Every finding on record at Mary Goss Nursing Home

Based on record review and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours a day, 7 days a week for 4 days within the Fiscal Year, Quarter 2 2025 (January 1-March 31). Findings:Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 2 2025 (January 1-March 31) revealed there were no consecutive 8 hours of RN coverage for 3 days within the quarter. Review of the RN time cards revealed on 02/01/2025 and 02/02/2025, the RN did not work 8 consecutive hours within the 24 hour period. Further review of the RN time cards revealed no RN worked on 03/05/2025. During an interview on 08/27/2025 at 1:00 p.m. with S1Administrator, he reported he was responsible for completing the PBJ staffing report. S1Administratior reviewed the PBJ for FY Quarter 2 2025 (January 1-March 31). S1Administrator confirmed there was not 8 hours of consecutive RN coverage for 02/01/2025 and 02/02/2025 and no RN worked in the facility on 03/05/2025.

Based on record review and interview, the facility failed to provide form CMS (Centers for Medicare and Medicaid Services) 10123- Notice of Medicare Non-Coverage (NOMNC) as required for 1 (#31) of 3 (#2, #11 and #31) residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Notification. The facility had a census of 37 residents. Findings: A review of Resident #31's SNF Beneficiary Notification Review form revealed the facility initiated the resident's discharge from Medicare Part A services when benefit days were not exhausted. Resident #31 was discharged from Medicare Part A services on 7/31/2025. Further review of Resident #31's record failed to reveal a Notice of Medicare Non-Coverage (NOMNC) form was provided to the resident. On 08/27/2025 at 10:50 a.m., an interview was conducted with S2Director of Nursing (DON). S2DON confirmed she was responsible for providing the Beneficiary Notifications (NOMNC forms) to the residents. S2DON stated Resident #31's discharge from therapy was facility initiated and the resident also had skilled benefit days remaining at the time of the discharge. S2DON reported she did not know Resident #31 required a NOMNC form.

Based on observations, interviews, and record reviews, the facility failed to provide thickened liquids as ordered by the physician for 1(#18) of 3 (#1, #4, & #18) residents reviewed for nutrition. Findings: Review of Resident #18's medical record revealed an initial admit date of 08/20/2018 and a readmit date of 12/19/2023. Further review revealed a primary diagnosis of chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated a yes response for C. Mechanically altered diet-require change in texture of food or liquids (e.g., pureed food, thickened liquids). Further review of the MDS revealed the resident had a Brief Interview of Mental Status (BIMS) score of 7 which indicated moderately impaired cognitive skills for daily decision making. Review of the August 2025 physician orders revealed an order for honey/moderately thick consistency liquids. Review of Resident #18's most recent care plan with a review date of 08/14/2025 revealed the resident had an alteration in nutrition: (gluten free, pureed with honey thick liquids). Review of the Dysphagia Evaluation completed on 11/20/2024 by a speech therapist revealed a recommendation for honey thickened liquid for pleasure. Observations on 08/25/2025 at 9:08 a.m. and 9:20 a.m. and on 08/26/2025 at 8:31 a.m. revealed Resident #18 was sitting upright in a chair with a bedside table in front of her with an 8-ounce water bottle opened with a straw. Further observation of the water bottle revealed the water was not thickened. There was also an open container with unopened packages of thickener on the resident's nightstand. Further observation of the room revealed a note on the resident's wall beside her bed stating, All liquids to be nectar thickened liquids only. In an interview with S4Certified Nursing Assistant (CNA) on 08/25/2025 at 12:55 p.m., S4CNA said she was told by the nurse that Resident #18 was supposed to have thickened liquids. She acknowledged there had been signage about thickened liquids on Resident #18's wall. In an interview with S2Director of Nursing (DON) on 08/26/2025 at 11:09 a.m., S2DON confirmed Resident #18 was supposed to receive thickened liquids and should not be drinking unthickened liquids. In an interview with S6Licensed Practical Nurse (LPN) on 08/27/2025 at 1:05 p.m., S6LPN confirmed Resident #18 was supposed to only have thickened liquids. In an interview with S3Speech Therapist (ST) on 08/27/2025 at 2:00 p.m., S3ST indicated the last time she saw Resident #18, S3ST recommended thickened liquids.

Based on observations, record review, and interviews, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 (#39) of 2 (#15, #39) residents reviewed for pressure ulcers. The facility failed to provide a low air loss mattress for resident #39. Findings:Resident #39Review of the medical record for Resident #39 revealed an admission date of 05/30/2025 with diagnoses that included hemiplegia and hemiparesis following non-traumatic intracranial hemorrhage affecting right dominant side, pressure ulcer of sacral region stage 4, and hypertension.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview for Mental Status (BIMS) score was unable to be obtained and indicated the resident is severely cognitively impaired for daily decision making. Per the MDS, the resident required substantial/maximal assist with bed mobility and was dependent with toileting. The resident utilized an indwelling catheter. Interventions for the resident's stage 4 pressure injury included a pressure reducing device for the bed. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 06/03/2025 revealed a score of 12 which indicated the resident is at high risk for pressure ulcer development. Review of the Electronic Order Summary Report as of 08/26/2025 revealed an order dated 01/29/2025- low air loss mattress.Review of the active plan of care addressed Resident #39's pressure ulcer and included an intervention to maintain a pressure reduction mattress to bed. The order for a low air loss mattress was not noted as an intervention to address the pressure ulcer. On 08/26/2025 at 1:59 p.m., an interview with S5CNA (Certified Nursing Assistant), revealed that the resident was to have a low air loss device in place to his pressure reducing mattress.On 08/26/2025 at 2:12 p.m., a follow-up observation with S5CNA at Resident #39's bedside revealed a deflated low air loss device on top of the resident's pressure reducing mattress. When S5CNA was questioned about how the device inflates, she reported that the pump to inflate the device was missing. On 08/26/2025 at 2:20 p.m., arrived to Resident #39's bedside with S2DON (Director of Nursing) who observed the deflated low air loss device and confirmed that the intervention was not implemented as ordered. On 08/27/2025 at 3:30 p.m., arrived to Resident #39's room for follow-up observation related to the low air loss device with S7Maintenance. It was noted that the low air loss device was deflated and this was confirmed by S7Maintenance.On 08/27/2025 at 4:00 p.m., S2DON was informed of the additional finding of the deflated low air loss device for Resident #39.

Based on observations and interviews, the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and help prevent the development and transmission of infection for 1 (#22) of 1 residents reviewed for respiratory care. The facility failed to store and dispose of suctioning equipment appropriately for Resident #22. Findings: Review of the facility's undated policy for Suctioning the Upper Airway (nasopharyngeal or oropharyngeal suctioning) revealed the following, in part: General Guidelines: 5. Oropharyngeal suctioning is performed using aseptic technique. Equipment and Supplies6. Curve-tipped #10 to #16 French catheter; with suction control port or adapter (nasopharyngeal) or Yankauer or opened tipped catheter (if oral secretions are thick and copious.) After Suctioning4. Discard water or saline in commode. Dispose of cup in designated receptacle.5. Empty and rinse collection container if necessary or as indicated by facility protocol. Review of the medical record revealed Resident #22 had an initial admission date of 02/15/2017 and a most recent admission date of 08/28/2020 with a primary diagnosis of transient cerebral ischemic attack, unspecified. Review of the August 2025 physician orders revealed an order dated 10/01/2025 for oral suctioning as needed. On 08/25/2025 at 9:28 a.m., Resident #22 was observed in her room sitting in a geri chair on the right side of the bed. Further observation revealed suction equipment on the side table with liquid in the clear canister of the machine and the connected Yankauer suctioning tip with a substance spread out inside in an uneven pattern which was white in color. The Yankauer suctioning tip was lodged uncovered between the wall and the side table standing in an upright position and was available for reuse. Further observation revealed new suctioning tips were not available in the resident's room at this time. During an interview on 08/25/2025 at 9:37 a.m. with S6Licensed Practical Nurse (LPN), S6LPN reported the suctioning machine and the Yankauer suctioning tip should not have been left out after being used and that it should have been cleaned and stored properly. S6LPN reported Resident #22 required suctioning at times and S6LPN did not know who had used the equipment last. During an interview with S2Director of Nursing (DON) on 08/27/2025 at 11:09 a.m., S2DON acknowledged the suctioning equipment should be cleaned and stored after each use, in addition to the Yankauer suctioning tip being covered in a clear plastic type of covering. S2DON acknowledged she was aware of the equipment being out in Resident #22's room but did not know who used the equipment and failed to store and dispose of the suctioning equipment appropriately.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#44) of 1 (#44) residents reviewed for restraints. The facility failed to 1) obtain a consent, 2) have a physician's order and 3) failed to assess the resident prior to placing the resident in a restraint. Findings:Review of the facility's policy for the Use of Restraints dated April 2017 revealed the following in part:Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls.When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.Policy Interpretation and Implementation 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint.12. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident.b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. Restraints with locking devices shall not be used.c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record.d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed.e. Restrained residents must be repositioned at least every two (2) hours on all shifts. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA), schizophrenia, major depressive disorder, anxiety disorder, insomnia, vascular dementia, and hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and unable to make daily decisions. Review of the functional limitation in range of motion revealed the resident did not have any impairments in the upper or lower extremities. Further review revealed the resident was dependent on staff for all activities of daily living and mobility. Review of the Physical Restraint section of the MDS revealed no restraints used. Review of the medical record revealed no documented evidence of an assessment prior to the use of a geri-chair and lap tray, no consent from the resident or the Responsible Party and there was no physician's order for a geri-chair.Observations on 08/26/2025 at 10:10 a.m. and 2:30 p.m. revealed Resident #44 was sitting up in a geri chair with lap tray in place in his room. Observation on 08/27/2025 at 08:15 a.m. revealed Resident #44 was sitting up in a geri chair with lap tray in place being fed his breakfast by the Certified Nursing Assistant (CNA). Interview with S8CNA at this time stated Resident #44 was placed in the geri chair with lap tray daily when out of bed. During an interview on 08/26/2025 at 09:35 a.m. with S9Licensed Practical Nurse (LPN), S9LPN stated there was not an order for the geri chair and lap tray or a care plan because the facility was trying it out to see if it would work for the resident, prior to doing the assessment, care plan or getting the physician's order.During an interview on 08/27/2025 at 03:50 p.m. with the S2Director of Nursing (DON), S2DON confirmed Resident #44 was placed in the geri chair with a lap tray when out of bed since admission without having a pre-restraining assessment, a written order from the physician or obtaining a consent from the resident or responsible party.

Based on observation, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 (#1) of 2 (#1 and #2) sampled residents reviewed for elopement. Findings: Review of the Wandering and Elopement and Implementation dated 03/22/2024 revealed the following: Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement or other safety issues utilizing the Elopement Risk Form, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses that included myocardial infarction, alcoholic cardiomyopathy, acute respiratory failure with hypoxia, heart failure, acute kidney failure, Stage 3, and metabolic encephalopathy. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed resident #1 had a brief interview for mental status score of 04. A score of 00 - 07 indicated the resident had severely impaired cognitive skills for daily decision making. Review of the August 2024 physician's orders revealed an order dated 05/07/2024 as follows: wanderguard bracelet to ankle. Should be 2 finger widths around ankle. Staff to answer door alarm immediately to ensure resident's safety. Further review revealed the following order dated 03/22/2024: Weekly check wanderguard is working properly on Fridays. Take resident to door and try to open door. Alarm should sound and door should not open. Review of resident #1's Medication Administration Record for August 2024 revealed there was documentation of the weekly wanderguard checks every Friday. Review of the Elopement Risk Record revealed on 05/20/2024 resident #1 was an elopement risk. Further review revealed resident #1 had eloped before, frequent monitoring was done every 30 minutes, and staff aware of resident's wander risk. Review of the incidents and accidents report dated August 2024 revealed resident #1 was found walking in the parking lot on 08/12/2024 at 9:00 p.m. Further review of the report revealed that resident #1 apparently got out of his wheelchair, out of back door, and he had unsteady gait with confusion noted. Review of the Elopement Risk Record revealed on 08/12/2024 resident #1 eloped through exit door at room (referring to resident #1's room). Discovered approximately 100 feet from door outside of building on feet. Brought back into building no injuries noted upon assessment. Dietary notified. Resumed every 30 minute census checks. The note was signed by S2Director of Nursing (DON). Review of the nurse's note dated 08/12/2024 at 9:00 p.m. revealed the following documentation: door alarm sounds off nurse calls to nurse station (referring to the nurse's station that was located on the hall resident #1 was residing on at that time), asks what door alarm is sounding off, nurse at desk gives location. Simultaneously CNA (Certified Nursing Assistant) comes running up hall, was stating Resident #1 is not in his wheelchair! Nurse runs down hall out the door alarming. Resident observed outside, ambulating then stops at end of facility's parking lot. No injuries observed. Resident then escorted back towards door exited. CNA goes around to open door. Resident escorted to room CNA prepares resident for bed. Resident examined for injuries, none observed. Vital signs, blood pressure 109/75, heart rate 86, respirations 18, temperature 98.1. Nurse Practitioner notified, family member notified. Bed alarm activated. Monitoring documented. The note was signed by S3Licensed Practical Nurse (LPN). On 08/21/2024 at approximately 8:35 a.m., an observation revealed resident #1 had a wanderguard intact to his right ankle due to a history of elopement. Further observation revealed S4LPN escorted resident #1 via his wheelchair into the hallway and to the exit door. An observation of the door revealed that it was fully closed and locked with the wanderguard key pad system showing a red light to indicate the door was locked. As S4LPN pushed the resident's wheelchair up to the exit door, the wanderguard system went off and an alarm then sounded to indicate that resident #1 was close to the exit door. During an interview on 08/22/2024 at 9:00 a.m., S1Administrator confirmed the exit door was working correctly prior to resident #1's elopement on 08/12/2024. S1Administrator further revealed it was undetermined as to how resident #1 was able to open the door to exit the building, however the alarm activated upon the opening of the exit door. On 08/22/2024 at 2:48 p.m., S2DON confirmed resident #1 required being monitored every thirty minutes due to his elopement on 08/12/2024 at 9:00 p.m. and to ensure that adequate supervisor was being provided for resident #1's safety.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidence by, 1) having dirty serving trays on a rolling cart, 2) having a grime build up on the kitchen cabinets, shelves, and window ledge, 3) storing an expired nutritional supplement in the refrigerator, and 4) storing food items that belonged to an employee in the storage room and available for resident use. Findings: During an initial tour of the kitchen on [DATE] at 8:10 a.m., an observation revealed a rolling cart located near the steam table. Further observation revealed there were six serving (meal) trays that had old dried food particles on the trays. Further observations revealed there were large amounts of thick, black grime build up on shelves that were located in the bottom and top cabinets throughout the kitchen. The dirty shelves had various cooking pots, pans, and /or eating utensils stored on them. After the initial tour of the kitchen was completed, a tour of the outside storage room revealed one, eight ounce carton of Boost stored inside of the refrigerator. Observation of the carton revealed a use by date of ,d+[DATE]. Further observation of the storage room revealed a small box that contained 2 boxes of macaroni and cheese, one box of wheat noodles, two cans of pork and beans, and one can of black beans. The can of black beans had approximately one half of the label stained with a dark colored unknown substance. S16Dietary [NAME] was present during the observations of the kitchen and outside storage room. She reported that a visitor had left the box of food items for an employee and she (S16Dietary Cook) had placed the box in the storage room for an employee. S16Dietary [NAME] confirmed that the kitchen cabinets and window ledge were dirty and needed to be cleaned and the serving trays contained old dried food particles. S16Dietary [NAME] further confirmed the carton of Boost was expired, and the box of food items left for the employee should not have been stored in outside storage room and available for resident use. On [DATE] at approximately 8:45 a.m., S1Administrator was notified of the above findings.

Based on review of the Resident Council Meeting minutes and interviews, the facility failed to organize resident group meetings in the facility monthly. Findings: An interview on 07/15/2024 at 2:55 p.m. with resident # 4 revealed the resident council has not had meetings in the last couple of months. Review of the Resident Council Meeting minutes revealed no documentation of resident council meeting minutes since 04/17/2024. An interview on 07/15/2024 at 3:05 p.m. with S15Activity Director confirmed the resident council has not had a meeting since 04/17/2024. An interview on 07/15/2024 at 3:40 p.m. with S2Director of Nursing (DON) confirmed the resident council has not had a meeting since 04/17/2024, and should be done monthly.

Based on observations, record reviews, and interviews the facility failed to ensure residents have a right to be treated with respect and dignity, including the right to be free from any physical restraint not required to treat the resident's medical symptoms for 2 (31# and #136) of 3 (#27, #31, and #136) residents investigated for restraints. The facility failed to ensure 1) a pre-restraining assessments was completed and the residents' pelvic restraints were identified on their care plans (#31, #136), and 2) that staff properly applied, monitored, and released a pelvic restraint (#136). Findings: Review of the facility's current Restraint Policies and Procedures, Restraint Alternatives, (no date noted) revealed the policies and procedures failed to include guidelines regarding pre-restraint assessments, obtaining consents for restraints, initiating the use of restraints, proper use of restraints, and monitoring restraint use. Resident #31 Review of the record for resident #31 revealed an admission of 05/11/2023 with following diagnoses: alcoholic cardiomyopathy, urinary tract infection, metabolic encephalopathy, syphilis, and heart failure. Review of the annual MDS (Minimal Data Set) dated 06/03/2024 revealed resident #31 was assessed to be severely cognitively impaired and was totally dependent on staff for activities of daily living. Review of Section P- Restraints, revealed trunk restraints were used daily. Observations of resident #31 on 07/15/2024 at 1:42 p.m. and 07/16/2024 at 9:00 a.m. revealed resident sitting up in wheelchair with pelvic restraint vest in place. Further observations revealed that the pelvic restraint was tied in the back of the wheelchair and that resident was unable to untie restraint. On 07/17/2024 at 10:50 a.m., resident #31 was observed in his room in a wheelchair with a pelvic restraint in place and tied in the back of wheelchair. Review of the active physician orders for July 2024 revealed an order for a pelvic restraint while up in a wheelchair. The order was written on 06/06/2024. Further record review revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #31. Review of the care plans revealed they were last updated on 05/20/2024. Further review of the care plans revealed the facility failed to identify his pelvic restraint and there were no approaches for the restraint. On 07/16/2024 at 9:05 a.m, an interview with S6LPN (Licensed Practical Nurse) confirmed resident #31 was wearing a pelvic restraint and he was unable to remove it. On 07/16/2024 at 2:00 p.m., an interview with S2DON (Director of Nursing) and S3LPN/MDS confirmed a pre-restraint assessment was not completed prior to the implementation of a pelvic restraint for resident #31. S3LPN/MDS confirmed there was no care plan for resident #31's pelvic restraint. 22575 Resident #136 Review of resident #136's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, hemiplegia following cerebral infarction affecting the left non-dominant side, congestive heart failure, abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination. Review of the Admission MDS dated [DATE] revealed resident #136 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Further review revealed resident #136 required extensive assistance to total dependence on staff for most activities of daily living. Observations on 07/15/2024 at 1:30 p.m. and at 4:41p.m. revealed resident #136 was in wheelchair in her room with a pelvic restraint in place. Observation on 07/16/2024 at 8:01 a.m. revealed resident #136 was in wheelchair in her room with a pelvic restraint in place. Further observation revealed the pelvic restraint was applied improperly with straps of restraint tied in a tight knot behind the back of the upper part of her wheelchair. An interview with resident #136 at this time revealed that she's comfortable today but sometimes the restraint feels too tight, especially when she goes out to Intensive Outpatient Program (IOP). Observation on 07/16/2024 at 8:30 a.m. revealed resident #136 was in wheelchair in a van to transport her to IOP. Further observation revealed the resident's pelvic restraint was still tied improperly behind her wheelchair in a tight knot. The surveyor informed the transportation staff that a nurse needed to check her restraint before she left the facility. At 8:35 a.m. S2DON observed resident #136's pelvic restraint and confirmed the pelvic restraint was not secured/tied appropriately and should not be tied in a tight knot. S12Certified Nursing Assistant (CNA) got in the van and confirmed resident # 136's pelvic restraint was tied in a tight knot instead of a slip knot. S13CNA also observed the resident's pelvic restraint at this time and she confirmed that she did not tie it correctly, and that it should have been tied in a slip knot. At this time, S12CNA retied the restraint straps in a slip knot before the resident left for IOP. Review of resident #136's July 2024 Physician's Orders revealed an order dated 07/08/2024 that resident may be up in wheelchair with pelvic restraint for doctor appointments and IOP program. There was no physician's order to monitor the restraint and release the restraint every 2 hours. Further review of the resident's medical record revealed there was no documented evidence that staff were monitoring and releasing resident # 136's pelvic restraint. Review of resident #136's record revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #136. Review of resident #136's Physical Restraint Informed Consent dated 07/08/2023 revealed the resident had a pelvic restraint while up in wheelchair for positioning and poor balance due to left hemiplegia to help prevent sliding out of her wheelchair. Review of resident #136's current care plan revealed there was no documented evidence the resident's pelvic restraint was identified and no interventions regarding the safe and proper use of the restraint. An interview on 07/16/2024 at 3:40 p.m. with S3LPN/MDS confirmed there was no pre-restraint assessment and resident #136's pelvic restraint was not identified on her care plan. An interview on 07/17/2024 at 9:30 a.m. with S14Nurse Consultant confirmed there was no pre-restraint assessment and #136's pelvic restraint was not identified on her care plan. During an interview on 07/17/2024 at 3:10 p.m. with S1Administrator and S2DON, they were informed of the following concerns regarding resident #136's pelvic restraint: there was no pre-restraint assessment, restraint was not identified on her care plan, and no documentation the restraint was monitored by staff.

Based on record reviews and interviews, the facility failed to conduct comprehensive assessments including 1) a smoking assessment for 1 (#15) of 1 (#15) resident reviewed for smoking, and 2) a pre-restraint assessment for 1 (#136) of 3 (# 27, #31, and #136) residents investigated for restraints. Findings: Resident #15 Review of the facility Smoking Policy revised 10/2023 revealed the following in part: Policy Interpretation and Implementation: 9. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. Review of resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses including quadriplegia, anxiety disorder, schizoaffective disorder, and dementia. Review of resident #15's quarterly Minimum Data Set assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 00 which indicated he had severe cognitive impairment. Further review revealed he required limited/ 1 person assistance for most activities of daily living. An observation on 07/17/2024 at 8:22 a.m. revealed resident # 15 was outside in his wheelchair in the designated smoking area with a white smoking apron on. S20Certified Nursing Assistant (CNA) was supervising resident as he smoked his cigarette. An interview with S20CNA at this time revealed resident #15 was an unsafe smoker and had to be monitored by staff. Review of resident #15's Safe Smoking assessment dated [DATE] revealed he was assessed as an unsafe smoker. Further review revealed there was no documented evidence that the facility had conducted a quarterly smoking assessment for resident #15 per the facility policy. An interview with S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) on 07/17/2024 at 2:30 p.m. revealed she had not completed resident #15's quarterly smoking assessments. S3LPN/MDS confirmed the most recent smoking assessment for resident #15 was on 10/31/2022. During an interview with S1Administrator and S2Director of Nursing (DON) on 07/17/2024 at 2:30 p.m. they were informed there was no documentation of quarterly smoking assessments for resident #15 and his most recent assessment was 10/31/2022. Resident #136 Review of the facility's current Restraint Policies and Procedures, Restraint Alternatives, (no date noted) revealed the policies and procedures failed to include guidelines regarding comprehensive assessments, including pre-restraint assessments. Review of resident #136's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, hemiplegia following cerebral infarction affecting the left non-dominant side, congestive heart failure, abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination. Review of the Admission MDS dated [DATE] revealed resident #136 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Further review revealed resident #136 required extensive assistance to total dependence on staff for most activities of daily living. Observations on 07/15/2024 at 1:30 p.m. and at 4:41 p.m. revealed resident #136 was in a wheelchair in her room with a pelvic restraint in place. Review of resident #136's July 2024 Physician's Orders revealed an order dated 07/08/2024 that resident may be up in wheelchair with pelvic restraint for doctor appointments and Intensive Outpatient Program (IOP). Review of resident #136's record revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #136. Review of resident #136's Physical Restraint Informed Consent dated 07/08/2023 revealed the resident had a pelvic restraint while up in wheelchair for positioning and poor balance due to left hemiplegia to help prevent sliding out of her wheelchair. An interview on 07/16/2024 at 3:40 p.m. with S3LPN/MDS confirmed there was no pre-restraint assessment for resident #136's pelvic restraint. An interview on 07/17/2024 at 9:30 a.m. with S14Nurse Consultant confirmed there was no pre-restraint assessment for resident #136's pelvic restraint. During an interview on 07/17/2024 at 3:10 p.m. with S1Administrator and S2DON, they were informed there was no pre-restraint assessment for resident #136's pelvic restraint.

Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental, and psychosocial needs. The facilitly failed to ensure 1) residents' care plan were developed for restraints and interventions for pelvic restraints (#31, #136); and 2) residents' care plan was not implemented regarding monitoring for bleeding (#24). Resident #31 Review of the record for resident #31 revealed date of admission on 05/11/2023 with following diagnoses: alcoholic cardiomyopathy, urinary tract infection, metabolic encephalopathy, syphilis,and heart failure. Review of the Annual MDS (Minimal Data Set) assessment dated [DATE] revealed resident #31 was assessed to be severely cognitively impaired and was totally dependent on staff for activities of daily living. Further review of the MDS for resident #31 dated 05/20/2024 revealed the following: Section P- Restraints: (2) side rails and trunk restraints used daily. Further review of the MDS section P revealed bed alarms and wander/elopement alarm scored 2 and also used daily. Review of the physician orders dated 06/06/2024 for resident #31 revealed an order for a pelvic restraint while up in wheelchair. Review of the Care plan for resident #31 with last update on 05/20/2024 revealed no care plan and/or approaches for a restraint. Observations of resident #31 on 07/15/2024 and 07/16/2024 revealed resident was sitting up in a wheelchair with pelvic restraint vest in place. Further observations revealed that the pelvic restraint was tied in the back of the wheelchair and that resident was unable to untie restraint. Interview on 07/16/2024 at 2:00 p.m. with S3LPN/MDS (Licensed Practical Nurse/Minimal Data Set) at this time confirmed no care plan was developed for pelvic restraint for resident #31. S3LPN/MDS also confirmed that no pre-restraint assessment was completed for resident #31. 22575 Resident #136 Review of resident #136's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, hemiplegia following cerebral infarction affecting the left non-dominant side, congestive heart failure, abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination. Review of the Admission MDS assessment dated [DATE] revealed resident #136 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Further review revealed resident #136 required extensive assistance to total dependence on staff for most activities of daily living. Observations on 07/15/2024 at 1:30 p.m. and at 4:41p.m. revealed resident #136 was in wheelchair in her room with a pelvic restraint in place. Review of resident #136's July 2024 Physician's Orders revealed an order dated 07/08/2024 that resident may be up in wheelchair with pelvic restraint for doctor appointments and Intensive Outpatient Program (IOP). Review of resident #136's record revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #136. Review of resident #136's current care plan revealed there was no documented evidence the resident's pelvic restraint was identified and no interventions regarding the safe and proper use of the restraint. An interview on 07/16/2024 at 3:40 p.m. with S3LPN/MDS confirmed there was no pre-restraint assessment and resident #136's pelvic restraint was not identified on her care plan. An interview on 07/17/2024 at 9:30 a.m. with S14Nurse Consultant confirmed there was no pre-restraint assessment and #136's pelvic restraint was not identified on her care plan. During an interview on 07/17/2024 at 3:10 p.m. with S1Administrator and S2Director of Nursing (DON), they were informed there was no pre-restraint assessment for resident #136's pelvic restraint and the restraint was not identified on her care plan. 32231 Resident #24 Review of the medical record revealed resident #24 was readmitted to the facility on [DATE] with diagnoses that included neuralgia, obesity, dementia with behavioral problems, late effects of cerebrovascular disease with dementia, chronic lymphedema of legs, left hemiparesis, heart disease, and arthritis. Review of the July 2024 physician's orders revealed an order for resident #24 to have Aspirin 81 milligrams, enteric coated, administer one by mouth every day. Review of the medical record revealed resident #24's care plans included that he was at risk for bleeding and falls, and at risk for limited movement related to neuralgia. Further review of the care plan revealed resident #24 had a risk for bleeding related to Aspirin use, and was identified on 02/03/2022. The documented approaches included to monitor for obvious bleeding: tea colored urine, black tarry stools, or petechiae. Review of the July 2024 Medication Administration Record (MAR) revealed no documenation of resident #24 being monitored for bleeding while taking Aspirin daily. On 07/16/2024 at 4:00 p.m., an interview with S3LPN/MDS confirmed that the approach of monitoring for bleeding had not been implemented, in accordance with resident #24's written plan of care.

Based on record reviews and interviews, the facility failed to ensure the residents' care plans were revised to meet the residents' needs, by failing to ensure the resident's care plan was revised to include all new fall interventions in a timely manner for 2 (#2, and #24) of 4 (#2, #7, #24, and #31) residents reviewed for falls. Findings: Resident #2 Review of the record for resident #2 revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, paranoid schizophrenia, spinal stenosis, muscle wasting and atrophy, age-related cognitive decline, hallucinations, generalized anxiety disorder, and osteoporosis. Review of resident #2's 07/05/2024 Annual Minimum Data Set (MDS) assessment revealed she had a Brief Interview for Mental Status (BIMS) score of 00, which indicated resident #2 was severely cognitively impaired. Further review revealed she required limited to extensive assistance for most activities of daily living. Review of the facility incident report dated 6/20/24 at 8:40 a.m. revealed resident #2 had a fall in the chapel and her walker was observed at her feet. She did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions were noted in the medical record. Review of the facility incident report dated 6/24/24 at 4:35 p.m. revealed resident #2 had a fall in her room. She was found sitting on the floor with rollator walker flipped over. Resident #2 did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions noted. Review of resident #2's current care plan, revealed she was at high risk for falls. Further review revealed her care plan was revised with the 6/20/2024 fall, but the new intervention, to remind resident to wait for assistance, was not added until 06/26/2024. Further review of resident #2's care plan revealed the resident's bilateral fall mats were not identified on her care plan. An interview on 07/17/2024 at 2:05 p.m. with S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) confirmed the following: Resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, and the resident's bilateral fall mats were not identified on her care plan. During an interview on 07/17/2024 at 2:05 p.m. with S1Administrator and S2Director of Nursing (DON), they both were informed of the following: resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, the resident's bilateral fall mats were not identified on her care plan. 32231 Resident #24 Review of the medical record revealed resident #24 was readmitted to the facility on [DATE] with diagnoses that included neuralgia, obesity, dementia with behavioral problems, late effects of cerebrovascular disease with dementia, chronic lymphedema of legs, left hemiparesis, heart disease, and arthritis. Review of the incident and accident reports revealed resident #24 was found on his knees while trying to get in the bathroom on 05/09/2024. Review of resident #24's current care plan revealed the care plan was not revised with the resident's fall on 05/09/2024. During an interview with S3LPN/MDS (Licensed Practical Nurse/Minimum Data Set) on 04/16/2024 at 4:00 p.m., she was notified of the findings regarding the plan of care not addressing resident #24's documented fall on the date of 05/09/2024. After reviewing the resident's care plan, S3LPN/MDS staff confirmed the plan of care had not been revised after the resident's fall on 05/09/2024. On 07/17/2024 at approximately 12:40 p.m., S1Administrator and S2Director of Nursing were notified of the findings regarding the care plan not being revised to address resident #24's fall on 05/09/2024.

Based on observations, interviews and record reviews, the facility failed to ensure residents remained as free of accident hazards as possible for 2 (#2, #31) of 4 (#2, #7, #24, and #31) residents reviewed for accidents. The facility failed to ensure: 1) a thorough investigation was conducted for a resident's falls, staff placed a resident's fall mat in proper place, the resident's care plan was revised to include all new fall interventions in a timely manner, and the fall interventions were appropriate for the type of incident that occurred (#2); and 2) an investigation was conducted for an injury of unknown origin (#31). Findings: Resident #2 Review of the facility policy Accidents and Incidents - Investigating and Reporting revised July 2017 revealed the following in part: Policy Statement: All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator. Review of the record for resident #2 revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, paranoid schizophrenia, spinal stenosis, muscle wasting and atrophy, age-related cognitive decline, hallucinations, generalized anxiety disorder, and osteoporosis. Review of resident #2's 07/05/2024 Annual Minimum Data Set (MDS) assessment revealed she had a Brief Interview for Mental Status (BIMS) score of 00, which indicated resident #2 was severely cognitively impaired. Further review revealed she required limited to extensive assistance for most activities of daily living. Review of the fall risk assessment dated [DATE] for resident #2 revealed she had a score of 8, which indicated she was at a low risk for falls. An interview on 07/17/2024 at 2:05 p.m. with S3Licensed Practical Nurse (LPN/MDS) confirmed resident #2 was at a high risk for falls with recent falls in June 2024. She confirmed the above fall risk assessment should have indicated she was at a high risk for falls. On 07/16/2024 at 4:15 p.m., resident #2 was observed in her room in bed with her eyes closed. The fall mat on the left side of the bed was positioned improperly underneath her bed. On 07/16/2024 at 10:50 a.m. resident #2 was observed in her room in bed. The fall mat on the left side of the bed was positioned improperly underneath her bed. On 07/16/2024 at 5:00 p.m. the surveyor and S11Certified Nursing Assistant (CNA) observed resident #2's fall mat on the left side of the bed was positioned improperly underneath her bed. An interview with S11CNA at this time confirmed the fall mat should have been placed on the floor to the left of the resident's bed. Review of the facility incident report dated 6/20/24 at 8:40 a.m. revealed resident #2 had a fall in the chapel and her walker was observed at her feet. She did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions were noted in the medical record. Review of the facility incident report dated 6/24/24 at 4:35 p.m. revealed resident #2 had a fall in her room. She was found sitting on floor with rollator walker flipped over. Resident #2 did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions noted. Review of resident #2's current care plan, revealed she was at a high risk for falls. Further review revealed her care plan was revised with the 6/20/2024 fall, but the new intervention was not added until 06/26/2024. Also the intervention was to remind resident to wait for assistance before trying to get up out of chair. This was an inappropriate intervention due to the resident's severe cognitive impairment and the fall occurred while she was using her walker. Further review of resident #2's care plan revealed the resident's bilateral fall mats were not identified on her care plan. An interview on 07/17/2024 at 2:05 p.m. with S3LPN/MDS confirmed the following: Resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, and the resident's bilateral fall mats were not identified on her care plan. During an interview on 07/17/2024 at 2:05 p.m. with S1Administrator and S2Director of Nursing (DON), they both were informed of the following: there was no thorough investigation of resident #2's 6/20/2024 and 6/24/2024 falls, staff placed the resident's fall mat underneath her bed while she was in the bed, resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, the resident's bilateral fall mats were not identified on her care plan. 17835 Resident #31 Review of the record for resident #31 revealed date of admission on 05/11/2023 with following diagnoses: alcoholic cardiomyopathy, urinary tract infection, metabolic encephalopathy, syphilis, and heart failure. Review of annual MDS (Minimal Data Set) assessment dated [DATE] revealed resident #31 was assessed to be severely cognitively impaired. Review of the fall risk assessment dated [DATE] for resident #31 revealed he had a score of 10, which indicated he was at a high risk for falls. Review of resident #31's care plan with last update on 05/20/2024 revealed he was at risk for falls related to an unsteady gait. Review of nurses' notes for resident #31 dated 05/25/2024 at 8:20 a.m. revealed that a housekeeper walked into resident #31's room and saw him lying on the floor. S5LPN entered his room and noted that he was lying on his right side with blood coming from the side of his right eye. Resident#31 was sent to a local hospital for evaluation. Review of nurses' note dated 05/25/2024 at 3:00 p.m. revealed resident #31 returned to facility via ambulance; stable condition; sitting in wheelchair; continues on 30 minute monitoring; 4 sutures noted above right eye. Observations of resident #31 on 07/15/2024 at 1:42 p,m, and 07/16/2024 at 9:00 a.m. revealed he was sitting up in wheelchair with a pelvic restraint vest in place. Resident #31 had a Wanderguard in place and he self-propelled his wheel chair in the hallway. On 07/16/2024 at 10:15 a.m. surveyor requested 05/25/2024 incident and accident report and investigation regarding resident #31's injury of unknown origin. Interview with S9LPN/treatment (Licensed Practical Nurse) on 07/17/2024 at 2:30 p.m. confirmed documentation on 05/25/2024 of a laceration above resident #31's right eye. Interview with S2DON (Director of Nursing) on 07/17/2024 at 3:00 p.m. revealed that she was unable to locate 05/25/2024 incident and accident report and investigation regarding resident #31's injury of unknown origin. Further interview with S2DON confirmed there was no 05/25/2024 investigation completed regarding resident #31's incident of unknown origin. Review of incident/accident report dated 04/14/2024 at 5:50 p.m. for resident #31 revealed S10CNA (Certified Nursing Assistant) pointed out to S8LPN that resident #31 has small laceration to left eye; origin unknown. Neuro-checks implemented; first aide given to injury and will continue to observe. S8LPN notified and began head injury scale on 04/14/2024 for 24 hours with no issues noted. Further review revealed no investigation was done to determine injury of unknown origin to laceration of left eye to resident #31. Interview with S9LPN/treatment on 07/17/2024 at 2:30 p.m. confirmed she had no 04/14/2024 documentation of a laceration above resident #31's left eye. Interview with S2DON on 07/17/2024 at 3:00 p.m. revealed that an investigation was not done for injury of unknown origin on above incident dated 04/14/2024. Further interview with S2DON revealed that she did not document the wound on the weekly status report.

Based on record reviews, and interviews, the facility failed to ensure that nursing staff are able to demonstrate competency in skills necessary to care for resident needs for 3 (#236, #27, and #186) of 3 (#236, #27, and #186) residents records reviewed. The facility failed by 1) not having documentation of sites for administration of insulin and by having omitted medications for resident #236, 2) not having a fall mat and bed alarm in place for resident #27 as ordered by the physician, and 3) not having documentation of accucheck results for resident #186 as ordered by the physician. Findings: Review of the Administering Medication Policy and Procedure revised April 2019, revealed in part 4. Medications are administered in accordance with prescriber orders, including any required time frames 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administered the medication records in the resident's medical record: b. the dosage; d. the injection site (if applicable); e. any results achieved and when those results were observed. Resident #236 Review of the medical record for resident #236 revealed an admitted [DATE], and readmitted [DATE] with diagnoses including diabetes mellitus, human immunodeficiency virus disease, pressure ulcer of sacral region stage 4, functional quadriplegia, paraplegia, dysphagia, cerebrovascular accident, anemia, urinary tract infection, other peripheral vascular disease, and type 2 diabetes mellitus. Review of the most recent discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of the July 2024 Physician's Orders revealed the following orders dated 07/08/2024: -Diflucan 100 milligrams (mg) 1 per tube (PT) every (q) morning (am) -Sulfamethoxazole-Trimethoprim 200-40/5 milliliters (ml) suspension- 4 teaspoons (tsp) (20 ml Per peg twice a day (bid) -Azithromycin 200 mg/5 ml- 6 tsp (30 cubic centimeters (cc)) by peg tube weekly -Sliding scale with Humulin R insulin <70 hypoglycemia protocol- give coke or apple juice, 151-200=2 Units (U), 201-250= 4 U, 251-300= 6 U, 301-350= 8 U, 351-400= 10 U and notify the physician -Lantus 8 U subcutaneously (SQ) q evening (pm) -Accu-checks before meals (ac) and at hour of sleep (hs) Review of the July 2024 Medication Administration Record (MAR) revealed the following: -No documentation of location of site for the administration of Lantus 8 U SQ q pm -No documentation of administration of Azithromycin 200 mg/5 ml- 6 tsp (30 cc) by peg tube weekly, indefinitely on 07/09/2024 and 07/16/2024 at 7:00 a.m. -No documentation of Sulfamethoxazole-Trimethroprim 200-40/5 ml suspension- 4 tablespoons (20 ml) per peg bid administered on 07/09/2024 for a.m. and p.m. doses; -No documentation of administration of Zidovudine 10 mg/ml give 30 ml PT bid on 07/09/2024 for 7:00 a.m. and 7:00 p.m. doses -No documentation of site administered for sliding scale Humulin R insulin administered to resident #236 on the following dates and times: 07/09/2024 through 07/17/2024 for 6:30 a.m., 07/10/2024, 07/12/2024, 07/14/2024, and 07/16/2024 at 11:30 a.m., 07/09/2024 through 07/11/2024, 07/15/2024 and 07/16/2024 at 4:30 p.m., and 07/08/2024, 07/11/2024, 07/15/2024, and 07/16/2024 at 9:00 p.m. An interview on 07/17/2024 at 12:52 p.m. with S2Director of Nursing (DON) confirmed no documentation of administration site for Lantus from 07/08/2024 through 07/16/2024; no documentation of administration of Diflucan on 07/09/2024, no documentation of administration of Azithromycin on 07/09/2024 and 07/16/2024, no documentation of administration of Sulfamethoxazole-trimethoprim and Zidovudine on 07/09/2024 for 7:00 a.m. or 7:00 p.m. doses. S2DON also confirmed no documentation of site administered for sliding scale Humulin R insulin administered to resident #236 on the following dates and times: 07/09/2024 through 07/17/2024 for 6:30 a.m., 07/10/2024, 07/12/2024, 07/14/2024, and 07/16/2024 at 11:30 a.m., 07/09/2024 through 07/11/2024, 07/15/2024 and 07/16/2024 at 4:30 p.m., and 07/08/2024, 07/11/2024, 07/15/2024, and 07/16/2024 at 9:00 p.m. 32231 Resident #27 Review of the medical record revealed resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified glaucoma, and primary open-angle glaucoma, stage unspecified. Review of the annual minimum data set assessment dated [DATE] revealed resident #27 had a documented brief interview for mental status score of 00 according to section c: cognitive status. A score of 00-07 indicated the resident had severe cognitive impairment with daily decision making. Review of the fall risk assessment dated [DATE] revealed a score of 14. According to the scoring scale documented on the fall risk assessment form, a total score of 10 or above indicated resident #27 was at a high risk for falls. Review of the 2024 physician's orders revealed an order dated 05/16/2024 for resident #27 to have a bed alarm, the staff were to answer promptly when it was activated, and for fall mats times 2 as fall precautions. During the survey dates of 05/15/2024 through 05/16/2024, observations of resident #27's room revealed there were no visible fall mats on the floor and no bed alarm on the resident's bed. Review of the July 2024 medication administration record revealed that the bed alarm and fall mats times 2 was documented daily on the day, evening, and night shifts from 07/01/2024 through the 07/16/2024. On 07/16/2024 at 4:13 p.m., S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) was notified of the physician's order for resident #24 to have a bed alarm and the staff were to answer promptly when activated. An observation of resident's room with S3LPN/MDS was conducted after the interview. During the observation, S3LPN/MDS confirmed there was no bed alarm/pad in the resident's room including on his bed. During a telephone interview with S3LPN/MDS on 07/16/2024 at 4:40 p.m., she confirmed there were no falls and bed alarm observed in resident #27's room. She further onfirmed the documented approaches of the fall mats and bed alarm had not been implemented, in accordance with the physician's orders. During an interview with S1Administrator and S2Director of Nursing on 07/17/2024 at approximately 12:40 p.m., they were notified of the above findings. Resident #186 Review of resident #186's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Type II diabetes mellitus with diabetic polyneuropathy. Review of the July 2024 physician's orders revealed an order dated 07/08/2024 for resident #186 to have Novolog 100 units/milliliter; give 8 units if accucheck greater than 240 (milligrams/deciliter), and to obtain the accuchecks twice a day. Review of the care plan revealed a problem onset of 04/05/2022; altered blood sugars due to diabetes. Further review revealed the documented approaches included accuchecks per physician orders, accuchecks twice a day, and notify the physician if the glucose was less than 60 or greater than 400. Review of the July 2024 MAR revealed that resident #186 was to have an accucheck obtained twice a day at 6:30 a.m. and 4:30 p.m. Further review of the MAR revealed there was no documentation of an accucheck result being obtained on the date of 07/15/2024 at 6:30 a.m. Review of the skilled nurse's notes dated 07/15/2024 revealed there was no documentation to indicate why the accucheck had not been obtained at 6:30 a.m. During a telephone interview on 07/17/2024 at 12:20 p.m. with the nurse practitioner, he confirmed that he was not aware of an accucheck not being obtained on 07/15/2024 for resident #186. During a telephone interview on 07/17/2024 at 12:25 p.m. with the physician, confirmed that he was not aware of an accucheck not being obtained on 07/15/2024 for resident #186. During an interview with S4Assistant Director of Nursing (ADON) on 07/17/2024 at 10:15 a.m., she confirmed that resident #186 was to have accuchecks obtained twice a day at 6:30 a.m. and 4:30 p.m. After a record review was completed, S4ADON confirmed that there was no documentation to indicate why resident #186 did not have an accucheck result on 07/15/2024 at 6:30 a.m., as ordered by the physician. On 07/17/2024 at approximately 12:40 p.m., S1Administrator and S2Director of Nursing were notified of the findings.

Based on review of the personnel records, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) of 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) personnel files reviewed. Findings: Review of S10CNA's personnel file revealed a hire date of 09/08/2022. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. Review of S11CNA's personnel file revealed a hire date of 12/06/1994. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. Review of S12CNA's personnel file revealed a hire date of 06/14/2010. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. Review of S17CNA's personnel file revealed a hire date of 03/25/2024. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. Review of S18CNA's personnel file revealed a hire date of 02/08/2024. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. Review of S19CNA's personnel file revealed a hire date of 10/10/2023. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024. On 07/17/2024 at 5:35 p.m., an interview with S1Administrator confirmed that monthly State Adverse Action checks were not being done monthly.

Based on observations, review of the policy, and interview, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an open medication cart, unlocked and drawers open with medications in direct view and staff not present. The medication cart was in a place where residents and unauthorized staff could access the medication cart. Findings: Review of facility's policy and procedure for Administering Medications (revised April 2019) revealed the following: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on 07/17/2024 at 7:08 a.m. revealed the medication cart for hall A was located in the hallway. Further observation revealed the cart was unlocked, and drawers were opened with medications in direct view. No nurse or staff members were present on the hallway at that time. Resident #306 was observed self-ambulating in a wheelchair, and passed by the open medication cart. Observation on 07/17/2024 at 7:10 a.m. revealed that S2Director of Nursing (DON) entered the hall A and also observed the medication cart unlocked with open drawers and left unattended. S2DON then notified S7Licensed Practical Nurse (LPN), responsible for the unlocked cart, to return to the cart and lock the cart. S7LPN was located behind a closed door assisting resident #236 when the medication cart was observed unlocked on hall A. Observation on 07/17/2024 at 7:54 a.m. revealed the medication cart for hall A was observed once again unlocked with no staff in view of the cart. Interview on 07/17/2024 at 7:15 a.m. with S2DON confirmed that the medication cart was to be locked when medications were not being prepared and the nurse was not in view of the cart.

Based on review of the personnel records and interviews, the facility failed to ensure all required in-service training for Certified Nurse Aides (CNA) included dementia management training for 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA and S19CNA) of 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) personnel files reviewed. Findings: Review of S10CNA's personnel file revealed a hire date of 09/08/2022. Further review revealed there was no documentation of dementia care management training. Review of S11CNA's personnel file revealed a hire date of 12/06/1994. Further review revealed there was no documentation of dementia care management training. Review of S12CNA's personnel file revealed a hire date of 06/14/2010. Further review revealed there was no documentation of dementia care management training. Review of S17CNA's personnel file revealed a hire date of 03/25/2024. Further review revealed there was no documentation of dementia care management training. Review of S18CNA's personnel file revealed a hire date of 02/08/2024. Further review revealed there was no documentation of dementia care management training. Review of S19CNA's personnel file revealed a hire date of 10/10/2023. Further review revealed there was no documentation of dementia care management training. On 07/17/2024 at 5:40 p.m., an interview with S1Director of Nursing confirmed that dementia care training had not been provided to the CNAs listed above.

Based on observation and interview, the facility failed to maintain all mechanical equipment in safe operating condition by having shavings on the manual can opener. Findings: During an initial tour of the kitchen on 07/15/2024 at 8:10 a.m., an observation revealed a large can opener with a buildup of metal shavings on the blade. Further observation revealed S16Dietary [NAME] began opening a large can of canned sweet green peas, for the lunch service. She was notified of the buildup of the metal shavings and confirmed that the can opener blade needed to be cleaned. On 07/15/2024 at approximately 8:45 a.m., S1Administrator was notified of the above findings.

Based on interviews and review of the facility's Infection Control Records, the facility failed to ensure the Infection Preventionist, who is responsible for the facility's infection prevention and control program, had completed specialized training in infection prevention and control. Findings: Review of the facility's Infection Control Records revealed there was no documented evidence the Infection Preventionist, S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS), had completed specialized training in infection prevention and control. An interview with S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) on 7/16/2024 at 1:30 p.m. revealed she had not completed the Infection Preventionist Training. An interview with S2Director of Nursing on 7/17/2024 at 3:10 p.m. confirmed S3LPN/MDS had not completed the Infection Preventionist Training.

Based on observations, record review and interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure 1(#1) of 1 ((#1) residents who was at high risk for elopement was adequately supervised to prevent Resident #1 from eloping from the facility. This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2024 at 3:30 p.m. when resident #1 (a cognitively impaired resident identified as an elopement risk) was found a 1/2 block away from the facility. Resident #1 was located 10 minutes after he eloped on 03/15/2024 through an unsecured door and was returned to the facility at 3:45 p.m. Resident #1 was located at 3:40 p.m., by a staff member and was found in a ditch, sitting in water, and had a laceration to his left eye and bruise to his left shoulder. Resident #1 was returned to the facility by S7 CNA (Certified Nursing Assistant) and S1Administrator in the nursing home van and then the resident was sent for evaluation to the local hospital by ambulance at 4:00 p.m. S1Administrator was notified of the Immediate Jeopardy on 03/22/2024 at 11:40 a.m. The Immediate Jeopardy was removed on 03/22/2024 at 5:40 p.m., as confirmed by onsite verification through observations, interviews and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Cross Reference F689 Review of the facilities Wandering and Elopement policy dated 12/2009 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring. Review of the Incident and Accident report dated 03/15/2024 at 3:40 p.m. stated the resident had an unwitnessed fall outside resulting in a gash over his left eye and bruise on his left shoulder. No other injuries noted at this time, the resident was able to move his upper and lower extremities. Further review revealed the resident was sent to the local emergency room for evaluation at 4:00 p.m. on 03/15/2024. An interview on 03/21/2024 at 09:50 a.m. with S1Administrator confirmed he began investigating how the resident eloped from the facility on 03/15/2024. The investigation found that the door the resident went out of was normally locked and a code would have to be used to open it. S1 Administrator stated the door must have not closed completely due to when the resident pushed the door opened the alarm did sound. S1Administrator stated he contacted the agency that maintains the facilities locked doors and they came immediately to inspect the doors. The agency determined that the door was functioning properly and if it happened again, to contact them and they would respond immediately. S1Administrator stated they would have placed a wander guard bracelet on the resident, but the facility did not have any bracelets on hand and he had to order them. S1Administrator stated the facility does not have a system in place to monitor the locked doors to ensure they are in working order. Interview on 03/22/2024 at 9:10 a.m. with S2DON (Director of Nurses) stated the facility had not received the wander guard bracelets, but they were ordered. She further stated the resident was being monitored by staff every 30 minutes but the monitoring had not been documented. During the survey, there was no documented evidence of monitoring the resident for elopement and monitoring proper working order of the locking of exit doors before or after the elopement incident on 03/15/2024.

Based on observations, record reviews and interviews the facility failed to provide an environment free of accident hazards for 1 (#1) of 1 (#1) residents identified at high risk for elopement. The facility failed to ensure all exit doors were secured to prevent residents at risk for elopement from exiting the facility unsupervised and failed to provide continued monitoring after resident #1 was returned to the facility. This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2024 at 3:30 p.m. when resident #1 (a cognitively impaired resident identified as an elopement risk) was found a 1/2 block away from the facility. Resident #1 was located 10 minutes after he eloped on 03/15/2024 through an unsecured door and was returned to the facility at 3:45 p.m. Resident #1 was located at 3:40 p.m., by a staff member and found in a ditch, sitting in water, and had a laceration to his left eye and bruise to his left shoulder. Resident #1 was returned to the facility by S7 CNA (Certified Nursing Assistant) and S1Administrator in the nursing home van and then the resident was sent for evaluation to the local hospital by ambulance at 4:00 p.m. S1Administrator was notified of the Immediate Jeopardy on 03/22/2024 at 11:40 a.m. The Immediate Jeopardy was removed on 03/22/2024 at 5:40 p.m., as confirmed by onsite verification through observations, interviews and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the current facility's Wandering and Elopement policy dated 12/2009 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring. Review of the medical record for resident #1 revealed an admitted [DATE] with a readmitted [DATE]. Further review revealed diagnosis of myocardial Infarction, alcoholic cardiomyopathy, acute respiratory failure with hypoxia, syphilis, heart failure, alcohol abuse, trichomonas, acute kidney failure, and metabolic encephalopathy. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed resident #1 had severe cognition for daily decisions making and required assistance with one person assist for bed mobility and supervision with one person assist with transfers. Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of resident #1's Elopement Risk Record dated 02/29/2024 revealed no complaints of elopement, but was high risk and the only intervention noted was a bed alarm. Further review revealed the risk record was updated 03/15/2024 to include the incident of the resident leaving the building without staff and interventions were noted as bed alarm, staff aware of residents wander risk and frequent monitoring. Review of resident #1's current care plan revealed he was care planned for elopement with an intervention of monitoring for needs and needs will be met as necessary. Further review revealed on 03/15/2024 care plan updated - resident eloped from the nursing home, with new approaches that included census checks q (every) 30 minutes for whereabouts and elopement attempts. Review of resident #1's record failed to reveal documentation of monitoring the resident's needs and needs being met prior to the elopement prior to 03/15/2024. Review of resident #1's Incident & Accident report dated 03/15/2024 at 3:40p.m. revealed an unwitnessed fall outside the facility, resulting in a gash over the left eye and bruise to the left shoulder. No other injuries noted at this time. Able to move upper and lower extremities. Resident #1 sent by ambulance to the local hospital for evaluation. Resident #1s discharge hospital report dated 03/15/2024 revealed CT (computed tomography) scan done with no injuries found, incision to left upper eye with fibrin sealant. Discharge back to nursing facility and follow up with resident's physician. An interview on 03/21/2024 at 9:55 a.m. with S4LPN (Licensed Practical Nurse) that was taking care of resident #1, confirmed there was no documentation of the monitoring for needs and needs will be met as necessary prior to the 03/15/2024 elopement and for the census checks for the resident's whereabouts every 30 minutes after the elopement on 03/15/2024. An interview on 03/21/2024 at 10:20 a.m. with S9CNA stated resident #1 was checked on by staff every 30 minutes, but they don't document it anywhere. An interview on 03/22/2024 at 9:00 a.m. with S8CNA and S10CNA that was taking care of resident #1, confirmed there was no documentation of monitoring the resident before or after the elopement attempt on 03/15/2024. An interview on 03/21/2024 at 9:50 a.m. with S1Administrator revealed when he was notified resident #1 was not in the facility, he drove the nursing home van down the block and saw the resident sitting on the ground in the water. The Administrator stated he and the other staff member assisted the resident to a standing position and assisted him to the van to be brought back to the nursing home. S1Administrator stated the resident was assessed and found to have a gash above his left eye and bruise to the left shoulder and nursing had received an order from the resident's physician to send the resident to the hospital for evaluation. S1Administrator stated he began investigating how the resident eloped from the facility. It was found that the door the resident went out of was normally locked and a code would have to be used to open it, but he stated it must not have closed completely due to when the resident pushed the door opened the alarm did sound. S1Administrator stated he contacted the agency that works on the facilities locked doors and they came to inspect the doors. The agency determined that the door was functioning properly and if it happened again, contact them and they would respond immediately. S1Administrator stated they would have placed a wander guard bracelet on the resident, but the facility did not have any bracelets on hand and he had to order some. S1Administrator stated resident #1 will be monitored by staff every 30 minutes until the wander guard arrives. An interview on 03/21/2024 at 9:55 a.m. with S4LPN that was taking care of resident #1, stated he had never tried to go outside by himself before the incident on 03/15/2024. When asked how he was being monitored after the elopement she stated staff make observations of the resident every 30 minutes, he is taken to the Chapel to eat all meals, and if the resident seems restless they will bring him to the nurse's station to be monitored. When asked where the observations every 30 minutes were documented S4LPN stated they were not documented. An interview on 03/22/2024 at 9:10 a.m. with S2DON (Director of Nurses) stated the facility had not received the wander guard bracelets, but they were ordered. She further stated the resident was being monitored by staff every 30 minutes, but the every 30 minute monitoring had not been documented.