Every finding on record at Little Sisters of the Poor

Based on interview and document review the facility failed to ensure all required discharge documentation was provided to the resident and receiving facility; and failed to ensure transfer and discharge notices were sent to the Office of the State Long-Term Care Ombudsman (OOLTC) for 1 of 1 resident (R37) reviewed for discharge.Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, independent with dressing, hygiene and mobility. There was no active discharge planning in place and medications included anticoagulants and anticonvulsants.R37's care plan dated 7/24/25, identified resident desires to transfer to assisted living when opening is available. Interventions included social services will assist in finding assisted living per doctor's orders. R37's Order Recap Report dated 1/01/25 through 1/31/26, lacked an order to discharge.R37's provider visits summaries dated 9/11/25 and 11/13/25, lacked information or orders related to discharge. R37's progress note dated 11/18/25 at 8:00 a.m., identified R37 discharged to an assisted living location in another state. Scheduled morning meds were administered prior to discharge. Resident was given all available medications; eye drops and ointments. Transfer discharge record, administration record, order summary, advanced directives, pertinent notes and labs sent. The progress note lacked inclusion of a recapitulation of R37's stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication. R37's Transfer/Discharge Report dated 1/27/26, lacked inclusion of a recapitulation of R37's stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication. R37's list of assessments from admission to discharge date d 7/25/24 through 11/18/25, lacked evidence a recapitulation of R37's stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication was completed and lacked notation if the OOLTC was updated on the discharge.During an interview on 1/27/26 at 9:03 a.m., registered nurse (RN)-A stated for a resident discharge an order was needed, and a discharge summary assessment would need to be completed in the facility's electronic medical record. During an interview on 1/27/26 at 10:10 a.m., licensed practical nurse (LPN)-A stated for a resident to discharge there needed to be a doctor order and a discharge summary assessment would need to be completed in the facility's electronic medical record.On 1/27/26 at 10:37 a.m., a phone interview was attempted with family member (FM)-A, however a return call was not received.During an interview on 1/27/26 at 1:16 p.m., the director of nursing (DON) stated they could not find R37's discharge summary which included a recapitulation of R37's stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication. The DON stated their discharge process needed some work to ensure the regulations were met.On 01/28/26 at 9:40 a.m., a phone interview was attempted with R37, and no return call was received. During an interview on 1/28/26 at 11:57 a.m., the administrator stated he was not sure who was updating the OOLTC on transfers and discharges, and he found a binder in the social services office which indicated the last transmittal to OOLTC was in 2023. The administrator stated it looked like there was a process, however the process was not maintained.During an interview on 1/28/26 at 12:22 p.m., the DON stated there was not a policy or procedure developed yet for the transfer and discharge process.In an email correspondence dated 1/28/26 at 5:04 p.m., the OOLTC identified their last transfer and discharge notice received from the facility was on 12/18/24.The facility's Admission, Discharge and Transfer (ADT) Report dated 1/1/25 through 1/28/26, identified there were five residents who were discharged , and 12 residents transferred out to the hospital.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R19) reviewed for activities of daily living (ADLs), and who was dependent on staff for her care.Findings include:R19's quarterly Minimum Data Set (MDS) dated [DATE] indicated R19 had moderate cognitive impairment, had no behaviors, and did not refuse personal cares. R19's MDS indicated she was independent with hygiene, bathing, transfers and used a rolling walker for mobility.R19's medical diagnosis report dated 1/28/26, indicated diagnoses of congestive heart disease, cerebral infarction (stroke) without residual deficits, dementia, back pain, and hypertension.R19's care plan dated 1/28/26, indicated R19 was independent with dressing and needed limited assistance of one staff member with personal and toileting hygiene. This care plan directed one staff member to assist R19 with dressing and applying shoes. R19's Kardex indicated she received showers on Monday mornings. R19's electronic medical record (EMR) indicated a skin assessment was completed on 10/20/25, and a comprehensive skin assessment was done on 1/24/25. There was no progress note about R19's shower, skin assessment or nail care provided on 1/26/25. During observation on 1/26/26 at 3:45 p.m., R19 was sitting up watching television. R19 was not wearing shoes or socks. R19's toenails were yellowish and about 1 centimeter long from the end of the toe. During interview on 1/27/26 at 9:31 a.m., nursing assistant (NA)-A stated R19's medical record indicated she received a shower yesterday, Monday 1/26/26.During interview on 1/27/26 at 11:26 a.m., director of nursing (DON) stated a skin assessment needed to be done every week on shower days. DON reviewed R19's EMR and verified there was no documentation of a skin assessment and/or nail care being performed on Monday 1/26/26. DON stated the nursing assistants should cut resident's nails, unless the residents were diabetics. DON stated she expected staff to check the residents' skin and nails every week on shower days, and document in residents EMR. The concern about not assessing the residents' skin was the staff might not be able to catch a skin or nail issue before it became a problem.During observation and interview on 1/28/26 at 10:50 a.m., DON verified R19's toenails were long and said, they need to be trimmed.Requested a facility's nail care policy and procedure but it was not provided.

Based on interview and record review, the facility failed to ensure narcotic and controlled substances destruction was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft for 1 of 1 resident (R7) reviewed for fentanyl patch removal. Findings include:R7's quarterly Minimum Data Set (MDS) date 1/14/26, indicated R7 was cognitively intact, required substantial/maximal assistance with most activities of daily living (ADLs) and mobility, and experienced almost constant pain. The MDS indicated R7 was taking opioids as scheduled pain medication regimen. R7's diagnoses included Parkinson's disease (neurological disease affecting movement), respiratory failure, and chronic pain.R7's care plan dated 5/27/25, indicated R7 required pain management due to chronic pain as a result of osteoarthritis, kyphosis (condition of humpback), scoliosis (abnormal curvature of the spine), and dorsalgia (pain anywhere in the back). R7's physician orders included:-Fentanyl Transdermal Patch 72 hour 12/mcg/hr.apply 1 patch transdermal every 72 hours for pain. Order date 4/12/25.-Documentation of removal and destruction of Fentanyl patch by two licensed staff nurses. Nurse #1 signature every 72 hours for destruction of used patch. Order date 1/5/25.-Documentation of removal and destruction of Fentanyl patch by two licensed staff nurses. Nurse #2 signature every 72 hours for destruction of used patch. Order date 1/5/25. R7's monthly pharmacy consultation report (MRR) dated 11/24/25, indicated, review of eMAR documentation for Fentanyl removal/destruction = 4 of 8 entries have same staff signature. The MRR indicated acknowledgment with a handwritten Noted to watch and signed on 12/1/25. R7's November 2025 medication administration record (MAR) indicated 4 of 10 entries had the same staff initials documented under removal and destruction of fentanyl patch nurse #1 and nurse #2 on the same dates. On 11/29/25, there was a nurse #1 entry with no corresponding nurse #2 entry. R7's December 2025 MAR indicated 6 of 10 entries had the same staff initials documented under removal and destruction of fentanyl patch nurse #1 and nurse #2 on the same dates. On 12/2/25, there was a nurse #1 entry with no corresponding nurse #2 entry. R7's January 2026 MAR indicated 7 of 10 entries had the same staff initials documented under removal and destruction of fentanyl patch nurse #1 and nurse #2 on the same dates. On 1/28/26, there was a nurse #1 entry with no corresponding nurse #2 entry.When interviewed on 1/28/26 at 10:46 a.m., registered nurse (RN)-B stated the process for fentanyl patch removal was for two nurses to witness the destruction of the patch after removal. The patch would be placed in a drug disposal container stored under the sink in the med room. Then each nurse would log in separately and sign off the removal and destruction of the patch in the resident's MAR. RN-B stated she removed R7's fentanyl patch this morning and the nurse from nights had witnessed the disposal, but must have forgotten to log in and sign it off in R7's chart. When interviewed on 1/28/26 at 11:13 a.m., director of nursing (DON) stated expectation that two staff witness destruction of the fentanyl patch after removal. They each have to log in and document under a nurse #1 and nurse #2 respectively to indicate the fentanyl patch was removed and destroyed appropriately. DON stated this process required two different staff nurses to complete. DON further stated this process should have been monitored more closely to ensure compliance. When interview on 1/28/26 at 12:14 p.m., consultant pharmacist (CP) stated expectation that there would be two different nurses witnessing and signing off the destruction of the fentanyl patches after removal. CP stated a breakdown in this process had been identified in the November 2025 MRR and should have been monitored by the facility. CP further stated this process was in place to reduce the likelihood of drug diversion or inappropriate use of the medications by staff. Facility policy Prescribing, Administration and Disposal of Fentanyl Transdermal Systems dated 9/15/24, indicated, Used fentanyl transdermal system should be folded so that the adhesive side of the patch adheres to itself.Place folded system in commercially available disposal kit and dispose per package directions. The policy further indicated, Two nurses or a nurse and another professional should witness the disposal of used and unused patches.

Based on observation, interview, and record review the facility failed to ensure open refrigerated items were dated and covered. Furthermore, the facility failed to ensure expired items were removed from storage. This had the potential to impact all 32 residents residing in the facility. Findings include: An observation on [DATE] at 11:40 a.m., the main kitchen was reviewed. A walk-in refrigerator contained an open package of Hillshire Farm sliced turkey lunchmeat. The lunchmeat was wrapped in saran wrap and had no label or date. At 11:57 a.m., the walk-in dairy refrigerator was reviewed. The refrigerator contained 4 half gallons of [NAME] 2% milk. The best by date for all 4 containers was [DATE]. Dietary aide (DA)-A verified the expired milk and stated they should be thrown away. At 11:59 a.m., the DietaryDirector entered the refrigerator and verified the expired milk. Dietary Director stated they were aware the date was close and didn't realize it had been expired for that long. after reviewed the date verified that date was a while back. At 12:04 p.m., an upright freezer was reviewed in the main kitchen. In the freezer was a tray of vanilla ice cream served up in parfait cups. They were not covered or dated and appeared to be freezer burnt. When interviewed at 12:07 p.m., cook-A verified the sliced lunchmeat contained no date of when it was opened. Cook-A was not sure when it was opened and further stated a date should've been placed. Cook-A further verified the ice cream and stated they must have been served up over the weekend. Cook-A stated the ice cream should be covered and dated. Cook-A stated the dietary director or himself review for expired items and remove them as they were found. An observation on [DATE] at 11:25 a.m., the 3rd floor kitchenette was reviewed. The refrigerator contained an unopened container of Hormel thicken-it juice. The use by date was [DATE]. When interviewed on [DATE] at 11:30 a.m., DA-B verified the expired thicken-it juice. DA-B wasn't sure why it was still in the refrigerator and removed it. DA-B further stated dietary staff reviewed items to ensure none were expired weekly and the juice must have been missed. When interviewed on [DATE] at 7:45 a.m., the Dietary Director acknowledged there were some improvements needed for food storage and further stated with the census being lower, items were not getting used as frequently. Dietary Director expected staff to be reviewing refrigerators for expired items and removing them when found. Dietary Director further expected all opened food items to be covered, labeled, and dated. When interviewed on [DATE] at 10:46 a.m., the Administrator expected expired items to be discarded and all opened items should be covered and labeled. A facility policy titled Accepting Food Deliveries no date, directed staff to properly covered, labeled and dated and stored as approporiate.

Based on observation, interview, and document review, the facility failed to ensure oxygen was administered according to physicians orders for 1 of 2 residents (R11) reviewed for respiratory care. Findings include: R11's Optional State Assessment (OSA) dated 10/10/24, indicated moderate cognitive impairment, did not reject cares, did not have shortness of breath, and used oxygen. R11's medical diagnoses form indicated the following diagnosis: pulmonary fibrosis (scarring and thickening of the tissue and between the air sacs in the lungs). R11's physician's orders dated 6/26/24, indicated the following order: oxygen 1 to 6 liters per minute per nasal cannula or mask as needed for dyspnea (shortness of breath keep oxygen saturations greater than 91% and notify the physician). R11's medication administration record (MAR) and treatment administration record (TAR) dated November 2024, indicated R11 used oxygen on 11/1,24, 11/3/24, and 11/7/24. The MAR and TAR lacked information regarding R11's oxygen saturation levels. R11's MAR and TAR dated December 2024, and printed on 12/11/24, indicated R11 did not use oxygen. Additionally, the MAR and TAR lacked information regarding R11's oxygen saturation levels. R11's O2 Sats Summary form indicated R11's oxygen saturation levels on the following dates: 11/3/24, at 7:27 a.m., R11's oxygen saturation was 93% with oxygen via nasal cannula. 11/3/24, at 12:06 p.m., R11's oxygen saturation was 93% on room air. 11/4/24 at 9:59 a.m., R11's oxygen saturation was 85% on room air and at 11:00 a.m., was 95% with oxygen. 11/5/24 at 1:30 a.m., and 5:10 a.m., R11's oxygen saturation was 95% with oxygen and at 5:15 a.m., was 92% with oxygen. 12/2/24 at 11:22 a.m., R11's oxygen saturation was 93% on room air. 12/9/24 at 8:13 p.m., R11's oxygen saturation was 99% on room air. The O2 Sats Summary form lacked information what R11's oxygen saturation levels were on other dates in November and December to know whether R11 required oxygen or not. R11's nursing progress notes were reviewed and R11 utilized oxygen on the following dates: 11/27/24, oxygen saturations were 82-83% on room air and was placed on 1.5 liters of oxygen. R11's Care Guide form undated, lacked information R11 utilized oxygen. R11's care plan was reviewed and lacked information R11 utilized oxygen. During interview and observation on 12/9/24 between 12:45 p.m., and 12:48 p.m., R11's oxygen was not turned on. R11 asked if oxygen was going to be applied because she stated she needed oxygen. R11's call light was activated and at 12:48 p.m., nursing assistant (NA)-A answered R11's call light and stated R11 used oxygen at night when going to bed, but did not need oxygen while up in the chair. During observation on 12/10/24 at 3:02 p.m., R11 was in bed and had oxygen on at 1.5 liters per minute. The MAR and TAR lacked information R11 utilized oxygen. During interview and observation on 12/11/24 at 6:56 a.m., and 6:57 a.m., R11 was in bed and the oxygen was off. NA-A stated at 6:57 a.m., R11 had the oxygen on, but NA-A turned it off. During interview on 12/11/24 between 7:01 a.m., and 7:04 a.m., licensed practical nurse (LPN)-A viewed R11's MAR and TAR and stated R11 did not have oxygen signed off as administered in the MAR and TAR. LPN-A stated R11 wore oxygen at night and the evening shift applied the oxygen. LPN-A stated R11 had oxygen on last night. Further, LPN-A stated she had inquired during report about acknowledging they were applying oxygen every night. During interview on 12/11/24 at 8:33 a.m., the director of nursing (DON) stated she expected staff take oxygen saturations as needed for dyspnea to keep oxygen saturations greater than 91%. A policy, Respiratory Care, dated 3/2024, indicated oxygen was administered under orders of the attending physician, except in the case of an emergency. Check the resident's oxygen saturations as ordered by the physician.

Based on observation, interview, and document review the facility failed to comprehensively assess and implement individualized person centered dementia care for 1 of 2 residents (R2) reviewed for dementia care. Findings include: R2's Clinical Diagnosis form, indicated the following diagnoses: vascular dementia with agitation, age-related macular degeneration, legal blindness, other symptoms and signs involving cognitive functions and awareness, primary generalized osteoarthritis, unilateral primary osteoarthritis of the left knee, aphasia (a language disorder making it difficult to communicate), insomnia, cerebral infarction (stroke) due to embolism (blood clot), type two diabetes mellitus with polyneuropathy (a complication where peripheral nerves are damaged throughout the body), and other cerebrovascular disease (a condition that affects blood flow to the brain). R2's Annual Minimum Data Set (MDS) dated [DATE], indicated R2 had unclear speech, had short and long-term memory problems, severely impaired cognitive skills for daily decision making, did not have delirium, inattention, disorganized thinking, or altered level of consciousness, did not have hallucinations or delusions, did not have physical symptoms such as hitting, grabbing others, pushing, or scratching, verbal, or other behavioral symptoms and did not reject care. Further, the MDS indicated R2 had an impairment of range of motion to both upper extremities, utilized a wheelchair, was dependent on staff for transfers, oral hygiene, toileting hygiene, showering and bathing, dressing, and personal hygiene, and was always incontinent of bowel and bladder, was at risk for development of pressure ulcers, took antipsychotics, antidepressants and a gradual dose reduction was contraindicated. R2's Area Assessment (CAA) dated 9/19/24, indicated R2 had severe difficulty communicating due to expressive aphasia from a stroke and progressive dementia and staff needed to anticipate all needs. Weepiness, moving self in wheelchair in the hall, or repetitious non intelligible content, and grimaces was R2's way of reporting discomfort. Additionally, R2 had severely impaired cognition and took psychotropic medications for depression and anxiety. The CAA did not trigger for behavior symptoms, or pain. R2's Care Guide undated, indicated R2 transferred with a Hoyer lift, was assist of 2 staff, required the wheelchair at the bedside with the brakes locked, required toileting before and after meals, at bedtime and as needed, had a tub bath on Wednesday and Friday a.m. shift, if agitated staff were to reapproach when calm for activities of daily living and report to the nurse if resident exhibited exit seeking behaviors. Further, the guide indicated R2 had behaviors and staff were to reapproach when agitated and provide time for R2 to calm down. R2's care plan dated 11/15/24, indicated R2 did not always have to have glasses on as R2 may remove glasses in periods of heightened anxiety and agitation. R2's care plan dated 9/18/24, indicated R2 had functional mobilities and unsteadiness with transfers, decreased range of motion in upper extremities and an intervention revised on 12/9/24, indicated R2 was non ambulatory. Other interventions indicated R2 required extensive assist of two staff for bed mobility, Hoyer transfers with two persons, wheelchair at bedside and locked at night, two assist for safety with bathing with getting in and out of the tub, baths completed on Tuesday and Friday morning shift, total assist of 2 with upper and lower body dressing, total assist of one to two in all areas of personal hygiene and oral care, and reapproach for any self care assistance if and when R2 declined. R2's careplan dated 11/13/24, indicated R2 had difficulty falling asleep and wandered and interventions included providing medications for sleep, offering one to one support, snacks, coke as needed, and when R2 was agitated staff were to ensure their safety and reapproach when calm for activities of daily living (ADLs). R2's care plan dated 9/16/24, indicated R2 required assistance to toileting before and after meals and before bed as R2 accepted. R2's care plan dated 10/16/24, indicated R2 had recurrent MASD (moisture associated skin damage) and interventions indicated to apply moisture barrier creams, assist to reposition every two hours to prevent skin breakdown, offer and assist with toileting and pericare every two hours while awake. R2's care plan dated 9/12/24, indicated R2 could not report pain and had restless legs associated with neuropathy, osteoarthritis, knee replacements, peritoneal adhesions, history of shingles, history of decreased range of motion to the right shoulder rotator cuff, hand and right knee pain, chronic gastrointestinal discomfort. R2's scheduled narcotic was discontinued on 8/5/24. Interventions included observing for pain and notifying the physician as needed for inadequate pain relief, observe for signs of pain such as facial expressions, rubbing at painful area, increased behavioral symptoms because she cannot express pain due to aphasia and cognitive loss and update the physician on neuropathy as needed. R2's behavior care plan dated 11/13/24, indicated R2 was at risk for elopement and was not easily redirectable. Interventions included to assess for falls risk, disguise exits, monitor for fatigue and weight loss, provide activities toileting, walking inside and outside, reorientation strategies, pictures and memory boxes. R2's psychotropic medication care plan dated 9/12/24, indicated R2 started Lexapro an antidepressant on 6/10/22, had Cymbalta discontinued on 6/22, trazodone was decreased on 3/15/24 for insomnia and restlessness, and Seroquel an antipsychotic was started on 9/29/23, and a dose reduction was contraindicated. Interventions included monitoring and documenting and reporting the physician as needed ongoing signs and symptoms of depression unaltered by antidepressant medications, sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood and comments, slowed movement, agitation, disrupted sleep, fatigue, and lethargy. R2's Physician Orders form indicated the following orders: 6/20/19, acetaminophen 500 mg tablet give 2 tablets by mouth three times a day for chronic pain. 4/29/21, lidocaine patch 4% apply to lower back topically in the morning for lower back pain and remove per schedule. 7/21/21, staff may offer aromatherapy, hand massages, topical analgesic to hands, and one to one time with resident which may help her to cooperate with allowing treatments and activity of daily living (ADL) cares. Staff may reapproach when resident refuses cares every shift for cares and comfort. 6/11/22, escitalopram oxalate 10 mg tablet give 1 tablet by mouth one time a day for depression. 9/23/23, Reapproach resident if she refuses her medications and document all refusals every shift for anxiety and paranoia. 12/5/23, monitor for paranoia and agitation evidenced by behaviors of hitting, screaming, kicking, refusing medications every shift for order of Seroquel. 3/15/24, trazodone 50 mg at bedtime for insomnia. 3/28/24, Seroquel 25 mg (milligrams) give 25 mg by mouth one time a day for agitation and paranoia. Give Seroquel in the evening. 3/28/24, gabapentin 300 mg by mouth in the evening for neuropathy pain. 3/28/24, document all behaviors for resident hitting, kicking, scratching, resistive to cares, pushing nurses hands, and any other behavior resident exhibits every shift for cognition. 7/16/24, Voltaren external gel 1% apply to both knees topically two times a day for pain apply two grams. 11/18/24, Voltaren external gel 1% apply to back and both hips topically two times a day for fall. Apply 2 grams to back and bilateral hips twice daily. R2's 30 day behavior symptoms task form printed 12/11/24 at 12:34 p.m., indicated R2 had no documented behaviors in the past 30 days. R2's nursing progress note dated 11/23/24, at 2:03 p.m., indicated, ok to use Hoyer lift assist of 2-3 with one staff to engage resident in attempt to ease anxiety. If any signs of resistance/aggression/fighting-do not use Hoyer. every shift for Transfer protocol. Using EZ stand. R2's nursing progress notes from 11/1/24, to 12/11/24, were reviewed and indicated R2 displayed behaviors or agitation on 11/8/24, 11/12/24, 11/14/24, 11/28/24, 12/4/24, and 12/11/24. R2's physician progress note dated 8/5/24, indicated R2 could not communicate verbally and agitation was similar in the past months with increased confusion and R2's oxycodone (opioid pain medication) was recently decreased, and moved both hips, knees and ankles without any pain. R2 had dementia, and agitation and agitation was improved with a scheduled low dose oxycodone and Seroquel, further the note indicated to continue the low dose of oxycodone 2.5 mg three times a day. R2's physician progress note dated 9/30/24, indicated R2's behavior was stable oxycodone dose was decreased, and to continue on Plavix and Seroquel. R2's physician progress note dated 11/11/24, indicated agitation was similar in the past months with increased confusion and R2's oxycodone was recently decreased, and moved both hips, knees, and ankles without any pain. Further R2 had agitation and plan to continue on Plavix and Seroquel as behavior was stable. During interview and observation between 12/9/24 at 1:18 p.m., to 1:26 p.m., R2 was heard yelling in her room. Nursing assistant (NA)-B stated she worked at the facility about 4 months and they planned to toilet R2. NA-A stated when R2 transferred from bed to chair, they used a Hoyer lift and they used a stand lift because it was too difficult to tuck in the Hoyer sling because R2 fights. Staff brought in the EZ stand lift and stated it was part of the plan of care because it was so difficult to apply the sling for the Hoyer and was their only choice because R2 was combative. NA-A stated she had worked at the facility for [AGE] years. At 1:26 p.m., R2 was vocalizing and staff stopped and took out the stand lift and stated they would come back and did not transfer R2. During interview and observation on 12/9/24 from 1:59 p.m., to 2:12 p.m., NA-A and NA-B brought the EZ way stand lift into R2's room. At 2:01 p.m., the sling was placed behind R2's back and R2 was hitting at staff when trying to put the sling under R2's arm. At 2:02 p.m., staff put R2's legs on the lift and R2 started making repetitive vocalizations, I, I, I, I, and was pushing the EZ lift away. R2's legs were strapped in the lift. At 2:03 p.m., staff attached the sling and instructed R2 to hold the handles and R2 grabbed the handles of the lift on the left and right side and resident kept stating I, I, I, I, and was transferred from the chair to the bed and R2's vocalizations slowed but continued yelling, I, I, I. R2 was positioned on the left side and vocalizations stopped. AT 2:06 p.m., staff started helping to change R2's pants and R2 began yelling out again and kicking her legs. Vocalizations stopped when staff completed the task. Staff engaged R2 with her stuffed animals and changed her brief at 2:07 p.m., and R2 was pushing away with the repetitive vocalizations. NA-A was trying to apply a new brief and R2 began hitting at NA-A. At 2:10 p.m., R2 was covered and the bed was lowered. R2 was not vocalizing and the wheelchair was placed by NA-A at the bedside but not locked. NA-B locked the brakes on the wheelchair at 2:11 p.m., and NA-A wiped down the EZ stand lift. At 2:12 p.m., R2 was quiet. NA-A stated registered nurse (RN)-A directed staff to use the EZ stand and further stated she spoke with RN-A about a month ago because the care plan indicated a Hoyer lift. NA-A stated RN-A observed them and further NA-A stated it was an every day struggle with R2 to toilet R2 because of her sling and added R2 holds the EZ stand and stands up and further stated they placed a chair by R2's bed because R2 tries to stand up and self transfer. During observation on 12/10/24 at 8:37 a.m., licensed practical nurse (LPN)-A introduced herself to R2 and offered her medication. R2 was softly stated, doe, doe, doe, doe. LPN-A gave the medication on a spoon to R2 and R2 put the medication into her mouth. During observation on 12/10/24 at 10:24 a.m., NA-A was pushing R2 in her wheelchair and R2 was making nonsensical vocalizations. During observation on 12/10/24 at 3:11 p.m., R2 was in bed and was not making any vocalizations. During observation on 12/11/24 at 7:21 a.m., R2's room was dark except the bathroom light was on and the curtain was pulled in R2's room. R2 was in bed and was not making any vocalizations. During interview on 12/11/24 at 9:24 a.m., NA-A stated she knew what kind of cares a resident received based on the care guide and stated R2 was dependent for cares and was a Hoyer lift now and two assist for everything because it was difficult R2 was combative every day and at night, R2 sleeps, but in the mornings, R2 does not want to be bothered and makes noises. NA-A stated R2 becomes upset when she is touched or when she is undressed, becomes angry and kicks and stated R2 was like that every day and only with the activities of daily living and when in the chair was fine and further stated it has been going on a while and was especially difficult on Wednesdays and Saturdays because it was R2's bath days and added R2 was probably in pain and stated the nurse documented behaviors and the NA's also had to document. During interview on 12/11/24 at 9:19 a.m., NA-C stated they looked to the care plan to know what cares a resident required and stated R2 hits if she doesn't sleep well and stated she was very aggressive and that was why they were letting her sleep in, but did not know how often R2 had behaviors because she did not normally work on this floor. During interview on 12/11/24 at 9:09 a.m., registered nurse (RN)-A stated R2 was supposed to be transferred with a Hoyer lift and stated she was aware staff used the EZ stand and saw the transfer as safe. RN-A stated R2 did not like physical care and when talking with her R2 will calm down and most of the time got upset and did not like toileting, and bathing and added even though R2 beats us up, R2 was sweet. RN-A stated behaviors should always be documented and added the NA's document in the medical record and report to nurses and then the nurse can document the behavior in the medical record. RN-A stated it was important to document because R2 was on Seroquel and they needed to see what behaviors R2 had and the necessity of the drug. RN-A stated overall R2's behaviors still existed and was not sure why R2 was combative with cares but did have long standing insomnia and stated overall, R2's behavior was better. During interview on 12/11/24 at 10:33 a.m., the director of nursing (DON) stated behaviors should be documented right after they occur. Staff would finish their task first and then document when the situation was safe to do so. The DON further stated it was important to document behaviors to have the documentation to see if there were any patterns and they could look at the root cause to find what triggered the behaviors and come up with interventions that help the resident whether they are cold, hot, hungry, tired, or in pain. The DON viewed the NA task form and verified there were no behaviors documented in the 14 day look back period. The DON further stated she was aware they had a problem with behavior documentation. A policy, Behavior Management, dated August 2017, indicated all behavior was an attempt to communicate a need and some behaviors interfered with the giving of safe care. Staff will be constantly vigilant for behaviors of residents that communicate a need and staff will communicate these observations to the nurse, who in turn will see that needs are addressed in care planning. Medications and environmental interventions may be utilized in managing the need underlying the behaviors. Problem behaviors are behaviors that either occur frequently and disrupt care or occur infrequently, but pose a serious safety concern for the resident and or staff. Staff is to record each occurrence or a shift total of behaviors for residents. Care-giving staff is to communicate with the nurse about the occurrence of target behaviors. It is the responsibility of the nurse to document on the behavior tracking sheet and an entry is made each time a target behavior occurs and if there is no entry, it is assumed that the behavior did not occur on a particular shift.

Based on interview and document review, the facility failed to ensure consultant pharmacist recommendations were acted upon timely for 2 of 5 residents (R2, R29) reviewed for unnecessary medications. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 had a short-term and long-term memory problem, did not have physical, verbal, or other behavioral symptoms, did not reject cares, had diagnosis of non-traumatic brain dysfunction, hypertension (high blood pressure), diabetes mellitus, aphasia (a disorder that affects how you communicate), and non-Alzheimer's dementia. Further, R2 had applications of ointments and medications other than to feet, and R2 took an antipsychotic. R2's physician orders indicated the following orders: 7/29/21, nystatin powder apply to affected areas topically as needed for moist, abdominal, groin, breast folds that become red or odorous add routine for 7 to 10 days when rash recurs and continue as needed dose after treatment completed. 1/15/24, nystatin powder apply to abdomen fold topically two times a day for moist fold. R2's medication administration record (MAR) and treatment administration record (TAR) dated December 2024, indicated R2 was receiving nystatin powder twice daily in the morning and p.m. R2's pharmacy consultation report dated 10/17/24, indicated R2 received a topical antifungal, nystatin powder apply to abdomen fold topically two times a day for moist fold for greater than 8 weeks without a stop date. Of note, R2 also has an order for nystatin powder apply to affected areas topically as needed for moist, abdominal/groin/breast folds that become red or odorous add routine for 7 to 10 days when rash recurs and continue as needed (PRN) dose after treatment completed. The pharmacist consultant recommended re-evaluating the ongoing topical antifungal use because prolonged use may increase the risk of adverse consequences, including the development of drug resistant organisms. Under the heading, Physician's Response, was undocumented and there was no physician signature to indicate the medication was addressed with the physician. During interview on 12/11/24 at 9:00 a.m., the director of nursing (DON) stated the previous DON didn't follow up on previous recommendations from October. During interview on 12/11/24 at 12:09 p.m., the pharmacist consultant (PC) stated each month she includes a pending report indicating which reports are not followed up on and spoke with the director of nursing (DON) and realize there has been a delay in getting the recommendations done and further, state anything over 30 days or more were being worked on to get completed. R29's Optional State Assessment (OSA) dated 9/11/24, indicated R29 had depression and took an antidepressant. R29's Medical Diagnosis form indicated R29 had major depressive disorder. R29's Physician's Orders form indicated the following order: 3/20/24, duloxetine oral capsule delayed release particles, give 60 milligrams (MG) by mouth in the evening related to major depressive disorder. R29's MAR and TAR dated December 2024, indicated R29 received duloxetine every 5:30 p.m. R29's pharmacy consultation report dated 9/18/24, indicated R29 received duloxetine 60 mg every p.m., for depression since admission 3/2024. Progress note dated 5/20/24, indicated depression was stable and Federal regulation required an evaluation for dose reduction because dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence and recommended a gradual dose reduction (GDR) for duloxetine. Under the heading, Physician's Response, was undocumented and there was no physician signature to indicate the medication was addressed with the physician. During interview on 12/11/24 at 12:13 p.m., the PC stated she would have expected follow up on the recommendation within 60 days and stated she resent the recommendation on 12/10/24. During interview on 12/11/24 at 8:41 a.m., the DON stated pharmacy recommendations were not being followed up on prior to November and did not know why they were not completed and stated R29's GDR was not followed up on, but going forward have a new process. A policy, Medication Regimen Review, dated March 2017, indicated each resident would have a medication regimen review by a licensed pharmacist. Irregularities identified would be documented on a separate, written report and sent to the attending physician, medical director, and director of nursing, listing the resident name, relevant drug and irregularity the pharmacist identified.

Based on interview and record review the facility failed to ensure a topical antibiotic was transcribed as written and further failed to ensure the topical antibiotic was still necessary for 1 of 1 residents (R14) reviewed for antibiotic use. Findings include: R14's quarterly MDS dated [DATE], indicated R14 was cognitively intact and had diagnoses of diabetes and hidradenitis suppurativa (disease causing puss filled boils on the skin). Furthermore, R14 was on an antibiotic. R14's dermatology provider note dated [DATE], indicated R14 was seen for a skin check. The note indicated R14s hidradenitis was clear and ordered R14 to continue the clindamycin lotion (antibiotic) for 1 year. R14's active provider orders indicated on [DATE], R14 required clindamycin phosphate 1% lotion to be applied to the abdomen/groin topically for hidradenitis. R14's clindamycin order had no end date. R14's medication administration record (MAR) dated ,d+[DATE], indicated clindamycin 1% lotion as an active order. The MAR further indicated it was unknown if R14 was using the medication as she was able to self-administer and store medications unsupervised. A review of R14's nursing progress notes indicated: -on [DATE] at 11:02 p.m., R14's skin was warm and intact with no skin concerns. -on [DATE] at 4:26 p.m., R14 had no skin issues. -on [DATE] at 9:17 p.m., R14 had no skin issues. -on [DATE] at 10:28 p.m., R14 had no new skin issues. R14's care plan revised [DATE], lacked indication R14 was prescribed an antibiotic. When interviewed on [DATE] at 12:53 p.m., R14 stated they had tumor like things on their groin area and that was why they were taking the clindamycin lotion. R14 verified they were still taking it daily. R14 further stated staff had been unable to get a refill and so she was working with her dermatologist. R14's dermatologist has said they would give 2 more refills but would not do any more until seen again. R14 stated once starting the clindamycin they were able to feel the little pockets under her skin but stated everything else cleared up right away. R14 stated when she had trouble getting it refilled, she was using the lotion every other day or so so it would last. R14 stated during the time of taking it sparingly, her skin had no change. R14 stated the facility or provider had not talked about any risks of long-term antibiotic use. When interviewed on [DATE] at 2:22 p.m., registered nurse (RN)-B stated when residents on antibiotics required monitoring of symptoms and tracking to determine if they are improving. This was documented as a progress note. When a resident has a topical antibiotic, the nurse would then monitor the skin. RN-B was not aware R14 was on the clindamycin topical ointment but verified the order and noted there was no end date. RN-B was not aware of any skin altercations or infections for R14 and wasn't sure if the antibiotic lotion was needed. RN-B stated R14 used an outside provider and it was more difficult as R14 handled her own medications. When interviewed on [DATE] at 2:50 p.m., with the infection preventionist (IP) and the Director of Nursing (DON), the IP verified R14's antibiotic was not included in the facility's tracking for antibiotic. IP stated this was not currently tracked and would need to investigate it further. When interviewed on [DATE] at 12:18 p.m., the Director of Nursing (DON) verified R14's dermatology note indicated the clindamycin lotion was to be used for a year and the order should have expired in ,d+[DATE]. DON was not sure R14 still required the medication and stated a risk and benefit was needed if she wanted it continued. R14 managed her medications and communications with the dermatologist and the DON stated collaboration was sometimes challenging. Furthermore, DON verified the antibiotic list the IP had been pulling from the electronic medical record was only oral antibiotics and had not included topical. DON expected all antibiotics to be tracked for residents in the facility. A facility policy titled Antibiotic Stewardship Policy 2024, directed the provider to ensure a duration was included in an antibiotic order. Furthermore, the policy directed the nurse to monitor and evaluation the effectiveness of the antibiotic and the residents response to the antibiotic to identify if the antibiotic was still indicated.

Based on interview, and document review, the facility failed to ensure physician notification of an abnormal lab for 1 of 1 resident (R29) reviewed for diabetes. Findings include: R29's Optional State Assessment (OSA) dated 9/11/24, indicated intact cognition, had diabetes mellitus, and received insulin injections 7 of 7 days. R29's Admission Orders form dated 3/19/24, indicated a check box, Yes R29 could use Standing House Orders. Directly under the line, May use Standing House Orders, indicated a heading, Diabetes Mellitus Standing Orders If Applicable, with check boxes for Yes, No, or N/A. None of the check boxes were marked. A form, Standing Orders for Skilled Nursing Facilities revised 2023, indicated the following standing orders for diabetes management: Notify the provider if two BG (blood glucose) results are less than 70 or greater than 400 in a 24 hour timeframe and or change in condition; if no condition change, notify provider on the next business day. For a BG less than 70, if patient is symptomatic, administer 6 ounces of fruit juice, milk, other high carbohydrate beverage, or glucose tabs or gel orally and if after 2 attempts to treat and BG is still less than 70, notify provider. A form, Diabetes Mellitus Standing Orders form dated 1/2010, directed, treatment for residents able to swallow or with a feeding tube as follows: For hypoglycemia (Blood sugar less than 70) Give 15 grams of glutose or 8 ounces of fruit juice, have resident rest, check BG in 15 minutes and if still below 70, repeat these steps. On the third test if blood sugar is still below 70 and resident continues to be alert and able to swallow, check equipment, clean meter if possible, check for accuracy, and look at the date and appearance of blood sugar strips. If all of these tests appear correct, give resident 115 grams of Glutose. On the fourth test, if blood sugar is below 70, notify the nurse practitioner or physician. A form, Guidelines for Action, Notification and Documentation dated March 2013, indicated the following guidelines for blood glucose and signs and symptoms of hypoglycemia: Notify the physician if BG is still up or down after rechecking and or intervention for gradual increase or decrease notify physician with routine call. Under a heading, Comments, follow diabetes standing orders if appropriate. R29's physician's orders indicated the following orders: 3/20/24, blood glucose (BG) before meals related to diabetes mellitus at 7:30 a.m., 11:30 a.m., and 1730 a.m. 4/2/24, Insulin lispro 100 unit/milliliter (ML) inject 12 units subcutaneously in the morning before breakfast, 20 units subcutaneously before lunch, and 10 units with supper. 9/30/24, Lantus (a long acting insulin) 100 unit/milliliter (ML) inject 60 units subcutaneously at bedtime for diabetes. 12/10/24 at 4:15 a.m., Hypoglycemic (low blood glucose) (BG) less than 70. Administer 6 ounces fruit juice, milk, other high carbohydrate beverage, or glucose tabs, gel orally repeat BG after 15 minutes, if less than 70, notify the provider as needed for diabetic management and treatment. R29's medication administration record (MAR) and treatment administration record (TAR) dated December 2024, indicated R29 received Lispro insulin with supper, and received Lantus insulin at bedtime on 12/9/24. The MAR and TAR indicated on 12/10/24, at 7:30 a.m., R29's blood glucose (BG) was 78. R29's Blood Sugar Summary report indicated the following BG levels: 12/10/24 at 4:00 a.m., 52 milligrams (MG)/Deciliter (DL). 12/10/24 at 4:07 a.m., 75 mg/dl. 12/10/24 at 4:29 a.m., 114 mg/dl. 12/10/24 at 4:31 a.m., 129 mg/dl. 12/10/24 at 7:00 a.m., 69 mg/dl. 12/10/24 at 7:20 a.m., 62 mg/dl. 12/10/24 at 8:45 a.m., 149 mg/dl. 12/10/24 at 12:33 p.m., 129 mg/dl. R29's care plan dated 11/15/24, indicated R29 had diabetes and interventions included to monitor, document, and report to physician as needed signs and symptoms of hypoglycemia (low BG) such as sweating, and tremors, increased heart rate, pallor, nervousness, confusion, slurred speech. R29's nursing progress notes dated 12/10/24 at 4:17 a.m., indicated R29's Dexcom (a company that specializes in continuous glucose monitoring) alarm was sounding and R29's BG level was 52 mg/dl. R29 requested orange juice and a glucose tablet and R29's BG was rechecked with a glucometer that indicated BG was 75 mg/dl. R29 had symptoms of being SHAKEY. R29 drank orange juice, had 2 glucose tablets and at 4:25 a.m., the Dexcom reading was 114 and shakiness was better. R29's license practical nurse (LPN)-A's nursing progress notes dated 12/10/24 at 7:17 a.m., indicated R29's BG at 7:00 a.m., was 69 and R29 requested a glucose tablet. At 7:25 a.m., R29's blood glucose was 62 and at 7:45 a.m., blood glucose was 78 and R29 reported feeling dizzy. The note further indicated R29 admitted she did not eat her snack the previous evening due to feeling too full. The note lacked information the physician was notified of the low BG. During interview on 12/11/24 at 7:32 a.m., licensed practical nurse (LPN)-A stated with labs you want to be timely on what you need to call the doctor for. LPN-A stated if you have to notify the physician, the notification is documented in the progress notes. LPN-A stated the guidance indicated it was the nurses discretion at notifying the physician and stated they used the standing orders and hypoglycemia was a BG less than 70. LPN-A further stated if after 2 attempts to treat and the BG was still less than 70 the physician should be notified and stated she did not notify the physician. LPN-A viewed R29's medical record and verified there was no documentation to indicate the physician was notified. During interview on 12/11/24 at 8:41 a.m., the director of nursing (DON) verified R29 could use standing house orders and stated staff should have notified the physician and it was important to notify the physician because it could indicate a change in condition, it could be a sign something is not correct such as not eating snacks and the physician could order changes in insulin, maybe the resident is not eating and the doctor may order further labs. During interview on 12/11/24 between 10:19 a.m., and 10:20 a.m., the DON stated their medical director clarified the blood glucose orders for R29 today to notify the physician of a blood glucose greater than 450 and less than 60. The DON further stated they were working on cleaning up the standing orders and the medical director wanted to look at everything.

Based on interview and document review the facility failed to identify, comprehensively assess, implement individualized interventions for wandering, exit seeking behaviors, and elopement for 2 of 2 residents (R1, R2) who had a history of repeated exit seeking behaviors. The facility's failures resulted in immediate jeopardy (IJ) when R1 eloped from the facility, was found on a city street, and returned by a passerby. The immediate jeopardy began on [DATE] after R1 attempted elopement multiple times, the facility failed to complete comprehensive wandering/elopement assessments, monitoring system, and appropriate intervention resulting in R1's actual elopement on [DATE]. The immediate jeopardy was identified on [DATE] and the chief executive officer and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 6:18 p.m. The immediate jeopardy was removed on [DATE] at 11:11 a.m., but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses that included Alzheimer's disease and had severe cognitive impairment. R1 did not have wondering behaviors. R1's progress note dated [DATE], indicated R1 was found walking to the elevator without shoes on, staff attempted to redirect, he became agitated, and upon reapproach was successfully walked back to his room. The note did not specify if R1 had been exit seeking and/or wandering. R1's Fall Risk assessment dated [DATE], contained a mental status section. The wanders box was selected with a checkmark with no other information identified. R1's quarterly MDS dated [DATE], indicated R1 did not have wondering behaviors even though the fall risk assessment dated [DATE] identified R1 wanders. The MDS indicated R1 was independent using a walker with ambulation of distances of 10 feet and required staff supervision/cues for distances of 50 to 100 feet. R1's record reviewed between [DATE] and [DATE], identified although progress notes identified a history of wandering behaviors the record did not include a comprehensive assessment of the wandering to identify trends/patterns and causal factors. Additionally, the record did not include a comprehensive elopement risk assessment. Further R1's care plan did not address R1's wandering and R1's risk for elopement until [DATE]. R1's progress note dated [DATE], indicated R1 was yelling in the hallway and wanted to go in another resident's room and was successfully redirected by staff. R1's progress note dated [DATE], indicated R1 was observed ambulating in the hallway in his socks and underwear and redirection took several attempts before resident was agreeable to return to his room. R1's progress note dated [DATE] at 6:58 a.m., indicated R1 was wandering the hallway in socks and boxers without his walker and was effectively redirected by staff. R1's progress note dated [DATE] at 11:15 a.m., indicated R2 made multiple attempts to exit the front door of the facility pushing his walker into the door at least six to seven times. Several initial staff attempts at redirection were unsuccessful but activity assistance staff walked with him outside and then convinced him to return to his room and get [R1] back into the facility safely. R1's progress note dated [DATE] at 3:51 p.m., indicated resident wandered today and was resistant to staff to return to his room. A family member was called, and this helped the resident. R1's progress note dated [DATE] at 3:53 p.m., indicated resident wandered down to main floor and was going outdoors. R1's Fall Risk assessment dated [DATE], identified R1 wandered, but lacked further information about his wandering behaviors or elopement risk. During an interview on [DATE] at 10:20 a.m., director of nursing (DON) stated the facility had an elopement assessment that nursing staff are supposed to complete on admission. The assessment should also be done if residents have a change in condition like exit-seeking or if they elope, or if they show a risk. DON expected nurses to document behaviors like wandering or exit-seeking in a progress note. When residents were identified to have wandering behaviors, staff should complete 30-minute safety checks to determine the resident's where abouts and safety. The DON identified the safety risks associated with elopement was high, especially for residents who were confused or lack proper clothing or awareness. Residents who eloped are at risk for getting sick, seriously injured, hit by a car, exposed to weather, and confused residents were at serious risk for getting lost in the community. DON stated an awareness of R1's elopement attempt on [DATE] and noted on that day it became very evident he was very high risk for elopement. The DON expected an elopement assessment to have been completed at that time with interventions put in place like 30-minute checks. R1's quarterly MDS assessment dated [DATE], indicated R1 had wandering behaviors on one-to-three of the seven-day assessment period, used a walker independently, and did not use a wander/elopement alarm. The impact of wandering section does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility) question was left blank. Even though R1's MDS assessment dated [DATE] identified R1 had wandering behaviors, R1's record did not include a comprehensive assessment of R1's wandering/exit seeking behaviors that would identify R1's mannerisms, precursors, or behaviors for determination and implementation of individualized interventions for management of wandering/exit seeking behaviors. R1's care plan was not revised until six (6) days after R1 displayed exit seeking behaviors and did not address target behaviors associated with wandering/exit seeking. The care plan included a behavior focus initiated on [DATE] that identified R1 was an elopement risk/wanderer with a history of attempts to leave the facility unattended and impaired safety awareness. Interventions dated [DATE] included: - Assess for fall risk - Distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate -Monitor for fatigue and weight loss R1's progress note dated [DATE], indicated R1's primary provider, Doctor of Medicine (MD)-A, visited the previous day and was updated on attempted on [sic] behavior, increased confusion, and elopement risk ([DATE]). In review of R1's record, it could not be determined what R1's level of risk of elopement was as a result of the R1's increased confusion on [DATE] and not evident R1's care plan was revised. R1's progress note dated [DATE] at 3:44 p.m., indicated R1 took a nap and was disoriented upon waking, looking for his wife. Staff tried to redirect resident showing him pictures of his family, but it did not work. R1's progress note dated [DATE] at 8:30 p.m., indicated R1 went down in the elevator by himself and passed through front door and went outside during dinner time. R1 had refused to come to dinner three times, when staff went to his room after dinner, they found he was missing. Staff conducted a search. A visitor found R1 on a street in the neighborhood and returned him home to the facility. R1 was assessed and appeared stable with no new injuries noted. Family and the on-call physician were notified. R1's progress note dated [DATE] at 8:59 a.m. [sic] indicated contracted registered nurse (CRN)-A was notified by staff that R1 was not on his unit, a full house search was completed, and R1 was located by a visitor on a street in the neighborhood. R1 returned home to the facility with the visitor, did not appear to have any injuries, was started on safety checks every 30 minutes, and the medical director and on-call physician as well as family were notified. R1's first recorded Elopement Risk Evaluation dated [DATE] at 11:22 p.m. identified R1 had a history of attempting to leave the facility without informing staff, wandered, had wandering behavior that was a pattern or goal-directed, and the wandering behavior was likely to affect the privacy of others. The evaluation identified R1 had not verbally expressed the desire to go home/packed belongings/or stayed near an exit door, did not wander aimlessly or in non-goal-directed fashion, and was not admitted or readmitted within the past 30 days with lack of acceptance of the situation. The two sections of the assessment with spaces to enter cognitive evaluation scores were blank. The question does the resident have a history of elopement or an attempted elopement while at home was marked no which was not accurate according to progress notes dated [DATE] and [DATE]. The question Is the resident's wandering behavior likely to affect the safety or well-being of self/others was marked no which was not accurate according to progress notes dated [DATE] to [DATE] when R1 repeatedly demonstrated wandering behaviors while improperly dressed, attempted to elope once, and successfully eloped once. A facility Elopement Incident Report dated [DATE], noted R1's elopement on [DATE] and the corresponding progress note. It further indicated R1 was oriented to person only, had no pre-disposing environmental factors, had predisposing physiological factors including confused and impaired memory, and had none of the above selected from a list of predisposing situation factors. Facility records of R1's elopement lacked a comprehensive causal analysis for the probable root cause that led to R1's elopement for the determination of appropriate interventions to prevent re-occurrence of elopement. R1's physician orders included an order dated [DATE] at 11:30 p.m., resident is on 30 minutes safety check every shift. However, review of R1's record did not include an assessment that corresponded with the determination of 30-minute safety checks. During an interview on [DATE] at 10:20 a.m. DON was not able to identify how R1 was comprehensively assessed to determine 30-minute checks were an appropriate intervention for R1, how R1's needed level of supervision was determined, or how R1's known specific wandering behaviors were monitored. Regarding a root cause analysis of R1's elopement, the DON stated, we have talked about in our IDT [inter-disciplinary team] meeting but haven't sat down to do it. R1's care plan was not revised until 2 days after the incident and did not include target behaviors and interventions associated with wandering/exit seeking. R1's care plan for functional abilities and mobility included an intervention initiated on [DATE], [R1] is able to walk independent[[NAME]] with walker but needs assist and cues to specific destination, particularly longer walks as he will wander and get lost specially if he gets on the elevator. R1's care plan for behavior included an intervention initiated on [DATE]: - Safety checks every 30 minutes - Report immediately to the nurse if resident is not on the unit - Photo at the reception desk. R1's care plan for behavior included interventions initiated on [DATE] that included: - Notify nurse if resident starts exhibiting exit seeking behaviors - Redirect resident if he is wandering. Review of R1's 30-minute safety checks documented on paper between [DATE] through [DATE] identified they were completed by staff member's initials and/or by initials with R1's location inside the facility. No other information pertaining to the checks was documented. Additionally, record did not identify and/or include a monitoring system and/or evaluation for of any wandering behavioral patterns or trends as directed by the care plan dated [DATE]. During a return phone call interview on [DATE] at 3:09 p.m., security officer (SO)-A stated he worked on [DATE] and saw R1 go outside for some fresh air between 6:30 and 7:30 p.m. SO-A was then notified R1 was missing, and he was returned to the facility by visitors. When SO-A asked R1 where he had been going, R1 responded, I was going home. SO-A stated he was not aware at the time that R1 was an elopement risk. SO-A noted he was aware now because R1's photograph had been placed at the front desk and he had received training to redirect R1 or other residents at risk of elopement away from the front door but did not articulate targeted interventions specific to R1's known behaviors. During an interview on [DATE] at 11:33 a.m., contracted registered nurse (CRN)-A stated she was working on [DATE] when R1 eloped. CRN-A stated it was around 6:00 p.m. when R1 was noted missing, and they conducted a full house search. A visitor who had been at the facility for a community event located R1 a few blocks away from the facility on the corner of North [NAME] Ave. and 7th street. CRN-A explained that was a busy intersection, the visitor found R1 on the corner and visitor reported R1 had been afraid to cross the street. R1 was then returned to the facility with the visitor in the personal vehicle at approximately 6:40 p.m. CRN-A noted R1 was placed on 30-minute safety checks upon his return and found to be unharmed. CRN-A identified R1 was not safe alone in the community and was at risk of eloping. CRN-A stated R1 had left the facility because he was looking for his wife and stated she did not have a good answer to how 30-minute checks addressed this behavior except that staff engage him, listen to him. CRN-A noted she might have put him on 15-minute checks, but she knew he was so tired when he returned that he was safe being on 30-minute checks. She further stated she ordinarily would do assessments, find out what activities he likes, what interventions are on his care plan, find out what had been done in the past, and determine what he liked and disliked. CRN-A explained, 30-minute checks seemed to have been what the standard has been at the facility for other residents with behaviors. That's been what they've [facility staff] done . it is just what they've been doing in the facility and that's why they went with 30. She confirmed that she completed an elopement assessment when R1 returned the evening of [DATE], it should have been done prior, I was shocked when I didn't find more elopement assessments on him During an interview on [DATE] at 3:43 p.m., nursing assistant (NA)-A reported she was the nursing assistant for R1 on [DATE] starting at 2:30 p.m. At approximately 2:40 p.m. R1 was in the common area with no pants on looking for his wife and NA-A redirected R1 to his room. NA-A noted she saw R1 exit-seeking and wandering without pants on looking for his wife a second time around dinner and redirected R1 to his room and left him there alone. NA-A then joined LPN-A in the dining room to assist with dinner and stated she did not report these behaviors to the nurse, licensed practical nurse (LPN)-A. NA-A was notified after dinner by LPN-A that R1 was missing. NA-A was aware of R1's continued confusion and desire to leave the unit on [DATE] but was not aware of additional interventions. During an interview on [DATE] at 1:26 p.m., nursing assistant (NA)-C stated R1 seemed to be declining and he just wanders. R1 wanders or try to go down the elevator when he was looking for his wife, thought it was mealtime, or wanted to go to church. NA-C explained staff check on R1 every 30 minutes; checks were documented by initially next to times on a printed paper. NA-C did not indicate any further information was expected to be documented such as what R1 was doing or where he was at the time the check was performed. NA-C stated she had checked on him that morning ([DATE]) at 10:30 a.m., and then went in another room. NA-C stated she wasn't even in there 15 minutes and [R1] had already gone down the hall and to the elevator . he's just that quick. NA-C stated to know who wanders she would ask in report and check the care sheets NA's use. NA-C stated she wished they had a wandering alarm system but was not sure what else to do except just be really diligent about keeping an eye on [R1]. NA-C stated it was definitely not safe for R1 to go out the front door or outside the facility alone and was aware he had eloped from the facility the previous weekend. During an interview on [DATE] at 7:44 a.m., NA-B reported R1 had wandering tendencies, and it was common for R1 to wander while inappropriately dressed, more commonly in the evening. NA-B recalled a time R1 was in his underwear and socks by the elevator looking for something and she redirected R1 to his room. NA-B reported R1 sometimes left the unit on his own, and she would follow R1 if he was agitated. NA-B stated she had concerns about R1 attempting to leave the building independently. NA-B stated some residents had specific charting to complete regarding if behaviors were present, but R1's behavior charting was only as needed. During an interview on [DATE] at 4:00 p.m., licensed practical nurse (LPN)-A stated currently R1 had some confusion, but stated R1 was not at risk for elopement, did not have wandering behaviors, and was not aware of the previous elopement attempt on [DATE]. However, LPN-A stated he worked on [DATE] when R1 eloped from the facility and was returned by a visitor; LPN-A was not aware of who the visitor was. LPN-A recalled the shift he worked on [DATE], he was not made aware of any earlier behaviors that had occurred that day. LPN-A stated earlier during his shift R1 had attempted to go down to church and was redirected. LPN-A did not endorse R1 attempting to go to church as wandering behavior, noted this was a typical behavior, and did not communicate to nursing assistants (NA) of R1's attempts. After dinner LPN-A went to check on R1 and noted him missing. After R1 returned LPN-A assessed R1 and noted no injuries. LPN-A stated he told the aides what happened and to prevent it from happening again, the intervention was checking him every 30 minutes but did not identify any specific behavior monitoring that was put into place. LPN-A was not able to articulate how residents were assessed for elopement risk and thought nursing leadership would follow-up on a need for increased elopement risk for R1. LPN-A identified currently it was okay for R1 to walk around the facility by himself because he doesn't go far. LPN-A articulated since R1's elopement on [DATE], current safety interventions were 30-minute checks and having a photograph of R1 at the front desk. He did not identify targeted behavior monitoring or interventions in place related to R1's known wandering behaviors, tendency to look for his family, and desire to go to church. During an interview on [DATE] at 7:43 a.m., LPN-C stated she was not aware of an official assessment for elopement. LPN-C stated she determined elopement risk by assessing cognitive status, ability, mobility, how alert residents were to their environment, and went from there. LPN-C stated, you just get to know your residents and you just inform staff to be mindful and keep an eye on them. LPN-C stated she would consult a resident's care plan to identify their wandering behaviors and it should note what staff are doing to decrease the changes of the resident leaving the facility or the unit. During an interview on [DATE] at 7:55 a.m., LPN-D stated to her knowledge there was no formal elopement assessment done for residents, but she thought it would be a good idea to have them. LPN-D noted staff would know if someone was an elopement risk or had wandering behaviors by knowing your residents. LPN-D stated she would check care plans for interventions related to wandering behaviors because behaviors can be very specific. During an interview on [DATE] at 1:53 p.m. DON and registered nurse (RN)-A, the DON confirmed the assessment completed on [DATE] was not accurate or complete. DON noted she would consider R1's wandering behavior likely to affect the safety or well-being of himself or others, though the assessment identified this was not likely. RN-A stated she was the MDS RN and had never completed elopement assessments, no one in this building has had an elopement assessment done. The DON stated R1 was not able to safely be out in the community independently. The DON stated she assessed R1's needed level of supervision by looking at his behaviors. DON was not able to further articulate how this assessment process worked, I don't know about the process. If residents require monitoring related to behaviors or falls, historically the nurses automatically implement 30-minute safety checks. DON stated there was no monitoring for R1's wandering behaviors in place prior to the survey. The DON stated she would expect updated interventions to be added to a care plan on the same day as an attempted elopement. She confirmed after R1's attempted elopement on [DATE] his care plan was not updated until [DATE]. RN-A noted R1 later eloped on [DATE] and his care plan was not updated until [DATE] when 30-minute safety checks were added. RN-A confirmed R1's need to be escorted by staff when leaving the unit was not added to his care plan until after surveyors were on site. RN-A further noted that if specific wandering behaviors were not noted on care plans, staff would not know how to manage the behaviors. The DON was not able to identify how the interventions added to R1's care plan related to elopement risk were determined to be individualized, comprehensive, or effective in the absence of a comprehensive elopement risk assessment and behavior monitoring. During an interview on [DATE] at 3:49 p.m., MD-A stated she was aware R1 had eloped. MD-A identified R1 was not safe to be independent in the community and had dementia and a poor cognitive status. MD-A stated R1 was definitely an elopement risk with a history of wandering behaviors. If he eloped, MD-A stated she would be worried about R1 getting lost, falling, or getting hurt and worried about vehicles in the area, people in the downtown community, and cold or weather exposure. MD-A would expect elopement assessments to have been completed, immediate interventions to be implemented, behaviors to be monitored and documented, in addition to strategies to be in place to minimize the risk of further elopements. During an interview on [DATE] at 3:49 p.m., the facility's medical director stated he was aware of R1's elopement on [DATE]. The medical director noted he would expect close monitoring of residents at risk for elopement, including close assessment of wandering behaviors and care planning. The medical director noted residents should be assessed to determine their elopement risk level including day to day behaviors, history, physical, risks such as dementia, and behavior management on admission and periodically. The medical director identified residents with dementia who are at increased risk of elopement as requiring increased monitoring from staff based on their behaviors. The medical director noted someone with a history or dementia and wandering should not be leaving the floor and they should not be leaving the facility . they should be escorted. The medical director stated a resident exhibiting behaviors like wandering in the hallway could be a risk to themselves or others and if they exited the facility could be at risk of getting lost, falling, getting injured due to weather conditions, getting in an accident, and identified the risk as quite high for the facility's location in downtown St. [NAME] and proximity to busy streets. R2 R2's MDS dated [DATE], identified R2 had severely impaired cognition and diagnoses including Alzheimer's disease with late onset and non-Alzheimer's dementia. R2 was ambulatory with substantial assistance from staff and utilized a walker. R2's Activity Assessment/Engagement Profile dated [DATE] identified R2 was able to make basic decisions, had a short attention span and did not follow directions. R2 was not identified as having precautions in place for fall prevention and elopement. R2's progress note dated [DATE], identified R2 came out of her room agitated and worried while calling out loudly several times, where is [NAME]? The writer discovered [NAME] was a six-year-old child that the resident was babysitting. Staff informed resident the child was safe at home with his mother and the mom was very appreciative of help. R2's fall risk assessment dated [DATE], identified R2 was disoriented, but the pre-populated wandering and intermittent confusion behaviors were not selected. R2's progress note dated [DATE] identified R2 attempted to get on an elevator going down which had a staff member in it. Staff attempted to distract R2, but she was determined to get back on and go to her old home stating, I just came yesterday, and I want to see my dog, we live next door. R2 and staff went down to the first floor and R2 did not recognize the area. R2 returned to her room with the assist of a second staff member but did not remain in her room. Staff assisted R2 to go downstairs again and helped R2 walk outside in the enclosed back garden for a few minutes. Staff then returned R2 to the unit who sat outside the nurses' station calmly. R2's progress note dated [DATE], identified R2 was crying on the phone with a family member (FM)-A stating she wanted to go home. FM-A was able to de-escalate. R2's record did not include a comprehensive elopement assessment nor an assessment that identified individualized target behaviors and interventions associated with wandering/exit seeking. Further, R2's record did not identify implementation of immediate interventions after R2's exit seeking behaviors on [DATE] and the care plan was not revised until [DATE], six (6) days after the incident. R2's care plan included a focus on behavior initiated on [DATE] identifying R2 was an elopement risk/wanderer as evidenced by history of attempts to leave facility unattended, impaired safety awareness, hearing and vision loss and intermittent confusion. Interventions dated [DATE] included: - Assess for fall risk - Disguise exits: cover doorknobs and handles, tape floor - Distract R2 from wandering by offering pleasant diversions, structured activities, food, conversations, television, and books - Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. - Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. R2's record did not include an evaluation of R2's pattern of wandering and associated behaviors to ascertain effectiveness of interventions. During an interview on [DATE] at 8:51 a.m., NA-B reported she was aware of R2's wandering and R2 typically wandered in the evening and overnight. NA-B noted R2 would wander looking for food, but not necessarily leave the unit. NA-B stated there was a time R2 was looking for her dog and attempted to leave the floor on day shift. NA-B described R2 as confused and unable to make her basic needs met independently. NA-B stated she had not documented these previously observed wandering behaviors and just let the nurse know when and if she was having them. NA-B noted she would know if someone was an elopement risk by seeing if they tried to leave the unit. During an interview on [DATE] at 11:47 p.m., LPN-B stated sheets of printer paper were taped over the elevator buttons as a distraction for residents that staff did not want getting on the elevator alone. LPN-B identified R2 was a resident she did not want on the elevator by herself because she had been told by another staff member that R2 had a history of confusion and had previously tried to get on the elevator. During an interview on [DATE] at 9:12 p.m., LPN-C reported R2 had wandering behaviors, typically slept all day, would get up between 5:00 p.m. and 6:00 p.m. and wandered around the unit. LPN-C reported R2 had her picture by the front desk, which was generally something done for people at risk of leaving the building. LPN-C reported she thought this was sensible due to the risk of R2 wanting to leave and the risk of her leaving at night. During an interview on [DATE] at 8:44 a.m., family member (FM)-A stated she was aware R2 had been looking for her dog on [DATE] and noted I know she [R2] wants to come home. FM-A stated R2 should not leave the facility on her own and would not know how to get back. During an interview on [DATE] at 1:53 p.m., the DON and RN-A both stated R2 had a known tendency to look for her dog who died a long time ago. The DON stated there are days where R2 gets up and looks for her dog, she walks from her room to the dining room and reported an incident where R2 was looking for her dog on [DATE]. RN-A stated R2 had gone down to the first floor on [DATE] and attempted to leave the facility. RN-A reported no elopement assessment had been completed and confirmed R2's care plan was not updated until [DATE]. RN-A further confirmed R2's record did not contain any elopement assessments and no elopement assessment had been completed. The DON stated she would expect an immediate intervention to be added and for R2's care plan to have been updated and an elopement assessment completed on [DATE] following the attempted elopement. DON noted R2 would not be safe to go out into the community independently and would not be able to make her own decisions safely. The DON confirmed there was no monitoring in place for R2's wandering behaviors. The DON was not able to identify how the interventions added to R2's care plan related to elopement risk were determined to be individualized, comprehensive, or effective in the absence of a comprehensive elopement risk assessment and behavior monitoring. During an interview on [DATE] at 4:07 p.m., R2's primary care physician who was also the facility's medical director reported R2 had severe dementia and patterns of wandering in the hallway. The medical director noted R2 had severe cognitive limitations and impaired decision making due to dementia. He noted R2 would not be successful on her own in the community and would not be safe by herself. The medical director stated, she is an elopement risk and definitely needs monitoring of her wandering behaviors. The medical director expected elopement assessments would have been completed for R2, including an assessment following the elopement attempt on [DATE]. The medical director further expected R2 would be being monitored and I would expect that she would have immediate interventions in place to reduce the risk of elopement. An untitled facility policy regarding elopement dated [DATE] included: All residents are to be assessed for elopement risk and those found at risk will have a resident care plan that addresses the issue . 2.) A Resident Elopement Risk Assessment will be performed at the following times: At time of admission, quarterly, annually, significant change in condition or in Resident behavior, after an elopement attempt, after return from a hospital stay of at least 24 hours, verbalizing desire to leave the facility, anytime a staff member feels a need to reassess a Resident. 3.) If found to be at risk, implement Plan of Care . In the case of an elopement: . 11.) Update Resident's service plan/plan of care to indicate elopement risk and provide approaches to maintain Resident's safety. The immediate jeopardy that began on [DATE], was removed on [DATE], when it was verified the facility implemented the following corrective actions: comprehensively assessed all residents for elopement risk, level of supervision needed, appropriate interventions, efficacy of current interventions, and updated care plans accordingly; reviewed and revised elopement policies and procedures; identified residents at high ris[TRUNCATED]

Based on interview and document review, the facility's governing body failed to establish and implement policies regarding the management and operation of the facility and further failed to ensure the administrator reported to and was held accountable to the governing body. This had to effect all current and future residents residing in the facility. Findings include: Policies: During a review of facility policies, the facility was unable to provide a copy of numerous requested policies which included: policy on physician visits, including frequency; policy on emergency physician care; policy on physician delegation of tasks; policy on physician delegation of dietary orders; policy on governing body; policy on communication between administrator and governing body; policy on administration accountability to governing body; policy on staff licensure verification. Policies provided after requested by surveyors dated after the survey began included: Policy Regarding the Governing Body, Administration Appointment and Accountability to the Governing Body dated 9/28/24; Policy Regarding the Communication of the Appointment of the Administrator and Director of Nursing to MSN [sic, State Agency] dated 9/28/24; Schedule of Physician Visits dated 9/30/24; Policy on Staffing dated 9/30/24, License Verification dated 9/28/24. The Facility Assessment with dates of assessment 1/29/24 to 2/1/24, included a section titled Describe the evaluation process for policies and procedures to ensure that all employees meet current professional standards and practice which noted the following: Our policies and procedures reflect resident needs as well as regulations, rules and laws demanded by the government. Our policies and procedures are reviewed annually and as needed depending on resident needs, new technology, a change in professional standards of practice, as well as a change in the physical plant or environmental hazards. Facility document titled Job Description for the administrator role dated 6/9/91, had an Essential Duties section which included administers, coordinates, and directs all activities of the nursing home, including, but not limited to establishing policies/procedures/programs . Responsible to establish and enforce all facility, departmental, personnel, and resident care policies and procedures in accordance with accrediting agency requirements, standards of practice and the core philosophy of [the organization] . Monitor changes in state/federal regulatory standards and long term care trends and implement new policies as needed. During an interview on 9/30/24 at 3:50 p.m. with the stand-in for the chief executive officer (SCEO), contracted registered nurse (CRN)-A, and the director of nursing (DON), facility policies were reviewed. SCEO stated physician visits are conducted in accordance with regulation, but we just do it, we don't have a policy. The DON stated, I have not seen a policy on emergency physician care. The SCEO, CRN-A, and DON confirmed they were not aware of a policy regarding physician delegation of tasks and the DON stated, I haven't seen a policy that physicians can delegate dietary orders. SCEO noted the governing body consisted of administrator-A as the president, the assistant to the administrator (AA) as the vice president, and CRN-B as the secretary treasurer and they meet annually but was not able to provide any facility policies dated prior to the survey regarding the governing body. During an interview on 10/1/24 at 1:31 p.m., administrator-A stated the governing body was responsible for establishing and implementing policies regarding the management and operation of the facility. Administrator-A stated the Quality Assurance and Performance Improvement team discussed policies at their meeting and they also had consultants for the region who would provide generalized policies that the facility then personalized. Administrator-A noted policies were available electronically on the internal organizational website for their region and quite a few policies and forms had been standardized on the regional level. Administrator: The Facility Assessment with dates of assessment 1/29/24 to 2/1/24, identified the facility's governing board members as the administrator-A, AA and CRN-B. Administrator-A was also identified as the current administrator and chief executive officer. Facility document titled Organizational Chart dated 9/14/24, identified the Mother Superior as the chief executive officer (CEO) of the organization to whom the administrator reported. Facility document titled Job Description for the administrator role dated 6/9/91, included Reports to: Governing Board. The Essential Duties section included Maintain ongoing communication between the facility governing body, supervisors and employees through routine meetings and periodic reports. Facility policy titled Policy Regarding the Governing Body, Administration Appointment, and Accountability to the Governing Body dated 9/28/24, was created and provided to surveyors after entrance. The policy included The [organization members] at [the facility] are governed on a local level by an appointed Mother Superior. She is responsible to a Provincial Superior and her council . The [facility's] Organizational Chart clearly shows that the administrator is directly responsible to the Mother Superior. During an interview on 9/30/24 at 3:50 p.m., regional consultant (RC) stated the governing body functions with the three members (administrator-A, AA, and CRN-B) making decisions, but the Mother Superior [administrator-A] is the final word and then the provincial Mother Superior and on up. The RC stated the provincial Mother Superior is over a group of homes for the sisters [facility's staff in clergy roles], not the residents or employees, but the sisters and the way we operate the homes. During a phone interview on 10/1/24 at 1:31 p.m., administrator-A stated the governing body had not discussed policies regarding the governing board and stated she would agree they were not addressing and not following the recommendations for the governing board. Administrator-A identified herself as the administrator, Mother Superior of the facility, and president of the governing board and stated she was held accountable to her regional director, the regional Mother Superior, who provided oversight of all the homes in the region. Administrator-A was not able to articulate how she, as the administrator, was held accountable and reported to the governing body of which she was president or how she, as the administrator, reported to the Mother Superior of the facility when she occupied both roles. She stated, We do the best we can, we are subject to the regulations, do our best with survey, and do our best with the regulations that are subject to long term care. We are in the process of hiring a lay [non-clergy] administrator. In most of our [the organization's] homes we are separating that function out because it was for many years that the governing body was the administrator also. During an interview on 10/1/24 at 2:12 p.m. with AA and CRN-B they confirmed they were the other members of the facility's governing body in addition to administrator-A. AA stated in the organization's homes the Mother Superior is usually the president of the governing board and in many homes they are trying to now have lay administrators because the Mother Superior and administrator are two different functions. AA noted that for administrator-A to report to the board, the three of them would meet and administrator-A would give us the update on things that were happening and that was basically all I can say. We would meet at the end of the day every day and go through what happened that day, informally. CRN-B stated the oversight for the administrator would be both of us and we would assure that she is doing the correct thing. And like [administrator-A] said, we are religious and we are held accountable, we are truthful and see each other and what is going on. AA stated, the oversight is really provincial [regional-level] . Mother reports to provincial if anything major goes on with the home or there is a problem with anything. AA further stated administrator-A is basically accountable to her [the provincial Mother Superior's] council or her [administrator-A's] team, me and [CRN-B]. AA and CRN-B were unable to further articulate how administrator-A was held accountable to and reported to the governing body when administrator-A was also CEO and president of the governing body.

49338 Based on interview and document review, the facility failed to ensure the Facility Assessment (FA) was complete and included an evaluation of the resident population and its needs using evidence-based data driven methods, the competencies and skill sets for all personnel necessary to provide that care, information on staffing levels needed based on the resident population, a plan for maximizing recruitment and retention of direct care staff, and all contracted services required to meet resident needs. The facility further failed to ensure the FA was conducted with input from all necessary individuals. This had the potential to affect all 36 residents residing in the facility. Findings include Facility assessment dated [DATE]th, 2024 through September 30th, 2024 (after survey entered), identified Administrator-A as CEO/Administrator and governing board. Facility assessment identified director of nursing (DON) to be involved in completing the facility assessment. Dates of assessments with review by QAPI/QAA dated 7/19/2024. The review of the assessment identified the following: 1) Facility assessment identified resident census and population by categorizing diseases and conditions, however lacked evaluation of the resident population and its needs based on acuity using evidence-based data driven methods. Title of acuity over the past year was blank. 2) Facility assessment reviewed for information on staffing levels needed based on the resident population. FA's page 9 identified a staffing plan based on full time equivalent (FTE's), however did not identify staffing levels required for specific shifts such as day, evening, and night and how it would be adjusted based on changes to resident population. 3) Facility assessment did not include competencies and skill sets for all personnel necessary to provide appropriate care. The facility assessment only included: the facility was a roman catholic organization. Various priests and deacons of the Archdiocese of Saint [NAME]/ Minneapolis to see the spiritual needs of our elderly. For those residents of other Christian denomination, pastors of their church come to the facility to offer spiritual help according to the needs of the elderly. 4) Facility assessment did not identify job descriptions for contracted registered nurses, unit supervisor or training. Additionally, it lacked job description/training/competency for volunteers mentioned in the FA related to resident care. Page 10 stated each job description identifies the required education and credentials, however lacks further detail on what is required. Page 11 directs you to refer to training and orientation plan. Training and orientation plan requested and not received. Job descriptions/policies for volunteers and unit supervisors, training and competency requested and not received. 5) Facility assessment reviewed for plan for maximizing recruitment and retention of direct care staff. Page 12 titled Describe the plan to recruit and retain employees who are knowledgeable of appropriate medical practices depending on the care of the residents. Lacked information on recruitment strategies or retention plan. 6) Facility assessment reviewed for plan for all contracted services required to meet resident's needs did not identify specific contracted services such as hospice, therapy, podiatry, audiology, vision or nutrition used in the facility. During interview on 10/2/24 at 8:10 a.m., regional consultant (RC) was unaware of a facility policy for volunteers. During interview on 10/2/24 at 9:48 a.m., Administrator-(B) identified to be the new acting Administrator as of 10/2/24 and reported being aware of the updated guidance and regulations for expectations of FA's. Administrator-B referred to page three and identified the FA described the resident condition and diagnosis, however lacked information regarding acuity. The information about specific staffing needs for shifts and units was not in the facility assessment. Administrator-(B) was unable to identify how the facility used the FA to inform staffing decisions and consider specific staffing needs for each resident until in the facility for each shift. Administrator-(B) reported the FA did not identify a recruit or retention plan. During interview on 10/2/24 at 9:00 a.m., DON reported she would not be the appropriate person to speak to regarding the FA. DON had never seen the FA and was uninvolved in its creation. During interview on 10/3/24 at 11:42 a.m., stand in chief executive officer (SCEO) and contracted registered nurse, CRN-A identified the facility assessment was updated over the weekend (September 28th to 30th). SCEO and CRN-A reported awareness of the updates the facility assessment required, however CNR-A did not feel responsible for mandatory regulatory updates and felt it was an administration duty. SCEO indicated she updated the assessment to include projects and quality meeting dates, but was not able to update any other part of the assessment because she was not in charge of it. CRN-A did not recall reviewing facility assessment at the quality meeting in July because she thought administrator-A had competed the review. During interview on 10/3/24 at 12:08 p.m., DON and SCEO reported the facility assessment was not up to date. SECO reported the facility should have an up-to-date facility assessment which reflected the facility needs. DON reported the facility should have policies in place for education, training, and competency of nursing staff. DON expressed it was very important for the facility to have knowledgeable staff for the work they are responsible for. FA policy requested and not received.

Based on document review and interview the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Q3), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This had the potential to affect all 36 residents residing in the facility. Findings include Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D dated 5/1/24 through 6/30/24 (Q3), identified no triggered metrics for staffing. During interview on 10/2/24 at 2:45 p.m., Providence payroll administrator (PA), reported her job role was to submit and complete the payroll-based journal regionally for Little Sisters of the Poor. PA explained the process was for the contracted services for the sisters who were considered contracted staff to submit reportable hours worked with a sisters contracted service time sheet via email. PA would use those emails to submit time into PBJ. PA was unaware of any process in place for how time was divided between spiritual hours which could not be constituted as direct care and direct care hours. During interview on 10/3/24 at 11:32 a.m., contracted nursing assistant CNA-A was the unit supervisor for the facilities fourth floor. CNA-A reported job duties included assisting getting residents up for the day, transferring residents, assisting in the dining room with tasks such as passing juice and cookies for meals. CNA-A reported residents on the fourth floor were pretty independent and did not require assistance for feeding but she would bring food to the table. CNA-A worked 7 days a week Monday through Sunday and took a vow of hospitality, which was different than an employee. CNA-A explained shifts she would assist with were not in a continuous chunk of time, but an as needed basis. CNA-A explained she assisted when staff called in during the middle of the night and on different floors; her job duties were to fill in and assist in the care of the residents. CNA-A reported the care was broken up and every day was different as far as quantity of hours providing direct job duties. CNA-A reported most of the residents could care for themselves and the care which was provided was spiritual care and talking with residents. The majority of the time and care provided to residents was to help assist residents with internal conflict CNA-A did not have any way of tracking specific hours or documented times of when she provided direct care and when spiritual care was provided. CNA-A's employee file was reviewed; the file did not include a job description that would define contracted staff roles or expectations. Review of the form titled sisters contracted service time sheet for PBJ direct care hours contracted identified contracted nursing assistant CNA(A) under job title of unit supervisor. The form identified CNA-A worked the following hours during quarter 3 (Q3). -5/12-5/25 - 76 hours for day shift 7:00 a.m.-3:00 p.m. -5/26-6/8 -76 hours for day shift 7:00 a.m.-3:00 p.m. -6/9-6/22 -76 hours for day shift 7:00 a.m.-3:00 p.m. -6/23-6/30-40 hours for day shift 7:00 a.m.-3:00 p.m. For a total of 268 hours Review of the facility's PB&J for Q3 submitted to CMS identified the hours the facility reported for contracted and facility staff for CNA-A was 492 hours which conflicted with the 268 hours identified on the facility form. In review of Q3 staffing schedules, CNA-A was not identified, actual direct care hours CNA-A performed could not be ascertained and there was no accounting of the difference of hours between the facility's contracted time sheet and the staff hours recorded and submitted to CMS. During interview on 10/1/24 at 4:04 p.m., certified registered nurse (CRN)-A, reported to work on the floor as needed to provide direct cares for staff call-ins or when the facility needs more assistance with residents. CRN-A did not identify as an employee however, identified as an unpaid volunteer with religious significance. CRN-A was a licensed registered nurse which qualified her to work on the floor as such. CRN-A reported to be active in the facility 24/7 and was weaved into the fabric of the day as needed. CRN-A would assist with all cares including medication pass, transfers and wound care. Additionally, would provide spiritual time as needed throughout the day. CRN-A worked as needed at night for sick call if an employee of the facility was not able to make it. CRN-A was aware of reportable hours for PBJ but was unaware of the details. CRN-A reported there was no way to track the hours and worked in chunks throughout the day as needed. CRN-A was unaware of a process that identified spiritual hours from direct care hours. CRN-A's employee file was reviewed; the file did not include a job description that would define contracted staff roles or expectations. Review of the form titled sisters contracted service time sheet for PBJ direct care hours contracted identified CRN-A under job title of unit supervisor, registered nurse. The form identified CRN-A worked the following hours during Q3. -5/12 -5/25 100 hours for day shift 7:00 a.m.-3:00 p.m. -5/26-6/8 24 hours for day shift 7:00 a.m.-3:00 p.m. -6/9-6/22 72 hours for day shift 7:00 a.m.-3:00 p.m. -6/23-6/30 48 hours for day shift 7:00 a.m.-3:00 p.m. For a total of 244 hours for Q3. Review of the facility's PB&J for Q3 submitted to Centers for Medicaid/Medicare Services (CMS) identified the hours the facility reported for contracted and facility staff for CRN-A was 328 hours which conflicted with the 244 hours identified on the facility form. In review of Q3 staffing schedules, CRN-A was not identified, actual direct care hours CRN-A performed could not be ascertained and there was no accounting of the difference of hours between the facility's contracted time sheet and the staff hours recorded and submitted to CMS. During interview on 10/3/24 at 11:45 a.m., CRN-B reported to assist with bringing residents to church services, going out to different marketplaces asking for community members financial donations, assisting residents with nail care and light activities of daily living (ADL's). CRN-B was aware of providing time to payroll administrator (PA) for accounting purposes. CRN-B did not always complete 8 hour shifts of direct care services as the care was on an as needed bases. CRN-B was unaware of any tracking the facility did for spiritual care versus direct patient care. CRN-B's employee file was reviewed; the file did not include a job description that would define contracted staff roles or expectations. Review of the form titled sisters contracted service time sheet for PBJ direct care hours contracted identified CRN-B under job title of unit supervisor, registered nurse. The form identified CRN-B worked the following hours during Q3. -5/12-5/25 72 hours for day shift 7:00 a.m.-3:00 p.m. -5/26-6/8 72 hours for day shift 7:00 a.m.-3:00 p.m. -6/9-6/22 -80 hours for day shift 7:00 a.m.-3:00 p.m. For a total of 224 for Q3. Review of the facility's PB&J for Q3 submitted to Centers for Medicaid/Medicare Services (CMS) identified the hours the facility reported for contracted and facility staff for CRN-B was 472 hours which conflicted with the 224 hours identified on the facility form. In review of Q3 staffing schedules, CRN-B was not identified, actual direct care hours CRN-B performed could not be ascertained and there was no accounting of the difference of hours between the facility's contracted time sheet and the staff hours recorded and submitted to CMS. During interview on 10/2/24 at 3:03 p.m., human resource manager (HR)-A reported the facility did not have a job description of the unit supervisors nor any contract information for CRN-A, CRN-B or CNA-A on role or contracted services they were able to provide. Request of unit supervisor job description requested and not received. The facility undated policy titled Payroll Based Journal, identified PBJ reporting was to be based on the primary role and/ official job title.

Based on interview and document review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. This had the potential to affect all 36 residents residing at the facility who received care from facility staff, contracted staff, and volunteers. Findings include: SEE F730: Based on interview and document review, the facility failed to complete annual performance evaluations for 4 of 5 nursing assistants (NA-D, NA-E, NA-F and NA-G) who had been employed by the facility for over one year. SEE F947: Based on interview and document review, the facility failed to ensure completion of 12 hours of annual in-service training for 2 of 5 nursing assistants (NA-F, NA-G) reviewed for annual training. Additionally, 1 of 5 nursing assistants had no abuse or dementia training which had the potential to affect all 36 residents in the facility. The Facility Assessment with dates of assessment 1/29/24 to 2/1/24, included Our training program is reviewed and revised as necessary but especially at the time of the Facility Assessment and Refer to Training and Orientation Plan. The Facility Assessment did not identify specific training nor competencies based on the resident population. The facility's training program that was identified in the facility assessment was requested and not received. The facility's Training and Orientation Plan was requested but not received. Policy and procedure regarding training requirements was requested but not received. During an interview on 10/1/24 at 2:50 p.m., the director of nursing (DON) stated she has had concerns about staff education. She noted the facility needed policies to be taken care of and the executive director might be the person to look at policies and identify who is responsible, people needed to be assigned to those duties, and things had been left hanging. During an interview on 10/2/24 at 9:58 a.m., the administrator-B stated he had reviewed the facility assessment and confirmed it addressed the facility's training program. Administrator-B stated he interpreted the facility assessment as directing that staff education is different for every discipline based on their direct care levels, did not see anything identified about education and training for volunteers specifically, and noted the assessment indicated contracted staff would be given a brief orientation and review of the facility prior to coming on to the premise. He was not able to locate further information about competency, training, or education needed for contracted staff. Administrator-B stated the facility assessment referenced a Training and Orientation Plan which should have further details about specific training. During an interview on 10/2/24 at 11:59 a.m. with director of nursing (DON) and human resources manager (HR)-A, DON stated the facility did not have a staff development person to identify and track all the education required for the staff. DON noted nursing staff have competencies completed upon hire at orientation and, after that, based on changes in policies, performance, and new things that happen she had some training's she completed with staff in meetings and on-the-floor training. The DON stated, I do not have an ongoing training plan for nurses after orientation and the competency checklist, and I do not have a standardized plan of training. DON confirmed she did not have one, human resources did not have one, and they did not currently have an employee in the staff development role. The DON confirmed she did not have a facility Training and Orientation Plan as referenced in the facility assessment and furthermore was unfamiliar with the contents of the facility assessment. DON identified a lack of a systemic or structural way of confirming that staff had completed needed education and training's. The DON was unable to identify the amount and types of training necessary for nursing staff or how they were determined and noted that would be in the role of staff development to do those things. HR-A stated, it hasn't been done because there is no process.

Based on interview and document review, the facility failed to ensure completion of 12 hours of annual in-service training for 2 of 5 nursing assistants (NA-F, NA-G) reviewed for annual training. Additionally, 1 of 5 nursing assistants had no abuse or dementia training which had the potential to affect all 36 residents in the facility. Findings include: During interview on 10/2/24 a 4:19 p.m., NA-F was unaware of how many hours of required training was provided but thought required training had been completed. Upon review of NA-F's employee file NA-F did not have 12 hours of employee training. During interview on 10/2/24 at 4:24 p.m. NA-G reported completed online Relias throughout the year. Outside of Relias training NA-G stated the director of nursing (DON) would compose a letter for all staff to sign every three to four months. NA-G reported recalled an incident which happened last year and received dementia training from signing off on a letter. Upon review of NA-G's employee file NA-G had not received 12 hours of annual training or required abuse dementia training. During interview on 10/2/24 at 2:35 p.m., DON and human resources manager HR-A, reported not being able to identify 12 hours of Inservice training for NA-F or NA-G from Relias or in employee files. DON confirmed NA-G did not have abuse or dementia training completed and should have. Training plans requested not received. Facility assessment dated [DATE]th 2024 through February 1st 2024, identified the facility insists staff were expected to be trained with necessary skills to care for the elderly because the staff were the facilities extended hands. Each person hired by the facility were to be determined competent to provide essential services to residents based on self-knowledge, completion of training/competency and licensure or certification. Each job description was to identify the required education and credentials for the job, Staff education and credentials were to have been verified before being hired and checked, at least yearly. Form titled little sisters of the poor job description for certified nursing assistant undated, identified all certified nursing assistants must attend in-services as mandated by local state/federal regulations and to attend department or unit meetings. Core Competencies identified human dignity logical thinking and ethical integrity and ability to prioritize work demands. Nursing assistant job description did not identify abuse or dementia training. 49338

Based on interview and document review, the facility failed to complete annual performance evaluations for 4 of 5 nursing assistants (NA-D, NA-E, NA-F and NA-G) who had been employed by the facility for over one year. Findings include: NA-D personnel record identified a hire date of 4/9/2007, with the last performance evaluation completed on 4/29/2020 and additional one completed in 2016. NA-E personnel record identified a hire date of 3/3/2005, with the last performance evaluation completed on 5/19/2021. NA-F- personnel record identified a hire date of 8/19/2020, with no job performance review. NA-G - personnel record identified a hire date of 04/29/201,5 with the last performance evaluation completed on 5/8/2020. During interview on 10/2/24 at 4:24 p.m., NA-G reported to have been working for the facility for 13 or [AGE] years. NA-G was unaware of when the last performance review completed. NA-G thought it was completed in the last year, however reported the facility has been very busy in the last three years. During a a return phone interview from 10/2/24 at 4:19 p.m., NA-F reported not having a performance review in approximately three years, sometime last done around 2020, NA-F was aware performance reviews were to be completed yearly, however didn't say anything to anyone and was unaware why they had not been completed. During interview on 10/2/24 at 4:27 p.m., NA-E reported the last performance review completed was around 2020 it had been a couple years since last one was completed. During interview on 10/2/24 at 2:35 p.m., human resources manager (HR)-A and director of nursing (DON). HR-A reported the employee files did not include annual performance reviews. NA-D's performance was last done on 4/29/2020, NA-E was last done on 5/19/2021, no record or evidence NA-F had completed a performance review and NA-G's was last completed on 5/8/2020. DON reported the facility did not have a staff development person and the job would be up to staff development to manage those tasks. The process should be for staff to have one completed yearly and it would be submitted to Human Resources and kept in employee files. Policies reguarding performance reviews requested, not received. 49338

Based on interview and document review, the facility failed to have a written transfer agreement with a hospital approved for participation under Medicare or Medicaid programs which reasonably ensured residents would be transferred to the hospital and ensured timely admission. This had the potential to affect all 36 residents in the facility who could require hospitalization on an emergency basis. Findings include: During a review of the facility's policies and procedures, a written transfer agreement was requested to demonstrate the facility had a transfer agreement in place with a Medicare and Medicaid participating hospital. During an interview on 10/1/24 at 2:45 p.m., the director of nursing (DON) stated she was unable to find a written transfer agreement with a hospital. She stated to her knowledge the facility did not have a transfer agreement and had not made a good faith effort to enter into an agreement with a hospital which was refused. Facility policy titled Hospital Transfers dated 11/10, did not address a transfer agreement with a hospital.

Based on interview and document review, the facility failed to report allegations of an unwitnessed fall with serious injury immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for falls. Findings include: A Facility Reported Incident (FRI) submitted to the SA on 2/5/24 at 8:34 p.m., indicated on 2/5/24 at 3:45 p.m., R1 was found on the floor in a face-down position, moaning and groaning in pain. R1 had a large amount of bright red blood all over her face a laceration wound to her forehead. R1 was unable to move her left wrist which was swollen and bruised. A nurse applied pressure to stop severe bleeding. Staff called 911, and R1 was transferred to the hospital by ambulance. R1's After Visit Summary with hospital discharge date d 2/5/24, indicated R1 sustained a traumatic head injury with multiple lacerations. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. R1's progress note dated 2/6/24 at 1:05 a.m., indicated R1 returned to the facility with 6-8 stitches on the forehead. On 2/7/24 at 2:23 p.m., licensed practical nurse (LPN)-A stated when a resident falls and has an injury, it should be reported immediately to a facility supervisor, and within two hours to the SA. On 2/7/24 at 2:49 p.m., registered nurse (RN)-A stated the incident should have been reported immediately, but within two hours. On 2/7/24 at 2:57 p.m., the administrator stated she understood the reporting timeframe was two hours and could not account for why the policy was late. The Abuse Prevention Policy updated 11/2023, indicated injuries of unknown source were reported immediately, within two hours to the administrator and to other officials in accordance with State law.

Based on interview and document review, the facility failed to designate one or more individuals as the infection preventionist who would be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all 38 residents residing in the facility. Findings include: The Infection Preventionist/Staff Development Position Description form indicated the infection preventionist (IP) qualifications included a current registration with the Minnesota Board of Nursing as a registered nurse in good standing, three years nursing experience in a nursing home/geriatric setting or equivalent, prior experience in infection control responsibilities required, and a valid CDC (Centers for Disease Control) nursing home infection preventionist certification. IP-G's resignation letter dated 9/13/23, indicated IP-G's last day of employment was 10/2/23. An Indeed advertisement for the facility IP position indicated an ad was placed on 9/16/23, however under the heading, Job Status was paused. During interview on 1/31/24 at 2:39 p.m., the director of nursing (DON) stated they did not have an IP currently and they did not have a certification and was not trained as an IP. During interview and record review on 2/1/24 at 8:24 a.m., human resources (HR)-F stated there were no current employees designated as the IP and their IP-G left in October 2023. HR-F stated the director of nursing (DON) did not have evidence of additional training for the IP role or any evidence of any certificate in specialized training. HR-F reviewed the DON's personnel record and verified the record lacked any information of additional training that met qualifications for an IP. HR-F further stated the DON was covering and they used Indeed to advertise for an IP and the ad that was placed was on pause because they determined the need for an IP was a part time versus full time position, and stated the facility had nobody who worked as the IP. During interview on 2/1/24 at 9:36 a.m., DON stated the facility had an IP, but left and the DON stated she completed infection control audits, kept lifts clean, and looked at urinary tract infections for QAPI while the facility searched for another IP, but was not an IP and was not trained as an IP. During interview on 2/01/24 10:33 a.m., HR-F stated the facilities only method used for recruiting the IP was advertising on Indeed, and added the problem they had finding an IP was the candidates were not qualified and further stated she released the hold on the advertisement on 2/1/24. See also F880, F883, and F868. A policy was requested but not recieved

Based on observation, interview, and documentation review, the facility failed to ensure hot foods are to be held at 135 degrees Fahrenheit or higher for 1 out of 3 steam tables used to serve food. This has the ability to affect 12 of 38 residents who ate food from the first floor dining room. Findings include: Resident Council meeting minutes were reviewed from 2/7/23, 10/10/23, and indicated on 2/7/23, a resident council agenda under the heading, Old Business indicated hot food being served cold and a person was invited to speak on the subject. Minutes from 10/10/23, indicated the large hot table for serving would open when there were 35 or more people served and the heating carts needed time to heat well, the kitchen must make note that the food is hot when brought out to the dining room. During interview on 1/29/24 at 3:16 p.m., R28 stated many times when eating meals from the first floor dining room, the food is cold when they received it. R28 further stated when you first walk into the main dining room area there is an area where they used to pick up their food and stated the food was hot when they used the tables but was told it was too expensive. R28 further stated mashed potatoes and green beans were cold all the time because they now use a separate warmer that did not keep the food hot and stated cold food had been mentioned previously in resident council meetings. A form, Resident Meal Times revised 1/2/24, indicated breakfast was served from 7:00 a.m., through 9:00 a.m., Lunch was served from 12:00 p.m., through 1:00 p.m., and Supper was served from 5:30 p.m., through 6:30 p.m. During observation on 1/29/24 at 5:32 p.m., R28 was in line at the small steam table and a staff person placed R28's meal on R28's seated walker and R28 brought the meal to the table. During observation on 1/29/24 at 5:34 p.m., the steam table was observed to be plugged into the outlet. During interview and observation on 1/29/24 at 5:37 p.m., cook (C)-A stated they served tater tots, chicken tenders, peanut butter and jelly sandwiches, and bean and ham soup with carrots. During observation on 1/30/24 at 11:48 a.m., kitchen staff were setting up and looking over the the small steam table. It was plugged into the wall. During observation on 1/30/24 at 11:52 a.m., residents were in the dining room on the main level awaiting lunch. During observation on 1/30/24 at 11:54 a.m., food was observed to be brought out of the kitchen to the small steam table. During interview and observation on 1/30/24 from 11:55 a.m., to 11:58 a.m., the food service director (FSD) stated lunch included turkey pot pie, potato wedges, roasted pork loin, mixed vegetables, and oven roasted potatoes. The warmer felt warm on the side towards the kitchen and juice machines. At 11:57 a.m., the turkey pot pie temperature in the small steam table was 184 degrees Fahrenheit, at 11:58 a.m., the potatoes were 158 degrees, at 11:58 a.m., the pork loin was 154 degrees, and at 11:58 a.m., the mixed veggies were 161 degrees. During observation on 1/30/24 from 12:03 p.m., thru 12:17 p.m., residents got in line and received their lunch. At 12:17 p.m., R4 ordered the roasted pork loin and potatoes. During observation and interview on 1/30/24 at 12:18 p.m., to 12:21 p.m., food temperatures were requested after the last resident (R4) was served. C-A stated the potato wedges were 112 degrees and FSD instructed C-A to find a hot one and C-A checked another potato wedge and stated it was still 112 degrees. At 12:20 p.m., FSD stated the pork loin was 125 degrees and stated the temperature drops quite a bit when its wide open. At 12:21 p.m., C-A stated the mixed veggies were 131 degrees. C-A stated food temperatures in the steam tables should be at 135 degrees and further stated in order for the steamer to hold heat, it had to be turned on 2.5 hours early. During interview on 1/30/24 at 12:46 p.m., R4 stated lunch was very good, however it was not warm and stated she had the pork adding nobody wanted to eat cold food and further stated they let staff know when they have conferences that the food is not warm and is not tasty when it is not warm. During interview on 1/31/24 at 7:42 a.m., dietary aide (DA)-C stated they had been using the current small steam table plugged in between the two doors outside the main kitchen by the juice machine about three years, and has heard concerns of food not staying warm enough and added they started using the smaller steam table because of COVID and less residents were coming down to the main dining area and stated it had to be plugged in for 45 minutes. During interview on 1/31/24 at 8:41 a.m., FSD stated he has been with the company for [AGE] years and was newer to the FSD position. FSD stated the small steam table was heated by water and took at least a half hour to warm up. FSD stated it was important to hold foods at the holding temperature for prevention of food borne illness, and for taste. FSD stated they were going to try a new procedure of leaving the steamer on and monitoring the water levels and thought it may be one of the issues of not keeping food up to temperature and verified that holding temperatures should be at 135 degrees. During interview on 1/31/24 at 9:18 a.m., FSD stated 12 of 38 residents ate food in the dining room on the main floor. During interview on 1/31/24 at 11:11 a.m., the maintenance supervisor stated he had just heard about the steam table that day but had not heard anything prior and it wasn't brought to his attention there were any issues with the steam table. During interview on 1/31/24 at 11:28 a.m., the director of nursing (DON) stated they had no copies of temperature logs of foods on the steam tables on the first floor. A policy Food Temperatures undated, indicated all hot foods were held and served at a temperature of at least 135 degrees Fahrenheit (F). Temperatures should be taken to assure hot foods stay above 135 degrees F. and cold foods stay below 41 F before food leaves the kitchen and again on each floor in at steamtable before service.

Based on observation, interview, and record review, the facility failed to ensure unpasteurized eggs were fully cooked and prepared in a manner to prevent food borne illness. This resulted in an immediate jeopardy (IJ) situation for 1 of 1 residents (R19) who consumed the undercooked, unpasteurized eggs and 10 of 10 residents (R10, R13, R20, R25, R27, R29, R46, R47, R56, R157) who were identified to routinely consume undercooked eggs and had an increased risk of contracting a potentially life-threatening food borne illness. The facility also failed to ensure food was prepared, distributed, and served in accordance with safe food handling practices to prevent food borne illnesses and to store food in a manner to prevent biological, chemical, or physical contamination. This had the potential to affect all 59 residents who consumed food from the facility kitchen. The IJ began on [DATE], when the facility prepared and served undercooked (runny yolk), unpasteurized eggs that could cause a potential for food borne illness. On [DATE], at 2:15 p.m. the administrator was notified of the IJ. The IJ was removed on [DATE], at 1:45 p.m.; however, non-compliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy (level E) Findings include: The United States (US) Food and Drug Administration (FDA) article, Egg Safety: What You Need to Know dated [DATE], indicated fresh, shelled eggs may contain a bacteria called Salmonella that could cause food borne illness (food poisoning). People infected with Salmonella may experience diarrhea, fever, abdominal cramps, and vomiting 12 to 72 hours after exposure. Symptoms usually last four to seven days and may be severe enough to require hospitalization . A Salmonella infection could also move from the intestines to the bloodstream and spread throughout the body causing death. Older adults, and people with weakened immune systems (transplant patients, individuals with diabetes, cancer, or [CONDITION(S)] [[CONDITION(S)]] or acquired immunodeficiency syndrome [AIDS]). The article also indicated when preparing raw or undercooked eggs use either shell eggs that have been treated to destroy Salmonella, by pasteurization or another approved method, or pasteurized egg products. The article further indicated using a food thermometer was the only way to ensure the safety of egg products for all cooking methods. These foods must be cooked to a safe minimum internal temperature to destroy any harmful bacteria. A Centers for Disease Control and Prevention (CDC) article, Salmonella and Eggs dated [DATE], indicated Salmonella from the inside of an egg that was raw or lightly cooked could cause illness such as diarrhea, vomiting, fever, and abdominal cramps. The article indicated to use only pasteurized eggs when consuming raw or lightly cooked eggs with an internal cooking temperature of 160 degrees Fahrenheit (F). The article further indicated people who are over the age of 65, or have weakened immune systems ([CONDITION(S)]/AIDS, diabetes, or an organ transplant) may have more serious symptoms that could be life threatening. R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was [AGE] years old with mild cognitive deficits, and had diagnoses of heart failure, stroke, and high blood pressure. R13's quarterly MDS dated [DATE], indicated R13 was [AGE] years old, was cognitively intact, and had diagnoses of diabetes, chronic kidney disease, and congestive heart failure (CHF) (causes water retention in the lungs and lower extremities). R19's quarterly MDS dated [DATE], indicated R19 was [AGE] years old, was cognitively intact, and had a diagnosis of chronic kidney disease. R20's annual MDS dated [DATE], indicated R20 was [AGE] years old with mild cognitive deficits, and had diagnoses of chronic kidney disease and irritable bowel syndrome. R25's quarterly MDS dated [DATE], indicated R25 was [AGE] years old, was cognitively intact, and had a diagnosis of pulmonary fibrosis (scar tissue in the lungs). R27's annual MDS dated [DATE], indicated R27 was [AGE] years old with mild cognitive deficits, and diagnoses of chronic obstructive pulmonary disease ([CONDITION(S)])(inflammation in the lungs), chronic kidney disease, and [CONDITION(S)] (inflammation and/or ulcers in the colon). R29's quarterly MDS dated [DATE], indicated R29 was [AGE] years old, was cognitively intact, and had diagnoses of pulmonary fibrosis and peripheral vascular disease (narrowing of the arteries, usually in the legs). R46's quarterly MDS dated [DATE], indicated R46 was [AGE] years old with mild cognitive deficits, and diagnoses of peripheral vascular disease and chronic kidney disease. R47's quarterly MDS dated [DATE], indicated R47 was [AGE] years old, was cognitively intact, and had diagnoses of CHF, peripheral vascular disease, [CONDITION(S)] (skin cancer) and [CONDITION(S)]. R56's quarterly MDS dated [DATE], indicated R56 was [AGE] years old, was cognitively intact, and had CHF, chronic kidney disease, basal cell [CONDITION(S)] (skin cancer), and diabetes. R157's quarterly MDS dated [DATE], indicated R157 was [AGE] years old with mild cognitive deficits, and diagnoses of stroke, chronic kidney disease, and diabetes. During an initial observation of the kitchen and interview on [DATE], at 11:53 a.m. one opened egg crate of 24 Fair Meadow grade AA Extra Large Originals shelled eggs were on a shelf in the dairy refrigerator next to two, white, sealed boxes that contained 15 dozen of the same eggs. There was no label or markings on the boxes or eggs to indicate the eggs had been pasteurized (a process used to eliminate bacteria and disease-producing microorganisms in foods, such as dairy; often denoted by a P stamped on eggs). The food service manager (FS)-C stated the distributor occasionally delivered unpasteurized eggs by mistake, which FS-C would return because she always ordered pasteurized eggs. FS-C stated she wasn't sure if the eggs were pasteurized or not and would call the distributor to clarify. During observation and interview on [DATE], at 1:43 p.m. FS-C stated the 24 eggs that were in the dairy refrigerator the previous day, had been served for breakfast. In the refrigerator there was a new brown box of donated eggs that was not there the previous day. There was no label or markings on the box or eggs to indicate if they were pasteurized. A carton that held a dozen eggs was removed from the brown box and four eggs were missing from it. FS-C verified the donated eggs had no label or markings to indicate if they were pasteurized or not. FS-C stated the facility poached eggs for certain residents every morning but stated the facility did not serve any undercooked (runny) eggs. FS-C also stated the residents could request undercooked eggs, but she did not like to serve them, even if they were pasteurized, because a nursing home residents' health was already compromised. FS-C called the distributor on [DATE], and was informed the four white boxes of eggs the facility received on [DATE], were unpasteurized. During an interview on [DATE], at 2:12 p.m. dietician (DT)-D stated undercooked, unpasteurized eggs would increase a resident's risk of infection from bacteria and would be a concern. DT-D stated he was unaware the facility had served undercooked, unpasteurized eggs. During an interview on [DATE], at 3:02 p.m. cook (CK)-B stated four white boxes of 15 dozen eggs were delivered on [DATE]. CK-B verified two of the boxes had been used for meals that began on [DATE], and two were unopened in the dairy refrigerator. CK-B further stated at least several residents liked their eggs with runny yolks every morning. During a continuous observation and interview on [DATE], from 6:54 a.m. to 7:45 a.m. in the main kitchen, CK-C removed an egg carton of a dozen eggs, from the brown, (unpasteurized) donated box of eggs in the refrigerator. At 7:05 a.m. CK-C fried the unpasteurized eggs from the carton. CK-C stated she made six fried eggs every morning, for every floor (second, third, and fourth). CK-C stated she used the 24 eggs from the open crate, the previous morning, and would continue to use the donated eggs in the brown box to make fried eggs before she would open the remaining two (unpasteurized) white boxes of eggs. CK-C further stated she always made the fried eggs with runny yolks each morning. At 7:31 a.m. CK-A began to make poached eggs with unpasteurized eggs from the donated, brown box of eggs. CK-A stated she made four poached eggs for the second floor, two for the third floor and two for the fourth floor, every morning. The undercooked, fried (runny yolk observed), and poached eggs were then placed in each floor's hot box for delivery to the residents. At 7:45 a.m. dietary aide (DA)-A came to the kitchen and took the third-floor hot box that contained the poached and undercooked eggs to the residents on the third floor. At 7:49 a.m. DA-A transferred the eggs from the hot box to the steam table. The fried eggs yolks remained visibly soft and runny. DA-A then took the temperature of the eggs that were fried (and unpasteurized) with a runny yolk. The temperature 120 degrees F and poached eggs were 85 degrees F. DA-A stated residents ate the fried eggs every day and this is how we serve it (the eggs) every day. Always the same. At that time DA-A was asked to stop the food service and not serve the undercooked eggs to residents. During an interview on [DATE], at 8:03 a.m. assistant administrator stated unpasteurized eggs should not have been served with runny yolks. On [DATE], at 8:14 a.m., a dietary cart was brought up to the fourth floor. In the heated cart were five plates with scrambled eggs. At 8:16 a.m. dietary staff brought up a covered plate with poached eggs. The dietary staff told the nursing staff to use these eggs if anyone wanted poached eggs. At 8:27 a.m. five more trays were served to residents in their rooms. Interview with nursing assistant (NA)-A at 8:35 a.m., indicated one resident had already received breakfast and always had a fried egg. On [DATE], at 8:37 a.m., R19 was observed in her room with a plate in front of her. On the plate was one half piece of toast, and dried yellow substance. When interviewed, R19 indicated she eats a fried egg every morning with a runny yolk, and had a fried egg this morning. During an interview on [DATE], at 8:16 a.m. CK-A stated she knew the eggs were unpasteurized and should have been fully cooked. CK-A stated she was used to poaching pasteurized eggs with runny yolks that she forgot to increase the cooking time so the yolks would be firm and fully cooked as required when using unpasteurized eggs. CK-A also stated poached or undercooked, unpasteurized eggs could cause the residents to get food poisoning. The IJ that began on [DATE], was removed on [DATE], after it was verified through observation, interview, and record review the facility stopped serving unpasteurized, undercooked (runny yolk) fried and poached eggs to residents. On [DATE], at 12:16 p.m. pasteurized eggs were observed separated from unpasteurized eggs in the main kitchen refrigerator. Signs hung on both shelves indicated the type and proper use for each product. Staff were educated on the CDC guidelines for Salmonella infections including signs and symptoms, treatment, and prevention. Staff were also educated a new policy that required pasteurized eggs to be used when preparing poached and fried eggs to prevent the spread of Salmonella. The staff monitored 10 residents who may have consumed the undercooked eggs since [DATE], and the 1 (R19) resident who was witnessed to consume the undercooked eggs on [DATE]. Documentation indicated no residents experienced adverse side effects from the undercooked eggs and the R19's family was notified of the incident. During an interviews on [DATE], from 11:00 a.m. to 12:30 p.m. all three cooks, and four nursing staff on various floors verified they received training on Salmonella and the proper use and storage of pasteurized and unpasteurized eggs. FOOD SERVICE During a continuous observation and interview, in the kitchen, on [DATE], at 7:04 a.m. to 7:45 a.m. the second-floor hot box (used to transport food from the kitchen to the resident floors) temperature reading was 111.5 degrees Fahrenheit (F), the third-floor hot box was 89 degrees F, and the fourth/fifth floor hot box was 110.6 degrees F. CK-A put the food into metal containers. CK-A covered each container with plastic wrap and placed one in each hot box to be served as a breakfast menu item. At 7:31 a.m. all breakfast food items were in the hot boxes and ready to be served. CK-A stated the DAs and nursing assistants (NA)s bring the hot boxes to the floors around 7:30 a.m. The second-floor hot box temperature reading was 155.8 degrees F, the third-floor hot box was 129.4 degrees F, and the fourth/fifth floor hot box was 156 degrees F. CK-A stated the hot box temperatures should have been at least 155 degrees F but they had been having problems with the third-floor hot box for over a week. CK-A was unaware if maintenance had been notified of the concern. At 7:45 a.m. DA-A came to the kitchen and took the third-floor hot box that contained all the breakfast food items, to the residents on the third floor. At 7:49: a.m. upon arrival on the third floor, the hot box temperature was 132.3 degrees F. DA-A transferred the scrambled eggs and ham, fried eggs, oatmeal, and poached eggs, to the steam table. DA-A checked the temperature of each food item and recorded the temps on the Resident Food Preparation Temperature Log as follows: Hot cereal (oatmeal): 120 degrees F Scrambled egg: 140 degrees F. DA-A stated although the log indicated the food item temperatures should have been above 150 degrees F, that was how she served it every day, always the same. During an interview on [DATE], 12:00 p.m. FS-C stated the poached eggs should have been at least 160 degrees F. FS-C further stated if the hot box was below 155 degrees F, the food items would not maintain the correct temperature for safe food practices and maintenance should have been notified when the staff was first aware of the problem. During an interview on [DATE], at 1:12 p.m. CK-A stated there was a log for each cooking station and she regularly took a temperature of the food before she placed it into the hot boxes, however, she did not record temperatures for the scrambled or poached eggs that morning. During an interview on [DATE], at 1:15 p.m. CK-C stated she took the temperature of the fried eggs and oatmeal that morning but did not write it in the log. CK-C and CK-A also verified there were no other temperatures logged for that cooking station since [DATE]. During an interview on [DATE], at 1:59 p.m. maintenance supervisor (MN)-A stated [DATE], was the first time he was notified about the third-floor hot box not working properly. MN-A stated the staff should have notified the maintenance department within a day or two of realizing there was a concern. FOOD STORAGE During the initial kitchen observation on [DATE], at 11:53 a.m. the following food items were found in the dry storage room: -approximately one-gallon (gal) of red wine vinegar: best by [DATE]. -thickened dairy drink: expiration (exp.) [DATE]. -Ensure Plus protein supplement drink box: exp. [DATE]. -[MEDICATION(S)] 2.0 supplement drink: exp. [DATE]. -four, one half gal thickened cranberry juice bottles: exp. [DATE]. -approximately a five-quart (qt) container, half full of almonds: date placed in container was ,d+[DATE]. -approximately an eight-qt container of orange colored sugar: date placed in container was [DATE]. -four out of five 66.5-ounce (oz) cans of Hidden Bay Skip Jack [MEDICATION(S)] packed in water salt added, had large dents near the top or bottom rims. One dent was approximately three inches long by one inch deep on the bottom rim: no expiration dates were noted on any of the cans. -six lb. can of sauerkraut had approximately a half inch deep dent on the top rim and two puncture-type dents on the top lid that did not appear to break the seal. The following food items were found in the main kitchen freezer: -chocolate boxed candy: dated [DATE]. -multiple boxes of turkey Italian sausage links: freeze by [DATE]. The following food items were found in the main kitchen refrigerator: -multiple single serve raspberry yogurts: best by [DATE]. -chocolate, ready to eat, desserts for dinner service covered with clear plastic, on a tray: not dated. -approximately two-gal container of tzasikis sauce: opened with no open date. -a large plastic tub of individual sour cream packets: exp. [DATE]. During an observation on [DATE], at 5:15 p.m., the 4th floor Tea Room refrigerator contained 11 four ounce (oz) containers of strawberry banana yogurt, all with an expiration date of [DATE], and four, four oz containers of raspberry yogurt with an expiration date of [DATE]. Also, four vanilla Mighty shakes (nutritional shake) and three strawberry Mighty shakes were observed in the refrigerator drawer. The mighty shakes were unfrozen, and were undated. Registered nurse (RN)-B verified the yogurt was expired and indicated the dietary staff was responsible for the items in the refrigerator. RN-B indicated the day nurse was responsible to remove the mighty shakes from the freezer, and verified the policy on the side of the refrigerator which indicated, when frozen health shakes are moved from the freezer to the refrigerator they must be labeled with the date they were moved. Shakes must be used with 14 days of thawing. RN-B did not know when the shakes were thawed. All eleven resident of the fourth floor had access to the expired yogurt, and one resident had a physician order for nutritional shake. During an observation and interview on [DATE], at 5:35 p.m. half of a resident's chicken salad wrap, in a plastic container from a grocery store was found in the third floor dining room, resident refrigerator, and dated [DATE]. FS-C stated the wrap should have been thrown out and could have caused the resident to get sick if they ate it. During an observation on [DATE], at 1:43 p.m. in the dry storage room, multiple large canned items including four, 103-ounce (oz) cans of salsa, corn, and beans had been removed from their original cardboard shipping boxes and lacked an expiration date. During an interview on [DATE], at 2:12 p.m. DT-D stated he had previously found expired items in the main kitchen such as yogurt and milk and had mentioned it to FS-C. DT-D also stated that FS- took care of the kitchen and food storage and that he was not really involved in it. During an interview on [DATE], at 3:02 p.m. CK-B stated orders were usually delivered on Tuesdays and Fridays. CK-B stated when new items are placed on the shelf, they should go behind the current items to ensure the older items were used first. CK-B also stated all items in the dry storage room were currently being served to the residents. CK-B was unsure when the almonds dated [DATE] or the orange-colored sugar dated [DATE], would expire. CK-B stated dented cans were acceptable to use if the seal was not broken. During an interview on [DATE], at 7:11 a.m. CK-B and CK-C to check the expiration dates on items before they use them or when they are stocking new items. CK-A stated most items could be frozen for six months to a year and still be used. CK-A confirmed the sour cream packets were expired and should not be used; however, CK-A did not know when the almonds, orange-colored sugar, or any other items poured into a plastic container for storage, would expire. CK-A also stated they would serve items from dented cans such as the [MEDICATION(S)] but not if the cans were punctured and the seal was broken. During an interview on [DATE], at 11:18 a.m. NA-B stated the NAs were responsible for throwing out food that was expired in the dining room refrigerators on each floor. NA-B also stated she thought the DAs were responsible for cleaning each floor's dining room refrigerators but there was no cleaning schedule. During an interview on [DATE], at 11:22 a.m. registered nurse (RN)-D stated on the fourth floor, the NAs are responsible for the refrigerator in the resident dining room. During an observation and interview on [DATE], at 11:23 a.m. trained medical assistant (TMA)-A stated the NAs on the fourth-floor check for expired food every day. TMA-A also stated there was a log for cleaning and defrosting the refrigerator once a week. Upon inspection of the refrigerator, one hard-boiled egg dated ,d+[DATE] was found. TMA-A stated the egg should have been thrown out since it is a week old. During an interview on [DATE], at 11:28 a.m. NA-A stated the TMAs and NAs were supposed to clean the fifth-floor dining room refrigerator every Sunday and check for expired food every shift. During an interview on [DATE], at 12:42 p.m. FS-C stated items that were acidic, like vinegar, or high in salt don't expire. FS-C also stated many items had an expiration date listed in Roman numbers even though they appeared not to have an expiration date listed. FS-C stated the Roman expiration date could be looked up online but that she was unfamiliar with how to read them. FS-C further stated, staff could ask her to look up orders online to find the expiration date of items that were removed from their original packaging. FS-C stated many of the items that were expired were donated but offered no further explanation of the donation process or whether the items were being served to the residents. The facility Handling Foods policy dated ,d+[DATE], indicated Salmonella bacteria can grow inside fresh, intact eggs and therefore, eggs should be cooked until the yolk and white are firm, not runny. The policy also indicated not to use recipes that require raw or partially cooked eggs. The facility Minimum Cooking and Reheating Food Temperatures and Holding Times policy dated ,d+[DATE], indicated raw eggs prepared for immediate service were to hold a minimum internal temperature of 145 degrees F for 15 seconds and raw eggs not for immediate service were to hold a minimum internal temperature of 150 degrees F for one minute and 145 degrees F for three minutes. The facility Food Temperatures Requirements policy dated ,d+[DATE], indicated calibrated thermometers were to be used to temp food before putting the food into food trucks (hot boxes). The policy also indicated hot carts (hot boxes) were to remain plugged in and the temperatures set properly to ensure food is served hot. The facility Leftover Food Shelf Life policy dated ,d+[DATE], indicated leftover foods containing mayonnaise should be discarded after three days and all other leftovers should be discarded after seven days. The policy also indicated the food service manager, the a.m. and p.m. cooks were responsible for discarding expired leftover food daily. The facility Food Safety Requirements (use and storage of food and beverages brought in for residents, food procurement) policy dated 2017, indicated education on safe food handling would be provided to all staff, family, residents, resident council, visitors, and community groups who may provide food to the residents. The policy indicated the education would include leftovers being used or discarded within three days. The policy further indicated staff would be appointed to check resident refrigerators and dispose of items per facility policy. The facility Infection Control policy dated ,d+[DATE], indicated the food service manager was responsible for all donated and purchased food items. The policy also indicated damaged packages were to be returned to the vendor. The policy further indicated the nursing department was to check temperatures and clean all nursing unit refrigerators and food storage areas. The facility Cold Storage policy dated ,d+[DATE], indicated turkey sausage could be frozen for one to two months. The facility's Reception and Use of Food Items and the Prevention of Food Borne Illnesses policy dated [DATE], indicated the food service manager would oversee all donated food item's receiving, storing, preparation, and serving, in accordance with federal, state, and local regulations, to prevent food borne illnesses. The policy also indicated dented, soiled, or bulging dry goods, and cans were to be discarded.