at 1:40 PM, the Intern Physician who documented on 10/20/23 that an Xray would be performed on Resident #42, was asked to explain the process for ordering x-rays since the Intern Physician didn't have access to the Electronic Medical record (EMR). The Intern Physician stated, .we communicate to the nurse, and she [the nurse] immediately puts in the order . During an interview on 3/25/2024 at 3:17 PM, the DON was asked for the Intern Physician order and results for the x-ray that was ordered on 10/20/2023 for Resident #42. The DON was unable to find a 10/20/2023 physician order for an Xray in the EMR. The DON stated the nurse must not have ordered the Xray on 10/20/2023. The DON was pointed out that some of the facility documentation states that Resident #42 experienced a witnessed fall and other facility documentation states Resident #42 experienced an unwitnessed fall. The DON was asked to clarify if witnessed or unwitnessed fall for Resident #42. The DON stated Resident #42's fall cannot be determined as witnessed or unwitnessed unless further investigation was completed.

Based on CDC (Centers for Disease Control and Prevention) guidelines, observation, and interview, the facility failed to ensure proper infection control practices were followed when 2 of 3 (Licensed Practical Nurse (LPN L and M) nurses failed to clean reusable equipment before use on residents during medication administration. The findings include: 1. Review of the CDC guidelines revealed, .CDC recommendations for disinfecting .stethoscopes include disinfecting between each patient . whereas semi critical stethoscopes [Semi-critical items which come into contact with the mucous membranes or with the skin that is not intact] should be disinfected before use on each patient . Review of guidelines at Health.com, .Wipe the sensor with a cotton swab or pad dipped in rubbing alcohol or bleach. Or you can rinse the forehead thermometer with lukewarm soapy water .Let the forehead thermometer air dry . 2. Observation during medication administration on the 100 Hall on 3/19/2024 at 7:15 AM, revealed LPN M entered the Resident #14's room, used a temple thermometer on the resident, LPN M then exited the room and placed thermometer in her jacket pocket. LPN M failed to clean the thermometer after use on Resident #14. Observation during medication administration on the 100 Hall on 3/20/2024 at 7:42 AM, revealed LPN M entered Resident #24's room, used a temporal thermometer on the resident, LPN M then exited the room and placed thermometer in her jacket pocket. LPN M failed to clean the thermometer after use on Resident #24. Observation during medication administration on the 200 Hall on 3/20/2024 at 8:09 AM, revealed LPN N entered Resident #54's room, with the medications, donned clean pair of gloves, removed the stethoscope from around her neck, checked for PEG tube placement and checked residual, LPN N replaced the stethoscope back around her neck. LPN N failed to clean or disinfect the stethoscope after use. During an interview on 3/22/2024 at 10:11 AM, the Director of Nursing (DON) confirmed that a stethoscope and temporal thermometer should be cleaned after checking PEG (Percutaneous endoscopic gastrostomy) tube (placed for nutrition) placement on a resident, and if a thermometer touches a resident's forehead it should be cleaned before using the next resident.

Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 8 of 35 resident's rooms (Resident #1, #2, #37, #43, #22, #39, #46, and #50), 1 of 4 communal bathrooms (200 Hall), and 1 of 3 scales (Standing Life Scale) observed. The findings include: 1. Review of the facility's undated policy titled, .Routine Cleaning and Disinfection, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .Consistent surface cleaning and disinfection .tray tables .resident chairs .sinks and faucets . 2. Observations in the resident's room on 3/18/2024 at 9:25 AM, and 3/19/2024 at 3:25 PM, revealed Resident #46's over the bed table was caked with dust and spots of what appeared to be dried liquids. Observations in the resident's room on 3/18/2024 at 9:30 AM and 11:34 AM, and on 3/19/2024 at 8:30 AM, revealed Resident #41's over the bed table had a dried brown circle on the top, table base with thick caked on dust in between the crevices, and crumbs on the floor. Observations in the resident's room on 3/18/2024 at 9:42 AM and 3/19/2024 at 8:06 AM, revealed Resident #2's wheelchair had hair wrapped around the axle of the wheel and dirty buildup of dried liquids and dirt on the frame of the chair. Observations in the 200 Hall women's communal bathroom on 3/18/2024 at 9:43 AM and 11:06 AM, revealed a clogged sink with standing cloudy water in the sink, a dirty floor with hair and marks from dirty wheels of a wheelchair, and numerous unlabeled bath basins in the floor. Observations in the 200 Hall women's communal bathroom on 3/18/2024 at 11:06 AM, revealed a paper towel on the floor, sink with standing water, hairbrush in windowsill with hair in it, plunger not wrapped up sitting in the shower area, unlabeled bath basins on the floor, and the door wouldn't shut properly. Observations in Resident #1's room on 3/18/2024 at 11:17 AM, revealed the wheelchair's safety tag that was hanging down from the back had a 4-5 inch brown smear down it. During an observation and interview on 3/18/2024 at 5:15 PM, the Director of Nursing (DON) confirmed the bathroom sink should be fixed and not have standing water in it and bath basins should not be in the floor or unlabeled. Observation in the 200 Hall women's communal bathroom on 3/19/2024 at 7:59 AM, revealed the sink had an out of order sign on it. The facility failed to provide a place for proper hand hygiene after toileting. Observations in the resident's room on 3/19/2024 at 8:02 AM, 3/20/2024 at 7:50 AM and 1:12 PM, revealed Resident #42's over the bed table had thick caked on dirt in the crevices of the base. Observations on the patio on 3/19/2024 at 8:25 AM, revealed Resident #1's tag had a 4 to 5 inch brown smear on it. Observation in the 200 Hall women's communal bathroom on 3/20/2024 at 1:10 PM, revealed a used washcloth in the sink, paper towels on sink, toilet paper on the floor by sink, dirty wheelchair tracks on the floor, and a used towel on the windowsill. Observation on the 300 Hall by the dining room on 3/20/2024 at 1:22 PM, revealed Resident #1's wheelchair's safety tag hanging down from the back had a 4-5 inch brown smear down it. During an observation and interview on 3/20/2024 at 1:22 PM, the DON was shown Resident #1's wheelchair. The DON confirmed that the brown smear stain should not be there. During an observation and interview in Resident #2's room on 3/20/2024 at 1:22 PM, the DON was shown the wheelchair with hair wrapped around the axle of the wheel, dirty buildup of dried liquids, and dirty frame of the chair. The DON confirmed that the wheelchair should be clean. Observations in the 200 Hall women's communal bathroom on 3/20/2024 at 4:00 PM, revealed the floor had wet paper towels and other white paper products on the floor. There were also multiple wet spots on the floor. During an observation and interview on 3/20/2024 at 4:07 PM, the DON was asked should the bathrooms be kept clean and tidy. The DON stated, Yes. Observations on the 100 Hall on 3/24/2024 at 4:36 PM, and 3/25/2024 at 5:20 PM, revealed the standing lift with a large number of crumbs and a black substance on the back of the lift. During an observation and interview on the 100 Hall on 3/26/2024 at 10:24 AM, RN N was asked to identify the particles on the standing lift. RN N stated, .looks like food crumbs from where it was on the residents' clothes when they stood on the lift, and the black stains look dirty . During an observation and interview on 3/20/2024 at 10:11 AM, the DON was taken to several rooms on the 200 hall. The DON was asked if she felt the over bed tables were dirty, she stated Yes . During an interview on 3/20/2024 at 10:27 AM, Housekeeper O was asked what she cleans in the resident rooms. Housekeeper O stated, .I clean the top of the over bed table . When asked if she was supposed to clean the base of the tables, she replied, .no, I don't have the right stuff [cleaning products] to clean them with . When Housekeeper O was asked if she thought they were dirty, she stated Yes . During an interview on 3/20/2024 at 10:35 AM, the Housekeeping Supervisor confirmed that there was no schedule to clean the over bed tables. The Housekeeping Supervisor stated, .the over bed tables are taken outside and pressure washed when it is warm out .

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by the paper towel dispenser not working, dirty trash cans, vent fans are coated with a thick grayish brown substance, large utensil holder dirty with package of crackers inside, greasy ice cream scoop, spice and condiment holder dirty with food crumbs, dirty kitchen floors, carbon build up on pots and pans, wet pans stacked on top of other pans, fryer baskets coated in yellow sticky substance; handles sticky, ice machine dirty, clean dishes on top of dirty trays, transport and bus (tiered utility cart) carts dirty, eye wash station with crumbs and dust, meat slicer greasy with reddish brown substance underneath, mixer and mixer table dirty, nutrition refrigerator dirty with spilled substance on rack, no thermometer, and supplements stuck to the rack. The facility had a census of 52 with 48 of those residents receiving a meal tray from the kitchen. The findings include: 1.Review of the facility's policy titled, FOOD SERVICE SAFETY, dated 10/18/2022, revealed .all equipment used in the handling of food shall be cleaned and sanitized .follow facility procedures .cleaning .fixed cooking equipment .must wear hair restraints [hairnet] to prevent hair from contacting food .Food and beverages shall be distributed and served to residents in a manner that prevent contamination .include .washing hands properly before distributing trays .washing hands between contact with residents and after collecting soiled plates and food waste .use of gloves when touching and assisting with ready-to-eat foods . 2. Review of the undated Daily Cleaning Schedule, revealed .Mixer (each shift), Knife Rack (each shift), Carts and Tray Carts wipe and sanitize (daily), Condiment/Silverware Bins/Cart (daily), Ice Machine (each shift), Hand Sink-Soap/Paper Towels (daily), Kitchen Floors (daily), Garbage Cans & Lids Washed (daily) . 3. Observation on 3/18/2024 at 8:12 AM, 3/20/2024 at 11:24 AM, and 3/20/2023 at 1:30 PM revealed the kitchen door was propped open. Observations on 3/18/2024 at 8:55 AM, 3/19/2024 at 4:00 PM, 3/20/2024 at 8:12 AM, and 3/21/2024 at 3:00 PM, revealed the paper towel dispenser was in disrepair. Observation on 3/18/2024 at 8:55 AM, revealed the trash can next to the hand washing sink was covered with thick, sticky, stains, and dried liquid and the foot pedal would not open related to the lid was stuck to the bag in the can. Observation on 3/18/2024 at 9:00 AM, revealed 2 vent fans in the walk-in refrigerator were coated with a thick grayish brown substance. Observations on 3/18/2024 at 9:05 AM, 3/19/2024 at 4:02 PM, and 3/20/2024 8:19 AM, revealed an ice cream scoop that was greasy, clear plastic bins for large utensils had crumbs inside, 3 packages of graham crackers inside a bin, and a sticky reddish-brown substance on bottoms of bins. Observations on 3/18/2024 at 9:05 AM, and 3/20/2024 at 8:19 AM, revealed 8 gray plastic containers holding spices and condiments were covered with dust and crumbs on the edges and on the inside. Observations on 3/18/2024 at 9:10 AM, and 3/19/2024 at 4:05 PM, revealed the floor around and behind stove was dirty with dried greasy splatters. Observation on 3/18/2024 at 9:12 AM, revealed 2 shallow pans, 1 medium size pan, and 4 large pans with dark thick carbon buildup. Observation on 3/18/2024 at 9:12 AM, revealed the dish washer staff member stored a wet pan on top of another pan under the steam table. Observation on 3/18/2024 at 9:13 AM, revealed one muffin pan with crumbs scattered inside of it in the clean pan area. Observation on 3/18/2024 9:13 AM, revealed 2 fry baskets on the counter next to the meat slicer, coated with thick hard dried yellow sticky substance around the edges and handles. Observation on 3/18/2024 at 9:15 AM, revealed 4 medium and 2 large metal pans stacked on the low shelf and were not completely dried. Observation on 3/18/2024 at 9:16 AM, revealed the right side of the ice machine had brownish red splashes and the top of the door had small brown crumbs scattered along the edge. Observation on 3/18/2024 at 9:17 AM, and 3/19/2024 at 4:01 PM, revealed a metal rack with clean dishes on top of 4 trays that had crumbs and dust on them. Observations on 3/18/2024 at 9:22 AM, and 3/19/2024 at 4:11 PM, revealed 3 food bus carts with dried drip marks down the sides and around the back of the vents, 2 bus carts had sticky build up in edges and corners of each shelf area, sticky handles with crumbs, and buildup in the textured/grooved areas. Observations on 3/19/2024 at 4:08 PM, and 3/20/2024 at 11:34 PM, revealed the eye wash station in dishwashing room had crumbs and dust in it. Observations on 3/20/2024 at 8:19 AM, revealed the meat slicer was greasy, covered with fingerprints, and had a reddish-brown substance on the base under the blade. Observation on 3/20/2024 at 8:19 AM, revealed the mixer table was covered with white/yellow, dried splatter marks. The body of the mixer was dusty and had a greasy looking film on it. The mixer shield had a brownish red sticky like substance under the metal guard. Observation in the nutrition refrigerator on 3/20/2024 at 3:02 PM, revealed a yellow sticky dried spill substance on bottom rack with a box of supplements stuck to it, and there was no thermometer in the freezer. The freezer was filled with stacks of frozen randomly shaped liquid ice packs and hard plastic ice packs that kept falling out when the freezer door was opened. During an interview on 3/20/2024 at 8:12 AM, the Dietary Manager (DM) was asked should the paper towel dispenser have been working for the last 3 days. The DM stated, .Yes ma'am, I need to get that fixed. During an interview on 3/20/2024 at 8:13 AM, the DM was asked if he had noticed the trash can was sticky it wouldn't even open when the foot pedal was pressed. The DM stated, .it shouldn't be like that. During an interview on 3/20/2024 at 8:14 AM, the DM was asked if the storage bins should have the crumbs and dirty buildup in them, and if the floors should be dirty. The DM stated, .No ma'am . During an interview on 3/20/2024 at 8:15 AM, the DM confirmed the pans needed to be free of carbon buildup and they should not be stacked while wet. During an interview on 3/20/2024 at 8:19 AM, the DM was asked if the mixer and the meat slicer should have been cleaned. The DM stated, Yes. During an interview on 3/20/2024 at 8:27 AM, the DM was shown the ice machine with the splash-over from the sink on the side, and the metal cart with clean dishes on it that had crumbs on the trays under them. The DM confirmed they needed to be cleaned and the vent fans on the walk-in refrigerator should be clean. During an interview on 3/20/2024 at 1:42 PM, the DM confirmed the kitchen doors should be closed and stated this could compromise a sanitary kitchen environment. During an interview on 3/20/2024 at 1:42 PM, the DM was asked if the carts should have multiple drip marks down the sides of them and the bus carts have dirty buildup all over them. The DM stated, .no ma'am . During an interview on 3/20/2024 at 3:04 PM, the DM was asked if the freezer in the nutrition refrigerator should have a thermometer. The DM stated, I didn't know I was supposed to be over the nutrition fridge .

Based on policy review, job description review, medical record review, and interview, the facility failed to report injuries of unknown source to the state agency, adult protective services, law enforcement, and Ombudsman for 1 of 13 (Resident #42) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled Resident Rights dated 9/21/2020, revealed .Consult with the Resident's physician .An accident involving the Resident which results in injury and has the potential for requiring physician intervention . Review of the facility's undated policy titled, .Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Possible indicators of abuse include, but not limited to .physical marks such as bruises .on a resident's body .physical injury of a resident, of unknown source .The facility will make efforts to ensure all residents are protected from physical .harm during and after the investigation .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies as is required .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 2. Review of the Facility's Administrator Job Description dated 7/29/2021, revealed .Leads, guides and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established policies and procedures to provide appropriate care and services to residents .Ensures residents incidents and concerns that rise to a reportable event such as alleged abuse, neglect .are reported to the correct entity within the stated regulatory requirement .reports any allegations of abuse, neglect .protects residents from abuse . Review of the Facility's Director of Nursing Job Description dated 10/22/2021, revealed .Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action .Monitors for allegations of potential abuse or neglect .participates in the investigative process .Reports any allegations of abuse, neglect .Protect residents from abuse . 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnosis of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia, Depression, Seizures, and Auditory Hallucinations. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #42 scored a 7 on the Brief Interview for Mental Status (BIMS), which indicated severely cognitively impairment. Review of the significant change MDS dated [DATE], revealed Resident #42 scored a 7 on the BIMS, indicating the resident is severely cognitively impaired and needs extensive assist dressing, bathing, and toileting. Review of a facility untitled document dated 3/16/2024, revealed CNA G provided a bed bath and documented that Resident #42's skin had no bruising. Observations in Resident #42's room on 3/18/2024 at 9:49 AM, revealed Resident # 42 in the bed with their arms under the sheet and blanket. A dime size purple/bluish bruise was noted to the resident's lip and chest area. Observations in Resident #42's room on 3/20/2024 at 1:12 PM, revealed the Resident sitting in the wheelchair with a short sleeve shirt on. A bruise that was yellow/greenish about the size of a tennis ball was observed and a dark purple bruise the size of a half dollar with a hematoma in the middle was observed to Resident #42's left arm. During an interview on 3/20/2024 at 1:18 PM, Licensed Practical Nurse (LPN) L was asked if she knew how Resident #42 received the bruises on the lips, chest area and arm. LPN L confirmed she had not identified the bruises on Resident #42 prior to the surveyor observation. Observation in the Resident's room on 3/20/2024 at 1:21 PM, the Director of Nurses (DON) was shown the bruised areas on Resident #42's lip and arm. The DON stated she had not made aware of the bruising to the Resident's lip and arm. Review of the facility's Investigation Statement dated 3/20/2024, revealed LPN L's action was to assess Resident #42's skin. This was done after DON and LPN L were made aware of bruising by the surveyors. Review of a facility Incident Report dated 3/20/2024 at 5:57 PM, and Investigation Statement dated 3/20/2024, revealed LPN L observed a small bruise to the left mid side of Resident #42's chin, purple in color and dime sized. LPN L did not address the bruise of unknown source to the Resident's left arm, lip and chest area on the Investigation Statement or Incident Report. Review of the facility's Weekly Wound Progress Note dated 3/21/2024, revealed Resident #42 had a chest, chin and left arm bruise. The lip bruise was not identified. During an interview on 3/21/2024 at 8:01 AM, CNA J was asked about the bruises on Resident #42. CNA J stated, I don't know anything about the bruises, I was already asked yesterday During an interview on 3/21/2024 at 8:06 AM, CNA A was asked about the bruises on Resident #42. CNA A stated, I don't [provide] care for Resident #42 and haven't heard anything about what happened CNA A was asked what would she do if she found a bruise on a resident. CNA A stated, I would report it to [the] nurse. During an interview on 3/21/2024 at 11:26 AM, the Treatment Nurse was asked if she had noticed bruising on Resident #42. The Treatment Nurse confirmed she noticed the bruise on Resident #42's lip on 3/20/2024 and that the bruise was new. The Treatment Nurse confirmed she did the Resident's skin assessment on 3/14/2024 and did not notice a bruise on the Resident's left arm. The Treatment Nurse confirmed there was no documentation related to Resident #42's bruises prior to 3/20/2024. During an interview on 3/21/2024 at 11:47 AM, the DON confirmed she had not identified a bruise to Resident #42's left upper arm or lip. The DON stated that LPN L did a skin assessment on 3/20/2024 and the LPN should have noticed the bruising. The DON stated the bruise on Resident #42's chest area was from the Resident scratching her chest. The DON verified that there was no documentation of Resident #42 scratching her chest and causing bruising. During an interview on 3/21/2024 at 6:06 PM, the Administrator confirmed a bruise of unknown source to Resident #42's left upper arm had not been reported to him. The Administrator stated he heard about the left lower lip bruise and would look into the bruising on Resident #42's arm. Review of a facility Incident Reporting System (IRS) form dated 3/21/2024 at 8:17 PM, for Resident #42 revealed staff became aware of an incident on 3/20/2024 at 6:40 PM, per outside agency. The Administrator became aware of an incident on 3/21/2024 at 5:40 PM, per outside agency. The report verified the bruising was of unknown source. Review of a facility Progress Note dated 3/21/2024, for Resident #42 revealed Late entry: 3/20/24 [2024] .assessment of patient [Resident #42] this shift a small bruise purple in color on left mid chin was observed . The note did not address the bruising to the Resident's arm, lip and chest area. Review of a facility Investigation Reportable Folder dated 3/21/2024, revealed the Administrator was made aware on 3/21/2024 that Resident #42 had a yellow color bruise to the outside upper extremity of unknown source. During an interview on 3/25/2024 at 3:17 PM, the DON confirmed a bruise of unknown source has to be investigated and reported to the Administrator. The DON was asked if she felt the investigation for the bruises for Resident #42 was conducted in a timely manner. The DON stated, .the arm was not done timely . The DON was asked when she had been made aware of the bruises on Resident #42. The DON stated, .It may have been when [named Surveyor #1] showed me . The DON confirmed a nurse should have noticed the bruising on Resident #42 and notified the DON. The DON was asked should LPN L performed a full skin assessment on Resident #42 3/20/2024. The DON stated, Yes. During an interview on 3/26/2024 at 10:24 AM, the Administrator confirmed he did not start an investigation, or report the injuries of unknown source until he was made aware of the bruises on 3/21/2024. The Administrator confirmed it was possible that a staff member should have seen Resident #42's bruises during shower and bathing. The Administrator was asked when Surveyor #1 reported the bruises to staff, should he have been notified. The Administrator stated, Yes.

Based on policy review, job description review, medical record review, facility investigation, observation and interview, the facility failed to thoroughly investigate an unwitnessed fall with injury and bruises of unknown source in order to identify possible factors of abuse and/or neglect for 1 of 13 sampled residents (Resident #42) reviewed for abuse/neglect. The findings include: 1. Review of the undated facility policy titled, Abuse, Neglect, and Exploitation, revealed .The facility will have written procedures to assist staff in identifying the different types of abuse .physical abuse .Possible indicators of abuse .include, but are not limited to: Physical mark's such as bruises .on a resident's body .Physical injury of a resident, of unknown source .Investigation of Alleged Abuse, Neglect and Exploitation .An immediate investigation is warranted when suspicion of abuse .occur .Written procedure for investigations include: Identifying staff responsible for the investigations .Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim .witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation . Review of the undated facility policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .When any resident experiences a fall, the facility will .Assess the resident .Complete a fall assessment .Complete an incident report .Notify physician and family .Review the resident's care plan and update as indicated .Document all assessments and actions .Obtain witness statements in the case of injury . 2. Review of the facility's Administrator JOB DESCRIPTION, dated 7/29/2021, revealed .Lead, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents Ensures resident incidents and concerns that arise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation .are reported to the correct entity within the stated regulatory requirement .Reports any allegations of abuse, neglect .or mistreatment of residents to supervisor and/or administrator .Protects residents from abuse, and cooperates with all investigations . Review of the facility's Director of Nursing JOB DESCRIPTION, dated 10/22/2021, revealed .Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations .Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation .Performs rounds to observe residents and ensure nursing needs are being met .Communicates directly with residents .and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns .Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action .Monitors for allegations of potential abuse or neglect, or misappropriation of resident property and participates in the investigative process .Reports any allegations of abuse, neglect .or mistreatment of residents to supervisor and/or administrator. Protects residents from abuse, and cooperates with all investigations . 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, and Dyskinesia. Review of the annual Minimum Data Set (MDS) dated [DATE], for Resident #42 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated Resident #42 was moderately cognitively impaired, required extensive assist for most Activities of Daily Living and required assistance of a walker with ambulation. Review of the Nursing Progress Notes dated 10/14/2023 at 4:13 PM, revealed Resident [Resident #42] is noted walking without walker this shift and was found lying on the floor on her right side she is noted with a small skin tear to the right elbow .no new orders at this time . Review of the Incident Report dated 10/14/2023 revealed .when [staff] walking in the room she [Resident #42] was calm laying on the floor on her right side in front of the tv .Injury Type Fracture .Right trochanter (hip) [unknown why the staff documented a hip fracture here prior to the 10/25/2023 Xray report] .no witnesses found . Review of the Nursing Progress Notes dated 10/15/2023 at 3:02 AM, revealed .resident had unwitnessed fall on 10/14 with noted skin tear on right elbow . Review of the Physician Progress Note dated 10/20/2023, revealed Nursing Home Visit .Right hip pain .DX [diagnosis] Hip Pain Reason for Visit .The patient reports right hip pain since having a fall over the last weekend 5 days ago .reports decreased movement .x-ray to be ordered to assess for acute fracture .will consider adding pain medication if needed . Review of the Physician's orders revealed there were no orders for the x-ray ordered on 10/20/2023. Review of the Nursing Progress Notes dated 10/24/2023 at 3:46 PM, revealed .therapy stated pt [Resident#42] c/o [complain of] hip pain today will cont'd [continued] to monitor as doctor stated we can get an x-ray if needed . Review of the Physician's order dated 10/25/2023, revealed . X-ray of (R) [right] hip STAT [immediately] for Pain . Review of the Nursing Progress Notes dated 10/26/2023 at 1:14 PM, revealed .[Resident #42] being monitored for hip pain. Xray completed and resulted 10/25/2023. Review of the Nursing Progress Notes revealed the physician was not notified of the STAT x-ray results from 10/25/2023. Review of the Physicians Progress Note dated 10/26/2023 at 2:51 PM, revealed .Closed fracture of right hip .Dx hip pain Reason for visit Hip Pain The incident occurred more than 1 week ago. The incident occurred at a nursing home. The injury mechanism was a fall. The pain is present in the right hip. The quality of the pain is described as stabbing. The pain is moderate. Associated symptoms include an inability to bear weight and a loss of motion. The symptoms are aggravated by weight bearing .Transfer to Emergency Department for further evaluation . Resident #42 was transferred to the hospital on 10/26/2023 and underwent surgical repair of the right fractured hip. Review of the medical record revealed that Resident #42 was readmitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia and Fracture of Head and Neck of Right Femur. There was no documentation the facility investigated the unwitnessed fall which occurred on 10/14/2023. Observation in Resident #42's room on 3/18/2024 at 9:49 AM, revealed Resident # 42 in the bed with her arms under the sheet and blanket. A dime size purple/bluish bruise was noted to the resident's lip and chest area. Observation in Resident #42's room on 3/20/2024 at 1:12 PM, revealed Resident #42 sitting in the wheelchair with a short sleeve shirt on and an old bruise that was yellow/green about the size of a tennis ball with a dark purple bruise the size of a half dollar with a hematoma in the middle was noted to Resident #42's left upper arm. There was no documentation of a facility investigation to determine the cause of the bruises. After the facility was questioned on 3/20/2024 regarding the bruises on Resident #42, the facility submitted an Investigation Statement dated 3/20/2024, for Resident #42 documenting the action plan was to assess Resident #42's skin. The facility Incident Report dated 3/20/2024 at 5:57 PM, and the facility Investigation Statement dated 3/20/2024, revealed LPN L assessed Resident #42 and observed a small bruise to the left mid side of chin, purple in color and dime sized. LPN L did not address the bruise of unknown source to left arm and chest area on the Investigation Statement or Incident Report. Review of an Incident Reporting System (IRS) form dated 3/21/2024 at 8:17 PM for Resident #42, revealed staff became aware of incident on 3/20/2024 at 6:40 PM, per outside agency. The Administrator became aware of incident on 3/21/2024 at 5:40 PM, per outside agency. The report verified the bruising was of unknown source. During an interview on 3/20/2024 at 1:18 PM, Licensed Practical Nurse (LPN) L was asked if she knew how Resident #42 received the bruises on her lips, chest area and arm. LPN L confirmed she had not identified the bruises on Resident #42 prior to the surveyor observation. During an interview on 3/21/2024 at 8:01 AM, CNA J was asked about the bruises on Resident #42. CNA J stated, I don't know anything about the bruises, I was already asked yesterday. During an interview on 3/21/2024 at 8:06 AM, CNA A was asked about the bruises on Resident #42. CNA A stated, I don't [provide] care for Resident #42 and haven't heard anything about what happened CNA A was asked what she would do if she found a bruise. CNA A stated, I would report it to [the] nurse. During an interview on 3/21/2024 at 11:26 AM, the Treatment Nurse was asked if she had noticed bruising on Resident #42. The Treatment Nurse confirmed she noticed the bruise on Resident #42's lip on 3/20/2024 and that the bruise was new. During an interview on 3/21/2024 at 11:47 AM, the DON confirmed she had not identified a bruise to Resident #42's left upper arm or lip. The DON stated that LPN L did a skin assessment on 3/20/2024 and the LPN should have noticed the bruising. The DON stated the bruise on Resident #42's chest area was from the Resident scratching her chest. The DON verified that there was no documentation of Resident #42 scratching her chest and causing bruising. During an interview on 3/21/2024 at 6:05 PM, The Administrator confirmed that interviews are a part of a complete investigation. During an interview on 3/25/2024 at 3:17 PM, the DON confirmed a bruise of unknown source has to be investigated. The DON was asked if she felt the investigation for the bruises for Resident #42 was conducted in a timely manner. The DON stated, .the arm was not done timely . The DON was asked when she had been made aware of the bruises on Resident #42. The DON stated, .It may have been when [named Surveyor] showed me . The DON confirmed a nurse should have noticed the bruising on Resident #42 and notified the DON. The DON was asked should LPN L have performed a full skin assessment for Resident #42 on 3/20/2024. The DON stated, Yes. The DON was asked how many witness statements she gets when investigating a fall. The DON stated, .I will usually get 2 or 3 . The DON confirmed she did not get a witness statement from the nurse. The DON confirmed that it is not a complete investigation if the fall cannot be determined as witnessed or unwitnessed. During an interview on 3/26/2024 at 10:24 AM, the Administrator confirmed he did not start an investigation, or report the injuries of unknown source until he was made aware of the bruises on 3/21/2024. The Administrator confirmed it was possible that a staff member should have seen Resident #42's bruises during shower and bathing. The Administrator was asked when the surveyors reported the bruises to staff, should he have been notified. The Administrator stated, Yes.

Based on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings for 1 of 14 (Resident #356) sampled residents and failed to update the care plan for 1 of 14 (Resident #42) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's undated policy 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 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 .The comprehensive care plan will be prepared by an interdisciplinary team [IDT], that includes, but is not limited to .A registered nurse .A nurse aide .A member of the food and nutrition services staff .The RAI [Resident Assessment Instrument] Coordinator .Activity Director .Licensed therapist .Social Services Director .Family members .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment . 2. Review of the closed medical record revealed Resident #356 was admitted on [DATE], with a readmission on 4/11/2023, with diagnoses of Dementia, Major Depressive Disorder, Diabetes, Post Traumatic Stress Syndrome, and Hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #356 had a Brief Interview for Metal Status (BIMS) score of 3, which indicated he was severely cognitively impaired with wandering behaviors and required total staff dependence for activities of daily living (ADLs). Review of the Monthly Calendar revealed Resident #365 was scheduled for a Care Plan meeting on 1/18/2023, and on 4/11/2023 at 10:00 AM. During a telephone interview on 3/26/2024 at 1:31 PM, Family Member A was asked if the facility conducted a care plan meeting to discuss the care and services Resident #365 was getting. Family Member A stated, No .there wasn't any care plan meeting .the only person I talked to was the Social Worker . During an interview on 3/26/2024 at 3:09 PM, the Social Service/Admissions was asked if she could provide documentation where Resident #365's care plan meeting was held on 1/18/2023 and 4/11/2023. The Social Service/Admissions confirmed she was unable to provide documentation the care plan meetings were held. During an interview on 3/26/2024 at 3:11 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked how often the care plan meetings were held. The DON stated, .quarterly . The DON was asked to describe the process for scheduling the care plan meetings. The DON stated, .they are held quarterly .we notify the family .Social Worker sends out an invite or invite by phone or mail . The DON was asked should Resident #365's Responsible Party have been invited to the Care Plan meeting scheduled in January and April of 2023. The DON stated, Yes. The facility was unable to provide documentation of the IDT Care Plan meetings. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Schizoaffective Disorder, Dementia, Depression, and Seizures. Review of the facility's MORSE FALL SCALE, dated 8/16/2022, revealed Resident #42 was a high risk for falls. Review of the care plan dated 8/22/2022, revealed there was no documentation of interventions to prevent falls for Resident #42, who was identified as high risk for falls. Review of the annual MDS dated [DATE], for Resident #42 revealed a BIMS score of 9 which indicated Resident #42 was moderately cognitively impaired, required extensive assist for most ADLs and required assistance of a walker for ambulation. There was no documentation the care plan had been revised to include fall interventions following Resident #42's fall on 10/14/2023. During an interview on 3/25/2024 at 3:17 PM, the DON confirmed there were no revisions to the care plan to prevent further falls for Resident #42.

Based on policy review, medical record review, observation, and interview, the facility failed to provide podiatry care and services for 1 of 1 (Resident #46) sampled residents reviewed for podiatry services. The findings include: 1. Review of the facility's undated policy titled, Activities of Daily Living (ADLs), revealed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses of Neuropathy, Bipolar, Osteoarthritis, Psoriasis, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Review of the Care Plan dated 2/8/2024, revealed .Resident is at risk for skin breakdown . impaired bed mobility . There was no documentation interventions related to nail care was included. Review of the (Named) Podiatry Services Progress Note dated 6/28/2023, revealed .Reason for visit: Thick/Myotic [Mycotic] Nails [a fungal infection that affects toenails or fingernails] .Painful on left great toe, left 2nd toe, left 3rd toe, right great toe right 2nd toe .Thickened .Crumbly .Plan to follow up in 2-3 months for at risk nail care . Observation in the resident's room on 3/20/2024 at 1:21 PM, revealed Resident #46's toenails were brown, thick, and long. Observation in the resident's room on 3/21/2024 at 4:03 PM, revealed Resident #46's toenails were extremely long, thick, and brown and it appeared as though one may have fallen off. During an interview on 3/20/2024 at 3:14 PM, the Social Service/Admissions was asked when the last podiatry appointment was for Resident #46. The Social Service/Admissions confirmed it was in January. The Social Service/Admissions was asked to provide a copy of the visit note from podiatry. The Social Service/Admissions was unable to provide a visit note for January. During an interview on 3/21/2024 at 9:42 AM, the Social Service/Admissions stated that (Named Podiatry Service) was unable to come in January due to the Business Office Manager (BOM) was unable to get the resident list to them in time. The Social Service/Admissions stated, .it will probably be May when podiatry comes back to the facility . The Social Service/Admissions confirmed that it had been almost a year since podiatry had been to the facility.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain adequate nutritional status via enteral feeding (nutrition provided via use of a gastric feeding tube) for 1 of 3 (Resident #11) sampled residents reviewed for enteral feeding. The findings include: 1. Review of the facility's undated policy titled, Care and Treatment of Feeding Tubes, revealed .It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complication to the extent possible .Feeding tubes will be utilized according to physician orders, which typically include .the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush .The resident's plan of care will address the use of feeding tube, including strategies to prevent complications .The facility will utilize the Registered Dietician [RD] in estimating and calculating a resident's daily nutritional and hydration needs . Review of the facility's undated policy titled, Weight System, revealed .Residents are weighed at admission, readmission, and per physician orders. Weekly weights are completed for an additional 3 weeks (or longer) if not stable on the following .Admit .Readmit .Significant weight change of 5% [percent] or more in 1 month or less, 7.5% in 3 months or 10% in 6 months .Physician's orders .Residents are to be weighed on admission and re-admission. These weights are to be completed within 24 hours of admission/readmission .Weight .is to be recorded in the EMR [electronic medical record] clinical record .Residents with a significant weight loss or gain .will be placed on weekly weights x [times] 4 week's or until weight is stable and no weight concerns are noted .If weight concerns are noted, weights are not stable, notify your RD and continue the weekly weights until stable .A designated person(s) will be assigned to obtain weights for accuracy and consistency . Review of the facility's policy titled, Dietary .Consultant Dietitian Services, dated 11/22/2017, revealed .The Consultant Dietitian prepares a list of clinical recommendations at each visit and discusses these with the Dietary Manager [DM] and Director of Nursing [DON] . Review of the facility's policy titled, NUTRITION MANAGEMENT, dated 10/18/2022, revealed .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition .Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy . 2. Review of medical record revealed Resident #11 was admitted on [DATE], with a readmission on 12/14/2023, with diagnoses of Acute Respiratory Failure, Dysphagia, Schizophrenia, Major Depression, and Gastroesophageal Reflux Disease. Review of the Progress Note, dated 1/23/2024, revealed .resident is noted in her wheelchair pupils sluggish not responding to stimuli unable to safely administer medications .new order to send resident to the ER [emergency room ] for treatment . Review of Named Hospital Records revealed Resident #11 was admitted to the hospital on 1/23/2024 with a discharge date of [DATE]. The Hospital record revealed .This is a 55 yo [year old] F [female] .who was admitted with acute encephalopathy .ESBL [extended spectrum beta-lactamases] [a type of enzyme or chemical produced by some bacteria] .She has been requiring tube feeds with possible indication for PEG tube .Back to her nursing facility once cleared . Review of the Hospital Discharge Physician's Orders dated 2/2/2024 (dated the day before hospital discharge), revealed .NOTHING BY MOUTH diet Nothing by mouth texture, Nothing by mouth consistency . Review of the Progress Note, dated 2/3/2024, revealed .Health Status Note .Resident returned via [by] stretcher x[times] 2 EMS [emergency medical service] transport . Review of Physician's Orders dated 2/5/2024, revealed .Isosource 1.5 @ [at] 45mL/hr [milliliters/hour] with 45cc [centimeter] Q [every] 4 hours H2O [water] flush per Kangaroo pump continuously . The facility failed to complete a readmission weight for Resident #11's readmission on 2/3/2024, within 24 hours of return to the facility. Record review revealed Resident #11's weight on 2/9/2024 was 104 pounds, 6 days after readmission from the hospital. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #11 was unable to complete the Brief Interview for Metal Status (BIMS), which indicated she was severely cognitively impaired. The facility failed to complete weekly weights for Resident #11 for the week of 2/11/2024 through 2/17/2024 and the week of 2/25/2024 through 3/2/2024. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #11 was unable to complete the Brief Interview for Metal Status (BIMS), which indicated she was severely cognitively impaired. Review of the Progress Note dated 3/13/2024, revealed .Nutrition/Dietary Note .Enteral feeding Isosource [high-protein, low fiber, whole protein formula] 1.5 [whole-protein formula with 18 % [percent] of calories from protein] .Has had wt [weight] loss. Significant x 90, 7.3% x 180 .Will recommend increasing rate of feeding to 50ml/hr continuous with 50ml flush every 4 hours for additional calories and protein . Review of the email dated 3/13/2024, revealed a communication between the Registered Dietitian (RD) and the Assistant Director of Nursing (ADON) .[Named Resident #11] .Will recommend increasing rate of feeding to 50ml/hr [milliliter/hour] continuous with 50ml flush every 4 hours for additional calories and protein . Review of the Physician's Orders dated 3/21/2024, revealed .Isosource [high-protein, low fiber, whole protein formula] 1.5 @ [at] 50mL/hr [millimeter/hour] with 60cc [cubic centimeter] Q [every] 4 hours H2O [water] flush per . The facility failed to address the 3/13/2024 RD recommendation to increase the enteral feeding for Resident #11 until 3/21/2024, 8 days later. Observation in the resident's room on 3/18/2024 at 10:12 AM, 3/18/2024 at 3:33 PM, 3/19/2024 at 8:09 AM, 3/19/2024 at 2:46 PM, 3/20/2024 at 8:43 AM, and on 3/20/2024 at 2:55 PM, revealed Resident #11's Isosource 1.5 infusing by pump at 45 ml/hr. The facility failed to act upon the RD recommendations of Isosource 50 ml/hr. Observation and interview in the resident's room on 3/22/2024 at 8:56 AM, with Certified Nursing Assistant (CNA) C and CNA K, revealed Resident #11 was fully dressed in a sweater, jogging pants, brief, socks, and an abdominal binder. Resident #11 weighed 105.7 pounds. CNA C and CNA K were asked if they felt Resident #11 looked thin. CNA C stated, Yes. Observation and interview in the resident's room on 3/25/2024 at 11:16 PM, with CNA C and RN (Registered Nurse) N, after being checked and changed, Resident #11 was dressed in a light weight gown and brief. Resident #11's weight was 104 pounds. During the observations of staff weighing resident #11 on 3/22/2024 and 3/25/2024 revealed the facility failed to consistently weigh Resident #11 with the same clothing. During a telephone interview on 3/21/2024 at 2:52 PM, the RD was asked about Resident #11's nutritional status. The RD stated, .she just came back with a peg tube [allows nutrition, fluids, and medication to be delivered directly into the stomach] on 2/2/2024 .on 3/13/2024, I increased the feeding to 50 cc/hour continuously. The RD was asked to tell about the process of making recommendations for changes. The RD stated, .I send the recommendation to the .[Named ADON] the orders .she would put it in place . The RD was asked should the recommendation have been started. The RD stated, .Yes .it should have been started .I increased the rate to 50 cc/hr [centimeter/hour] she had a weight lost [prior to the hospitalization on [DATE]] .I looked at that and for additional proteins and calories .her ideal body weight is 120 pounds .I used her adjusted body weight to increase her calories to get her close where she needs to be . The RD confirmed that Resident #11 had a significant weight lost in January 2024 of a 7.9 % in 3 months. During an interview on 3/21/1024 at 3:27 PM, the ADON was asked to tell about the process for when a recommendation is received from the RD. The ADON stated, .once she [RD] sends the email, I call the doctor and tell him the recommendation . The ADON confirmed that the RD sent an email on 3/13/2024 for the increase in Resident #11's enteral feeding. During an interview on 3/22/2024 at 9:00 AM, the ADON was asked if the facility had a weight log that shows what the residents are weighed in (clothing) for consistent weights obtained. The ADON stated, .No .I don't have a log . The ADON was asked about the process for the resident's weights. The ADON stated, .at the first of the month I give [Named CNA C] a printed log with resident names and there is a spot to write in the resident weights .when she get all the weights she brings it back and I go over the weights and look at the weights .if it is 4 pounds greater or less from the previous weights .I send [Named RD] an email with the differences .then she will send recommendations .I log the weights in [Named EMR] .the new admissions are weighed on arrival .then weekly times 4 weeks .when the resident leaves and goes to the hospital .they come back and are weighed [weekly] times 4 as well .the residents should be checked and changed and weighed in their gown and brief only . The ADON confirmed that Resident #11 should have been weighed within 24 hours of admission and readmission and weekly if triggered for a significant weight loss. During an interview on 3/25/2024 at 10:50 AM, CNA C was asked who helps weigh the residents. CNA C stated, .I grab who is on the hallway with the lift .or the aides who are assigned to the resident . CNA C was asked how she knows what clothes Resident #11 should have on when she weighs her. CNA C stated, .She has a variety of clothes .she has long sleeve .shirt and sweat pants . CNA C was asked if she ever weighed Resident #11 in her gown and brief before and if so how often. CNA C stated, Yes .it depends on what time a day it is . CNA C was asked if she had a log to document what the residents are weighed in. CNA C stated, No ma'am . CNA C was asked who monitors the weights to make sure they are accurate. CNA C stated, .I just give them [to Named ADON] .the weights .they [ADON] let me know who gets the weight and how often CNA C was asked when a resident goes out to the hospital how often they are weighed on readmission. CNA C stated, .Once a week. CNA C was asked why Resident #11 did not get weekly weights on readmission in February 2024 and in March 2024, and if she (CNA C) was out during the readmission. CNA C stated, .No .they just give me a list of residents who need to be weighed . CNA C was asked if she was aware Resident #11 was on weekly weights. CNA C stated, No. During an interview on 3/26/2024 at 8:49 AM, CNA K was asked if she completed the resident's weights when CNA C is off. CNA K stated, Yes .I get someone off the floor to help me . CNA K was asked how she is made aware of what clothing the resident had on when CNA C weighed the residents. CNA K stated, I don't know .I have no idea . CNA K was asked when she weighs Resident #11 what she normally weighs her in. CNA K stated, .In a gown and make sure she is dry [clean brief] .

Based on policy review, video footage review, facility investigation review, medical record review, observation, and interview, the facility failed to provide a safe environment and ensure supervision to prevent neglect for 1 of 3 residents (Resident #1) reviewed for elopement risk. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy when Resident #1, a moderately impaired, vulnerable resident was left unsupervised beside an exit door and exited the facility in his wheelchair without staff knowledge or supervision after a staff member entered the facility through the Main Entrance Sliding Door. The facility was unaware of the resident's location for approximately 10 minutes. Resident #1 was located on the front sidewalk adjacent to a city street approximately 176 feet from the building, where he had propelled himself in his wheelchair. Immediate Jeopardy (IJ) is 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 Administrator, Chief Operating Officer, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Clinical Services #1, and Regional Director of Clinical Services #2 were notified of the Immediate Jeopardy (IJ) on 6/15/2022 at 11:20 AM, in the Break Room. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 2/26/2022 through 3/1/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 6/14/2022 and 6/15/2022. The facility was cited as past noncompliance and is not required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect .Neglect .means failure of the facility, its [it's] employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written .Employee Training .Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as .Wandering or elopement-type behaviors .identification, ongoing assessment .and monitoring of residents with needs and behaviors which might lead to .neglect . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement and unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised 12/28/2021, revealed .The resident is an elopement risk/wanderer . Review of a Mental Health and Wellness Progress Note dated 12/30/2021, revealed Resident #1 had short-term memory impairment, illogical thought processes, and impaired judgement. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #1 was moderately cognitively impaired for daily decision-making skills, displayed wandering behaviors on 1-3 days of the 7-day lookback period, and required staff supervision for mobility. Review of the facility's investigation dated 2/26/2022, revealed .February 26th [2022] at 12:45pm [PM] a dietary worker [Dietary Staff Member #1] entered the building with the facility code. The dietary worker didn't pay attention to the resident beside him when he entered the building. [Resident #1] exited through the front door as the dietary worker walked into the building. Resident was in his wheelchair and rolled to the right side of the building and onto the front sidewalk. Dietary Staff [Dietary Staff Member #2] coming to work brought [the] resident back into the facility. Resident returned to inside of the building at 12:54 PM .Resident was wearing a long sleeve shirt, jeans, long socks, and tennis shoes . Review of a Punch Report dated 2/26/2022, revealed Dietary Staff Member #2 clocked in at 12:57 PM. Review of the facility's video footage dated 2/26/2022, revealed Dietary Staff Member #1 entered the facility at 12:45 (10 seconds) PM and walked right by Resident #1 as he self-propelled toward the Main Entrance Sliding Door. At 12:45 (14 seconds) PM, Dietary Staff Member #1 turned the corner to the 300 hallway and was unable to see Resident #1, as he continued toward the exit door. Resident #1 began to self-propel his wheelchair out of the facility at 12:45 (22 seconds) PM, was completely outside of the facility at 12:45 (42 seconds) PM, and the door was completely closed at 12:45 (52 seconds) PM. At 12:45 (59 seconds) PM, Resident #1 was completely out of sight of the video camera footage inside the facility. During a telephone interview on 6/13/2022 at 12:18 PM, Dietary Staff Member #1 stated that he did not see Resident #1 propel himself beside him toward the exit door when he came to work on 2/26/2022, and that he did not see Resident #1 leave the facility. Dietary Staff Member #1 denied the facility had educated him on ensuring the doors closed and the lock engaged prior to entering and exiting the facility on hire. Review of Dietary Staff Member #1's personnel file revealed his date of hire was 1/25/2021, and that he had signed his acknowledgement of the Abuse, Neglect, and Exploitation policy. During an observation and interview on 6/13/2022 at 12:57 PM, Dietary Staff Member #2 confirmed she was riding with Dietary Staff Member #3 when she arrived at the facility on 2/26/2022 for her 1:00 PM shift. Dietary Staff Member #2 confirmed that Resident #1 was on the sidewalk in front of the facility and no staff were present with him. Dietary Staff Member #2 and #3 went to the front sidewalk with the surveyor and showed the surveyor where they had first observed Resident #1 when they arrived at work. The area demonstrated was on the sidewalk, adjacent to a city street, and beside the facility exit sign. During an interview on 6/13/2022 at 1:48 PM, the Administrator confirmed he had watched the video camera footage and saw Dietary Staff Member #1 punch in the code and enter the facility at 12:45 PM on 2/26/2022. The Administrator stated, .It [video camera footage] showed [Dietary Staff Member #1] come in the door not looking left or right .walked straight in .[Resident #1] went by him and went straight out the door .saw [Resident #1] come out into the parking lot .he headed up towards the top of the parking lot and by then I saw [Dietary Staff Member #2 and #3] coming to work .guess they spotted [Resident #1] .looks like one of them called somebody .one of them stayed with [Resident #1] . The Administrator confirmed Resident #1 was back in the facility at 12:54 PM and that Dietary Staff Member #1 had been disciplined following the incident. Observation on 6/13/2022 at 2:55 PM, revealed Resident #1 seated in his wheelchair in front of the men's restroom and asking other residents for help. No staff were present at the time. During an interview on 6/14/2022 at 9:39 AM, Floor Technician (Tech) #2 confirmed that prior to Resident #1's incident of elopement on 2/26/2022, staff were educated to ensure the Main Entrance Sliding Door closed and the lock engaged when they entered or exited the facility. Floor Tech #2 stated, .Watch the residents when you're on the way in or out .look at the door until it closes completely .make sure no residents get out . Floor Tech #2 was asked what staff should do when a resident was near the exit door. Floor Tech #2 stated, Move them away. During a telephone interview on 6/14/2022 at 11:32 AM, Registered Nurse (RN) #1 confirmed she was Resident #1's nurse on 2/26/2022. RN #1 confirmed that Resident #1 was cognitively impaired. RN #1 stated, No, he's not .kind of confused .keeps repeating himself . RN #1 confirmed that prior to the elopement incident the facility had educated staff to make sure the exit door locked before they left the area. RN #1 stated, .there's a lot of wanderers there [in the facility] .Yes ma'am .[Resident #1 wanders] all over the facility . During an interview on 6/14/2022 at 12:00 PM, the DON confirmed that on 2/26/2022 Resident #1 had eloped from the facility, Dietary Staff #2 and #3 had found him outside, and Floor Tech #1 returned him to the facility. The DON confirmed that as part of the orientation process on hire, all staff were educated to watch the doors and ensure that a resident did not get out of the facility when they entered or exited, and that the door codes should not be given out. Observation on 6/14/2022 at 3:50 PM, revealed Resident #1 self-propelled his wheelchair in the facility hallway, using only his right hand and foot. During an interview on 6/14/2022 at 4:40 PM, Certified Nursing Assistant (CNA) #4 confirmed that Resident #1 required limited staff assistance back and forth to the smoke break, to his room when he asked where it was located, that he self-propelled in his wheelchair, and wandered all over the facility. CNA #4 confirmed that Resident #1 was a wanderer and an elopement risk. During an interview on 6/14/2022 at 5:07 PM, Dietary Staff Member #2 stated, I forgot about [Floor Tech #1] .he no longer works here .After we [Dietary Staff Member #2 and #3] saw him, she [Dietary Staff Member #3] let me out [of the car] and I wheeled him to the door .[Floor Tech #1] was by the Dining Room mopping and he took over and took him to his room while I clocked in and [Dietary Staff Member #3] went to the Nurses' Station and told them . During an interview on 6/15/2022 at 10:41 AM, the Administrator confirmed that when Resident #1 exited the facility, he propelled himself to the right of the facility, up to the sidewalk, and then up the sidewalk toward the facility exit sign. During an observation and interview on 6/15/2022 at 10:45 AM, the Maintenance Director confirmed the distance Resident #1 propelled himself from the Main Entrance Sliding Door to where he was found in his wheelchair on the sidewalk, was approximately 176 feet, and the distance from the sidewalk to the adjacent city street was approximately 2.5 feet. The facility's corrective action plan included the following: 1. On 2/26/2022, an investigation of the incident was initiated. The surveyor reviewed the facility's investigation, interviewed the Administrator, the DON, and facility staff. 2. On 2/26/2022, Resident #1's elopement risk status and Care Plan were updated to reflect his elopement risk status and a clinical audit was conducted to ensure all residents at risk or high risk of elopement had the risk reflected in their plan of care. The surveyor reviewed the elopement risk assessments, Care Plans, and interviewed the DON and ADON. 3. All facility exit doors were checked for proper functioning on 2/26/2022 and no abnormalities were identified. The surveyor interviewed the DON and Maintenance Director. 4. On 2/26/2022, in-servicing of all staff on elopement and abuse policies were initiated and completed on 3/2/2022. All facility and agency staff were in-serviced to ensure the Main Entrance Sliding Door engages prior to walking away. Elopement post-tests were administered to assess understanding of the education. The surveyor interviewed facility staff on all shifts, reviewed the Elopement post-tests, and reviewed the in-service sign-in logs. 5. Ad Hoc (impromptu) Quality Assurance and Performance Improvement (QAPI) meetings were held on 2/26/2022 and 2/28/2022. The surveyor interviewed facility staff and reviewed the QAPI sign-in logs. 6. A QAPI committee meeting was held on 3/8/2022, the elopement procedure and door audits were reviewed, and the findings will be reported to the QAPI committee going forward. The surveyor interviewed the QAPI committee and reviewed the sign-in log. 7. On 2/26/2022 a 3-foot sign was placed inside of the Main Entrance Sliding Door to alert facility staff and visitors to stop upon entry or exit and ensure the door lock engages prior to walking away. The surveyor observed the 3-foot sign upon entry into the facility and interviewed facility staff. 8. On 2/28/2022, the facility moved the Advanced Entry Machine (sign-in kiosk) closer to the Main Entrance Sliding Door. The surveyor observed the machine beside the Main Entrance Sliding Door and interviewed facility staff on all shifts. 9. On 2/28/2022, a clinical review of Resident #1 was conducted by the Nurse Practitioner. The surveyor reviewed the Nurse Practitioner's documentation of the assessment. 10. On 2/27/2022, daily door audits were initiated to ensure staff watched for the Main Entrance Sliding Door engagement prior to walking away. These audits were conducted daily Monday through Friday by the Administrator, and on the weekends by the Charge Nurses until 3/31/2022. The audits will continue every Monday through Friday for the next 4 months. The surveyor interviewed the Administrator, Charge Nurses, and reviewed the Audit Tools. 11. The facility placed a sign on the inside and outside of the Main Entrance Sliding Glass Doors on 2/27/2022, alerting families and visitors to ask staff before assisting anyone out of the facility. The signs were observed by the surveyor and a visitor was interviewed by telephone. 12. The facility sent a message to all family members on 2/27/2022 asking them to please take the time to visibly ensure the Main Entrance Sliding Door engaged prior to turning away from the door, when entering or exiting the facility. The surveyor interviewed the Administrator, DON, and reviewed resident charts for documentation of the message. 13. The facility held elopement drills on 2/28/2022, 3/15/2022, 4/25/2022, 4/30/2022, 5/2/2022, and 5/24/2022. The surveyor interviewed the Administrator, the Maintenance Director, facility staff on all shifts, and reviewed the sign-in logs.

Based on policy review, weather website review, camera footage review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for a vulnerable, cognitively impaired resident with wandering behaviors for 1 of 3 sampled residents (Resident #1) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility in his wheelchair without staff knowledge or supervision after a staff member entered the facility through the Main Entrance Sliding Door. Resident #1 was found on a sidewalk adjacent to a city street, approximately 10 minutes after exiting the facility. Immediate Jeopardy (IJ) is 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 Administrator, Chief Operating Officer, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Clinical Services #1, and Regional Director of Clinical Services #2 were notified of the Immediate Jeopardy (IJ) on 6/15/2022 at 11:20 AM, in the Break Room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 2/26/2022 through 3/1/2022. The Immediate Jeopardy was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated onsite by the surveyor on 6/14/2022 and 6/15/2022. The facility was cited as past noncompliance and is not required to submit a Plan of Correction. The findings include: Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered care plan addressing the unique factors contributing to wandering or elopement risk .Elopement .occurs when a resident leaves the premises or a safe area without authorization .and/or necessary supervision to do so .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement and unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks .Supervision will be provided to help prevent accidents or elopement . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)] following [CONDITION(S)], [CONDITION(S)], Diabetes, [CONDITION(S)] Disorder, Major Depressive Disorder, [CONDITION(S)] Disorder with Psychotic Features, Pseudobulbar Effect, Traumatic Subdural Hemorrhage, Anxiety Disorder, Dementia with Behavioral Disturbance, and Psychotic Disorder with Delusions. Review of the Wandering/Elopement User Defined Assessment (UDA) revealed the following: a. Assessment dates 2/16/2021 and 5/8/2021, revealed Resident #1 had a history of wandering and had wandered within the facility but had not left the grounds. b. Assessments dated 8/13/2021, revealed .Has no history of wandering .Has wandered within the home without leaving the grounds . c. assessment dated [DATE], revealed Resident #1 had a history of wandering. d. assessment dated [DATE], revealed .Has no history of wandering .has not wandered . Review of the Care Plan revised on 12/28/2021, revealed Resident #1 was at risk for elopement, had cognitive loss, and poor memory. The interventions to address this concern were to use distraction and identify the pattern of wandering. Review of a Mental Health and Wellness Progress Note dated 12/30/2021, revealed .He [Resident #1] has significant impairment in short term memory .unable to be redirected at times .Behavior: disorganized, evasive .Thought Process: illogical .Thought Content: delusions .Judgement/Insight: Impaired .Intellectual functioning observed to be below average . Review of a Nurse Practitioner Progress Note dated 2/2/2022, revealed Resident #1 displayed emotional lability, high irritability, functional impairment, and poor concentration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #1 had moderate cognitive impairment for daily decision making and displayed wandering behaviors on 1-3 days of the 7-day lookback period. Resident #1 required supervision of one staff member for mobility in the facility. Review of the facility's investigation dated 2/26/2022, revealed that on 2/26/2022 at approximately 12:45 PM, Dietary Staff Member #1 entered the facility to begin his shift and did not pay attention to Resident #1 who passed beside him and exited the facility door prior to the door closing and the lock engaging. Resident #1 self-propelled to the right side of the facility and then on to the sidewalk, in front of the facility. Dietary Staff Member #2 and #3 observed Resident #1 on the sidewalk when they arrived at work approximately 10 minutes later. Dietary Staff Member #2 brought the resident back into the facility at approximately 12:54 PM. Resident #1 wore a long-sleeved shirt, jeans, long socks, and tennis shoes. Review of an undated typed statement revealed that the Administrator spoke with a visitor who had entered the facility on 2/26/2022 at 12:51 PM, to visit another resident. The Visitor confirmed he observed Resident #1 outside the facility on 2/26/2022. Review of the timeanddate.com website revealed a high temperature of 37 degrees Fahrenheit and a low temperature of 36 degrees Fahrenheit on 2/26/2022. Review of the facility's video footage with timestamps revealed the following on 2/26/2022: a. At 12:45 (0 seconds) PM, Resident #1 self-propelled in his wheelchair to the Lobby area in front of the Main Entrance Sliding Door. b. At 12:45 (9 seconds) PM, Dietary Staff Member #1 entered the door code outside of the facility. c. At 12:45 (10 seconds) PM, Dietary Staff Member #1 entered the facility through the Main Entrance Sliding Door as Resident #1 wheeled himself toward the door, using his right hand and foot. d. At 12:45 (12 seconds) PM, Dietary Staff Member #1 and Resident #1 passed each other in the Lobby area. e. At 12:45 (14 seconds) PM, Dietary Staff Member #1 rounded the corner and could no longer see the Main Entrance Sliding Door. Resident #1 continued toward the exit door in his wheelchair. f. At 12:45 (15 seconds) PM, the Main Entrance Sliding Door began to close as Resident #1 neared the door. g. At 12:45 (18 seconds) PM, the Main Entrance Sliding Door stopped and began to retract. h. At 12:45 (22 seconds) PM, Resident #1 began to self-propel his wheelchair out of the facility through the Main Entrance Sliding Door, using his right hand and foot. i. At 12:45 (26 seconds) PM, Resident #1's wheelchair appeared to hang on the door threshold, and he used both hands to continue his movement from the facility over the threshold. j. At 12:45 (36 seconds) PM, the Main Entrance Sliding Door began to close and hit the back portion of Resident #1's wheelchair, then the door retracted. k. At 12:45 (42 seconds) PM, Resident #1 had completely exited the door and propelled his wheelchair onto the facility's covered drive-through. l. At 12:45 (52 seconds) PM, the Main Entrance Sliding Door closed completely, and Resident #1 propelled himself further onto the facility's covered drive-through. m. At 12:45 (56 seconds) PM, Resident #1 turned his wheelchair to the right side of the covered drive-through and continued to propel himself forward. n. At 12:45 (59 seconds) PM, Resident #1 completely disappeared from the facility's video camera footage line of sight. During a telephone interview on 6/13/2022 at 10:53 AM, the Visitor who observed Resident #1 outside the facility confirmed he saw Resident #1 sitting in his wheelchair to the right of the facility under the facility's covered drive-through. The Visitor stated, .I know it was cold that day .I was there to see a patient .where he was at if you just come and open the door you probably wouldn't have saw [seen] him [Resident #1], he was kind of at the side of the building .just assumed he was supposed to be out there . The Visitor confirmed facility staff opened the door for him to enter, but no one went outside the facility at that time. During an interview on 6/13/2022 at 11:48 AM, Certified Nursing Assistant, (CNA #1) confirmed that the last time she had seen Resident #1 on the day he eloped from the facility was after breakfast when he asked her where his room was located. CNA #1 stated that she told him where his room was located, and he went to his room. CNA #1 stated, .seems like it [Resident #1's cognitive status] comes and goes .have to repeat over and over with him . During a telephone interview on 6/13/2022 at 12:18 PM, Dietary Staff Member #1 confirmed that when he arrived at work on 2/26/2022, he entered the door code and then entered the facility through the Main Entrance Sliding Door. Dietary Staff Member #1 denied he saw Resident #1 propel himself toward the door and exit the facility. Dietary Staff Member #1 confirmed there were no other staff members present at that time. Dietary Staff Member #1 denied that on hire the facility had educated him on ensuring the doors closed and the lock engaged prior to entering and exiting the facility. Review of Dietary Staff Member #1's personnel file with a hire date of 1/25/2022, revealed he was in-serviced regarding the Abuse, Neglect, and Exploitation Policy which documented, .Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as .Wandering or elopement-type behaviors . Dietary Staff Member #1 signed his acknowledgement of the policy. Observation in the hallway on 6/13/2022 at 12:29 PM, revealed Resident #1 self-propelled himself up to the exit door that led to the smoking area, using his right hand and foot During an interview on 6/13/2022 at 12:57 PM, Dietary Staff Member #2 and #3 confirmed they saw Resident #1 sitting in his wheelchair on the sidewalk in front of the facility when they arrived at work on 2/26/2022. Dietary Staff Member #2 stated, .he was alone .on the sidewalk in front of the building . Dietary Staff Member #2 confirmed that she assisted Resident #1 back into the facility, turned him over to a Floor Tech so she could clock in, and that she clocked in at 12:57 PM. Dietary Staff Member #2 and #3 confirmed they first observed Resident #1 slowly wheeling his wheelchair on the sidewalk beside the facility exit sign. During an interview on 6/13/2022 at 1:24 PM, CNA #2 confirmed that Resident #1 had a history of exhibiting wandering behaviors. CNA #2 stated, He does the bit where he asks you when is the bus coming to get him and how he's getting home . CNA #2 confirmed that prior to Resident #1's incident of elopement the facility had educated staff to be sure the Main Entrance Sliding Door closed, and the lock engaged before they left the area when they entered or exited the facility. During an interview on 6/14/2022 at 8:36 AM, the Housekeeper confirmed she observed Dietary Staff Member #2 bringing Resident #1 into the facility when she went to empty the trash on 2/26/2022 but could not recall the time. The Housekeeper stated, .They were almost back under the awning [Facility's covered drive-through] . The Housekeeper confirmed that all staff were educated that the Main Entrance Sliding Door lock does not engage until it clicks, and staff were to remain at the door until the lock engaged prior to the elopement. Observation on the 300 Hall on 6/14/2022 at 9:05 AM, revealed Resident #1 in his wheelchair and repetitively asking staff when it was time to eat. Resident #1 had finished 100% of his breakfast prior to this observation. During an interview on 6/14/2022 at 9:16 AM, CNA #3 was asked to describe the training staff was provided on elopement prior to Resident #1's elopement incident. CNA #3 stated, .We had in-services and drills .and it's on the chart [elopement list] to watch certain ones .told everybody [all staff] .you're supposed to stand there and monitor that door until it locks . CNA #3 confirmed that Resident #1 was on the elopement/wandering list. During an interview on 6/14/2022 at 12:00 PM, the DON confirmed that all staff were educated during orientation to watch the Main Entrance Sliding Door until the lock engaged upon entrance to/exit from the facility. The DON stated, .On hire we go over that .watching the door .[to ensure] residents don't get out .we go over that with new employees. The DON was shown the Abuse, Neglect, and Exploitation Policy and pointed out the education that was provided during new employee orientation. The DON confirmed that it was each staff member's responsibility to ensure residents did not exit the facility when they opened the door. During an interview on 6/14/2022 at 1:10 PM, the Administrator confirmed that prior to Resident #1's incident of elopement, all staff were educated to monitor the Main Entrance Sliding Door when they entered or exited the facility, until the lock engaged, to ensure residents did not get out of the facility. During an interview on 6/14/2022 at 1:45 PM, the ADON confirmed she completed the Wandering/Elopement UDA dated 2/13/2022. The ADON was asked why she documented Resident #1 did not have a history of wandering. The ADON stated, .the only wandering I know of was him [Resident #1] wandering in here [the facility] . The ADON confirmed that she interpreted that question to mean the resident had actually eloped from a previous hospitalization or from the family or home (on the Wandering/Elopement UDA form in parenthesis behind wandering history states from family history or previous hospitalization ). During an interview on 6/14/2022 at 2:35 PM, the Regional Director of Clinical Services confirmed that if a resident truly had a history of wandering the Wandering/Elopement UDA should always reflect that history. During an interview on 6/14/2022 at 5:07 PM, Dietary Staff Member #2 stated, I forgot about [Floor Tech #1] .he no longer works here .After we [Dietary Staff Member #2 and #3] saw him, she [Dietary Staff Member #3] let me out [of the car] and I wheeled him to the door .[Floor Tech #1] was by the Dining Room mopping and he took over and took him to his room while I clocked in and [Dietary Staff Member #3] went to the Nurses' Station and told them . During an interview on 6/14/2022 at 5:36 PM, Licensed Practical Nurse (LPN #1) confirmed that Resident #1 was considered a wanderer and at risk for elopement. LPN #1 stated, .[Resident #1] wanders hall to hall nonstop .[asking] where's my room, where do I go .I've been here 6 years that's what he does . Observation and interview on 6/15/2022 beginning at 10:45 AM, the Maintenance Director confirmed the distance from the Main Entrance Sliding Door to the sidewalk beside the Exit Sign where Resident #1 was found was approximately 176 feet and the distance from the sidewalk to the adjacent city street was approximately 2.5 feet. The facility's corrective action plan included the following: 1. On 2/26/2022, an investigation of the incident was initiated. The surveyor reviewed the facility's investigation, interviewed the Administrator, the DON, and facility staff. 2. On 2/26/2022, Resident #1's elopement risk status and Care Plan were updated to reflect his elopement risk status and a clinical audit was conducted to ensure all residents at risk or high risk of elopement had the risk reflected in their plan of care. The surveyor reviewed the elopement assessment and Care Plan and interviewed the DON and ADON. 3. All facility exit doors were checked for proper functioning on 2/26/2022 and no abnormalities were identified. The surveyor interviewed the DON and Maintenance Director. 4. On 2/26/2022, in-servicing of all staff on elopement and abuse policies was begun and completed on 3/2/2022. All facility and agency staff were in-serviced to ensure the Main Entrance Sliding Door engages prior to walking away. Elopement post tests were administered to assess understanding of the education. The surveyor interviewed facility staff on all shifts, reviewed the Elopement post-tests, and reviewed the in-service sign-in logs. 5. Ad Hoc (impromptu) Quality Assurance and Performance Improvement (QAPI) meetings were held on 2/26/2022 and 2/28/2022. The surveyor interviewed facility staff and reviewed the QAPI sign-in logs. 6. A QAPI committee meeting was held on 3/8/2022, the elopement procedure and door audits were reviewed, and the findings will be reported to the QAPI committee going forward. The surveyor interviewed the QAPI committee and reviewed the sign-in log. 7. On 2/26/2022, a 3-foot sign was placed inside the Main Entrance Sliding Door to alert facility staff and visitors to stop upon entry or exit and ensure the door lock engages prior to walking away. The surveyor observed the 3-foot sign upon entry into the facility and interviewed facility staff. 8. On 2/28/2022, the facility moved the Advanced Entry Machine (sign-in kiosk) closer to the Main Entrance Sliding Door. The surveyor observed the machine beside the Main Entrance Sliding Door and interviewed facility staff on all shifts. 9. On 2/28/2022, a clinical review of Resident #1 was conducted by the Nurse Practitioner. The surveyor reviewed the Nurse Practitioner's documentation of the assessment. 10. On 2/27/2022, daily door audits were initiated to ensure staff watched for the Main Entrance Sliding Door engagement prior to walking away. Theses audits were conducted daily Monday through Friday by the Administrator, and on the weekends by the Charge Nurses until 3/31/2022. The audits will continue every Monday through Friday for the next 4 months. The surveyor interviewed the Administrator, Charge Nurses, and reviewed the Audit Tools. 11. The facility placed a sign on the inside and outside of the Main Entrance Sliding Glass Doors on 2/27/2022, alerting families and visitors to ask staff before assisting anyone out of the facility. The signs were observed by the surveyor and a visitor was interviewed by telephone. 12. The facility sent a message to all family members on 2/27/2022, asking them to please take the time to visibly ensure the Main Entrance Sliding Door engaged prior to turning away from the door, when entering or exiting the building. The surveyor interviewed the Administrator, DON, and reviewed resident charts for documentation of the message. 13. The facility held elopement drills on 2/28/2022, 3/15/2022, 4/25/2022, 4/30/2022, 5/2/2022, and 5/24/2022. The surveyor interviewed the Administrator, the Maintenance Director, facility staff on all shifts, and reviewed the sign-in logs.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to provide necessary care and services by not following physician's orders [REDACTED]. The failure to administer pain medication as ordered resulted in actual harm to Resident #45 when the resident experienced increased agitation. The findings included: Review of the facility's medication administration general guidelines policy documented, " ...If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time... the space provided on the front of the MAR (medication administration record) for that dosage administration is initialed and circled..." Review of the facility's "Pain Management" policy documented, "...Any resident who experiences pain will be reviewed and a plan will be established to treat his or her pain... Chronic pain is pain that is persistent or recurrent... In the long-term care setting, the comfort and well-being of the individual resident should always be paramount... Medications used to treat chronic pain should be given by the clock, on a regularly scheduled basis..." Medical record review for Resident #45 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented, "...section C0500 a BIMS (Brief Interview for Mental Status) Res (resident) interview: summary score 3..." A score of 0 to (-) 7 indicates severe impairment for cognition. Review of section J0300 documented the resident has pain; section J0400 documented a "frequency 1" indicating pain is almost constant and section J0500A indicated pain makes it hard for resident to sleep and section J0600B indicated the pain is moderate. Review of a physician's orders [REDACTED]. [REDACTED]. order dated 12/24/12 documented, "[MEDICATION NAME] mg 1 PO (by mouth) BID (twice a day) @ (at) 9a (am) & (and) 9p (pm) for chronic pain..." Review of the facility's physician progress notes [REDACTED]. a. 11/20/12 - "...still having significant leg pain..." b. 12/13/12 - "leg pain/[MEDICAL CONDITIONS]... leg still hurts... [MEDICAL CONDITION] (sign for with) PAD ([MEDICAL CONDITION])..." c. 3/6/13 - "...Chronic leg pain (sign for secondary to) PAD..." Review of the January 2013 MAR indicated [REDACTED]. The back of the MAR indicated [MEDICATION NAME] 100mg 1 medication N/A (not available) due from pharmacy... 1/29/13 6 A [MEDICATION NAME] 100mg 1 medication N/A due from pharmacy..." The [MEDICATION NAME] was not given due to not being available. Review of the February 2013 MAR for 2/1/13 through (-) 2/28/13 revealed no documentation that Resident #45 had received [MEDICATION NAME] mg at 9:00 AM on 2/28/13 and there was no documentation on the back of the MAR indicated [REDACTED]. Review of the nurses notes dated 2/28/13 at 8:44 PM documented, "...resident showed some signs of agitation earlier in the shift, but was able to redirect and talk him down. But he also has not had his [MEDICATION NAME] for at least 2 days and the pharmacy did not bring it again tonight. He started showing more signs of agitation around 8 PM, so I went ahead and gave his PRN (as needed) [MEDICATION NAME] shot hoping to calm the agitation and limit the possible withdrawals. Pharmacy cannot be called right now, because they are not business hours, so they will need to be called in the morning about why he hasn't got his [MEDICATION NAME]. Will watch for signs of withdrawal or increased pain..." Review of the care plan dated 2/12/13 documented, "...Risk for anxiety, agitation, depression, [MEDICAL CONDITION], aggression R/T (related to) [MEDICAL CONDITION] with [MEDICAL CONDITION]; BLE (Bilateral Lower Extremity) PAIN for which complete relief is not achieved..." The documented interventions included "...administer pain meds as ordered..." Revisions of the care plan dated 2/25/13 documented, "...Resident has (sign for increased anxiety poss (possible) R/T pain... 2/27/13 Med (medication ) (sign for changes)... Meds as ordered..." Review of the facility's February 2013 pain assessment sheet revealed no documentation of pain assessment on the 11-7 shift or 3-11 shift on 2/28/13. Review of the facility's narcotic count sheet II documented, on lines 10 and 11 to "...REORDER NOW!!..." The facility did not reorder the medication for Resident #45 to ensure the medication was available for administration. Review of the facility's medication delivery receipt documented, 30 tablets of [MEDICATION NAME] ER were ordered on [DATE] by the facility staff and received on 3/1/13. During an interview in the conference room on 3/6/13 at 3:30 PM, Nurse #3 was asked about the documentation in the nurses notes dated 2/28/13. Nurse #3 stated, "He (Resident #45) didn't have it (MS Contin) the night of the 27th and the 28th morning. I forgot to circle it." Nurse #3 was asked if the initials on the MAR indicated Yes, it is..." Nurse #3 was asked who initialed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"(Named Nurse #1)." During an interview in the medication room on 3/6/13 at 3:45 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked if [MEDICATION NAME] is available in the lock box for after hour use. The DON and the ADON stated, "We have [MEDICATION NAME] IM (intramuscular) in the box. We have 10 milligrams and 20 milligrams, not po (by mouth) tablets only suspension in the lock box..." During an interview in the conference room on 3/6/13 the nurse consultant stated, "He (Nurse #3) made a mistake on that documentation..." During an interview in the conference room on 3/6/13 at 5:00 PM, the Nurse Consultant stated, "I am going to let you look at it (the narcotic sign out sheet) and figure it out. I can't tell anything about it. I will let you look at it and ask me questions..." The Nurse Consultant was then asked if Resident #45 received the [MEDICATION NAME] January 27th or 28th or [MEDICATION NAME] on January 28th or 29th (2013). The Nurse consultant stated, "No, he didn't get the [MEDICATION NAME] January 27th or 28th nor the [MEDICATION NAME] on January 28th or 29th..." The Nurse Consultant was then asked what it means when the initials of the nurse are circled. The Nurse Consultant stated, "When it is circled, as a nurse, I know they (resident) didn't get it..." During an interview in the conference room on 3/6/13 at 4:10 PM, the DON stated, "We have a back up pharmacy. I think it is (Named Pharmacy) we can call after hours, they will deliver it or put it in a cab and send it... he (Nurse #3) should have called the pharmacy, the doctor and faxed the order to the backup pharmacy..." The DON stated, "The medication was delivered after midnight on the 28th so it was delivered on 3/1/13..." During an interview in the conference room on 3/6/13 at 5:55 PM, the DON stated, "It wasn't here the evening of the 27th (2/27/13) and morning and evening of the 28th (2/28/13) and (Named Nurse #3) called the evening of the 28th (2/28/13) and the med was delivered after midnight the 28th (2/28/13) and it was signed for on 3/1/13..." During an telephone interview on 3/7/13 beginning at 8:05 AM, the Pharmacist stated, "Nurses responsibility to order medication before they run out... they should still have a couple of days left..." The Pharmacist confirmed the pharmacy will not send medication refills until the count sheet is received from the facility. The failure to administer pain medication as ordered resulted in actual harm to Resident #45 when the resident experienced increased agitation.