Every finding on record at Maple Crest Manor

Based on observation, document review, policy review, and staff interview, the facility failed to prepare the correct puree servings and serve the dietician approved pureed menu to 4 of 4 residents reviewed (Resident #13, #19, #32 and #36). The facility identified a census of 38 residents. Findings include:The Week Five 5/5/26 Dietician Approved Pureed Menu for lunch on 7/7/26 listed the following:a. 3 ounce (oz) lemon garlic pork loinb. 4 oz Pasta Alfredoc. 4 oz broccolid. 1 slice garlic toaste. 1 square pumpkin earthquake cake.Observation on 7/7/26 at 11:25 AM, Staff D, Dietary stated she planned to prepare five servings of pork loin. Staff D measured out 16 oz of pork loin, placed in the blender and added two ladles of gravy to the blender and blended. Staff D checked the mixture and added additional ladles of gravy to the blender and blended again. At 11:32 AM the Dietary Supervisor informed Staff D to measure. Staff D proceeded to take the same 4 oz scoop that she measured the pork loin with and scooped four, 4 oz serving from the blender into a steam pan. The blender had over 1/2 cup of the mixture left in the blender. Observation on 7/7/26 at 11:39 AM Staff D placed four, 4 oz servings of broccoli into the blender. Staff F added milk and blended the mixture. Staff D checked the mixture and added more milk and blended again. Staff D using the same 4 oz scoop placed four, 4 oz scoops of the broccoli puree into a steam pan and placed the pan in the oven. The blender still had approximately 1/2 cup of broccoli puree left in the blender. Observation on 7/7/26 at 11:46 AM Staff D stated she would prepare five puree servings of the pumpkin earthquake cake. Staff D placed five cake squares into the blender and added milk, then blended. Staff D added milk to the blender three more times as she prepared the puree. Staff D took a 4 oz spoodle and scooped out four spoodles of the cake puree and placed each 4 oz scoop into individual dessert bowls. The blend had approximately one cup of cake puree mixture left in the blender. Staff D failed to measure the total volume of food and utilize the Pureed Diet Portion Sizes/Dishers Chart to obtain correct serving sizes after more volume was added during the food preparation. Staff D failed to puree the pasta alfredo and the garlic bread. Resident #13, 19, #32, and #36 were not served the approved menu. Observation on 7/7/26 at 1:10 PM revealed Resident #13, #32 and #36 had eaten almost all of the pureed food and staff continued to assist Resident #19 with her meal. Interview completed on 7/7/26 at 2:35 PM, Staff F, Dietary explained when she prepared pureed food, she looked at the menu for each item to get the correct serving size. She used the appropriate scoop size to place the number of servings she needed into the blender, then added whatever liquid she needed to puree. Then she used the scoop size from the menu to serve out the pureed food. Staff F failed to identify she would measure the total volume of the pureed mixture and use the Pureed Diet Portion Sizes/Dishers chart to ensure a corrected serving size for each resident. During an interview on 7/7/26 at 3:00 PM the Dietary Supervisor reported she expected the staff to measure the total volume of the puree mixture during food preparation, then use the Pureed Diet Portion Sizes/Dishers Chart that was on the refrigerator in the kitchen to get the correct serving size. She reported the cook had not prepared and served out the pasta alfredo and a substitution had not been provided. She failed to identify that the garlic bread had not been provided. The How to Measure Correct Puree Foods Policy dated 2026 directed to measure the appropriate number of servings into the blender (i.e. 3 oz of meat x 4 servings = 12 oz meat). Add liquid, such as milk or meat broth. Blend to a pudding consistency. Use thickener if necessary. Pour all the blended product into a measuring pitcher to measure the amount of product and refer to the Pureed Diet Portion Sizes/Dishers Chart for serving sizes. The Puree Food Preparation Policy, 2026, directed residents receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet.

Based on observation, 2017 United States (US) Food and Drug Administration (FDA) Food Code, document review, policy review, and staff interview the facility failed to ensure food was dated when stored, maintain clean equipment per the cleaning schedule, prevent soiled gloves from contacting food, failed to wash hands between glove changes and before starting new tasks, maintain appropriate cold beverage temperatures, and ensure staff entering the kitchen wore hairnets. The facility identified a census of 38 residents. Findings include: During an initial visit to the kitchen on 7/6/26 at 9:32 AM the following observations were made:a. Staff C, Dietary Aide had two bottles mild thickened consistency Cranberry juice (one 1/2 full and one 1/4 full); one bottle thickened Peach Mango juice (1/4 full); and one bottle of mild thickened consistency orange juice 1/2 full as she placed pieces of tape dated 7/4/26 onto each bottle. When queried if she was just now dating the bottles, Staff D responded, yes. The bottles contained a statement to discard the product if not used within 10 days. b. The microwave had an orange, greasy, tacky substance splattered throughout the top, back and sides of the microwave. c. The refrigerator contained a bottle of mild thickened water, 1/4 full, undated. The Label directed if the product was not used within 14 days to discard the product. A gallon of chocolate milk, 1/2 full was undated. d. Observation of the griddle revealed a black stuck down tacky substance coming out from the back part of the griddle down the entire length of the right side of the griddle from the back to the front. And approximately 10 inches from the back toward the front of the griddle on the left side. A large blacked area extended from the right middle part of the griddle out approximately 10 inches toward the middle of the griddle. e. The oven directly below the griddle observed with a thick black, gritty, stuck down substance a from the right side of the oven extended from the back to the front of the oven and out to the middle of the oven with a piece of tin foil rumpled up in the middle of the black, gritty, tacky substance.During a follow-up visit to the kitchen on 7/7/26 at 10:51 AM all the observations from 7/6/26 were still present. Further observation at this time revealed:a. The electric toaster contained a build-up of a brown/black gritty tacky, substance along all the horizontal bread holders. The bottom of the toaster had a brown, red, rust type surface approximately 5 inches deep and 12 inches across filled with bread crumbs.b. A large bowl with two 3-inch by 4-inch blocks of butter sat next to the electric toaster covered with plastic wrap, undated. c. The freezer contained an open, untied, undated bag of breaded shrimp. A bag of French fries with a 1.5-inch rip in the bag with fries exposed, a bag of four, 8 to 10 inch pie crusts, undated with an approximate 2 inch tear in the bag with crusts exposed, a plastic bag 1/2 full of snickerdoodle cookies, undated, 1/2 bag frozen bread rolls unsecured, and undated, 1/2 plastic bag of frozen bread cubes, undated. d. The refrigerator contained a 1/2 gallon of white milk, undated, a 5-pound container of sour cream, 1/2 full, undated, a 16 ounce container of chicken base, 1/2 full, undated. e. A brownish black gritty substance noted along the top of the ice machine. A finger swipe along the top of the top of the ice machine brought up a black, moist substance. The Dietary Supervisor reported she had seen that. f. Observation of the griddle revealed a black stuck down tacky substance coming out from the back part of the griddle down the entire length of the right side of the griddle from the back to the front. And approximately 10 inches from the back toward the front of the griddle on the left side. A large blacked area extended from the right middle part of the griddle out approximately 10 inches toward the middle of the griddle. The oven under the griddle continued to have a black tacky substance from the right side of the oven extended from the back to the front of the oven and extended out into the middle of the oven with a piece of tin foil rumpled up in the middle of the black gritty, tacky substance. Further observation at 10:58 AM Staff D, Dietary placed a sheet pan of garlic bread in the oven that would be served for lunch. g. The first steam table well from the left-hand side contained a black sticky, gritty, stuck down substance approximately 24 inches in length and 12 - 14 inches across. The second well had a black stuck down substance along the front half of the well. At 11:01 AM the Dietary Supervisor asked if there was a special way to clean it. The third well had a black orange stuck down substance along the left side of the well approximately 12 inches in length and 8 inches in width. The area below the steam table shelf had food spills extending approximately 8 inches in length down the steam table above the burner dials extending from each well. At 11:07 AM the Dietary Supervisor reported she had spilled something in the first steam table well a while back and it was hot so by the time she got done it was stuck down. h. At 11:10 AM the Dietary Supervisor stated she had to find some testing strips to test the quat sanitizing bucket. She was told if the buckets were premixed, they no longer had to test the buckets. At 11:12 AM the Dietary Supervisor returned to the kitchen and tested the Quat bucket. Review of the [Brand Name] Testing Strips showed they were expired 6/1/23. i. At 11:20 AM Staff D failed to wash her hands, applied a glove to her right hand, and grabbed a bag of breaded shrimp with her right gloved hand, used scissors placed in her right gloved hand to cut open the bag of shrimp, dumped the bag of shrimp out onto a baking sheet, the proceeded to take her right gloved hand in a sweeping motion across the breaded shrimp pieces to smooth them into a single layer on the baking sheet. j. At 12:12 PM Staff D placed her left hand on the left upper part of her uniform and wiped it along her face, then proceeded to place foil over a pan of breaded shrimp and placed it on the steam table without washing her hands. k. At 12:17 PM Staff D place a dirty spoodle into the dishwasher, then proceeded to set up clean tongs and scoops on the steam table preparing for the noon meal without washing her hands. l. At 12:24 PM Staff D opened a drawer and removed a white handled, 3-ounce scoop by touching the inside of the scoop directly with her left hand which had touched multiple surfaces. She placed the scoop into the pureed pork loin to serve Resident #32. m. At 12:41 PM Staff D placed dirty dishes into the dishwasher, then returned to the steam table without washing her hands and plated up Resident #6 lunch meal and served it out. At 12:42 PM Staff D obtained the food processor blade and canister from the dishwasher, touched the food processor blade to place directly into the food processor with her bare hand, placed Resident #1's serving of pork loin into the food processor and proceeded to grind the meat which was served out to Resident #1. n. At 12:45 PM the Dietary Supervisor washed her hands, proceeded to remove several packages of meat from the refrigerator and dispose of it into the garbage. She then took a package of meat and a bag of white bread and placed it on the front preparation table. She donned gloves and opened the bread bag with her left hand and reached into the bread bag with her right gloved hand to remove two slices of bread placing the bread on a plate. She then picked the bread up with the left glove to hold the bread in place as she buttered the bread with a knife in her right hand. Then she opened the meat package with her gloves, removed three slices of meat with the same gloves and placed the meat on the bread. She steadied the sandwich in her left gloved hand as she cut the sandwich in half with a knife in her right hand, then picked up the two sandwich halves with her soiled gloves and placed the sandwich on a plate. The sandwich was served out to Resident #28. o. Continuous observation of the meal service provided on 7/8/26 from 12:21 PM to 1:17 PM revealed various juices, a gallon of white milk and a gallon of chocolate milk in a square cold container positioned in front of the steam table. The cold container did not contain any ice. At 1:17 PM Staff D placed a thermometer in a glass of white milk at the end of the meal service which revealed a temperature of 44.5 degrees Fahrenheit.During an observation and interview on 7/7/26 at 1:18 PM Staff D took a sip of the glass of milk and made a wrinkled face, slightly shaking her head side to side, stating she would like the milk to be colder. She explained 44 degrees was not an appropriate temperature for the milk. Staff C informed Staff D the temperature guide was hanging on the [redacted] refrigerator. Staff D walked over to the [redacted] refrigerator. A sign outlined cold beverages were to be maintained between 38-40 degrees. On 7/7/26 at 2:35 PM Staff F, Dietary reported she was the afternoon cook. She explained during the supper meal they placed the juice and milk bottles in a cold container on a cart to serve out during meals. They did not put ice in the cold container. They had the hot/cold temperatures posted on the refrigerator. She stated milk should be held at 35 degrees. She further explained gloves were used for a single task only, then staff needed to wash their hands after they removed the gloves. The griddle and the ovens were to be cleaned every week. The steam table could not be cleaned with abrasive chemicals, so she just tried to wipe it down with soap and water the best she could. They tried to do a deep cleaning on the steam table once a week. The microwave was supposed to be wiped out twice a day. She had a cleaning chart every weekend that she had to complete. The Dietary Supervisor placed a list of duties in the communication book for them to follow-up on. Staff F didn't think they tested the quat buckets on a regular basis as part of their regular duties. She had not tested the bucket since she was hired. They didn't have any place to document any type of check. Observation on 7/7/26 at 2:40 PM revealed therapy personnel entered the back door of the kitchen without wearing a hairnet and obtained ice from the ice machine. Observation on 7/7/26 at 2:55 PM revealed Staff G, Registered Nurse (RN) in the kitchen without a hairnet on and poured two cups of coffee to take out to residents. The Point of Care Audit Report for Dietary Cleaning documented the following cleaning:1. Microwavea.7/6/26 at 1:47 PM by Staff H.b.7/6/26 at 5:30 PM by Staff I.c.7/7/26 at 2:07 PM by Staff D.d.7/7/26 at 7:14 PM by Staff F.2. Refrigerator Outdated Food:a.7/6/26 at 1:46 PM by Staff H.b.7/7/26 at 2:07 PM by Staff F. 3. Steamtable:a.7/6/26 at 1:47 PM by Staff H.b.7/6/26 at 6:52 PM by Staff I.c.7/7/26 at 2:07 PM by Staff D.4. Stovetop/Griddle:a.7/6/26 1:46 PM by Staff H. b.7/6/26 at 5:29 PM by Staff I. c.7/7/26 at 2:06 PM by Staff D. d.7/7/26 at 7:10 PM by Staff F. 5. Toastera.7/6/26 at 1:46 PM by Staff H. b.7/6/26 at 5:30 PM by Staff I. c.7/7/26 at 2:06 PM by Staff D. d.7/7/26 at 7:15 PM by Staff F. During an interview on 7/7/26 at 3:00 PM the Dietary Supervisor reported the steam table was to be wiped out every shift with soapy water. According to the manual, they could not use any abrasive cleaners. The microwave was to be cleaned out after each shift with soapy water. She stated the ovens are to be cleaned weekly and they really don't use the griddle anymore. The staff were to place ice in the cold containers with the drink containers during the meal to keep items cold. Ideally, she would like to have the cold temperatures held at 37 degrees. She expected the staff to use hairnets before coming into the kitchen. They hung racks outside of the kitchen to remind staff to wear the hairnets. Staff should wash their hands before and after glove use. Once they finished a task, they should remove the gloves and wash their hands. Ready to eat foods should be handled with gloved hands. The Dietary Supervisor explained she had a daily cleaning list that moved to the computer and they were documenting on the computer. On 7/7/26 at 3:35 PM the Consulting Dietician, present during the Dietary Supervisor interview, stated it was obvious they needed to work on some things. The Cleaning Duties and Schedules Policy, undated, directed the dietary area would be kept clean and in an orderly, sanitary way. The Policy Procedure directed the kitchen would be cleaned each day as the regular work schedule states, and every week, the kitchen would receive an extra thorough cleaning by a dietary staff person. The policy further stated extra cleanings were listed with names of those responsible for completing them. These were to be initialed as completed. The Dietary Manager would file. The Deep Cleaning List directed on week 2 for the AM cook to clean the ovens, the oven drip trays, and wipe the stove down. The (Brand Specific) Electric Sealed Well Food Warmer Service Manual for the steam table under Maintenance, Stainless Steel Care and Cleaning directed to use non-alkaline-based or non-chloride cleaning solutions. Anything containing chloride will damage the protective film on stainless steel. Chlorides are found in household and industrial cleaners and also in hard water and salts. If a chloride or alkaline cleaner has been used, rinse repeatedly and dry thoroughly. Always use only soft cloths or plastic scouring pads. For routine cleaning, use warm soapy water. For stubborn stains, use a non-abrasive cleanser. For heavy grease, use a degreaser. For best results, rub with the grain of the steel.The Glove Use in Food Service Policy, undated, directed the staff to wash hands thoroughly before and after wearing or changing gloves. When feasible, no direct contact with food should occur. Sanitized utensils should be used for handling ready-to-eat foods. Change gloves whenever changing activity. Wear gloves only when needed. The Hand Washing Technique Policy, undated, directed to wash hands before and after contact with a source of microorganisms (body fluids, mucous membranes, nonintact skin). The Ready to Eat (RTE) Foods Policy, undated, directed tongs would be used for RTE foods. RTE foods could not be handled with bare hands. The Food Temperature Check Policy, undated, directed cold beverages should be held less than or equal to 38-40 degrees Fahrenheit.The Food Storage Policy, undated, directed all opened food would be dated and sealed before returning to storage. The Cleaning Oven Policy, undated, directed ovens would be cleaned weekly and as spills occurred. The United States Food and Drug Administration 2017 Food Code outlined:a. Chapter 2, Section 2-402.11 Food employees shall wear hair restraints such as hats, hair coverings or nets that are designed and worn to effectively keep hair from contacting exposed food. b. Chapter 2-301.14 When to Wash (hands) directs food employees to clean their hands and exposed portions of their arms immediately before engaging in food preparation, after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, before donning gloves to initiate a task that involves working with food, and after engaging in other activities that contaminate the hands. c. Chapter 3-301.11 Preventing Contamination from Hands directs food employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves or dispensing equipment. d. Chapter 4, part 4-6 Cleaning of Equipment and Utensils directs at 4-601.11 (B) food contact surfaces of cooking equipment shall be kept free of encrusted grease deposits and other soil accumulations; non-food contact surfaces of equipment must be kept free of accumulations of dust, dirt, residue and other debris.

Based on observation, interview, record review, and policy review the facility failed to ensure a staff member treated a resident with dignity and respect regarding an interaction between the resident and Staff O, Certified Nursing Assistant (CNA) for 1 of 3 sampled residents reviewed for dignity (Resident #27). The facility reported a census of 38 residents.Findings include:Review of Resident #27's Minimum Data Set (MDS) dated [DATE] documented the resident had short-term and long-term memory problems and had severely impaired cognitive skills for daily decision-making. The assessment indicated the resident experienced physical and verbal behavioral symptoms directed toward others on 4 to 6 days during the 7-day look-back period. Per the assessment, the resident used a wheelchair and had impairment on both sides of her lower extremities. Resident #27 was dependent on staff for hygiene, bathing, dressing, and transfers. The resident frequently experienced urinary and bowel incontinence. Resident #27's diagnoses included non-Alzheimer's dementia and depression, and she received hospice care.Review of Resident #27's Care Plan, initiated on 12/24/24, revealed a focus on Activity of Daily Living (ADL) self-care deficit related to aggressive behavior and dementia. The care plan goal directed staff to help the resident maintain her current level of function. Interventions initiated on 3/27/25 directed staff to accommodate the family's preference to let the resident sleep in, and to offer breakfast snacks, cereal, toast, or supplemental drinks when she woke to prevent weight loss. Toileting interventions initiated on 2/3/25 required the assistance of two staff members for toilet use. Transfer interventions initiated on 1/14/25 required a two-person pivot transfer with a gait belt, handheld assistance, or a grab bar.A second Care Plan focus initiated on 12/13/24 identified that the resident was physically aggressive toward staff who tried to intervene and redirect related to dementia, The intervention initiated on 12/29/25 directed staff to clear clutter, reduce noise, and create a calm and supportive environment, considering factors like temperature and lighting. An intervention for agitation, initiated on 12/29/25, instructed staff to intervene before agitation escalated, guide the resident away from distress, and engage calmly in conversation. If the resident responded aggressively, staff received instructions to walk calmly away and approach her later. Review of the Director of Nursing (DON) Recap, titled Events from 5/29/26 investigation, revealed the DON wasn't present in the facility on 5/29/26. The Assistant Director of Nursing (ADON) served as the on-call supervisor that day. The DON checked the phone around 11:00 AM and returned a phone call to the Administrator at 11:03 AM. When asked about the situation, the Administrator replied he called to keep the DON in the loop because Staff L, Licensed Practical Nurse (LPN) heard Staff O, CNA yelling at a resident and intervened. The DON requested specific details regarding the identity of the resident, the words spoken by Staff O, and whether the interaction constituted abuse or an approach issue. The Administrator repeated the initial statement. The DON requested a complete description including the who, why, what, where, and when to understand the situation. The Administrator stated he read what happened, reported the incident to the Department of Inspections, Appeals, and Licensing (DIAL), and sent Staff O home for the day. The DON noted the lack of details made it difficult to provide direction or assistance without being onsite and stated she would speak with Staff L. The DON asked the Administrator what Staff O said during their office meeting, and the Administrator replied he hadn't met with Staff O yet. The DON messaged Staff L to schedule a follow-up call, and Staff L responded that the ADON and the Administrator handled the matter. The ADON later called the DON, read staff statements, reported that the Administrator called DIAL, and noted that resident and staff interviews indicated a coachable moment rather than suspected abuse. On 6/1/26, the DON returned to the facility and asked the ADON about the status of the investigation. The ADON stated she gave the information to the Administrator, who planned to complete the investigation. The Administrator remained out for the day on 6/1/26. The DON called Staff O to obtain her statement. Staff O stated she raised her voice because the resident hit her and it hurt. Staff O told the resident it hurt and asked her to stop. On 7/8/26 at 11:52 AM, Staff O, CNA stated on the morning of 5/29/26, she worked the 6:00 AM to 2:00 PM shift, communicated well with the day staff, and coordinated care duties with her partner, Staff M, CNA, while Staff L served as the hall nurse. Staff O and Staff M entered Resident #27's room and approached her quietly to avoid agitation. Staff O noted Resident #27 required a two-person transfer. Resident #27 selected her clothing, and when the staff attempted to stand her up from the toilet, Resident #27 began hitting and pinching Staff O. Staff O explained that sitting the resident back down to reapproach would create a safety hazard. While Resident #27 struck her, Staff O used a stern voice and told the resident it hurt and asked her to stop hitting. Resident #27 later ate breakfast, and management subsequently instructed Staff O to go home.Staff O further stated Resident #27 exhibited aggressive behaviors daily, typically sat by the nurse's station, and experienced frequent mood shifts despite being generally sweet and kind. Staff O noted the resident hit, pinched, and grabbed staff on multiple occasions. The facility instructed staff to remain calm, talk through procedures, and suggested customer service. Management later suggested Staff O review online CNA customer service education modules and recommended staff maintain eye level during reapproaching techniques. On 7/8/26 at 12:17 PM, Staff N, CNA, stated she worked on the [redacted] hallway around 8:30 AM on 5/29/26. She observed Staff O used an inappropriate tone of voice with Resident #27. Staff N noted she witnessed Staff M going to assist Staff O, and the tone of voice caused her concern.On 7/9/26 at 9:41 AM, Staff M, CNA, stated Resident #27 could be hard to get up. Staff O and Staff M assisted Resident #27 into the bathroom, where the resident began displaying her typical behavioral symptoms. Staff O began yelling at Resident #27, which Staff M disliked, prompting Staff M to call the Licensed Practical Nurse (LPN), Staff L, into the room. Staff O continued yelling while Resident #27 pinched, scratched, bit, kicked, and hit Staff O. Staff O yelled at Resident #27 to stop it and knock it off. Staff M noted sometimes had to get stern, but not in a mean way.On 7/9/26 at 9:36 AM, Staff L, LPN, stated she didn't witness the physical interactions between Resident #27 and Staff O. She heard Staff O yell at Resident #27 to stop, quit, and avoid those actions. Staff L explained felt the interaction went too far, though she didn't suspect abuse. Resident #27 appeared slightly worked up but remained safe after the incident. Staff L noted Resident #27 pinched, scratched, spit, bit, kicked, and hit staff, and Staff L had experienced these behaviors firsthand. Staff L described Staff O as a naturally loud person who should've used a quieter voice to instruct Resident #27 to stop.On 7/9/26 at 10:28 AM, Staff K, CNA and Restorative Aide, stated Resident #27 participated in activities and transfers depending on her daily mood. She exhibited positive behaviors when staff allowed her to wake up on her own, but she hit and kicked staff on difficult days. On the morning of 5/29/26, Staff K stood at the nurse's station while Staff O and Resident #27 remained in the resident's room. Staff K heard Staff O yelling at Resident #27 to stop being rude and telling her she acted rudely. Staff L entered the room to check on the situation. Staff K characterized the voice as more than just a loud voice. On 7/9/26 at 10:21 AM, Staff J, CNA, stated Resident #27's behaviors depended heavily on the day. She experienced good moods, but she also spit, grabbed, pinched, and cursed at staff on difficult days, particularly during morning care when staff woke her up.On 7/9/26 at 10:43 AM, the DON stated the facility assigned customer service education to the staff and initiated visual audits on Resident #27.The facility's undated Residents' [NAME] of Rights policy instructed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, The facility must protect and promote the rights of the resident.

Based on clinical record review, Centers for Medicare and Medicaid (CMS) Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 User Manual, facility policy review, and staff interview, the facility failed to ensure nursing staff accurately completed Minimum Data Set (MDS) assessments for 2 of 15 residents reviewed (Resident #23 and Resident #7). The facility reported a census of 38 residents. Findings include: 1.Resident #23's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 had a diagnoses of Alzheimer's Disease and received an antipsychotic medication. The May 2026 Electronic Medication Administration Record (EMAR) lacked documentation Resident #23 received an antipsychotic medication in the 7 day lookback period. Review of Resident #23's Clinical Physician Order list included Aricept (Donepezil) (a medication classified as a cholinesterase inhibitor and used to treat dementia) Oral Tablet 5 milligram (mg), give 1 tablet by mouth in the morning with start date 2/13/26. On 7/8/26 at 10:16 AM, during an interview, the Assistant Director of Nursing (ADON)/MDS Coordinator confirmed she was responsible for completing the MDS Assessments for residents, and had completed the MDS assessments for Resident #23 and #7. The ADON/MDS Coordinator explained she thought that the Centers for Medicare and Medicaid (CMS) had classified drugs used to treat dementia, like Donepezil and Memantine, as antipsychotics. The ADON/MDS Coordinator reported both residents took Donepezil, so she had coded them as receiving an antipsychotic medication. Review of the facility policy, titled Conducting an Accurate Resident Assessment, dated 2025, revealed, in part, Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status). 2a. Resident #7's Significant Change in Status MDS assessment dated [DATE] documented diagnoses of Non-Alzheimer's Dementia, and the resident received antipsychotic medication during the seven day look-back period. The May 2026 EMAR lacked documentation Resident #7 received antipsychotic medication. The EMAR documented Resident #7 received Donepezil Hydrochloride Tablet 10 mg, give 1 tablet by mouth at bedtime related to vascular dementia with unspecified severity, psychotic disturbance, mood disturbance and anxiety. Start date 5/24/24. The EMAR showed all doses signed out as administered from 5/1/26 – 5/27/26. During an interview on 7/8/26 at 2:46 PM, the Director of Nursing (DON) reported she didn't know what the MDS Coordinator used as a drug resource guide to code antipsychotic medications. Originally when she discussed it with the ADON, she referenced when she put a physician order in the electronic healthcare record (EHR), it would come up as a psychotropic medication or neuropsychotropic medication and that is where she was getting it from. Then the ADON reached out to the pharmacist and the pharmacist stated no as well. On 7/8/26 at 2:55 PM, the ADON reported she swore she received an email communication regarding information to code those medications as antipsychotic medications. When queried if she was aware that the RAI Section N required medications to be coded based on the drug classification, she responded not off the top of her head. She explained she used the RAI to code the MDS, but some of it could be the interpretation of how you read it. The LTC RAI User's Manual October 2025 revealed per Chapter 3, Page N-6 under Coding Instructions to code all high-risk drug class medications according to their pharmacological classification, not how the medications are used. Page N-9 further directed: a. Facilities may wish to identify a resource that their staff consistently use to identify pharmacological classification as assessors should be able to identify the source(s) used to support coding the MDS 3.0. b. Assessors should consult the manufacturer's package insert, which may contain the medication's pharmacological classification. They can also work with the resident's pharmacist to confirm the medication classification(s) for a resident's medication(s). c. Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. 2b. Resident #7's Quarterly MDS dated [DATE] documented diagnoses of respiratory failure and exhibited shortness of breath/trouble breathing when lying flat. The MDS lacked documentation Resident #7 utilized oxygen. The June 2026 Electronic Treatment Administration Record (ETAR) showed a physician order for oxygen 2-5 liters per nasal cannula for comfort, every shift, start date 5/29/26. The ETAR showed nursing staff signed off the oxygen daily as provided during the 7 day lookback assessment period. During an interview on 7/8/2026 at 9:33 AM the ADON/MDS Coordinator explained she reviewed progress notes, talked with the staff, and she filled out an MDS Assessment Worksheet with the resident information when she completed the MDS. The ADON provided the last quarterly MDS Assessment Worksheet which showed Section O oxygen with continuous circled. She reported the MDS was a miscode and needed to be modified. The CMS RAI User Manual, October 2025, Chapter 3, Section O, Page O-4 directed to code continuous or intermittent oxygen administered via cannula.

Based on observation, clinical record review, manufacturer user manual, policy review, and staff interview, the facility failed to change and date oxygen tubing and maintain a clean exterior filter for 1 of 1 resident receiving oxygen therapy (Resident #7). The facility identified a census of 38 residents.Findings include:The Minimum Data Set (MDS) Assessment for Resident #7 dated 6/15/26 showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. The MDS documented Resident #7 exhibited shortness of breath when laying flat and a diagnosis of respiratory failure. The MDS lacked documentation Resident #7 utilized oxygen therapy. An 5/29/26 Order Audit Report showed a physician order for oxygen via nasal cannula, 2-5 liters for comfort. Observation on 7/6/26 at 12:20 PM revealed Resident #7 sat in the wheelchair at the dining room table with portable oxygen running at 2 liters per nasal cannula. Further observation revealed the oxygen tubing was not dated. During an observation on 7/6/26 at 2:09 PM, Resident #7 lay in bed resting with oxygen running at 2 liters per nasal cannula continuously per concentrator. The oxygen concentrator external filter noted with a white, gritty white film and the oxygen tubing was not dated to indicate when the tubing had been changed. Observation on 7/7/26 at 6:35 AM revealed Resident #7 lay in bed with oxygen running continuously at 2 liters per nasal cannula per oxygen concentrator. The oxygen tubing was not dated and the condition of the external concentrator filter was unchanged. Observation on 7/8/26 at 7:30 AM revealed Resident #7 lay in bed with oxygen running per nasal cannula at 2 liters per oxygen concentrator. The oxygen tubing lacked a date and the external concentrator filter condition was unchanged. A 7/8/26 review of Resident #7's Care Plan revealed the Assistant Director of Nursing (ADON) updated the Congestive Heart Failure Care Plan to include the use of oxygen on 7/8/26. A 7/8/26 review of the June and July 2026 Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) lacked documentation nursing staff changed the oxygen tubing or cleaned the concentrator external filter. Interview on 7/8/26 at 9:07 AM revealed Staff A, Certified Medication Aide (CMA) reported they checked oxygen saturation levels several times a day on Resident #7. His oxygen was ordered for his comfort and he tolerated it well. Night shift changed the oxygen tubing, but she didn't know when, how often, or where they documented the change. On 7/8/26 at 9:10 AM, Staff B, Licensed Practical Nurse (LPN) reported the oxygen tubing was changed by the night shift, but she didn't know where the nurses documented the change. She thought it would be documented on the ETAR. Staff B reviewed Resident #7's ETAR and reported she did not find any documentation. Observation on 7/8/26 at 9:11 AM revealed Resident #7 sat in the wheelchair in his room and got a haircut. Resident #7 received oxygen at 2 liters per nasal cannula from the oxygen concentrator. The oxygen tubing was undated and the concentrator external filter condition was unchanged. On 7/8/2026 at 9:12 AM, the Director of Nursing (DON) explained the oxygen tubing was changed every 14 days. When queried how often the external filter was rinsed out and cleaned, the DON checked the monthly cleaning list and stated the changing of the oxygen tubing was not on the cleaning list and the ADON would have more information as she took care of the oxygen. On 7/8/26 at 9:18 AM, the ADON explained the oxygen supplier addressed the cleaning of the filter. At this time, the DON informed the ADON Resident #7 did not have an order to have his oxygen tubing changed. Observation on 7/8/2026 at 9:27 AM revealed the ADON walked down to Resident #7's room and stated the oxygen concentrator was one of the facility's concentrators. The oxygen concentrator external filter was removed and revealed a white, gritty film visible 1/4 inch into the half-inch filter. The ADON confirmed the external filter was dirty and needed to be cleaned. She reported she had completed batch orders for the oxygen care for residents, but Resident #7 was not in the orders. She further explained the nurses were responsible to get the oxygen orders, so the nurses missed setting up an order to change the oxygen tubing and cleaning the filter. On 7/09/26 at 11:25 AM, the DON reported she had talked with the night nurse last night and the night nurse stated they do wash out the external oxygen filters on the oxygen concentrators, but they don't document it. She further reported, the facility did not do any maintenance on the oxygen concentrators, they called a vendor that maintained the machines. The DON referenced if not documented, it was not done. The Oxygen Policy, 2025, documented a purpose was to establish responsibilities for the care and use of oxygen concentrators. The Policy under Care of the Concentrator directed to follow the manufacturer's recommendations for the frequency of cleaning filters and servicing of the device. The Nurse Responsibilities included to change the oxygen cannula/tubing every 14 days. The Oxygen Concentrator (Brand Specific) Patient Manual under Filters revealed, Air enters the unit through an air intake gross particle filter located on the back of the oxygen concentrator. The filter removes dust particles and other impurities from the air. Make sure the filter is clean and positioned correctly before the unit is in operation. On a weekly basis, wash the air intake gross filter (external concentrator filter). Remove and wash in a warm solution of soap and water. Rinse the filter thoroughly and remove excess water with a soft absorbent towel, then replace the filter.

Based on observation, clinical record review, document review, resident interview, and staff interview, the facility failed to provide adaptive equipment of divided plates necessary to meet resident needs for 2 of 7 residents sampled (Resident #12 and #30). The facility identified a census of 38 residents.Findings include:On 7/7/26 the facility provided a Diet Order Excel Spread sheet, updated July seventh. The List identified seven resident that required the use of divided plates, including Resident's #12 and #30. A 7/7/26 review of Resident #12's Nutritional Problem Care Plan, dated 2/24/26, related to a diagnosis of Parkinson's Disease lacked direction to provide a divided plate for meals. A 7/7/26 review of Resident #30's Potential for Nutritional Problem Care Plan noted a diagnosis of Parkinson's Disease and included a 4/14/26 intervention per Occupational Therapy (OT) recommendations to provide a divided plate for meals.Observation on 7/7/26 at 12:35 PM revealed Staff D, Dietary plated a serving of broccoli, breaded shrimp, and cocktail sauce on a regular plate which was served out to Resident #12. Staff E, Dietary looked at Resident #12's meal ticket as she took the plate from Staff D and continued to serve the plate out to Resident #12. Resident #12's Meal Ticket at the bottom under Adaptive Equipment listed to use a divided plate. Observation on 7/7/26 at 12:54 PM revealed Staff D plated breaded shrimp, French fries, garlic bread on a regular plate which was served out to Resident #30. Resident #30's Meal Ticket at the bottom under Adaptive Equipment listed to use a divided plate.On 7/7/26 at 2:15 PM, Resident #12 reported she usually received her meals in a divided plate and she had received her lunch meal on a regular plate. Resident #12 reported it would have been nice if her lunch would have come on her divided plate as she lost a lot of food off her plate and on the floor when she tried to eat lunch. Resident #12 stated she needed her divided plate. On 7/7/26 at 2:25 PM, Resident #30 reported she usually received her meals on a divided plate but had a regular plate today. Resident #30 reported it did not cause her any issues at lunch. Resident #30's family member stated she had received finger food, so she was able to eat her lunch off of the regular plate, but she was supposed to get her meals on a divided plate. On 7/7/26 at 2:36 PM Staff F, Dietary stated the adaptive equipment was listed on the resident's meal ticket and on a list above the steam table. They checked the list as they served out the meals. During an interview on 7/7/26 at 3:00 PM, the Dietary Supervisor reported she was not aware Resident #12 had not received her meal on a divided plate, but the Director of Nursing (DON) reported Resident #12 had not received her divided plate. They communicated the adaptive equipment on the meal tickets and also on a cheat sheet on the steam table that communicated who got the divided plates. Staff should check the ticket and the list as they served out the meals.

Based on clinical record review, review of the facility's hospice contract, and staff interview, the facility failed to ensure the written agreement with a contracted hospice included required language to address immediate hospice administration notification in the event of alleged abuse by hospice staff for 1 of 1 resident reviewed with hospice services (Resident #16). The facility reported a census of 38 residents. Findings include:Review of the Care Plan for Resident #16, dated 7/5/2026, revealed a focus area of hospice level of care related to terminal prognosis of CVA (stroke) and heart failure and identified a Hospice A as the provider. On 7/8/2026, review of the facility's contract with Hospice A, dated 9/23/2015, revealed, in part, the contract included the following language: .Incident reporting. Any of the following alleged incidents involving a Hospice Patient residing at a Facility: mistreatment or neglect; verbal, mental, sexual or physical abuse; injuries of an unknown source; or misappropriation of patient property. The contract language failed to specify facility staff must report alleged incidents of abuse, mistreatment, neglect or misappropriation of resident property by hospice staff to the hospice administrator immediately when the facility becomes aware. On 7/08/2026 1:28 PM, during an interview, the Administrator reported that they did not have an updated contract with the hospice that included the required language that was missing from contract, dated 9/23/2015.

Based on clinical record review, and resident and staff interview the facility failed to complete pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis services (Resident #24). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) for Resident #24 dated 4/9/25 documented the Resident's diagnoses included hypertension, renal insufficiency, and diabetes mellitus. The MDS documented the Resident received dialysis while a resident at the facility. The Care Plan for Resident #24 included a focus area of care of a resident on dialysis services. The interventions included dialysis 3 times a week. It also included to document and monitoring of complications, pre and post dialysis weights and access site. The Care Plan directed nurses to complete pre and post dialysis assessment twice a day on Mondays, Wednesdays, and Fridays before and after her dialysis treatments. During an interview on 5/20/25 at 9:34 AM, Resident #24 explained she went to dialysis 3 times a week, on Monday, Wednesday, and Friday. She further explained she rides the public transit bus Monday and Wednesday but on Friday her kids take her. Review of the clinical record including assessments and the Progress Notes revealed the pre-dialysis assessment had not been completed on 11/22/24, 12/2/24, 2/17/25, 5/5/25, 5/7/25 and 5/9/25. Further review of the clinical record revealed the post-dialysis assessment had not been completed on 8/5/24, 9/9/24, 9/16/24, 10/4/24, 10/14/24, 12/9/24, 1/17/25, 2/17/25, 2/26/25, 2/28/25, 3/3/25, 4/4/25, 4/7/25 and 5/9/25. During an interview on 5/21/25 at 2:35 PM the Assistant Director of Nursing (ADON) explained she expects both pre and post dialysis assessments to be completed. She acknowledged the clinical record was lacking assessments as listed above.

Based on observation, clinical record review, staff interview, and facility policy review the facility failed to utilize enhanced barrier precaution for 1 of 1 residents reviewed (Resident #39). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #39 dated 4/24/25, listed diagnoses of hypertension, coronary artery disease (CAD), and depression. The MDS included a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairments). The MDS identified an indwelling urinary catheter for Resident #39. The Care Plan for Resident #39 dated 5/1/2025, revealed the diagnosis for the indwelling catheter as hydronephrosis with ureteropelvic junction (UPJ) obstruction occurs when a blockage at the point where the kidney connects to the ureter (the tube that carries urine to the bladder) causes urine to back up and swell the kidney. The Care Plan failed to direct the use of enhanced barrier precautions (EBP). The Treatment Administration Record (TAR) dated 5/2025, directed to monitor catheter output every shift. On 5/21/25 at 11:31 AM, a sign hung on the wall outside of Resident #39's room door undated that read STOP ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: The sign direct providers and staff must: Wear gloves and a gown for the following high contact resident care activities, that included device care or use: urinary catheter. The bottom of the sign identified the guidance came from the United States Department of Health and Human Services Centers for Disease Control (CDC) and Prevention. On 5/21/25 at 11:32 AM, Staff A, Certified Nurses Aid (CNA) entered Resident #39's room, explained the need to empty his urinary catheter bag. She completed hand hygiene applied gloves and emptied the urine from the catheter bag. She took the urine into the bathroom and dumped it into the toilet. Staff A failed to wear the gown for the EBP as she completed the high contact activity with Resident #39. On 5/22/25 at 10:22 AM, the Assistant Director of Nursing (ADON) Infection Preventionist (IP) reported she expected staff to use EBP with cares for any resident with a catheter. The need to wear gloves, gowns, and face shield in case of a splash. The ADON stated Staff A reported to her after she completed the cares for Resident #39, that she failed to use the needed EBP. On 5/22/25 at 2:30 PM, the ADON/IP reported the EBP needed to be included in the Care Plan, then it would show on the Kardex. On 5/22/25 at 1:31 PM Staff A reported she forgot to use a gown when she emptied Resident #39's catheter leg bag. The facility provided Enhanced Barrier Precaution Policy undated that directed, Purpose: EBP require the use of gowns and gloves during high-contact resident cares. Implementation: The policy is particularly relevant for residents with chronic wounds or indwelling medical devices. This policy aligns with guidelines from the Center for Disease Control (CDC) and Centers for Medicare & Medicaid Services (CMS) to ensure safety and infection control in long-term care facilities. She stated they follow the CDC guidelines.

Based on observation, clinical record review, policy review, Novolog highlights of prescribing information (manufacturer's directions for use) review, and staff interview, the facility failed to prime an insulin pen with 2 units of insulin prior to the administration of the physician ordered dose of insulin for 1 of 1 residents observed for insulin administration (Resident #4). The facility identified a census of 37 residents. Findings include: Resident #4 Minimum Data Set assessment dated [DATE] showed a Brief Interview for Mental Status score of 8 indicating moderate cognitive loss. The MDS listed a diagnosis of diabetes mellitus and documented Resident #4 received insulin injections 7 days per week. The Care Plan dated 9/18/23 noted a diagnosis of diabetes mellitus and directed the staff to administer medications as ordered by the doctor. The December 2023 Medication Administration Record (MAR) detailed the following physician orders: a. Blood sugar check four times a day before meals and hour of sleep for diabetes mellitus management. b. Novolog Flex Pen Subcutaneous Solution Pen-injector 100 units (U)/milliliter (ML). Inject as per sliding scale: if 0 - 149 = 0; 150 - 199 = 2 units; 200 - 249 = 5 units; 250 - 299 = 6 units; 300 - 399 = 8 units; 400 - 499 = 10 units, subcutaneously four times a day related to type two diabetes without complications. During an observation on 12/19/23 at 7:12 AM Staff B, Licensed Practical Nurse (LPN) completed a blood sugar as ordered with a result of 190. Staff B obtained a Novolog Flex insulin pen, attached the needle without wiping the connection site with an alcohol swab, then set the dial to 2 units. Staff B locked the medication cart and walked two feet into Resident #4's room doorway when she was stopped by the Surveyor. Staff B reported she didn't know how to prime the insulin pen and would have to go ask the Director of Nursing (DON). Staff B walked up to the nurse station and asked the Assistant Director of Nursing (ADON) if she knew how to prime the insulin pen. The ADON explained to Staff B to set the insulin pen to 2 units and express the insulin pen until you see a drop of insulin come out of the tip which indicates the pen is working, then set the pen to the amount of insulin that you need. The ADON primed the insulin pen. Staff B set the pen to 2 units after the pen was primed. At 7:20 AM Staff B administered Resident #4 Novolog 2 units of insulin holding the pen to Resident #4 abdomen, pressing the dose knob down and immediately removing the needle from the abdomen after depressing the insulin pen. Staff B failed to hold the insulin pen for a full 6 seconds to ensure all the insulin had been fully administered. On 12/20/23 at 7:14 AM the ADON reported she expects the nurses to administer the insulin medication as ordered by the physician and per the manufacturer's direction for use. The Administration of Insulin via Insulin Pen Policy dated 1/17/19 provided by the facility documented a purpose to provide medication regimen safely and effectively. The Policy Procedure directed the nurse to wipe the rubber seal with an alcohol swab before pushing the capped needle straight onto the pen, prime the insulin pen by turning the dose knob to 2 units, holding the pen with the needle pointing up, push the dose knob until it stops and a zero is seen in the dose window, hold the dose knob in until insulin is seen at the tip of the needle. If an insulin drop is not seen after the first attempt, repeat the process. The Novolog Highlights of Prescribing Information under priming the Novolog Flex Touch Pen instructed the following: a. Turn the pen dose selector to select 2 units. b. Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. c. Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. d. A drop of insulin should be seen at needle tip. If an insulin drop is not seen, repeat the priming steps, no more than 6 times. e. If an insulin drop is still not seen, change the needle and repeat the priming steps. f. Under giving the injection the following steps were listed: keep the needle in the skin after the dose counter has returned to 0 and slowly count to 6. When the dose counter returns to 0, the full dose of insulin is not administered until 6 seconds later. If the needle is removed before the count to 6, a stream of insulin may be seen coming from the needle tip. If a stream of insulin comes from the needle tip, the full dose has not been administered.

Based record review, document review, staff interviews, and the facilities Quality Assurance Performance Improvement (QAPI) Plan the facility failed to implement a successful QAPI program for 1 of 1 repeated citations. The facility reported a census of 37 residents. Findings include: A Summary Statement of Deficiencies and plan of corrections dated 2/25/21 and 6/23/22 documented citation F582 Beneficiary Notices cited from the two prior recertification surveys. The facility submitted plans of correction which included ongoing monitoring of the process to ensure compliance. On 12/19/23 at 9:00 AM Staff C, Registered Nurse reported the facility has 2 -4 skilled residents receiving Medicare Services at any given time. The Summary Statement of Deficiencies dated 12/21/23 included the following repeat deficiency of F582. On 12/21/23 at 10:04 AM the Administrator acknowledged the facility had addressed their beneficiary notices through the QAPI program from the prior annual survey and had not fully fixed the process. She reported going forward they will be putting processes in place through the QAPI program to address and correct their system. The Quality Assurance and Performance Improvement (QAPI) Plan Policy, undated, provided by the facility documented the QAPI program aimed for safety and high standards of quality of care with all clinical interventions. The facility ensures all data collection and monitoring systems to gather accurate data and promote quality using the best available evidence-based practice material to define and measure goals. The Facility tracks, investigates, and monitors adverse events and implements action plans through the plan, do, study, act cycle of improvement to prevent recurrence of issues. The Facility approach comprehensively assesses all involved systems to prevent further events and promotes sustained quality of improvement.

Based on clinical record review, document review, and staff interview, the facility failed to provide a Medicare Notice of Non-Coverage (NOMNC) notification to the resident or their legal representative two days prior to the ending of services and failed to provide the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) notice for 2 of 3 residents sampled (Resident #4 and #21). The facility identified a census of 37 residents. Findings include: 1. A Point Click Care (PCC) Electronic Census record showed Resident #4 admitted to Medicare Part A skilled services on 10/20/23 and discharged off of Medicare services on 10/26/23. A SNF ABN detailed Resident #4 would incur out of pocket expenses as of 10/28/23 due to no longer requiring care by a licensed therapist and no longer requiring skilled level of nursing care at $410 per day. The Resident Representative indicated the Resident did not want the care listed. The Resident representative signed the notice on 10/31/23. A NOMNC form detailed Medicare services would end on 10/27/23 explaining the Resident's appeal rights if they did not agree with the decision to end Medicare services. The Legal Representative signed the notice without a date indicating when they had been notified of their rights. The facility failed to provide a two day notice to the Resident's legal representative. 2. A PCC Electronic Census record showed Resident #21 admitted to Medicare Part A skilled services on 7/10/23 and discharge from service on 7/18/23. A Discharge of Therapies Notice detailed Resident #21 planned discharge from physical and occupational therapy services on 7/18/23. The Notice documented the facility as notified on 7/14/23. The Facility lacked documentation of a SNF ABN or NOMNC being provided to the resident or their legal representative. On 12/20/23 at 10:17 AM the Administrator reported the facility did not have a beneficiary notice policy. During an interview on 12/20/23 at 10:20 AM the Administrator reported she had been in the social services position prior to taking the Administrator position. She had been serving the beneficiary notices prior to September 2023. The MDS Coordinator took over serving the beneficiary notices in September 2023. The Administrator reported therapy provides them with a notice of when therapy will be ending. They try to call the legal representative/family the same day as the notice and see if they can come to the facility to sign the notices. If not, they mail the notices out to the legal representative/family. She reported they try to give a two day notice.

Based on clinical record review, staff interview, and policy review, the facility failed to provide a bed hold notice for 2 of 2 residents reviewed (Resident #10 and #21). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 11/22/23 for Resident #10 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of the Clinical Census revealed Resident #10 transferred to the hospital on 1/07/23, 1/17/23, and 4/8/23. The clinical records for Resident #10 lacked documentation of any explanation of the bed hold notification to the resident or the resident's representative when the resident discharged to the hospital on 1/07/23, 1/17/23, and 4/8/23. On 12/20/23 at 8:43 AM, the Administrator reported she did not have a bed hold for the January and April transfers to the hospital. She reported the nurses do the bed holds when a resident transfers either with the resident or calls the family and gets a verbal consent to hold the bed and documents it. On 12/20/23 at 8:47 AM, the DON reported the bed hold is in the transfer packets and she expects the nurses to complete them. If it is not completed and she gets a verbal with the family then she should document it. A review of the facility Bed Hold Policy lacked documentation on when the resident or the resident's representative is provided a bed hold form upon transfer to the hospital. 42133 2. A Health Status Note dated 5/12/23 documented Resident #21 went from the clinic to the local emergency room . The facility was notified the Resident had been moved to the medical surgical floor. A Nurses Note dated 5/15/2023 at 11:42 AM documented Resident #21 returned to the facility at 11:28 AM with a notation the resident admitted to the hospital on 5/12/23 and discharged on [DATE]. A review of the May 2023 electronic medical record progress notes and assessments revealed no documentation of a bed hold completed. A review of the paper medical record on 12/19/23 revealed no documentation of a bed hold for 5/12/23. On 12/20/23 at 8:45 AM the Administrator reported she did not have a May 2023 bed hold for Resident #21.

Based on record review and staff interviews, the facility failed to electronically transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid (CMS) system timely for 3 of 3 residents reviewed (Resident #6, #15 and #28). The facility reported a census of 37 residents. Findings include: The review of Resident #6, Resident #15, and Resident #28 MDS assessments dated 10/17/23 documented a transmission date of 12/15/23. On 12/19/23 at 2:20 PM, the DON reported she expected any MDS to be transmitted in the timely manner. During an interview on 12/19/23 at 3:49 PM, the MDS coordinator reported MDS assessments should be transmitted in a timely manner. She reported within 24-hours of submission she gets a report if they are accepted or not. She verbalized she was aware of the late transmissions on the 3 residents. She verbalized she goes by the Resident Assessment Instrument (RAI) for reference for submission times. The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual revised on October 2023 instructs MDS assessments must be submitted within 14 days of the MDS Completion Date.

Based on clinical record review, document review, Center for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Resident and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment to accurately reflect the status and care needs of the resident for 2 of 12 residents reviewed (Resident #9 & Resident #2). The facility identified a census of 37 residents. Findings include: 1. Resident #9's MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The Resident required limited assistance of one staff for bed mobility and extensive assistance of one staff for transfers. The MDS listed a diagnosis of Parkinson's Disease and indicated Resident #9 utilized bed rails on a daily basis as a physical restraint. The Care Plan with revised intervention date 2/20/22 detailed Resident #9 utilized two half bed rails up to assist with bed mobility/repositioning. A Bed Rail assessment dated [DATE] documented the following: a. Resident is able to make own decisions. b. Resident requested side rails. c. Resident has history of falls. d. Resident has problems with balance or poor trunk control. e. Recommended device for assistance with bed mobility. f. Side rails do not impede resident's freedom of movement. A review of the 802 Matrix provided by the facility on 12/18/23 revealed Resident #9 did not utilize restraints. On 12/18/23 Resident #9 reported she uses the half bed rails and the bed trapeze bar to move in bed, but it doesn't restrict her freedom of movement. During an interview on 12/20/23 at 9:45 AM Staff A, Licensed Practical Nurse (LPN) reported Resident #9 uses her half rails for bed mobility and positioning. She does not utilize restraints. On 12/20/23 at 12:56 PM the MDS Coordinator reported there are no residents that use restraints in the facility. She reviews the MDS information, signs the MDS and then submits the assessment. They have an MDS tool that they use to collect information. The DON would have collected the information on Resident #9 for that MDS. The MDS Coordinator reported she probably didn't go through the MDS with a fine tooth comb, but it is a coding error that she should have caught. She reported they don't have any audits for MDS accuracy. They have a nurse consultant but they are not familiar with the MDS. She reported she has one side rail up for bed positioning. Section P would only be coded as a restraint if they had a physician order for a restraint. It was a coding error. She uses the RAI Manual to ensure she is coding correctly. On 12/20/23 at 1:21 PM the Director Of Nursing (DON) reported she completed Resident #9's MDS and miscoded the bed rails as a restraint in section P. She reported she must not have caught it. She reported it was clearly a miscoding error and the RAI should be utilized for coding accuracy on the MDS. On 12/20/23 at 1:50 PM the MDS Coordinator provided a MDS Checklist reporting she used it as a tool to collect MDS data. The Checklist listed side rails and hospice areas to review. She reported she followed the RAI Manual for coding accuracy. The CMS LTC Facility RAI 3.0 User's Manual Version 1.18.11, Chapter 1, page 1-4 documents the RAI process has multiple regulatory requirements. Federal regulations at 42 Code of Federal Regulations 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. 2. Resident #2's MDS assessment dated [DATE] showed a BIMS score of 1 indicating severe cognitive loss with diagnoses of Non-Alzheimer's Disease and diabetes mellitus. The MDS detailed Resident #2 required scheduled and as needed pain medication for mild occasional pain and documented a chronic condition with a prognosis of life expectancy of six months or less to live. The MDS lacked documentation of Resident #2's hospice level of care. Resident #2's Significant Change in Status (SCSA) MDS assessment dated [DATE] showed a BIMS score of 7 indicating severe cognitive loss and a diagnosis of Non-Alzheimer's Dementia. The Resident required extensive assistance with bed mobility, transfers, eating, toilet use, dressing, and personal hygiene. The resident needed scheduled and as needed pain medications for vocalized daily pain. The MDS lacked documentation Resident #2 had a prognosis of life expectancy of less than six months to live and lacked documentation of hospice level of care services. A Hospice Comprehensive Assessment and Plan of Care dated 12/14/23 documented Resident #2 admitted into hospice care services on 10/02/19. A review of the Point Click Care Electronic Census Record on 12/19/23 showed Resident #2 had been a resident at the facility since 2017. The CMS LTC Facility RAI 3.0 User's Manual Version 1.18.11, Chapter 2, Page 2-25 defines an SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Based on clinical record reviews, policy review, and staff interviews the facility failed to ensure the CPR (Cardiopulmonary Resuscitation)/ DNR (Do Not Resuscitate) status matched across the clinical record for 1 of 16 residents (Resident #17) reviewed. The facility reported a census of 43 residents. Findings include: Resident #17's Physician's Orders documented an order dated [DATE] as CPR. The Electronic Health Record's Code Status indicated that Resident #17 want to have CPR preformed. Resident #17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17's Care Plan documented that she wanted to be a DNR. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR) last reviewed [DATE] stated the resident's chart will ne marked as to CRP status. During an interview on [DATE] at 12:48 PM the DON (Director of Nursing) stated she would expect the orders and the Care Plan to match.

Based on clincial record reviews, staff interviews, and policy review the facility failed to notify 3 of 3 residents (Resident #6, #27, and #45) of their Notice of Medicare Non-Coverage (Form -NOMNC) two (2) days prior to discharge from their Medicare part A (skilled services paid for by Medicare) stay. The facility reported a census of 43 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] recorded a Medicare stay from 1/6/22 until 2/22/22. Resident #6's census reviewed on 6/21/22 at 7:40 AM documented that he had a Medicare part A stay that started on 1/6/22 and ended on 2/22/22. On 2/23/22 he transitioned to private pay status and remained at the facility. Resident #6's clinical record review lacked documentation of a NOMNC notice prior to him discharging from a Medicare part A stay 2. Resident #27's census reviewed on 6/21/22 at 7:42 AM documented that he had a Medicare part A stay that started on 5/5/22 and ended on 5/18/22. On 5/19/22 he transitioned to insurance payment status and remained at the facility. Resident #27's clinical record review lacked documentation of a NOMNC notice prior to him discharging from a Medicare part A stay 3. Resident #45's MDS assessment dated [DATE] documented that she had a Medicare Stay from 1/5/22 until 3/1/22. Resident #45's census reviewed on 6/21/22 at 7:40 AM documented that she had a Medicare part A stay that started on 1/5/22 and ended on 3/1/22. On 3/2/22 she transitioned to private pay status and remained at the facility. Resident #45's clinical record review lacked documentation of a NOMNC notice prior to her discharging from a Medicare part A stay On 6/21/22 at 12:44 PM the Administrator revealed she didn't know that Form -NOMNC needed to be given to Resident #6, Resident #27, and Resident #45 prior to the end of their Medicare part A stay. A facility policy for notice of Medicare non-coverage notification was requested but not provided. On 6/23/22 at 8:24 AM the Administrator confirmed that the facility did not have a policy for Notice of Medicare Non-Coverage notification.

Based on Facility Assessment review, staff interview and policy review the facility failed to complete annual and as necessary, conduct, document, review and update the Facility Assessment. The facility reported a census of 43 residents. Findings include: The Facility Assessment reviewed on 6/22/22 at 7:44 AM revealed that the assessment lacked a creation date and the dates for the facility's most recent annual review or an as needed review. On 6/22/22 at 8:33 AM the Administrator acknowledged that the last person to review the Facility Assessment was Staff A, prior Administrator, in February 2021. In addition the facility couldn't produce documentation or records to show completion of the review in February 2021. A Facility Assessment policy was requested but not provided. On 6/23/22 at 8:24 AM the Administrator confirmed that the facility did not have a Facility Assessment policy.

Based on observations, interviews, and record review the facility failed to keep 1 of 5 wandering residents safe from injury from an unsupervised steam table in the dining room (Resident #40). Wandering residents still able to access steam table with little to no intervention measures in place.The facility reported a census of 40 residents. Findings included: 1. The Minimum Data Set (MDS) assessment for Resident # 40 dated 05/27/20, included a [DIAGNOSES REDACTED]. The MDS reflected the Resident # 40 wanders daily. The MDS recorded Resident is independent ambulatory without supervision. The Care Plan for Resident # 40 dated 5/20/20, directed staff the resident needs directional cues for ambulation, and a Wander Alert bracelet. The Care Plan further identified Resident # 40 needed a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in a low position at night. Review of the documents in the paper chart included a form titled Intervention For Skin Concerns for Resident # 40 dated 6/16/20, the form documented signs posted on steam table STOP HOT. The Care Pan intervention dated 6/18/20, directed signs on steam table STOP HOT. Review of the Notification of Skin Condition from Incident report dated 6/16/20, documented Resident # 40 touched the lids on the top of the steam table in the dining room resulting in red areas to the palms of both hands and complaints of severe pain. Review of the Nurses Progress Notes dated 06/16/20 through 06/25/20, lacked documentation of the incident. During an observation on 02/17/21 at 6:40 a.m., Resident # 40 was at the front door attempting to exit as staff let someone in from the outside of the building. During an observation on 02/17/21 at 11:32 a.m., the steam table was assessable to residents in the dining room. During an observation on 02/17/21 01:00 p.m., Resident # 40 was wandering in the halls. During an observation on 02/17/21 at 03:00 p.m., the Steam table sat in the dining room outside the kitchen doors. The steam table was unplugged. The steam table lacked signs on or around the table to direct not to touch or warning. During an observation on 02/17/21 at 04:25 p.m. Resident # 40 wandered through a closed door into the East Conference room, shut the door behind her. Resident # 40 sat down stood back up and remained in the room until 04:35 p.m., when the resident open the room door and walked out of the room at 4:37. During an observation on 02/17/21 at 05:00 p.m., Resident # 40 was wandering in the dining room and pulling on the decorations hanging from the ceiling when staff noticed and redirected. During an observation on 02/18/21 at 06:53 a.m., steam table was located in the dining room, not plugged in or hot. No signs on or around the cart. A resident was up with walker wandering around in the dining room. During an observation on 02/18/21 at 07:47 a.m., 3 residents were sitting at tables in the dining room with the steam table plugged in and no staff in the area. During an observation on 02/18/21 at 09:53 a.m., visualized no signs present on or around the steam table. During an observation on 02/22/21 at 11:01 a.m., the steam table lids felt hot before contact, with steam coming out of the sides. The steam table burners are set to 4. During an observation on 02/22/21 at 11:51 a.m., the steam table sat in the dining room the Dietary Manager (DM) walked away from the steam table, back in the kitchen leaving no staff observing the table for 1.5 minutes During an observation on 02/22/21 at 04:44 p.m., the temperature, taken with the facility thermometer, of the top left corner of the steam table, with steam present read 283 degrees. During an observation on 02/23/21 at 11:12 a.m., the temperature from the top of steam table lid with the facility's inferred Fluke 62 Mini thermometer read 135 degrees. Surveyor attempted to touch the top of the steam table lid with her hand to verify temperature to touch, had to pull her hand away immediately. During an interview on 02/17/21 at 03:28 p.m., the Assistant Director of Nursing (ADON) reported that from last survey date Resident # 40 received a burn from the steam table in the dining room while it was heating up. During an interview 02/17/21 at 03:00 p.m., Staff D Night Cook reported normally plugging in the steam table at 3:30 p.m. and the Certified Nurses Aids (CNA) will watch to make sure no resident are going around it. Staff D stated the steam table does not have constant supervision. During an interview on 02/17/21 at 03:58 p.m., Staff F Certified Nurses Aid (CNA) verified knowing the facility does not have one to one care and the expectation was to keep an eye on the wandering residents. During an interview on 02/18/21 at 08:50 a.m., Staff G Registered Nurse (RN) reported, they have to keep an eye on Resident # 40 around the steam table. During an interview on 02/18/21 09:40 a.m., the Administrator reported the steam table location has not changed in a few years and does not have someone to watch it constantly in the dining room. The Administrator confirmed not having one to one staffing for wandering residents. During an interview on 02/18/21 09:54 a.m., Staff C RN reported a CNA brought Resident # 40 to her with a report that the resident touched the steam table in the dining room. Staff C stated the palms of the resident's hands were red and the resident kept complaining hurts, hurts. Staff C reported that the incident was around lunchtime because kitchen staff had been setting up for the meal. During an interview on 02/22/21 at 11:01 a.m., the DM reported the steam table was normally set to 4. During an interview on 02/22/21 02:15 p.m., the DM remembered Resident # 40 burned her hands on the steam table and that the nurses told her to put a stop, hot sign on the steam table because the resident could still read, but stated the resident just tore them up so they stopped placing the signs. During an interview on 02/22/21 at 1:08 p.m., the Director of Nursing (DON) reported the facility failed to complete whiteness statement or an investigation about the incident. The DON revealed the resident was guarding her hand related to the pain for the next few days when she was up wandering the hall. The facility provided an undated list titled Wandering Residents, the list included 5 residents. The facility provided an undated policy titled Accidents and Supervision with the purpose directed at point # 1: To ensure the facility provides an environment that is free from accident and hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. Point # 2. To ensure the facility has the following systems in place to prevent accidents and hazards. a. Identify hazards(s) and risk(s); b. Evaluated and analyze hazard(s) and risk(s); c. Implement interventions to reduce hazard(s); d. Monitor for the effectiveness and modify approaches as indicated. The Guidelines included Accident- refers to any unexpected or unintended incident or chain of events, which may or may not result in injury or illness to a resident. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accord with recognized standards of practice. Avoidable Accidents - means that a resident had an accident and the facility failed to: Identify environmental hazards and individual resident risk of an accident, including the need for supervision: and/or Evaluate/ analyze the hazards and risk; and/ or Implement intervention, including adequate supervision, consistent with resident's needs, goals plan of care and recognized standards of practice in order to reduce the risk of an accident The situation detailed above resulted in Immediate Jeopardy (IJ) for the facility. The facility was notified of the Immediate Jeopardy on 02/22/21. The facility removed the IJ situation on 02/24/21. The scope and severity of the deficiency was lowered from a J to a D. The facility removed the IJ by removing steam table from dining area, assigning staff to be at steam table at all times when in hall during Covid, locking kitchen doors when meals not being served, and educating staff to new policy. Facility also conducting audits to ensure ongoing compliance with new procedure. IMMEDIATE JEOPARDY declared 02/22/21 at 4:30 p.m. The facility initiated corrective action and removal of the state of IMMEDIATE JEOPARDY was verified onsite by the surveyors on 02/24/21.

Based on observation, interviews, and record review the facility failed to follow the Centers for Disease Control and Prevention (CDC) recommendation for hand hygiene after contact with residents and the resident's environment, staff failed to follow Guidance for [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Point-of-Care Testing dated 02/02/21, failed to screen resident according to Preparing for COVID-19 in Nursing Homes Updated 10/20/20. The facility reported a census of 40 residents. Findings included: 1. During a random observation on 02/16/21 at 01:30 p.m., Staff A Certified Nurses Aid (CNA) went in Resident # 22's room in quarantine, removed the full body lift from next to the bed, and pushed it out in the hall and up into room [ROOM NUMBER]. Staff failed to clean the lift after removing from a quarantine room and before moving the lift into a non-quarantine room. 2. During observation of meal time on the 200 Hall 02/16/21 at 12:41 p.m. through 12:56 p.m., Staff A CNA sat in a chair with wheels and went back and forth from feeding Resident # 8 and Resident # 18 with out completing hand hygiene between feeding the 2 residents. At times Resident #8 and Resident #18 handled their own silverware that the Staff handled. 3. During a Dining Room observation on 02/17/21 at 08:05 a.m. through 8:16 a.m., Staff B CNA held the red meal tray under her armpit and then continued to serve meals off of it. Staff E CNA held the red meal tray completely against the front of her top until setting it on the steam table picked it back up after plate placed on it and took food to a resident. Staff E scratched her nose over mask and continued to hold the meal tray and serve residents. During an observation on 02/17/21 at 11:52 a.m., Staff H Dietary Aid moved a resident's walker and continued to serve dessert to residents in the dining room. During an observation on 02/17/21 at 11:56 a.m., Staff B CNA got up from helping set Resident # 8 up for the meal and went directly over to get a tray from the Dietary Manager (DM). Staff B delivered food to Resident #8 and handed her silverware, Staff B went to the DM picked up another tray of food served Resident #8 all without performing hand hygiene. During an observation on 02/17/21 at 11:59 a.m., the Speech Therapist (ST) sitting next to Resident # 38 at the dining room table with gloved hands got up from the table and picked up something from floor, the ST then touched Resident # 18 on the back. The ST walked over put trash in the trash can, and went back to sit next to Resident # 38. The ST put her hand on the shoulder of Resident # 38 and sat down. The ST failed to complete hand hygiene after handling trash off the floor and touching another resident. At 12:03 p.m., the ST still with same set of gloves on got up from the table, and pushed Resident # 18 up to the table in the wheelchair. The ST then sat back down next to Resident # 38. From 12:07 to 12:12 p.m., the ST still wearing the same unchanged gloves fed Resident # 18 and rubbed her back. 4. During a random observation on 02/17/21 at 03:53 p.m., Staff C Licensed Practical Nurse (LPN) obtained Covid tests on the 200 hall. Staff C lacked wearing a gown going in and out of resident's room to complete the COVID-19 test. 5. During an observation on 02/18/21 at 11:46 a.m., the Dietary Manager (DM) and Staff D Cook took turns serving a plate and delivering food to residents. The DM and Staff D went from delivering to resident and on to the next resident to and then taking orders from residents. The DM placed hand on the tabletops when asking resident what they want to eat 2 times and went back to serving the meal without hand hygiene. During an observation on 02/18/21 at 11:54 a.m., the DM scratched her head with right hand and continued to serve food from the steam table without completing hand hygiene. During an observation on 02/22/21 at 12:13 p.m., the DM pulled down the bottom of her facemask to talk, then went back to serving lunch without completing hand hygiene. 6. During a random observation on 02/18/21 at 11:12 a.m., Staff I Laundry pushed an uncovered basket full of laundry down the 200 hall. During an observation on 02/22/21 at 10:45 a.m., Staff I pushed a laundry cart stacked full of clean towels wash clothes on the 200 hall the sides exposed to residents and staff passing by. During an interview on 02/22/21 at 10:45 a.m., the Director of Nursing (DON) stated the expectation is that the laundry carts are covered. During an interview on 02/23/21 at 12:14 p.m., Staff F CNA reported hand hygiene is done whenever needed, after glove use, after cares, before meals, after touching residents or resident things, and after contact with any of the PPE I have on. Staff F continued to report hand hygiene is also done between feeding residents. Staff F revealed a lack of training on when and how to clean the lifts. Staff F stated the lifts are cleaned on the night shift. During an interview on 02/23/21 01:33 p.m., the DON stated the expectation is staff to complete hand hygiene after adjusting PPE, touching masks, between feeding residents, after coming in contact with the resident environment. The DON further stated expecting staff not to remove mask to talk to people staff/resident. During an interview on 02/23/21 at 01:42 p.m., the Infection Preventionist reported expecting the laundry covered while out of the laundry room. During an interview on 02/23/21 at 03:16 p.m., the DON reported the personal protective equipment (PPE) needed for staff obtaining a COVID-19 test from asymptomatic resident is gloves, face shield, and mask. The DON stated a gown is not needed. The DON continued to report residents are screened daily by having the staff check respiration, temperature, pulse, and oxygen saturation. The DON further stated if any of the vitals were abnormal, or if a resident had a complaint, the nurses would assess further for other signs and symptoms of COVID-19. During an interview on 02/24/21 at 11:29 a.m., the Assistant Director of Nursing (ADON) reported the facility did not have the Medical Director complete an annual review of Infection Control policies and procedures. The facility provided an undated sheet titled Report Sheet, listing all the resident names per room with blanks per resident for pulse, temperature, respirations, and oxygen saturation. The facility provided a sheet titled Remember undated, directing hand washing is the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact, and after contact with resident belonging and equipment. Alcohol based hand rub may be used when hands are not visible soiled. The facility provided an undated policy titled Standard Precautions instructing that -Patient Care Equipment - under which the following guidance is found -Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and sanitized. The facility provided a policy titled Laundry Guidelines undated, directing clean linen will be covered when stored or transported. The policy further directed clean laundry will be transported to the area of use in a covered container

Based on observation, clinical record review, and interviews with staff, the facility failed to provide adequate supervision to protect 1 of 4 residents from hazards. On 10/28/17, Resident #1 wandered away from the facility without staff knowing her whereabouts and sustained a facial laceration and contusion of the face. The resident had been seen by a witness walking on the access road to the nursing home which runs parallel to the nearby highway (approximately 40 steps) with a speed limit of 45 miles per hour. Staff interviews revealed the resident had two prior attempts early on 10/28/17 to exit the facility. Staff interviews revealed no staff were aware of Resident #1 whereabouts until alerted by the hospital emergency room . The facility reported Resident #1 may have left unnoticed when visitors exited and entered the front door code and turned off the alarm. The findings constitute an immediate jeopardy situation to resident health and safety. The facility identified a census of 51 residents. Findings include: According to clinical record review, Resident #1 entered the facility on 09-27-2017 and had [DIAGNOSES REDACTED]. The facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 scored 3 points (of 15) on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. The assessment also indicated Resident #1 required limited staff assistance with bed mobility, transferring, ambulating in the room and corridor, toilet use and personal hygiene. Resident #1 required extensive staff assistance with dressing and bathing and was able to eat independently. Facility staff completed an Elopement Risk assessment dated [DATE]. The assessment identified Resident #1 as being ambulatory, alert and oriented to person but not capable of making decisions. The assessment also indicated Resident #1 exhibited 4 of the possible 11 behaviors including: 1. new admission 2. currently takes medication which may cause confusion 3. exhibits routine or sporadic confusion, anxiety or disorientation 4. anger or resistance related to placement (e.g. wanting to go home, or to work, or somewhere else). Resident #1 was identified (with a check mark) to be at risk for elopement and to proceed with care plan. An additional comment was added dated 10-05-2017 indicating no wandering behaviors noted at this time. (Resident #1 did not use a Wanderguard or similar alarm. ) Resident #1's care plan (printed 10-13-2017) was reviewed. The plan identified the resident had cognitive impairments and short term memory. The care plan did not address an intervention for wandering, elopements or increase supervision. Documentation in the nurse's notes dated 10-28-2017 at 1303 (1:03 p.m.) indicated Resident #1 was very upset that morning wanting to exit and walk home. Staff redirected Resident #1 multiple times. The notation also indicated Resident #1 was combative with staff and refused to use the walker or let staff walk with him/her. After taking medication it was noted Resident #1 calmed down. Documentation in the nurse's note dated 10-28-2017 at 1444 (2:44 p.m.) indicated Resident #1 went outside with staff following and then walking with Resident #1. The notation indicated Resident #1 would not allow staff to touch him/her. The notation also indicated that Resident #1 exited the building two times during the time frame of 2:00 to 2:44 p.m. Documentation in the nurse's notes dated 10-28-2017 at 1600 (4:00 p.m.) indicated the facility received a call from the ambulance crew questioning about Resident #1. The ambulance crew indicated they had picked up Resident #1 south of the facility. The resident had fallen and an unidentified driver driving by on Highway 150 had seen her and called 911. The emergency room report dated 10-28-2017 at 1615 (4:15 p.m.) indicated Resident #1 sustained a facial laceration, contusion of the face and abrasions of multiple sites. The resident report revealed the resident had most likely sustained the injuries while walking and landed on concrete with the point of impact as her head. The resident had been walking near the access road near the nursing home and a witnessed driving by observed her fall forward onto the cement and stopped to assist. Upon discharge, the resident's right eye was swollen shut. Observation during the investigation identified : Resident #1 was found in front of the yellow house located at a dead end road that also runs in front of the facility and adjoins the facility parking lot. At the end of the dead end is a small wooded area. The road also runs parallel to a busy highway, Highway 150, which is a bypass to the city proper of Fayette and proceeds to the town of West Union. The road on which Resident #1 was found runs parallel to Highway 150 and is approximately 40 steps (less than 80 feet) between the two highways. The speed limit at the spot parallel to where Resident #1 was found was 45 miles per hour. For vehicles traveling south on Highway 150, the speed limit increases at that point from 35 miles per hour, which would indicate vehicles are increasing their speed at that point. The climatologist reported the weather on 10/28/17 at 3:30 p.m., had been 36 degree, cloudy with wind North at 12-18 miles per hour, 27 degree wind chill. The facility investigation dated 10/28/17 revealed the code for the door alarm had been written on a piece of paper and placed by the door. During an interview on 11-13-2017 at 2:12 p.m. Staff A indicated Resident #1 had been upset the morning or 10-28-2017. Staff A explained that Resident #1 had been awake by 6:30 a.m. and was at the door, setting off the (door) alarm. At approximately 7:15 a.m. Resident # 1 wanted to go outside. At that time Staff A stated Resident #1 did take her medication. Staff A stated about 9:00 a.m. a family member visited Resident #1 and Resident #1 cried and wanted to go home. The family member expressed concern to Staff A, so she administered a PRN (as needed) medication and sat with Resident #1. Resident #1 continued to express the desire to go home, but Staff A noted Resident #1 to be calmer after lunch and participated in looking at pictures and folding laundry. Staff A stated when she left the facility at 2:00 p.m. Resident #1 was seated in the lounge waiting for a music activity to begin. During an interview on 11-13-2017 at 3:09 p.m. Staff B stated she arrived at work about 2:00 p.m. on 10-28-2017 and heard the front door alarm sound. Staff B stated a resident from the assisted living unit was shutting the door alarm off and when Staff B responded to the alarm she immediately observed Resident #1 outside the building just a few feet from the front door. Staff B stated she went to Resident #1 and explained that it was cold outside and Resident #1 agreed to return into the facility. Staff B stated she assisted Resident #1 to sit in a recliner in the lounge. Staff B also stated she alerted the nurse on the 200 hall, and was told to just keep an eye on him/her. During an interview on 11-14-2017 at 10:59 a.m. Staff C stated he was assisting residents to the living room when the door alarm sounded. He stated Staff B responded and that Staff B came back into the facility with Resident #1. Staff C stated Staff B assisted Resident #1 to sit in the recliner. Staff C stated about 15 to 20 minutes after the music had started he heard the door alarm again and observed Resident #1 leave the building. Staff C stated he ran after Resident #1 and tried to talk to her trying to convince Resident #1 that it was cold outside and she should go back inside where it was warm. Staff C stated Resident #1 kept arguing that she had been inside all day and wanted to go outside for awhile. Staff C stated it was several minutes before Resident #1 was finally convinced that it was cold out and to return in the building. Once inside, Staff C stated Resident #1 sat at a dining room table, seemingly enjoying the music and accepted a cup of coffee and a cookie. Staff C stated the music ended at 3:00 p.m. and he then began assisting residents out of the dining room. Staff C stated he last observed Resident #1 about 3:05 p.m. seated at a dining room table with another resident and their family. Staff C stated he did note about 3:30 p.m. that Resident #1 wasn't' in her usual chair, but thought one of the nursing assistants had probably assisted Resident #1 to use the restroom. During an interview on 11-14-2017 at 10:33 a.m. Staff D stated she was alerted at report that Resident #1 had been irritated/restless during the day and had attempted to exit the front door, or at least headed in that direction. Staff D stated about 2:15/2:20 p.m. the door alarm sounded and as she responded, she noted Staff B returning into the building accompanied by Resident #1. Staff D stated the alarm sounded again about 2:35/2:40 p.m. and when she responded she observed Staff C outside with Resident #1. Staff D stated it didn't look like it was going well, so she went outside and touched Resident #1 to guide her to turn around and Resident #1 stated, Get your hand off me. Staff D stated she and Staff C walked with Resident #1 to the assisted living door, and then Staff D said to Resident #1, Do you realize we are going north; do you know north is the coldest place; we should go south. At this point Staff C and Staff D were able to assist Resident #1 in turning around and head back towards the facility. Resident #1 was able to read the sign, Maple Crest Manor and commented on who would want to live there, but then agreed to return inside the building after being told it was warm inside. Staff D stated Resident #1 joined other residents in listening to the music activity and noted Resident #1 was tapping his/her hand in time to the music. Staff D stated she then went to the nurse's station to chart what had just occurred. Staff D stated the music concluded at approximately 3:00 p.m. and she assisted residents in returning to their rooms. She also had a medication pass to begin. Staff D stated she did not notice that Resident #1 was missing until she received a phone call from ambulance personal. Staff D stated she did not hear another alarm sound, and can only assume that Resident #1 followed someone out of the building. Staff D also indicated nothing additional was implemented, other than to keep an eye on her to ensure Resident #1 did not exit the building. Staff D stated Resident #1 seemed to enjoy the music and Staff D thought the alarm would sound if Resident #1 attempted to leave again. A test of the front door alarm was conducted on 11-13-2017 at 11:24 a.m. The Director of Nursing entered the code on the alarm pad (to silence the alarm) and then activated the automatic door opener. The door remained opened for approximately 20 seconds at a 90 degree opening, (the surveyor counting 1001, 1002, 1003 ). After approximately 20 seconds the door closed, with the alarm not sounding at any time. The Director of Nursing stated at one time the alarm did sound before the door closed, but she checked with the facility Administrator who thought maintenance had made an adjustment so the alarm did not sound before the door closed. During an interview on 11-14-2017 at 9:37 a.m. the Administrator indicated it was her understanding that (on an unknown date) State had directed that all residents were to be considered an elopement risk. In addition it was her understanding that all doors needed to be alarmed at all times. As a result, the facility discontinued the wanderguard system since all doors were alarmed. The facility Administrator stated that family members, frequent visitors and other individual such as sales representatives were given the code to silence/bypass the door alarm. The Administrator also expressed some concern that on weekends, there are less staff in the front office to observe if residents are near the front door, or attempting to exit. On 10/28/17 the facility implemented 15 minute checks for Resident #1. The front door code that was placed at the front door (for visitors) was removed. Resident #1's care plan was updated to address elopement intervention(s). On 10/30/17, the facility abated the IJ when they completed the following: Added a sign to the front door that indicated to not let residents follow them out the door. Staff were educated that before they reset the door alarm, to ensure a resident had not gone outside. The facility changed the code for the front door. The facility re-assessed all residents for elopement risk and Wanderguard bracelets were placed on resident at risk including Resident #1. The facility placed a new system which will lock if a resident has a Wanderguard bracelet on them and they are in close promityity which will be alarmed 24/7 hours with a special code to bypass the lock which will only be known by selected employees (charge nurses, etc.).

Based on record review and staff interviews, the facility failed to provide appropriate care and services to promote healing, prevent infection, and prevent sores from developing. The sample consisted of 2 residents (Resident #3, #4) identified by the facility with pressure ulcers and the facility reported a census of 51 residents. Findings include: The Admission Nursing Assessment identified Resident #3 had an admission date of [DATE] at 1:30 p.m. for skilled nursing care. The note identified the resident had [DIAGNOSES REDACTED]. According to documentation on the initial skilled care plan, dated [DATE], Resident #3 was alert and oriented times 3 spheres. Documentation related to skin condition identified Resident #3 had hospital laboratory acquired bruising on both arms. Bottom pink in color, make sure barrier (Alo-Vista) used after perineal cares. Review of the facility skin risk assessment tool identified the staff completed a skin assessment on [DATE], [DATE] and 09- ,[DATE] (and one additional date which is not legible). Scores for each of these assessments totaled 10 with a score of 8 or over representing high risk for the resident. An initial pain assessment dated [DATE] reflected Resident #3 complained of constant dull pain at bilateral groin regions and buttocks if sitting too long or lying on back too long. At the time of the assessment, Resident #3 rated his/her pain at ,[DATE] on a scale of ,[DATE] and was present 75% of the time. A second pain assessment dated [DATE] reflected Resident #3 complained of a constant dull ache on the buttocks region if sitting too long and pain in the bilateral groin region. A level of pain was not documented but Resident #3 indicated the pain was present 75% of the time. According to documentation in the nurses notes dated [DATE] at 1:00 p.m. staff noted skin issues on bilateral inner buttocks. A skin sheet indicated an open area on the right inner buttock measured 1.8 cm (centimeter) by 1.8 cm and an open area on the left buttock measured 1.5 cm by 1.3 cm. Further assessment indicated the area to be bright red in color without drainage. Additional comments directed staff to cleanse area with water and soap, rinse and pat dry, apply [MEDICATION NAME] two times daily and as needed. Documentation in the nurse's notes dated [DATE] at 9:00 p.m. indicated the open area on the coccyx has a brownish area around it, no drainage noted. Resident states it is tender to the touch, Calmo ([MEDICATION NAME]) applied. Documentation on the skin sheet dated [DATE] identified a scant amount of serosanguinous (bloody drainage) was present. No measurements of the area were documented. Documentation in the skin assessment sheet dated [DATE] indicated the area on the right inner buttock now measured 2.9 by 3.8 cm and the area on the left inner buttock measured 4.9 by 0.7 cm. The assessment also indicated the skin was pink, with a scant amount of serosanguinous drainage without an odor. The comments included that the area appeared much worse, right buttock with slough, left buttock pink, larger than last week. According to the documentation in the Nurse ' s Notes dated [DATE] at 12:45 p.m. the physical therapist went to apply the resident ' s TED ([MEDICAL CONDITION] Embolic Deterrent) stockings and noted a fluid filled blister on the right medial aspect of the right heel. The blister measured 6.4 cm (centimeter) by 5.0 cm. The nurse documented she received an order to wipe the area with [MEDICATION NAME] three times a day until the fluid was absorbed in the blister. The note reflected the resident would not wear the TED stockings or a shoe to the right foot until resolved. The note reflected the resident would use gripper socks until the area resolved. The skin assessment dated [DATE] identified the area on the right heel measured 6.5 cm by 5.0 cm and further reflected the blister had ruptured, with no skin flap. Treatment was changed to [MEDICATION NAME] and several 4 by 4 gauze pads and wrapped with kling. There were no further measurements of the area on the right heel. Documentation in the Nurse ' s Notes dated [DATE] at 9:15 p.m. reflected the staff elevated Resident #3's heels off the bed. Documentation in the Nurse ' s Notes dated [DATE] at 11:30 a.m. reflected Resident #3 had an elevated temperature of 100.1 degrees Fahrenheit and Resident #3 complained of pain on the bottom of feet and right heel. Documentation at 9:00 p.m. reflected staff applied heel protectors to bilateral heels with a pillow to help keep (the heels) off of the bed. The note reflected the staff put a foam positioning device on the right lower leg to help keep the heel off the bed. The resident had an elevated temperature of 99.8 (normal is 98.6). Documentation on a skin sheet dated [DATE] indicated Resident #3 presented with a 1.0 cm x 1.0 cm fluid filled blister on the posterior midline. Additional comments were to monitor the area to help keep blister intact. Documentation on [DATE] indicated the blister had opened, with a small amount of serous drainage. The area measured 0.6 x 0.4 cm. Documentation in the Nurse ' s Notes on [DATE] at 1:00 p.m. reflected the resident ' s temperature as 100.7 degrees and staff noted a 3.1 by 2.0 cm intact blister on the left heel. The notation also reflected Resident #3 complained of the bottom of his/her feet hurting. Documentation on [DATE] at 5:40 a.m. reflected Resident #3's heels were elevated with a pillow and heel protectors. At 10:00 a.m. Resident #3's temperature registered 99.6 degrees and he/she complained of heel and bottom of feet hurting. At 2:00 p.m. the nurse received a physician's orders [REDACTED]. On [DATE] at 8:15 a.m. Resident #3 left the facility and transferred to the wound clinic. Resident #3 subsequently was transferred and admitted to the hospital. The hospital admission document dated [DATE] identified the resident presented with a coccyx unstageable with necrotic material and slough. The wound had a foul odor and [DIAGNOSES REDACTED] (redness) around the wound. The note reflected a wound culture of the coccyx was obtained. The hospital note reflected the right heel as non-stageable and from pressure. The right heel measured 6.5 by 4.9,The left heel had an intact blister and measured 3.5 by 1.8. The blister was at least a Stage II pressure ulcer. The resident arrived with light blue boots. The hospital record identified impressions of Septic Shock secondary to infected pressure ulcers and pneumonia and an infected coccygeal pressure ulcer - unstageable with probable OM (osteo[DIAGNOSES REDACTED]) with necrosis and sloughing. The resident would need surgical debridement and wound nurse consult. The individual plan of care for Resident #3 identified a problem dated [DATE] of actual impairment to skin integrity of the buttocks, left thigh and right heel related to fragile skin and [MEDICAL CONDITION], urine incontinence manifested by current skin issues. Interventions and tasks directed the staff to the following: Be aware the resident has had problems with blistering in various areas on his/her body, most likely related to [MEDICAL CONDITION]. Most areas have ruptured. Observe sign and symptoms of infection and report to the charge nurse and physician/physician assistant. Encourage good nutrition and hydration in order to promote healthier skin. Resident has a pressure reduction mattress for comfort and to protect the skin while in bed. Resident has some open areas on the buttocks and an open area on the heel. See TAR (treatment administration record) for current treatment and refer to for any changes. Resident is to have a gel pad when in wheelchair and recliner to protect the skin while up in the chair. Keep skin clean and dry. Use lotion on dry skin as needed. Do not apply on open areas. Offer bath/shower 2 times a week. Lotion as needed. Trim fingernails/toenails as needed. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. The facility form titled Interventions for Skin Conditions for Resident #3 was blank. The facility form titled Turn and Reposition Record for Resident #3 identified the staff were to reposition the resident every two hours, to keep Resident #3 off his/her back due to buttocks, and to use support with pillows. Documentation on the record was completed only on [DATE], [DATE] and [DATE] at the following times: 12:00 a.m., 2:00 a.m. and 5:00 a.m. Occupational therapy notes dated [DATE] directed staff to use gel cushions in the wheelchair and bed, and to while Resident #3 was in bed, to position a pillow under bilateral lower extremities to decrease pressure on heels and also position pillow under calves with foot rest elevated when in recliner. On [DATE], an Occupational Therapy note directed staff to position Resident #3 in the recliner after lunch for 1 to 2 hours with legs elevated. A physician's orders [REDACTED]. O [DATE] at 1:40 p.m. a nurse requested from the physician's assistant for an order for [REDACTED]. The facility form titled Resident Care Protocols was signed by the physician and noted by nursing staff dated [DATE]. Protocols for pressure ulcers (Stage I) included: relieve pressure, implement interventions needed to relieve pressure to area involved. For Stage II and Stage III ulcers, staff were directed to implement daily treatments. On [DATE] at 7:23 a.m. the MDS (Minimum Data Set) assessment Coordinator was interviewed and stated skin assessments are performed weekly and the physician uses standing orders. The orders are to assess the area if red and if open, then the nurses use the standing order protocol. Once the resident developed blisters, the shoes and Ted stockings were kept off on the one leg/foot. The Coordinator stated the resident used a recliner and the legs were elevated. On [DATE] at 1:07 p.m. the PAC (Physician Assistant Certified) was interviewed and stated he had not seen the resident at the nursing home but thought the resident had only been at the facility a couple days. 2. According the documentation in the clinical record, Resident #4 entered the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #4 had a MDS assessment with a reference date of [DATE]. The MDS reflected the resident required extensive staff assistance with bed mobility, transferring, dressing and toilet use. Resident #4 required total staff assistance with hygiene and bathing. Resident #4 did not ambulate. According to the documentation in the Nurse ' s Notes dated [DATE] at 2:00 p.m. staff noted an open area on Resident #4's coccyx measuring 2.0 by 0.8 by 0.1 cm. Staff initiated the standing physician's orders [REDACTED]. According to documentation in the facility form titled Interdisciplinary Progress Notes, Resident #4 was admitted to hospice services on [DATE]. The Admission Hospice Notes indicated Resident #1 had a pressure area on the coccyx and gluteal fold and a low air loss mattress would be provided. The initial hospice comprehensive nursing assessment dated [DATE] described Resident #4 as having 2 pressure sores, pink in color. No other descriptions of the wound were documented and no measurements of the wound sizes were documented. Documentation in the facility Notification of Skin Condition form dated [DATE], described the wound as 3.8 cm by 2.7 cm by 0.3 cm. The comments included the wound to have more slough present and appeared worse. The interventions were hydrogel and [MEDICATION NAME]. Hospice notes dated [DATE] described the wound as being 2.5 cm by 2.0 cm with no depth measurement and yellow-brown in color. The hospice narrative note indicated Resident #4 complained of tailbone pain. Documentation in the facility form titled Notification of Skin Condition dated [DATE] described the wound as 2.4 cm by 1.9 cm and 0.9 cm depth with the added notation that it may be deeper and unstageable. The comments included that hospice assessed the area and a new treatment was ordered. In addition the notation indicated presents as a Kennedy ulcer. Documentation in the hospice notes the same date ([DATE]) described the area with slough, eschar, depth moderate, foul odor, small amount of drainage on [MEDICATION NAME]. The notes reflected the resident complained of discomfort with direct palpitation to the coccyx and the skin described as nonblanchable around the wound with reddened induration. The nurse obtained physician orders [REDACTED]. Hospice notes dated [DATE] indicated the coccyx dressing was intact and Resident #4 complained of tailbone pain. No measurements of the open area were documented. The form titled Notification of Skin Condition, dated [DATE] described Resident #4's wound as 5.4 by 2.8 cm and unable to measure depth due to eschar. The comments identified the area as worse due to declining condition; continue treatment and monitor. The hospice notes dated [DATE] reflected the wound as deeper with order (sic) dressing change yesterday and request not to remove to look at wound. The facility form titled Notification of Skin Condition dated [DATE], identified the wound measured 5.5 by 4.5 cm with tunneling and not measured due to discomfort. Comments included the area worsening, odor prevalent, draining brown drainage and to continue to monitor. Documentation in the nurse ' s notes dated [DATE] reflected the resident expired at 9:30 a.m.

Based on record review and staff interviews, the facility failed to ensure that each resident received adequate supervision to prevent falls. Resident #2 used a pressure alarm for safety which sounded to alert staff the resident was rising without assistance. The staff person responded to the alarm and assisted the resident out of bed to go to the bathroom. The staff did not supervise the ambulation of the resident to the bathroom and then left the resident unsupervised while in the bathroom. The resident fell and hit head in the bathroom. The resident had a fractured a hip, head hematoma (bleeding under the skin) and an elbow abrasion. The sample reviewed consisted of 4 residents and the facility reported a census of 48 residents. Findings include: 1. The [DIAGNOSES REDACTED]. According to the facility Minimum Data Set (MDS) assessment, with a reference date of 03/28/2013, Resident #2 scored 3 on the "Brief Interview for Mental Status" (BIMS). A score of 3 identified the resident had a severe cognitive impairment. The plan of care for Resident #2 identified the potential for falls related to a CVA (cerebral vascular accident -stroke) and a history of falls. Documentation in Resident #2's record indicated the resident experienced falls on 06/22/12 and 09/15/12 with no injury, 09/24/12 which required first aide and 10/25/12 with no injury. The planned interventions directed staff to perform the following: ? Follow transfer and mobility lists for any changes. Resident #2 has a sign in his/her room to remind him/her to wait for assistance. ? Resident #2 ambulates with a front wheel walker and one assist. Resident #2 had a PSA (personal safety alarm) to remind him/her to wait for assistance. The facility transfer list indicated Resident #2 required the assistance of one or two staff with a front wheeled walker and a gait belt. The facility mobility list indicated Resident #2 could ambulate with a front wheeled walker and one staff assist with a gait belt to and from meals and activities. The facility personal alarm list indicated Resident #2 had a pressure alarm on his/her bed and chair. On 04/16/2013 at 1:36 p.m., Staff A stated she had been providing cares for Resident #2's roommate, when she heard the personal alarm sound and observed Resident #2 sitting up in bed. Staff A stated she went to Resident #2 and turned off the personal alarm, and assisted Resident #2 out of bed so the resident "could walk to the bathroom". Staff A stated she then went back to assisting Resident #2's roommate to bed, and then heard a crash and found that Resident #2 had fallen, and hit head. Staff A acknowledged that she did not use a gait belt and assisted Resident #2 to be up and not attended in ambulating to the bathroom. Staff A stated she was trying to help two residents at once, and didn't take time to call for help, nor did it occur to her what she should have done at the time. According to documentation in the facility investigation Staff A did not assist Resident #2 to have any foot wear on his/her feet. The facility staff obtained physician's orders [REDACTED].