Every finding on record at Nursing and Rehabilitation Center at Good Shepherd

Based on observation, record review, interview, and facility policy review the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during medication administration through a Percutaneous Endoscopic Gastrostomy (PEG) tube for one (Resident #3) sampled resident based on one of one observation. Specifically, nursing staff did not wear a gown for Personal Protection Equipment (PPE) during medication pass. The findings include: A review of Resident #3's Medical Diagnosis revealed the resident had diagnoses which included stroke, dysphagia, and heart attack. A review of Resident #3's quarterly Minimum Data Set with an Assessment Reference Date of 11/20/2025, revealed a Brief Interview for Mental Status score of 00, which indicated the resident had severe cognitive impairment. Resident #3's MDS also indicated the resident had a feeding tube. A review of Resident #3's Care Plan, revised 07/01/2024, revealed the resident was on EBP related to a PEG tube, gown and glove during high contact resident care including feeding tubes. A review of Resident #3's Order Summary indicated on 09/02/2025, 10 milligrams of medication for reflux was ordered every six hours through the resident's PEG tube. Resident #3's Order Summary also revealed on 10/20/2025, 30 cubic centimeters (cc) of an oral laxative solution to reduce issues caused by muscle wasting was ordered via PEG tube. During an observation on 01/14/2026 at 11:28 AM, Licensed Practical Nurse (LPN) #1 was observed mixing water with medication for reflux and a laxative for Resident #3. LPN #1 walked past an EBP sign and PPE hanging on the inside of Resident #3's inside doorway. LPN #1 turned off the resident's feeding pump with gloves in place, but without a gown. LPN #1 unhooked Resident #3's feeding tube and flushed it with 30cc of water, after auscultating placement. LPN #1 revealed staff flush PEG tubes with 30cc of water before and after administering medications. Medication solution was observed being poured into the feeding tube, then LPN #1 flushed Resident #3's tube with 30cc of water after administering medications. The feeding tube was reconnected and the pump turned on. During an interview in Resident #3's room on 01/14/2026 at 11:53 AM, LPN #1 said he was not aware of any special precautions for Resident #3. LPN #1 reviewed the resident's electronic record and said, I do not see anything on the orders. LPN #1 indicated the procedure used when giving medications or water through a PEG tube was to just make sure it is not clogged or kinked. LPN #1 then said infection control concerns were to just make sure the equipment is clean and to replace the syringe and tubing in 24 hours. LPN #1 was observed washing hands prior to putting on gloves but was not observed wearing additional PPE. EBP signage and PPE were noted inside Resident #3's doorway, and Resident #3's name was in orange, indicating EBP, outside the doorway. During an interview on 01/14/2026 at 1:18 PM, Certified Nursing Assistant (CNA) #2 revealed staff could tell when a resident was on EBP because their name outside the door is in orange, PPE and EBP signage is hanging up inside the resident's doorway. CNA #2 revealed EBP's were an infection control measure. During an interview on 01/14/2026 at 1:22 PM, LPN #3 said EBP's are for residents with an open wound, foley catheter, or feeding tubes and staff were expected to follow EBP's, because it would be easy to introduce an infection to residents. LPN #3 indicated handwashing, gowning up, and wearing gloves was expected during direct patient care, to prevent the spread of infection and in-services were held monthly. LPN #3 confirmed that residents on EBP's names were in orange, and signage with PPE hung inside the resident's doorway. During an interview on 01/14/2026 at 2:50 PM, the Director of Nursing (DON) said, staff should follow EBP, and put on a gown and gloves when administering medications through a feeding tube. The DON revealed the last in-service on EBP was within the last few weeks [11/14/2025] and stated it was important to gown and glove when giving medications through a PEG tube to protect the resident more than anything. The DON was then asked to provide EBP and general infection control policies, and in-services. During an interview on 01/15/2026 at 11:06 AM, the Administrator revealed that nursing staff were expected to follow EBP, and she was already told by LPN #1 that LPN #1 did not put on a gown during the medication pass and this medication pass had helped identify some areas where the facility could provide some additional teaching on EBP's for infection control. Administrator revealed not following EBP increased the risk for infection. A review of a facility in-service titled Enhanced Barrier Precautions, dated 11/14/2025, revealed providers and staff were expected to wear gown and gloves during high contact resident care including feeding tubes. LPN #1 could not be found on the EBP signature roster. A review of a facility policy titled EBP in Nursing Homes, dated 03/20/2024, revealed Multi Drug Resistant Organisms (MDROs) were common in long-term care and residents were at increased risk for colonization and developing MDROs. EBP's were controlled interventions designed to reduce MDRO transmission through the use of gown and gloves during high contact resident care including wounds, central lines, urinary catheters, tracheostomies and feeding tubes.

Based on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 100 residents. The findings are: A review of the Comprehensive Facility Assessment, dated November 2017, did not contain the following required information: - The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population. - The care required by the resident population, using evidence-based, data-driven methods that consider an evaluation of diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population consistent with resident assessments to help the facility understand the potential implications regarding the intensity of care and services needed. - Staffing's plan is to evaluate of the overall number of facility staff needed to ensure available and sufficient number of qualified staff are available to meet each resident's needs based on the facility census and address staffing needs for each resident unit, each shift, and to include weekend and emergencies to ensure coordination and continuity of care - Competency-based skill set approach to make informed staffing decisions to ensure there are a sufficient number of staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice as identified through the resident assessments and plans of care - Plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in the care of residents and/or how management expectations of medical personnel. - The facility's resources including all buildings and/or other physical structures and vehicles, medical and non-medical equipment necessary to provide for the needs of residents, services provided (physical therapy, pharmacy, behavioral health, etc.), and all personnel, (management, direct care staff, and volunteers) which include employees and contracted employees along with their education and competencies - Heath information technology resources for managing resident records and sharing information with other organizations. - A contingency plan for events that do not require the activation of the facility emergency plan but have the potential to impact resident care, such as the availability of direct care nurse staffing or other resources needed for care of residents. On 10/04/2024 at 12:45 PM, an interview with the Administrator was completed. The interview revealed that overall, the facility assessment was not completed, and the facility would work on the facility assessment to make it more accurate.

Based on observation, interview, and in-service review, it was determined that the facility failed to ensure resident's call lights were in reach for 5 (Residents #13, #24, #51, #80, and #96) of 25 sampled residents. The findings are: 1. On 9/30/2024 at 9:52 am, observed Resident #80's call light was not in reach. Resident was sitting in a chair in front of the dresser and the call light was located under the right side of the bedframe. a. At 11:18 am, Resident #96's call light was not in reach. The call light was located on the left side of the bed with the button dangling right above the floor. b. At 12:30 pm, Resident #13's call light was not in reach. The call light was tied to the left side handrail that was pushed up against the wall and the button was hanging below the handrail where it was not visible. 2. On 10/01/2024 at 8:59 am, observed Resident #24's and Resident #51's call lights were not in reach. Resident #24's call light was tied to the left side of the handrail with the button dangling below the handrail, not visible to the resident. Resident #51's call light was hanging through the right side handrail dangling above the floor, out of reach of the resident. At 9:04 am, observed Resident #80's call light was not in reach. The call light was hanging below the left side of the bedframe. At 9:07 am, observed Resident #13's call light was not in reach. The cord was wrapped around the left side of the handrail with the button hanging below the handrail, not visible to the resident. At 9:11 am, observed Resident #96's call light not in reach. The call light was hanging over the handrail and dangling just above the floor where the resident could not reach it. On 10/02/2024 at 8:24 am, Certified Nursing Assistant (CNA) #5 confirmed that residents are to have their call lights where they can reach them in case they have a need or an emergency. On 10/02/2024 at 8:46 am, CNA #5 stated that the last thing that is done before leaving a resident's room is checking to ensure the call light is in the resident's reach in case they want or need something. CNA #5 stated that if the resident had an emergency and couldn't reach their call light, the resident may suffer harm. On 10/03/2024 at 8:10 am, Licensed Practical Nurse (LPN) #8 confirmed that the residents should have their call lights before exiting their rooms because they may want or need something that they aren't able to get themselves. LPN #8 confirmed that emergencies can happen, and the residents need their call lights in reach. On 10/04/2024 at 8:08 am, observed Resident #51's call light on the nightstand. CNA #6 was asked where the resident's call light was located. CNA #6 confirmed that it was not where it was supposed to be. CNA #6 was asked if the resident could reach it on the nightstand. CNA #6 confirmed that the resident would not be able too. CNA #6 confirmed that if the resident choked or had an emergency that it would be very harmful if the resident didn't have their call light. The Administrator provided in-services dated 11/17/2023, 4/11/2024, and 6/28/2024 that were issued to staff regarding call lights and confirmed that the facility did not have a policy specific to call lights.

Based on observations, interviews, and facility document review, it was determined that the facility failed to clean and sanitize the shower room on 500 Hall which was reviewed for environmental concerns. Findings include: A review of a facility policy titled, Resident Rights, revised on 11/22/2016, indicated the resident would receive adequate and appropriate care to include personal cleanliness in a safe and clean environment. During an observation on 10/01/2024 at 8:30 AM, the spa/shower room on the 500 hall was noted to have large scrape marks along the shower room stalls, an unidentified brownish/black residue was noted along the edges of each shower room stall where the floor meets the walls, there was unidentified brownish substance stain on the tiled walls and the sink area was cluttered with supplies. During an interview on 10/01/2024 at 2:15 PM, the Director of Nursing (DON) confirmed that there was a black/brown substance noted along the edges of the shower stalls, brown substances splattered on the walls of the shower stalls and that the shower room needed to be cleaned. During an interview on 10/01/2024 at 2:18 PM, the Housekeeping Supervisor confirmed there was a black-brown substance noted along the edges of the shower stalls, brown substances splattered on the walls of the shower stalls and that the shower room needed to be cleaned. The housekeeping supervisor stated that someone would be cleaning the shower room later in the afternoon. During an interview on 10/02/24 at 3:00 PM, the Administrator showed the surveyor pictures of the shower room on the 500 hall and stated that the room had been cleaned. During an observation on 10/3/2024 07:55 AM, the shower room on 500 hall was noted to have new white [NAME] over some of the shower stall edges. Some stalls were still noted to have the same brownish-black residue, and the shower room stalls were still with brown-black substances on the walls.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Resident #88, and Resident #30) of 25 residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's medication regimen was accurately completed for Resident #30 and failed to ensure information regarding a fall with major injury was accurately completed for Resident #88. Findings include: On 10/03/2024 at 11:05 AM, the nurse consultant stated the facility did not have a policy for the Minimum Data Set (MDS) and that the facility uses the Resident Assessment Instrument (RAI) manual. 1. A review of the Admission Record indicated the facility admitted Resident #88 with diagnoses that included polyneuropathy (damage to multiple nerves outside of the brain and central nervous system), muscle weakness, lack of coordination, muscle wasting and atrophy, chronic pain, and scoliosis. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/20/2024, revealed Resident #88 had one fall with no major injury. A review of the care plan initiated 06/27/2024 indicated Resident #88 had an actual fall with serious injury with no interventions to prevent reoccurrence and a care plan initiated 06/16/2023 stating Resident #88 was at increased risk for falls due to gait instability and weakness and falls prior to hospitalization with no interventions listed to prevent fall from occurring or reoccurring. Care plan was updated on 06/26/2024 for shower bed for showers as tolerated related to leaning and was changed to a mechanical lift for transfers on 07/01/2024. A review of the CMS-802 facility roster matrix was supplied on 09/30/2024 and failed to include a fall with major injury for Resident #88. A review of the incident and accident report dated 06/26/2024 was supplied by the Director of Nursing on 10/02/2024 for Resident #88 for a witnessed fall on 06/26/2024 at 12:00 PM. A review of hospital records for 06/26/2024, x-ray reports indicated that Resident #88 had a closed fracture of proximal end of left tibia. 2. A review of the Admission Record for Resident #30 indicated the facility admitted Resident #30 with diagnoses that included specified depressive episodes and schizoaffective disorder, depressive type. The quarterly MDS with an ARD of 07/16/2024, indicated that Resident #30 was not currently taking an antidepressant medication. A review of the Order Summary Report for Resident #30 indicated that the resident was currently receiving an antidepressant, which was ordered on 04/15/2024. A review of the care plan, initiated 04/11/2024, indicated Resident #30 used antidepressant medication. During an interview on 10/03/2024 at 12:35 PM, Long Term Care (LTC) MDS Coordinator confirmed the long-term care MDSs were completed by the LTC MDS Coordinator. She confirmed that training had been completed but that it was difficult to understand and that as the coordinator, needed more training. Confirmation was given that the MDS had been coded incorrectly, because Resident #88 had a fall that resulted in significant injury. The LTC MDS Coordinator confirmed that Resident #30 was taking an antidepressant and that it was missed when the MDS was completed. When the LTC MDS Coordinator was asked what could occur if assessments were not completed accurately. She stated that it could cause a deficit in the residents' care. During an interview on 10/04/2024 at 8:40 AM, the Director of Nursing (DON) confirmed Resident #88's MDS should have included the fall with major injury. The DON stated the Skilled Nursing Facility (SNF) MDS Coordinator assists when questions need to be answered or when something is not understood and the use of the RAI manual. During an interview on 10/04/2024 at 9:06 AM, the Administrator stated the MDS should indicate if the resident had a fall with major injury.

Based on observations, interviews, record review, facility document review, it was determined the facility failed to update and/or revise the resident's care plan for 5 (Residents #7, #36, #91, #30, and #72) of 25 residents reviewed for comprehensive care planning. Specifically, the facility failed to include unnecessary medications for Resident #30, change in wound care status for Resident #72, and falls for Resident #7, #36, and #91. Findings include: On 10/03/2024 at 11:05 AM, the nurse consultant stated the facility did not have a policy for care plans and the facility followed the Resident Assessment Instrument (RAI) manual. 1. A review of the Admission Record, indicated the facility admitted Resident #7 with diagnoses that included dementia, cognitive communication deficit, age related osteoporosis, muscle wasting and atrophy, and glaucoma. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had moderate cognitive impairment. Resident #7 required maximal assistance for mobility and has had two falls since the last assessment. A review of Resident #7's care plan revised on 07/23/2024, indicated the resident was a high risk for falls due to weakness and the resident had a fall on 07/22/2024 without injury. The facility developed interventions to include staff to follow facility fall protocol. There were no interventions initiated after 2018. Further review indicated the resident had limited physical mobility; however, the resident was weight bearing. The facility also indicated Resident #7 had an Activity of Daily Living (ADL) self-care performance deficit related to cognitive deficit, weakness, and impaired mobility. A review of Nsg [Nursing] [Named] Fall Scale and Care Plan with Tasks with an effective date of 02/14/2024 indicated Resident #7 was a high risk for falling and the resident overestimates or forgets limits. There were no new interventions listed. A review of Un-witnessed Fall incident and accident (I&A) report indicated on 05/22/2024 at 4:15 AM, indicated Resident #7 had an unwitnessed fall in the resident's room and was found lying on the floor between the bed and the wall in the left lateral position. The resident's upper body was slightly under the bed. The resident could not state what happened. The immediate action taken was to continue to make sure the bed was in the lowest position and locked. There was no other information provided regarding the fall, including witness statements or investigation regarding the fall. A review of Nsg [Nursing] [Named] Fall Scale and Care Plan with Tasks with an effective date of 05/24/2024 indicated Resident #7 was a high risk for falling and the resident overestimates or forgets limits. There were no new interventions listed. A review of Un-witnessed Fall incident and accident (I&A) report indicated on 07/22/2024 at 6:35 PM, indicated Resident #7 had a fall in their room and was found on the floor, lying in front of their wheelchair next to the resident's bed. Their legs were extended out in front of the resident and their arms were to the side of the resident. The resident requested assistance to bed. There was no other information provided regarding the fall, including witness statements or investigation regarding the fall. A review of Nsg [Nursing] [Named] Fall Scale and Care Plan with Tasks with an effective date of 07/22/2024 indicated the resident was a high risk for falling and the resident overestimates or forgets limits. There were no new interventions listed. During an interview on 10/03/2024 at 3:30 PM, Licensed Practical Nurse (LPN) #12 stated Resident #7 had dementia, and a mechanical lift was needed for all transfers. LPN #12 stated Resident #7 was in their room when the fall occurred and there were no injuries. LPN #12 could not recall the official interventions in place at that time but could recall Resident #7 had a fall mat in place. When a resident has a fall, staff were to fill out an I & A in the computer, notify the DON (Director of Nursing) and family, notify the doctor, chart how it happened, how they found the resident, complete neurological checks, monitor vital signs, assess for injuries and if injuries are present, staff notify the doctor. Staff make sure an intervention is put in place and documented in the I & A under risk management in the electronic health record 2. A review of the Admission Record, indicated the facility admitted Resident #36 on 10/10/2019 with diagnoses that included acute respiratory failure, severe speech and language deficits due to a stroke, partial paralysis, traumatic brain injury, dementia, post-traumatic stress disorder (PTSD), visuospatial deficit, and spatial neglect. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated Resident #36 had moderate cognitive impairment. Resident #36 required partial to moderate assistance for mobility and had no falls since the prior assessment. A review of Resident #36's care plan revised on 03/06/2024, indicated the resident was at an increased risk for falls due to gait instability, weakness, impaired mobility, and noncompliance with call light use. The resident had a fall on 01/26/2024 without injury. The facility developed interventions to include, attempt to maintain bed in low position and to remind to call for transfer assistance, to encourage non-skid socks, non-skid strips on bathroom floor, remind frequently to call for assistance, remind resident to call for assistance. Further review indicated the resident had another fall that was initiated on 05/17/2024 and to initiate neurological checks. No other interventions were indicated. The facility also indicated the resident had an Activity of Daily Living (ADL) self-care performance deficit related to cognitive deficit, weakness, and impaired mobility as well as the resident having a stroke that resulted in paralysis to the left non-dominant side. During an interview on 10/03/2024 at 3:25 PM, with LPN #14, she stated the Long Term Care (LTC) Coordinator was responsible for updating the resident's care plan. Staff bring the I & A to attention of the LTC Coordinator when anything changes with a resident. During an Interview on 10/04/2024 at 10:25 AM, the Director of Nursing (DON) stated Resident #36's fall interventions included anti-roll backs for the wheelchair, fall mat, non-skid socks, and padding the bottom bed rail. Resident #36's last fall was on 09/26/2024, which resulted in an abrasion on the left ankle. The DON stated the resident's care plan did not include some of the fall interventions and there should be an intervention after each fall and interventions should be reviewed to see what is working and what is not. During an interview on 10/04/2024 at12:44 PM, the LTC MDS Coordinator stated the resident's care plan should be updated when there is a change in condition, new orders, medication reduction, or if the resident falls. At this time, the LTC MDS Coordinator reviewed Resident #36's care plan and stated the care plan was not updated to reflect the most recent fall because they were on vacation until the end of September and still catching up from being off work. 3. A review of the Admission Record, indicated the facility admitted Resident #91 with diagnoses that included rheumatoid arthritis, one sided paralysis following stroke to the left non-dominant side, necrosis of unspecified bone, anxiety and depression. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/27/2024, revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Resident #91 used a wheelchair for mobility and had a fall with major injury since the prior assessment. A review of Resident #91's care plan revised on 07/11/2024, indicated the resident was at increased risk for falls due to weakness and paralysis and had a fall without injury on 07/03/2024. The facility developed interventions to include a pommel cushion to the wheelchair, which was initiated on 07/03/2024. Further review of the care plan indicated the care plan was updated on 09/09/2024 to indicate the resident had a fall with no injury and to continue interventions on the at-risk plan. There was no indication what the at-risk plan was. The facility also indicated Resident #91 had an Activity of Daily Living (ADL) self-care performance deficit related to a stroke with residual left paralysis. A review of Nsg [Nursing] [Named] Fall Scale and Care Plan with Tasks with an effective date of 07/03/2024, indicated the resident was a high risk for falling and the resident overestimates or forgets limit and the intervention was to add a pommel cushion to the wheelchair. This form was completed by LPN #14. A review of Nsg [Nursing] [Named] Fall Scale and Care Plan with Tasks with an effective date of 09/04/2024, indicated the resident was a high risk for falling and the resident overestimates or forgets limits and the intervention was to lower the wheelchair seat. This form was completed by the Director of Nursing (DON). This form was completed prior to Resident #91's fall on 09/06/2024 and is linked to the resident's care plan, which was not updated until 09/09/2024 A review of Progress Notes indicated on 09/06/2024 at 2:43 PM, LPN #14 indicated there was a new order for an x-ray to Resident #91's left shoulder, left humerus, left elbow, left wrist, and left hand related to pain. There were no progress notes indicating Resident #91 had a fall that day or within the month. A review of Un-witnessed Fall incident and accident (I&A) report indicated on 06/26/2024 at 5:15 PM, LPN #15 indicated Resident #91 had an unwitnessed fall from their wheelchair and was discovered against the wall, lying on their left side by a CNA. Resident #91 stated they were trying to lean over in their wheelchair to fix a shoe and stated they knew they should not have leaned over. The resident complained of pain and rated it an 8 out of 10, and denied any new pain related to the fall. Other information included that Resident #91 overestimated their abilities. There was no other information provided regarding the fall, including witness statements or investigation regarding the fall. During an interview on 10/03/2024 at 3:25 PM, with LPN #14, she stated the Long Term Care Coordinator (LTC Coord) was responsible for updating the resident's care plan. Staff bring the I & A to the attention of the LTC Coordinator when anything changes with a resident. During an interview on 10/04/2024 at 10:25 AM, the Director of Nursing (DON) stated the interventions of a drop seat and pommel cushion were in place when the resident fell . The DON stated it was appropriate to keep the resident from falling. The DON stated she was not aware the cushion did not fit the resident's wheelchair. 4. A review of the Admission Record, indicated the facility admitted Resident #72 with diagnoses that included Alzheimer's Disease with late onset, peripheral vascular disease (PVD) and polyneuropathy (damage to multiple nerves outside of the brain and central nervous system). No active diagnosis of leprosy. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024, revealed Resident #72 was at risk of developing pressure ulcers and Resident #72 had one or more unhealed pressure ulcers/injuries. A review of Resident #72's care plan, revised on 07/28/2024, revealed the resident had a pressure ulcer or potential for pressure ulcer development related to immobility. Resident #72 had a deep tissue injury (DTI) to the bottom of left foot, healed; DTI to right lateral heel, healed, DTI to left heel, resolved, a DTI to right heel that was unstageable and an unstageable to the medial aspect of the right second toe. Interventions included using a pressure relieving device for bilateral heels, a pressure relieving mattress and to utilize a foot cradle when in bed. The care plan updated 09/26/2024 also indicated Resident #72 had the potential to skin integrity related to leprosy, polyneuropathy and PVD with a history of ulcerations. Documentation on care plan included: 09/26/2024 - red, moist area under left abdominal fold; 09/17/2024 - Stage 3 Pressure Injury (PI) to right heel; 09/23/2024-Stage 3 PI to right ankle and 09/23/2024 - Skin tear (ST) to right shin. A review of Order Summary Report, revealed Resident #72 had treatment orders as follows: - Cleanse right shin with wound cleanser, apply moisture enhancing gel, cover with foam border dressing, change every Monday, Wednesday and Friday and as needed. - Cleanse Stage 3 PI to right heel with wound cleanser, apply moisture enhancing gel, cover with border dressing every Monday, Wednesday and Friday and as needed. - Paint DTI to tip of right big toe with iodine and leave open to air every day. - Right lateral malleolus, cleanse with wound cleanser, pat dry, apply moisture enhancing gel, apply anti-biotic, cover with protective dressing three times a week, and as needed. A review of the Skin & [and] Wound Evaluation V7.0 reports for 09/26/2024 indicated that Resident #72 had: - An in-house acquired DTI to the right shin measuring 3.3 centimeters (cm) x 1.7 cm x 0.1 cm. - An in-house acquired (09/13/2024) Stage 3 pressure injury to the right lateral malleolus measuring 0.8 cm x 0.9 cm x 0.2 cm. - An in-house acquired (06/20/24) Stage 3 pressure injury to the right heel measuring 2.0 cm x 2.0 cm x 0.2 cm. - An in-house acquired DTI to the right dorsum-first digit (hallux-tip) measuring 0.7 cm x 0.7 cm x 0.1 cm. During an interview on 09/30/2024 at 2:32 PM, the Treatment Nurse verified that Resident #72 had four wounds being treated which included the right outer ankle, right outer heel, the right great toe and the right shin. The Treatment Nurse stated all the wounds were caused by pressure and were acquired in the facility and that hospice would be bringing an air mattress for Resident #72. The Treatment Nurse stated that the Wound Advanced Practice Nurse had made rounds on 09/30/2024 and that changes in orders had been made. 50505 5. A review of the Admission Record indicated the facility admitted Resident #30 with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris and acute absence of right leg below the knee. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/16/2024, revealed Resident #30 was not taking an anticoagulant but was marked for taking an antiplatelet with the indication noted. A review of Resident #30's care plan, revised 04/11/2024, revealed the resident was on anticoagulant and/or antiplatelet therapy, aspirin (ASA) and (anticoagulant x 14 days). Intervention included: administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. A review of the Order Summary Report, revealed Resident #30 had an order for aspirin one time a day. There were no other orders for antiplatelets, or anticoagulants noted. A review of the medication administration record (MAR), revealed Resident #30 had been receiving aspirin once a day and no other anticoagulant or antiplatelet. During an interview on 10/03/2024 at 12:35 PM, Long Term Care (LTC) MDS Coordinator confirmed the care plans for long-term care residents were completed by the LTC MDS Coordinator. Confirmation was given that the care plan was not accurate with the wounds for Resident #72 and the anticoagulant needed to come off from the care plan on Resident #30, as the medication course had been completed. During an interview on 10/04/2024 at 8:40 AM, the Director of Nursing (DON) confirmed Resident #72's care plan should have included the current wounds with the proper classification and Resident #30's should have had the anticoagulant resolved from the care plan. 49981

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure nutritionally balanced meals were provided for the residents for 2 of 2 meals observed. The findings are. 1. On 9/30/2024, the noon meal menu indicated residents on pureed diets were to receive 8 ounces of pureed pizza, this was the resident's choice for the meal of the month. 2. On 9/30/2024 at 12:30 PM, Dietary [NAME] (DC) #3 used a #8 scoop, which is equivalent to 4 ounces, to serve a single portion of pureed pizza to the residents who received pureed diets. Instead of 8 ounces of pureed pizza. 3. On 9/30/2024 at 1:19 PM, when asked during an interview the Dietary Manager stated this was residents' choice for the meal of the month. The residents on pureed diets were to receive 8 ounces of pureed pizza. 4. On 10/1/2024, the breakfast menu indicated residents on pureed diets were to receive pureed hot cereal. On 10/01/24 at 7:45 AM, the residents on pureed diets were served regular oatmeal, instead of pureed oatmeal. The Dietary Manager confirmed the residents on pureed diets received regular oatmeal. Dietary [NAME] #3 stated it was her mistake for serving regular oatmeal, instead of pureed oatmeal.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator and freezer were dated to ensure first in and first out; expired dairy products were promptly removed/discarded on or before the expiration or use by date, to prevent the potential for foodborne illnesses; manufacturer's instructions were followed to prevent potential for food spoilage and or bacteria growth; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and hot food items were maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service to prevent potential food borne illness for 1 of 1 meals observed. The findings are: 1. On [DATE] at 10:03 AM, an opened bottle of Worcestershire sauce was on the rack. The manufacturer specification on the bottle indicated, Refrigerate after opening. 2. On [DATE] at 10:15 AM, Dietary Aide (DA) #1 picked up the water hose with his gloved hand and used it to spray off leftover food from inside of the dishes, contaminating his gloves in the process. He placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, he placed new gloves on his hands, contaminating the gloves, he moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean counter to be used in serving noon meal to the residents. DA #1 stated he should have washed his hands. 3. On [DATE] at 10:42 AM, the following observations were made on a shelf in the refrigerator in the medication room for the 100, 200, 300, 400 Halls to the front 700 Halls: - One undated and unlabeled box of country chicken dinner. - One undated and unlabeled jar of peanut butter. - One undated and unlabeled sugar free dipping sauce. On [DATE] 10:50 AM, the following observations were made in the freezer in the medication room for the 100, 200, 300, 400 Halls to the front 700 Hall: - One carton of nutritional drink with expiration date of [DATE]. - An opened and undated box of homemade ice cream. The ice cream was discolored and had ice cycles on it. Licensed Practical Nurse (LPN) #2 stated it looked like it started melting and was stuck back in the freezer. 4. On [DATE] at 10:59 AM, the following observations were made on a shelf in the refrigerator in the medication room for the 400, 500, and 600 Halls, to the front of 700 Hall: - One container of nectar thickened apple juice with an expiration date of [DATE]. - One bottle of yellow mustard with an expiration date of [DATE]. 5. On [DATE] at 12:16 PM, the temperatures of the food on the steam table in the kitchen were checked and read by Dietary [NAME] (DC) #3 with the following results: - Mashed potatoes - 120 degrees Fahrenheit. - Pureed vegetable blend - 120 degrees Fahrenheit. - Gravy - 115 degrees Fahrenheit. - Cheese sticks - 119 degrees Fahrenheit, the first pan on the steam table.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to provide dignity regarding cleaning the resident after meals for one (Resident #72) of one resident reviewed for resident rights regarding dignity. Findings include: A review of a facility policy titled, Resident Rights, revised on 11/22/2016, indicated residents would receive adequate and appropriate nursing care and personal cleanliness in a safe and clean environment. A review of the Admission Record, indicated the facility admitted Resident #72 with diagnoses that included Alzheimer's disease with late onset and chronic pain. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024, revealed Resident #72 required set up or clean up assistance with eating and supervision and touching assistance with personal hygiene and upper body dressing. A review of Resident #72's Care Plan, initiated on 01/19/2023, revealed the resident had an Activity of Daily Living (ADL) self-care performance deficit. Intervention included that the resident required extensive assistance of one staff member for personal hygiene and oral care. During an observation on 09/30/2024 at 10:29 AM, Resident #72 was noted to have a large dropping of oatmeal on the top sheet of the bed and the resident's shirt was covered with food particles. During an observation on 09/30/2024 at 1:49 PM, Resident #72 was noted to have a large dropping of oatmeal on the top sheet of the bed and shirt was covered with food particles. During an observation on 10/01/2024 at 8:46 AM, Resident #72 was in bed, sitting up eating breakfast. Oatmeal was noted on the resident's shirt. At 1:01 PM, Resident #72 was in bed, wearing a shirt which had oatmeal droppings. The top sheet of the bed was stained with a yellowish/beige liquid. At 2:10 PM, Resident #72 was assisted by staff to change bed linens and the resident's clothing. During an interview on 10/01/2024 at 2:15 PM, Licensed Practical Nurse, (LPN) #9 confirmed that Resident #72 had oatmeal on the top sheet of the bed and food particles on the resident's shirt. LPN #9 confirmed that Resident #72 required assistance and needed to be cleaned after meals. During an interview on 10/01/2024 at 2:20 PM, the Director of Nursing (DON) confirmed Resident #72 should have been cleaned after breakfast and that linens should have been changed at that time.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure an oxygen concentrator was clean, set at the correct rate for delivery, and the tubing was dated appropriately for 1 (Resident #25) of 1 sampled resident reviewed for oxygen therapy. Findings include: A review of a facility policy titled, Oxygen Safety, revised on 11/22/2016, indicated oxygen therapy is to be administered to the resident per physician orders and that it must be tagged, or properly labeled. There was no policy regarding oxygen concentrators provided. A review of the Admission Record, indicated the facility admitted Resident #25 with diagnoses that included acute respiratory failure with hypoxia. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/23/2024, revealed Resident #25 required oxygen therapy. A review of Resident #25's care plan, initiated on 07/18/2024, revealed the resident had oxygen therapy. Interventions included to give the medications as ordered by the physician, monitor and document side effects and effectiveness and to monitor for signs and symptoms of respiratory distress. A review of the Order Summary Report, revealed Resident #25 had an order for oxygen at 3 liters per minute (LPM) via nasal cannula as needed for shortness of breath, comfort or pulse oximetry reading of less than ninety percent, and an order to change oxygen tubing, clean filter, and oxygen cabinet, and to date all tubing every Sunday night on the eleven to seven shift for maintenance. A review of Medication Administration Record (MAR), revealed Resident #25's oxygen tubing change, cleaning of oxygen cabinet, and tubing being dated, had been initialed as being completed on 09/01/2024, 09/08/2024, 09/15/2024, 09/22/2024 and 09/29/2024. During an observation on 09/30/2024 at 10:53 AM, Resident #25 was receiving oxygen at a rate of 2.5 LPM via nasal cannula. The oxygen concentrator (cabinet) had undetermined particles and dust located on the machine. The oxygen tubing was dated 08/12/2024 and the humidified water bottle was dated 08/12/2024. During an observation on 10/01/2024 at 09:29 AM, Resident #25 was receiving oxygen at a rate of 2.5 LPM via nasal cannula. The oxygen concentrator (cabinet) continued to have debris noted on the machine. The humidifier water bottle and oxygen tubing were dated 08/12/2024. During an interview on 10/01/2024 at 9:35 AM, Licensed Practical Nurse (LPN) #9 confirmed that the oxygen tubing and water bottle were dated 08/12/2024 and that the oxygen concentrator (cabinet) was dirty with debris and that the oxygen rate was set at 2.5 LPM. LPN #9 stated that the resident had been placed on the oxygen on the previous Friday and that the bottle that was on the concentrator had not been opened and that is why it was used. During observation on 10/03/2024 at 3:10 PM, upon arrival to Resident #25's room, the oxygen concentrator rate was set at 1.5 LPM. The oxygen concentrator had been cleaned with new tubing and humidified water bottle dated 10/01/2024. During an interview on 10/03/2024 at 3:15 PM, LPN #9 confirmed that the rate of oxygen on the oxygen concentrator was set on 1.5 LPM. LPN #9 confirmed that rate should be at 3 LPM. During an interview on 10/03/2024 at 3:21 PM, as the Director of Nursing (DON) and this surveyor were about to enter the room of Resident #25, LPN #9 was leaving the room and stated that the oxygen rate on the concentrator had just been adjusted. During an interview on 10/03/2024 at 3:23 PM, the DON confirmed the oxygen had not been set at the rate of 3 LPM for Resident #25 and that resident's oxygen saturation would need to be checked. The DON checked Resident #25's pulse oximetry which was at 98 percent.

49071 Based on observation and interview, the facility failed to ensure dairy product stored in the refrigerator was sealed to prevent potential for cross contamination; kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, dish washer door frames, kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, debris, dirt, grease, grime, rust, stains, and spills; wall tiles were replaced, kitchen sink was free of utility tape on it; 2 of 2 ice machines were maintained in clean and sanitary condition to prevent potential for bacteria growth for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 3 residents who received crushed ice in the front dining room and one resident who received crushed ice from the ice machine by the kitchen door, 109 residents who received meals from the kitchen (total census: 115), as documented on a list provided by Dietary Supervisor on 11/15/2023 at 10:47 AM. The findings are: 1. On 11/13/23 08:03 AM the following observations were made in the kitchen area. a. The entrance door to the kitchen door frames were chipped exposing the metal. The areas that were chipped are covered in rust. The wall above the steam table was chipped exposing the cement. The area had dirt and debris. The hand washing sink had utility tape around it. The surveyor asked the Dietary Supervisor the reason utility tape was around the sink. She stated, It had a crack on it. b. The ceiling air vent panels located between the counter where the tea and coffee makers were and the food preparation counter by the steam table were rust stains on them. c. The baseboard below the hand washing sink was missing exposing the concert. d. The door facing leading to the walk-in refrigerator was rusty. e. The left side of the door frame had sage discoloration on it. f. The frame was chipped. The area that was chipped had rust and sage color on them. g. The gap in front of the door leading to the walk-in refrigerator had rust build up on it. h. The right side of the door frame floor leading to the walk-in refrigerator had accumulations of sage discoloration on it. i. The walk-in refrigerator floor covering was loose and was raised up. j. The wall between two cabinets where clean dishes were stored had paint peeling off, exposing the cement. There were holes in the wall close to the areas where paint had peeled off. k. The floor of the freezer was rusty. l. The door leading to the janitor's closet was chipped, exposing the metal. The door frames were chipped. The areas that were chipped were covered in rust. m. The door tiles leading to the outside were broken. There were chips of broken tiles on the floor mixed with sawdust shading from the door frame. n. The door facing was rusty and had a hole in it. o. The bottom of the door frame was rotten. The area where the frame was rotted out had a buildup of sawdust on it. There was a gap from the area where the floor was broken that extended to the outside, that could allow any pest to crawl into the kitchen. p. The ceiling air vent panels above the stove and the food preparation counter had rust on them. The air vent panels above the plate warmer had rust on them. q. The air vent above the milk refrigerator has rust on it. The bottom of the metal rack in the storage room where containers that contained boxes of dry cereal had rust. r. The legs of the metal racks in the storage room where containers that contained bags of chips, pudding and rice were kept had rust stains on them. s. The metal rack from the bottom to the 3 racks where canned goods were stored had rust. The legs of the metal rack were rusty. t. On 11/13/23 at 01:09 PM, observed Certified Nursing Assistant (CNA) #5 resting her hand on her cheek then taking a tray to resident without sanitizing hands. CNA #5 came back sanitized hands then scratched her chin and got a tray for another resident without hand sanitizing. CNA #5 sanitized hands after passing tray and slapped her head scarf, then got another tray without sanitizing after touching head scarf. u. On 11/15/23 at 12:48 PM observed male Dietary employee #5 and #6 in kitchen with their beard nets down while they were in area where food was being prepared and served during meal service.

Based on observation, interview, and record review, the facility failed to ensure a suprapubic urinary catheter drainage bag was concealed in a privacy bag when visible to promote dignity and privacy. This failed practice had the potential to affect Resident #81 sample mixed resident with a urinary catheter according to a list of residents with catheters provided by the Administrator on 11/17/23 at 9:10 AM. The findings are, Resident #81's diagnosis showed neuromuscular dysfunction of bladder, unspecified. The Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 8/30/23 showed a, .Brief Interview for Mental Status [BIMS] score of 15 [a score of 13-15 points indicates cognitive intactness] .resident has an indwelling urinary catheter (including suprapubic) . The care plan dated 9/16/23 showed, Focus: Resident has Suprapubic Catheter related to [r/t] neuromuscular dysfunction of bladder. Interventions: Position catheter bag and tubing below the level of the bladder and away from entrance room door. On 11/13/23 at 11:25 AM, the Surveyor observed Resident # 81 in the hallway with a suprapubic catheter bag attached below an electric wheelchair with no dignity bag or cover in place. On 11/14/23 at 12:52 PM, the Surveyor observed a resident in the dining room with a suprapubic catheter bag hanging under electric wheelchair with no dignity bag or cover. On 11/14/23 at 1:38 PM, the Surveyor observed the resident by the door of the room with a suprapubic catheter bag hanging under the electric wheelchair with no dignity bag or cover. On 11/14/23 at 1:38 PM, the Surveyor asked Resident #81, How do you feel about your catheter bag being visible? The resident said, I would like it covered up. On 11/15/23 at 11:44 AM, the Surveyor asked Licensed Practical Nurse [LPN] #5, how should a resident's indwelling catheter bag be contained while the resident is out of the room? LPN #5 said, the bag should be in a privacy bag, or it should be a bag with a leaf cover. On 11/15/23 at 12:18 PM, the Surveyor asked the Director of Nursing [DON], how should an indwelling catheter bag be contained when a resident is out of the room? The DON said, it should be in a privacy bag or have a fig leaf over it. A policy titled Resident Rights provided by the Administrator on 11/15/23 at 12:57 PM showed, each and every resident in this facility has the right, .to be treated with consideration, respect and full recognitions of dignity and individuality .

Based on observation, interview, and record review the facility failed to ensure call lights were in reach to ensure a safe environment for 2 Residents [Resident #30 and #59] out of 23 Residents [Residents #4, #9, #15, #17, #26, #30, #36, #39, #40, #59, #60, #68, #71, #74, #77, #84, #98, #100, #103, #106, #108, #110, and #221] sample mixed residents from a list of Residents able to use call lights provided by the Administrator on 11/17/23 at 9:10 AM. The findings are, 1. Resident #30 Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 9/4/23 showed, .a Brief Interview for Mental Status [BIMS] score of 4 [0-7 points suggest severe cognitive impairment] . 1A. The care plan dated 10/27/23 showed, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. 1B. On 11/13/23 at 11:45 AM, the Surveyor observed Resident #30's call light on the floor. 1C. On 11/14/23 at 09:51 AM, the Surveyor observed the Resident #30's call light on the floor. 1D. On 11/14/23 at 02:31 PM, the Surveyor observed the call light on the floor. 2. Resident #59's Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 9/2/23 showed, .a Brief Interview for Mental Status [BIM] score of 03 [0-7 points suggest severe cognitive impairment] . 2A. The care plan dated 9/16/23 showed, ensure call light is within reach with each round. 2B. On 11/13/23 at 2:23 PM, the Surveyor observed Resident #59's press call light hanging on the overhead bed light out of reach. 2C. On 11/14/23 at 8:36 AM, the Surveyor observed the press call light hanging on the overhead light out of reach. 2D. On 11/14/23 at 01:23 PM, the Surveyor observed the press call light hanging on the overhead light out of reach. 2E. On 11/15/23 at 11:23 AM, the Surveyor asked Certified Nursing Aid [CNA] #3, What is the process when a resident is assisted to bed or left in a room alone? CNA #3 said, when we assist a resident to bed or into a chair, we place the call light in reach. The Surveyor asked, should a call light be in reach at all times? CNA #3 said, yes. 2F. On 11/15/23 at 11:28 AM, the Surveyor asked CNA #4, What is the process when a resident is assisted to bed or left in a room alone? CNA #4 said, make sure the resident is properly placed so they don't fall or struggle and make sure the call light is within reach. The Surveyor asked, should a resident always have a call within reach? CNA #4 said, yes. 2G. On 11/15/23 at 12:18 PM, the Surveyor asked the Director of Nursing [DON], When a resident is assisted to bed or a chair, how should the call light be left? The DON said, it should be within reach, preferably clipped somewhere to stay in place. Is it acceptable for a call light to be out of reach? The DON said, no.

Based on interview, and record review the facility failed to ensure 2 Residents (Resident #108, and Resident #4) of 4 Residents (Resident #4, Resident #100, Resident #108, and Resident #221) sampled residents who were reviewed for advance directive had an advance directive readily available in their clinical record. The findings are: 1. On [DATE] at 3:30 PM Resident #108 clinical record was reviewed. There was no advance directive in the clinical record. On [DATE] at 2:30 PM the surveyor asked the administrator, When should an advance directive be formulated? She stated, Upon admission if they are with it, and they go over it with social. She was asked, Should an advance directive be in the residents clinical record, or documentation that information concerning an advance directive was provided? She stated, Yes. She was asked, Can you tell me why Resident #108 doesn't have an advance directive in the clinical record? She stated, They have started the audit and we're doing an in-service. On [DATE] at 12:17 PM the administrator provided a form titled, Advance Directives. It documented, .Prior to, or upon admission, a representative of the social services department or designee will provide resident with written information concerning the resident's right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare an advance directive. Such information will include a written description of our facility's policies to implement advance directives and applicable state law . 2. After reviewing Resident #4's electronic record, it showed no completed advance directive on file. On [DATE] at 11:26 AM, the Surveyor requested a copy of Resident #4's Advance Directive from the Director of Nursing [DON]. On [DATE] at 1:52 PM, the DON brought the Surveyor a Capacity Verification and Do Not Resuscitate [DNR]/Cardiopulmonary Resuscitation [CPR] Instructions. The DON said, the resident came back in 2017 and I guess they did not fill out an Advance Directive, and this is the only documentation available. On [DATE] at 3:05 PM, the Surveyor asked the Social Services Director [SSD] who is responsible for completing advance directives upon admission? The SSD stated, me . The SSD stated, I was told when I took this position that an advance directive had to be filled out by the person it is for. If the resident has no capacity, then I don't ask them to sign the form. If they have capacity, then I ask them. The Surveyor asked, do you have the resident/family/Power of Attorney [POA] sign anything that an advanced directive was offered or explained? The SSD stated, I have a form that they can sign to continue the physician's order or to formulate an advanced directive. There is not a form to sign refusing to formulate an advance directive. The Surveyor asked, why do you think it is important to have an advance directive formulated? The SSD stated, Besides the code status, it lets us know the resident's prolonged wishes. 48483

48483 Based on observation, interview, and record review the facility failed to maintain resident rooms in good repair [rooms [ROOM NUMBERS]] of 12 rooms on 400 hall, failed to maintain resident rooms in good repair for 1 (room [ROOM NUMBER]) of 8 rooms on 500 Hall. The findings are, 1. On 11/13/23 at 9:39 AM, the Surveyor observed what looked like scribble marks on the commode rim in room [ROOM NUMBER]'s bathroom. 1A. On 11/13/23 at 2:48 PM, the Surveyor observed no change to the commode. 1B. On 11/14/23 at 8:57 AM, the Surveyor observed no change to the commode. 1C. On 11/15/23 at 3:40 PM, the Surveyor accompanied Maintenance to rooms [ROOM NUMBERS]. As we entered room [ROOM NUMBER] Maintenance said that ' s all fresh, we just painted it last month (indicated the gouges and missing paint on the wall). The Surveyor asked were you aware of the marks on the floor? Maintenance stated, No, all of this is new. The Surveyor accompanied Maintenance to room [ROOM NUMBER] and asked, were you aware of the marks on the commode? Maintenance stated, No. I believe it will come off with some elbow grease though (proceeded to wet a piece of toilet paper and scrub at the marks). Maintenance stated, I will get all of this taken care of. The Surveyor asked, does any of this look homelike to you? Maintenance stated, No. 2. On 11/13/23 at 10:05 AM, the Surveyor observed several small gouges in the wall with paint peeling and black marks on the floor approximately 5 feet long and a foot wide in room [ROOM NUMBER]. 2A. On 11/13/23 at 2:57 PM, the Surveyor observed no change to the wall or floor. 2B. On 11/14/23 at 10:14 AM, the Surveyor observed no change to the wall or floor. 2C. On 11/13/2023 at 8:51 AM, the Surveyor observed a wall beside A bed in room [ROOM NUMBER] with damage measuring 24 inches by 26 inches. The damaged section of the wall surrounded an electrical outlet. There were pieces of drywall missing from the wall, and white debris was observed on the floor. The adjoining wall had a section of wallpaper that had peeled away from the wall that measured 60 inches by 6 inches. 3. On 11/13/2023 at 03:21 PM, the damage to the wall and peeling wallpaper were unchanged. Debris from the damage to the wall remained on the floor beside the A bed. 3A. On 11/14/2023 at 09:14 AM the damage to the wall and peeling wallpaper were unchanged. 3B. On 11/15/2023 at 3:54 PM, Maintenance stated, Yes, it's been like that since [named Resident] moved in. [named Resident] doesn't like me in there, so I'll have to fix it when he's out of the room. 3C. On 11/16/2023 at 9:45 AM, the Administrator stated, Yes, I'm aware of that now, we're already working on getting it fixed. 3D. On 11/16/2023 at 10:49 AM, the Administrator provided a Policy titled, Maintenance. It documented, .buildings will be maintained in a clean, orderly condition, in good repair .

Based on interview and record review, the facility failed to ensure either a Death or Discharge Minimum Data Set (MDS) was performed for 2 (Residents #2 and #87) sampled residents identified as having MDS records over 120 days old. The findings are: 1. Progress Notes for Resident (R) #2 documented the resident expired in the facility on [DATE]. The MDS section of R#2's chart documented the required Death-MDS was 116 days overdue. 2. Progress Notes for R #87 documented the resident being discharged from the facility on [DATE]. The MDS section of R #87's chart documented the Discharge, Return Not Anticipated-MDS was 113 days overdue. 3. On [DATE] at 3:54 PM, the MDS Coordinator, LTC (Long Term Care) was asked to locate the Death-MDS for R #2 and the Discharge, Return Not Anticipated-MDS for R #87 and voiced that neither were in the resident's charts. The MDS Coordinator, LTC stated that R #2 and R #87 were residents in the facility prior to their assuming the position of MDS Coordinator, and that their predecessor had failed to perform the Death-MDS for R #2 and the Discharge, Return Not Anticipated-MDS for R #87. 4. On [DATE] at 9:31 AM, the Assistant Director of Nursing (ADON) confirmed that the Death-MDS for R #2 and the Discharge, Return Not Anticipated-MDS for R #87 should have been performed upon R #2 and R #87 leaving the facility. The ADON stated that the MDS Coordinator, LTC had been instructed to correct the error. 5. On [DATE] at 10:21 AM, the Director of Nursing (DON) confirmed that the Death-MDS for R #2 and the Discharge, Return Not Anticipated-MDS for R #87 should have been performed upon R #2 and R #87 leaving the facility.

Based on observation, record review, and interview, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming. for 2 [Resident #4 and #77] Residents of 23 [Residents #4, #9, #15, #17, #26, #30, #36, ##9, #40, #59, #60, #68, #71, #74, #77, #84, #98, #100, #103, #106, #108, #110, and #221] sample mixed residents from a list of residents provided by the Administrator on 11/17/23 at 9:10 am who require assistance with nail care. The findings are: 1. Resident #4's MDS with an ARD of 9/4/23 showed a BIMS (Basic Interview for Mental Status) of 4 [0-7 points suggest severe cognitive impairment] and needs extensive assistance with personal hygiene with one-person physical assistance. 1A. The care plan with a date of 9/14/23 showed, Focus: The resident has actual impairment to skin integrity of the R side of trunk 05/05/18. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions: The resident needs their nails kept short to reduce risk of scratching or injury from picking at skin. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. 1B. On 11/13/23 at 9:34 AM, the Surveyor observed Resident #4's fingernails approximately 1/2 inch long with jagged edges and dark matter underneath. 1C. On 11/14/23 at 8:31 AM, the Surveyor observed resident's fingernails approximately 1/2 in long with jagged edges and black matter underneath. 1D. On 11/14/23 at 1:04 PM, the Surveyor observed resident's fingernails approximately 1/2 inch long with jagged edges and dark matter underneath. 1E. On 11/15/23 at 11:21 AM, the Surveyor asked CNA (Certified Nursing Assistant) #3, Could you describe Resident #'4's fingernails? CNA #3 stated, They are long with sharp corners, and they look dirty underneath, maybe some food residue. The Surveyor asked who is responsible for nail care and how often the resident's nails cleaned and trimmed? CNA #3 said their nails are trimmed and cleaned every other day on their shower day and the 7-3 aide is responsible since they give them their showers. 1F. On 11/15/23 at 11:48 AM, the Surveyor asked LPN (Licensed Practical Nurse) #5, can you describe the resident's fingernails? LPN #5 stated, They are long with some sharp edges and a little dirty underneath. The Surveyor asked, who is responsible for nail care and how often are the resident's nails cleaned and trimmed? LPN #5 stated, They are cleaned and, if needed, trimmed on shower days. The aides clean and trim them unless they are diabetic, then the nurse does it. 2. On 11/13/2023 at 9:45 AM, the Surveyor observed Resident #77 with 1/2-inch nails on both hands with dark brown substance under nails. 2A. On 11/14/2023 at 8:51 AM, the Surveyor observed Resident #77 with long 1/2 inch nails on both hands with brown substance under nails on both hands. 2B. On 11/15/2023 at 8:11 AM, the Surveyor observed Resident #77 with long 1/2 inch nails on both hands with brown substance under the nails. The Surveyor asked the Resident, does the facility staff clean and cut your nails and resident stated, not very often. 2C. On 11/15/2023 at 9:54 AM, the Surveyor interviewed CNA #1. The Surveyor asked how often the residents receive nail care? CNA #1 stated On their shower days. The Surveyor asked who is responsible for making sure nail care is done. CNA #1 stated The CNAs are. The Surveyor asked should brown substance be under the resident's nails? CNA #1 stated No it should not. 2D. On 11/15/2023 at 10:01 AM, The Surveyor asked CNA #2, how often do residents receive nail care CNA #2 stated, On their shower days. The Surveyor asked who is responsible for making sure nail care is provided to the residents. CNA #2 stated, We are. Should brown substance be under the resident's nails. CNA #2 stated, No it shouldn't. 2E. On 11/15/23 at 10:17 AM, The Surveyor interviewed the Director of Nursing (DON), and asked how often is nail care provided to residents? The DON stated, On their shower days. The Surveyor asked who is responsible for making sure that nail care is done? The DON stated, Nursing is. The Surveyor asked should brown substance be under a resident ' s nails? The DON said a resident ' s nails should not.

Based on observation, interview, and record review, the facility failed to ensure an ongoing schedule of activities was provided to meet the needs of 16 Residents (Residents #15, #26, #30, #36, #40, #53, #68, #71, #77, #98, #100, #103, #108, #110, #116, and #221) of 24 sampled residents. The findings are: On 11/17/2023 at 10:42 AM, the Administrator was asked to provide the activity records for the month of October 2023. The Administrator produced documents titled Event Calendar Report. The Event Calendar Report for October 2023 for Resident #15 documented that the Resident had been invited to one event for the month of October. The Event Description was for a medical appointment on 10/6/23. The Event Calendar Report for October 2023 for Resident #40 documented that the Resident had been invited to three events for the month of October. The Event Description was 1 on 1 activities, including music therapy, tactile therapy, aroma therapy, cards, games, and socializing. The resident was invited on 10/5/23, 10/12/23 and 10/19/23. The Event Calendar Report for October 2023 for Resident #100 documented that the Resident had been invited to one event for the month of October. The Event Description was for a medical appointment on 10/9/23. Event Calendar Reports for 13 (Residents #26, #30, #36, #53, #68, #71, #77, #98, #103, #108, #110, #116, and #221) sampled residents were not provided. The Administrator confirmed that no additional documentation was available. On 11/17/2023 at 11:50 AM, the Assistant Director of Nursing stated, Yes, the residents need to be invited to more activities .I'd like to see them involved in something at least weekly, if not more frequently. On 11/17/2023 at 11:58 AM, the Administrator stated, Yeah, we've got work to do on Activities the residents need to be invited to every activity. On 11/15/2023 at 12:57 PM, the Administrator provided a document titled, Resident Rights. It documented, Participate in activities of the facility and social, religious and community groups unless medically contraindicated .Be provided a schedule of daily activities that allows flexibility in what the resident will do and when the resident will do it. On 11/17/2023 at 11:07 AM, the Administrator provided a Policy and Procedure titled, Activity Program. It documented, .The facility will provide an ongoing program supporting residents in their choice of activities, both facility sponsored and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, and encouraging both independence and interaction in the community.

Based on observation, interview, and record review the facility failed to obtain a physician's order to administer oxygen for 1 [Resident #15] resident out of 11 [Resident's #15, #36, #53, #59, #60, #74, #77, #98, #100, #110, and #221] sample mix residents on oxygen. The facility failed to complete a Neurological Assessment after an unwitnessed fall, for 1 [Resident #30] resident of 6 [Residents #30, #74, #77, #84, #98, #103] sample mixed residents who had an unwitnessed fall in the past 3 month The facility failed to follow a physician's order, for 1 [Resident #74] resident out of 11 [Resident's #15, #36, #53, #59, #60, #74, #77, #98, #100, #110, #221] sample mix residents who receive oxygen. The findings are: 1. Resident #15 diagnosis showed heart failure. The Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 10/16/23 showed .a Brief Interview of Mental Status [BIMS] score of 15 [a score of 13-15 points indicates cognitive intactness] . Resident received oxygen while a resident . 1A. Review of Resident #15's Physician's Order Summary Report dated 11/13/23 showed no order for oxygen. 1B. Review of Resident #15's care plan dated 10/27/23 showed, Focus: The resident has oxygen therapy related to [r/t] shortness of breath on exertion and while lying flat. Resident has had a previous right lobectomy. Goal: The resident will have no signs or symptoms [s/sx] of poor oxygen absorption through the review date. Intervention: Give medications as ordered by physician. Monitor/document side effects and effectiveness. 1C. On 11/13/23 at 1:53 PM, the Surveyor observed Resident #15 receiving 0.5 Liters [L] of oxygen [O2] via nasal cannula [NC]. 1D. On 11/14/23 at 8:39 AM, the Surveyor observed the resident receiving 2L of oxygen via NC. 1E. On 11/14/23 at 1:30 PM, the Surveyor asked LPN [Licensed Practical Nurse] #1, can you show me the order for Resident #15's oxygen? LPN #1 stated, No, I can't. He doesn't have an oxygen order. It looks like he had one and it was discontinued on October 26th before he moved to this hall. The Surveyor asked, is an order required to administer oxygen? LPN #1 said yes. 1F. On 11/15/23 at 12:18 PM, the Surveyor asked the Director of Nurses [DON], should a resident receiving oxygen have a physician's order? The DON said yes. The Surveyor asked who is responsible for ensuring an order is being followed and that the order is being followed? The DON said the nurse is responsible and they should verify the settings every shift. 2. The MDS with an ARD of 10/15/23 for Resident #30 showed a, .BIMS score of 04 [0-7 points suggests severe cognitive impairment]. Dependent for chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) . 2A. Resident #30's care plan showed, Focus: The resident is at increased risk for falls due to gait instability and weakness -10/23/23-fall without injury-self transfer -11/13/23-fall without injury Goal: The resident will be free of falls through the review date. Interventions: encourage to call for transfer assistance. non-skid socks. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a prompt response to all requests for assistance. Follow facility fall protocol. 2B. Resident #30 ' s progress note dated 10/23/23, .14:45 Incident Description: Certified Nursing Assistant [CNA] was doing morning rounds and found resident on floor in between bed and wheelchair. Resident stated she was trying to get back in bed from wheelchair. Immediate Intervention: Resident was assessed. No signs and symptoms of distress or injuries present. Resident was transferred back onto bed with 2-person assistance. Vitals: 97.5 74 18 153/66 . 2C. Resident #30's progress notes dated 11/12/23, .23:08 No new injuries or bruises noted from I&A fall. Neuro checks .10:18 This nurse called to residents' room by aide. Upon arrival resident noted on the floor beside bed, sitting upright with legs extended outward. No visible injuries noted. Immediate Intervention: Resident assessed, assisted back into bed, vital signs and pain measurement taken, non-slip socks applied, and call light placed into resident's hand. Appropriate parties notified. Vitals: *see neuros . 2D. Review of the neurological assessments started on 10/23/23 and 11/12/23 were within normal limits, but not complete. 2E. On 11/16/23 at 8:50 AM, the DON brought the neurological assessments, dated 10/23/23 and 11/12/23, for Resident # 30 and stated, This one isn't complete yet because they are still ongoing (indicated 11/12/23). 2F. On 11/16/23 at 3:36 PM, the Surveyor asked the DON, when are neurological assessments started when a resident falls? The DON stated, They should be started immediately. The Surveyor asked, how long should the neurological assessments last? The DON said they last 72 hours. The Surveyor asked who records the information for the assessments? The DON stated, Sometimes the nurses write them down and give them to an administrative nurse to enter in the computer and some of the nurses enter their own. The Surveyor asked, should these assessments be complete? The DON said yes. 2G. A Policy titled, Incident and Accident Policy revised on; 11/22/17 provided by the Administrator on 11/16/23 at 10:55 AM showed, .If there is an unwitnessed injury or a suspected head injury, the nurse will perform and document neurological checks and vital signs for 72 hours . 3. Resident #74's diagnosis showed respiratory disorders in diseases classified elsewhere. The MDS with an ARD of 10/11/2023 showed, .BIMS of 07 [0-7 points suggests severe cognitive impairment] .resident is on intermittent oxygen therapy . 3A. Resident # 74's care plan showed, the resident has altered respiratory status/difficulty breathing r/t shortness of breath while lying flat. Oxygen [O2] settings: O2 via nasal cannula @ 1-2 liters [L] as needed for shortness of breath [sob]/comfort as tolerated. 3B. Resident #74's physician's Order Summary showed, O2 at 1-2 L/minute [M] via nasal cannula as needed for sob/comfort phone active order date: 10/14/2023, start date: 10/14/2023. 3C. On 11/13/23 at 10:34 AM, the Surveyor observed Resident #74 receiving 2 1/2 L of O2 via a nasal cannula. 3D. On 11/15/23 at 8:16 AM, the Surveyor observed the resident receiving 2 1/2 L of O2 via nasal cannula. 3E. On 11/15/23 at 11:41 AM, the Surveyor observed the resident receiving 2 1/2 L of O2 via nasal cannula. 3F. On 11/15/23 at 11:44 AM, the Surveyor asked LPN (Licensed Practical Nurse) #5, what is Resident #74's oxygen concentrator set on? LPN #5 stated, 2 1/2 liters. The Surveyor asked, can you tell me the resident's order for oxygen? LPN #5 stated, The order shows 1-2 liters. 3G. On 11/15/23 at 12:18 PM, the Surveyor asked the DON, how does the staff know what the resident's oxygen settings are to be set on? The DON stated, The nurse should check the oxygen settings at least every shift, if not more often. If the resident is known to change the settings it should be added to the care plan. 49071

49071 Based on observation, record review and interview, the facility failed to ensure resident medication was not left at the beside. for 1 Resident #110 out of 24 sampled residents, and the facility failed to provide the proper trash can for the disposal of cigarette butts in the smoking area. This had the potential to affect 115 residents provided by the Administrator from the census list on 11/13/23. The facility failed to post alerts that oxygen was being administered for 4 (Residents #15, #60, #100, #221) of 12 (Residents #15, #36, #53, #59, #60, #74, #77, #98, #100, #104, #110, and #221) sampled residents that had orders for supplemental oxygen. The facility failed to secure a maintenance access hatch in 1 room [ROOM NUMBER] of 8 rooms on 500 Hall. The facility failed to ensure that outside food intended to be served to residents was dated properly in 1 of 2 medication storage room refrigerators. The findings are: 1. On 11/13/2023 at 10:27 AM, the surveyor entered resident #110 room and observed a cup with 3 oval blue pills and one smaller light blue oval pill in the cup. The Surveyor asked the resident what is this? Resident stated, The nurse left them there for me to take, I normally only take one but she left 4 today. The Surveyor asked resident #110 do you normally give yourself your medication? The Resident replied, Sometimes if they leave it for me, I give it to myself. 1A. On 11/15/2023 at 10:30 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #4. The Surveyor asked, how should medications be given to a resident? LPN #4 said by the nurse. The Surveyor asked should medications be left at bedside in a cup? LPN #4 stated No ma'am, the nurse should stay with them and make sure they take them. To your knowledge has anyone been assessed by the Inter Disciplinary Team to self- administer medications? LPN #4 stated, Not that I am aware of. 1B. On 11/15/23 at 11:18 AM, The Director of Nurses (DON) was interviewed and asked, how should medications be given to the residents? DON stated According to the MD orders. The Surveyor asked should medications be left at the bedside in a cup for a resident to administer themselves when they want to? The DON stated absolutely not. The Surveyor asked has anyone on hall 700 been assessed by the Inter Disciplinary Team and approved to self- administer their own medications. The DON, stated No not that I am aware of. 1C. On 11/15/23 at 12:17 PM, a policy was received from the Administrator titled Medication, General Administration of. The policy showed, 9. Self- administration of drugs is permitted when approved by the interdisciplinary team and with a physician's order . 2. On 11/14/23 at 2:04 PM, the Surveyor observed the smoking area only had gray plastic trash can with a plastic bag liner. 2A. On 11/15/23 at 11:11 AM, the Surveyor observed the smoking area with only a gray plastic trash can with a plastic bag liner. 2B. On 11/15/23 at 11:17 AM, the Surveyor interviewed Resident #81. The Surveyor asked, where do you dispose of your cigarette butts when you go to the smoking area? Resident #81 stated In that gray trash can that is out there that's the only thing we got. 2C. On 11/15/23 at 11:21 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) #3 and asked can you show me where the residents dispose of their cigarette butts? CNA #3 stated In that gray trash can right there. The Surveyor asked could this be a hazard? CNA #3 stated Yes ma'am it could catch on fire. 2D. On 11/15/23 at 11:33 AM, the Surveyor interviewed DON, and asked, what type of trash can should there be in the smoking area? The DON stated, The metal smoking trash cans. 2E. On 11/15/223 at 12:17 PM, received a policy from the Administrator titled Smoking Policy and Procedure. Policy: It is the facility's intention to maximize its ability to provide a safe environment to all residents admitted to the facility, including residents who smoke or use electronic cigarettes, as well as visitors and staff. Procedure .3. Designated smoking areas include ashtrays made of noncombustible material and safe design. Metal containers with self-closing covers into which ashtrays can be emptied are also readily available . 3A. Resident #15 had a physician's order that documented, [Oxygen] at 2 [liters per minute] via [nasal cannula] continuously. 3B. Resident #60 had a physician's order that documented, [Oxygen] at 2 [liters per minute] via [nasal cannula]. 3C. Resident #100 had a physician's order that documented, [Oxygen] at 3 [liters per minute] via [nasal cannula]. 3D. Resident #221 had a physician's order that documented, [Oxygen] at 2 [liters per minute] via [nasal cannula]. 3E. On 11/15/2023 at 1:26 PM, the Assistant Director of Nursing (ADON) provided a list of residents in the facility that were receiving supplemental oxygen. 3F. On 11/15/2023 at 9:11 AM, during interview Licensed Practical Nurse (LPN) #2 stated, Yes, any room where oxygen being administered needs to have a sign on the door I didn't realize there were rooms that weren't marked .it's for safety. 3G. On 11/15/2023 at 9:31 AM, the Assistant Director of Nursing (ADON) stated, Yes, those rooms should be marked .it was my understanding they had been. 3H. On 11/15/2023 at 12:17 PM, the Administrator provided a policy titled Oxygen Safety. It documented, .Prior to administering oxygen, Oxygen in Use sign must be posted on the outside of the room entrance door . 4. On 11/13/2023 at 9:47 AM, an unlocked and opened maintenance access hatch was observed above the A bed in room [ROOM NUMBER]. Readily visible was a yellow, fibrous material that appeared to be fiberglass insulation and a large, vertical pipe with 2 ball valves installed. Resident #68 confirmed that she could. 4A. On 11/13/2023 at 3:24 PM, the maintenance access hatch remained unlocked and opened in room [ROOM NUMBER] 4B. On 11/14/2023 at 9:16 AM, the maintenance access hatch remained unlocked and opened in room [ROOM NUMBER]. 4C. On 11/15/2023 at 12:51 PM, Maintenance stated, Yeah that's the drain for the sprinkler system. Should it be locked? I don't think we have a key for it, it's never been locked. Maintenance was asked if opening the ball valves on the pipe would drain the water from the sprinkler system that would be used in response to a fire in the facility? Maintenance stated, Yeah, I guess we should put a lock on it. 4D. On 11/15/2023 at 12:58 PM, the Administrator stated, No, that's not good .Yeah, we're going to get that fixed right now. 4E. On 11/16/2023 at 09:43 AM. the Director of Nursing stated, Oh yes, that's a safety issue. 4F. On 11/16/2023 at 10:49 AM, the Administrator provided a Policy titled Maintenance. It documented, .Buildings, grounds, and parking areas will be maintained in a clean, orderly condition, in good repair, and be monitored for possible hazards . 5. On 11/15/2023 at 11:31 AM, a refrigerator located in the Medication Room at the intersection of 100 Hall and 200 Hall contained resident medications, food items, opened bag of grapes, an opened clear plastic container of watermelon chunks, and an opened white plastic container of cottage cheese. None of the food items were labeled with a date. 5A. On 11/15/2023 at 11:35 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 who the food items in the refrigerator belonged to. LPN #2 stated, It's for the residents. LPN #2 was asked if the food items were dated. LPN#2 stated, No I don't see dates on any of it. LPN #2 was asked how outside food items should be labeled when brought into the facility. LPN#2 stated, Yeah they should have the resident and the date it's brought in on it. 5B. On 11/15/2023 at 9:31 AM, the Assistant Director of Nursing (ADON) stated, Yes, it should have a name and date on it, I've cleaned it out before. 5C. On 11/15/2023 at 9:43 AM, the Director of Nursing (DON) stated, Yes, I know [ADON] has had to deal with that that ' s a safety issue. 5D. On 11/13/2023 at 9:30 AM, the Administrator provided a document titled, Use and Storage of Foods Brought to Residents by Family/Others. It documented, .Any outside food must be stored in covered containers and labeled with the resident's name and the date the food was bought into the facility .

Based on interview and record review, the facility failed to ensure residents were provided with adequate supervision and implement appropriate measures to identify and respond promptly to wandering and elopement to prevent accidents/injuries as evidenced by failure to ensure planned elopement-prevention interventions (Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book., wander guard bracelet to left ankle, etc.) were implemented to prevent an elopement for 1 (Resident #1) of 3 (Residents #1, #2, and #3) case mix residents who had a high risk for elopement/wandering and failed to respond promptly as evidenced by resident was not redirected/distracted resident wandering about facility and authorities were not notified in a timely manner when an actual elopement was discovered to prevent further risk of injury for 1 resident (Resident #1). The failed practice resulted in past non-compliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1, who was at high risk for elopement, left unsupervised to wander about the facility at night, eloped from a door that was not equipped with the wander guard system, and was not located for 2 1/2 hours for the time the elopement occurred. This failed practice had the potential to cause more than minimal harm to 6 residents who were at high risk for elopement and had wander guards, as documented on a list provided by the Director of Nursing (DON) on 10/18/22 at 5:14 p.m. The Administrator was informed of the past immediate jeopardy condition on 10/18/22 at 7:45 pm. The findings are: 1.Resident #1 had diagnoses of Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 7/18/22 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and required supervision with one-person physical assistance when walking in his room, in corridor, and on and off the unit. a. A Care Plan dated 4/14/21 with a revision date of 4/21/22 documented, . The resident is an elopement risk r/t [related to] wandering, dementia, seeks a way out . The resident will not leave facility unattended through the review date . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . monitor wander guard placement q [every] shift . take resident to front lobby or 200 halls to ensure alarm is functioning properly and sounding q shift .Wander Gard to left ankle . b. A Physician's Order dated 7/16/21 documented, .Monitor wander guard to left ankle q [every] shift . c. An Alert Note dated 5/31/22 documented, .Wandering Late entry for 05/29 [Resident #1] likes to walk the halls to main dining area to get ice and water and then back to room . d. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/22 documented, .Section E0900. Wandering-Presence & Frequency: Has the resident wandered? 0. Behavior not exhibited . e. An Elopement Risk assessment dated [DATE] documented an Elopement Risk Score of 13 (11 and above. High Risk to Wander) which also documented, .Care Planning: The resident is an elopement risk r/t [related to] wandering, dementia, seeks a way out . f. A Police Report on 10/15/22 indicated a call was made at 0252 and documented, .Type of Call: MISPER (Missing Person) .Narrative: Officers were dispatched to the Listed Location regarding a missing person report. Upon arrival contact was made with PR#1 [Administrator]. The Administrator advised officers he noticed the alarm was going off which indicated a door had been opened. The Administrator stated when reviewing the camera footage, it showed [Resident #1] walking out of the facility at 0054 hours. The Administrator advised officers [Resident #1] has dementia. 3L34 [officer] was notified of the incident. The Officers circulated [circulated] the area and located [Resident #1]. [Resident #1] was returned to the [the] facility. The [Resident #1] refused medical attention. Bodycam in use . g. An Incident and Accident Next Day Reporting form 7734 with a fax date and time of 10/15/22 at 5:31am documented, .On 10/15/2022 at approximately 1:30 am, the Administrator was notified that [Resident #1] was missing. Resident was last seen at the 1st [first] nurses' station at approximately 12:30 am. Lead CNA [Certified Nursing Assistant] heard exterior alarm sounding in the main dining room and immediately notified the nurse. The staff then began internal search for the resident and were unable to locate him. All other residents were accounted for. Staff then began to do an exterior search of the perimeter of the building and surrounding areas. The DON [Director of Nursing] notified. The Administrator was notified. The Physician was notified. The DON searched cameras and discovered that the resident exited the facility through the kitchen door at 12:54 am. Administrator arrived at the facility. Staff continued searching for the resident but had been unsuccessful. Law enforcementnotified. Family notified.) Resident was located on property by on-call nurse and police officer at approximately 3:30am. Resident stated that he was just trying to get somefresh air. Physician notified. APRN Notified. Resident assesed. Labs ordered. Body audit performed. No injuries noted. Wonder guard bracelet intact. Resident has a BIMS score of 11. Resident placed on one on one observation resting quietly in his room. Investigation initiated and is ongoing at this time. STEPS TAKEN TO PREVENT CONTINUED ABUSE OR NEGLECT DURING THE INVESTIGATION - CONTINUED FROM PAGE 1 Resident was located on propety with wonderguardintact, Resident placed on one no one observation uponarrival to the facility. Body audit performed. Resident educated on the danger of leaving the facility without assistance, He voiced understanding. Began inservicing on elopement/wandering and abuse/negiect, Administrator, DON, Law Enforcement, Family and Physician Notified. Facility wide searched performed. All residents present. All exterior doors checked and are functioning properly. Investigation initiated and is ongoing . h. An OLTC (Office of Long-Term Care) Witness Statement form dated 10/15/2022 (no time documented) written by CNA #1 documented, .I heard the kitchen door alarm sounding. I was aware [Resident #1] was at station 2 around 12:50 am. The Resident has wander guard. I then went to resident's room and notice resident wasn't in his room, I notify the Licensed Practical Nurse (LPN#2). I then did an indoor head count, and all residents was accounted for. Then myself and (CNA #2) did an outside perimeter check until [Police Department] arrived. Dispatch on call at 0100 . i. An OLTC (Office of Long-Term Care) Witness Statement form dated 10/15/2022 (no time documented) written by LPN #2 documented, .Resident last seen approx. [approximately] 12:50 am. He had stopped at the nurse's station for a fruit jello snack. He ate his snack and proceeded to go down the hall. He states, he was just walking . j. An OLTC (Office of Long-Term Care) Witness Statement form dated 10/15/2022 at 01:27 am written by LPN #1 documented, Recd [received] a call from [CNA #1] asking if we have seen [Resident #1]. I informed her that it had been about 30mins [minutes] since I've last seen him. She stated that the dining room door alarm was sounding and the green light on the door was on. This nurse informed nurse [LPN #3] then we both started looking for resident, room by room, bathrooms, kitchen and outdoors. We looked about 15mins [minutes] then I notified the on-call phone @ [at] 0127 [1:27am]. Spoke with Dispatch who then notified the Administrator . k. An OLTC (Office of Long-Term Care) Witness Statement form dated 10/15/2022 at 4:39 am written by CNA #2 documented, .As I was doing my 11pm rounds checking on the residents [Resident #1] was in his room in bed as he normally would be. As I was getting ready to start my 1am rounds [Resident #1] was at the nurse station looking for a snack. As I was finishing up rounds, I was informed of [Resident #1] missing. I finish up what I was doing and started helping with finding [Resident #1]. l. On 10/18/22 at 2:23 pm, Resident #1 was lying in his bed in his room. The Surveyor asked Resident #1, I heard you got out of the building? He replied, You did? The Surveyor asked, How did you get out? He replied, Through that door by the kitchen The Surveyor asked, It wasn't locked? He replied, No, it usually is, but it wasn't this time. The Surveyor asked, Have you tried to leave before? He replied, No, I wasn't trying to leave. I just wanted to go outside for a little bit. The Surveyor asked, Where did you go? He stated, I went out to the edge of the woods and sat down for a little while. The Surveyor asked, Did you see people looking for you or calling your name? He replied, No I was hiding. The Surveyor asked, Were you hiding? He replied, No, I wasn't hiding. The Surveyor asked, How far did you go? He replied, I could see the building because it was lit up. The Surveyor asked, You weren't scared? He replied, No, I wasn't scared. Scared of what? The Surveyor stated, Of getting hurt? He replied, Naw, I fell a couple of times, but I didn't get hurt. The Surveyor asked, How long were you outside? He stated, I was out there 3 or 4 hours. The Surveyor asked, What were you doing all that time? He replied, Just leaning up against a tree. The Surveyor asked, Did you try to come back? He replied, No, but I knew when I saw the blue lights, it was over. m. On 10/18/22 at 2:45 pm, The Surveyor asked the Administrator what occurred the night of the elopement. He explained, At about 1:30 am Saturday morning, I got a call from [RN #1], the on- call nurse stating that she [RN #1] had received a call from a floor nurse. She [RN #1] said that [Resident #1] couldn't be located. She [RN #1] said that the lead CNA (CNA #1) on night shift noticed an alarm going off, so she (CNA #1) began looking for [Resident #1] because she [CNA #1] had seen him at the desk eating jello just a few minutes earlier. She [RN #1] stated that the lead CNA [CNA #1] checked [Resident #1]'s room and he wasn't in there, so she got another CNA, and they went outside and looked for him and did not see him. She said that they [staff] had done a head count and he was the only resident not accounted for. The Surveyor asked, What happened next? He stated, Well the DON was notified, we all came to the facility and started looking for [Resident #1]. I live in [another town], so it took me a little bit to get here but I got here around 2-2:15 am. The Surveyor asked, What time were the police called? He stated, I'm not sure exactly, I will have to look at the report, but it took them 30-45 minutes to get here. The Surveyor asked, What time was [Resident #1] found? He stated, About 3:30, the on-call nurse and the police located him at the back of the property in a wooded area. n. On 10/18/22 at 3:17 pm, The Surveyor asked the Administrator to be shown the door where [Resident #1] exited the building. He took the surveyor to the door adjacent to the dining room and kitchen, and it had a Velcro Stop sign across the door and a red sign on the door that stated, Emergency Exit Only . The Surveyor asked the Administrator to see the area where Resident #1 was found. The Surveyor accompanied the Administrator, Nurse Consultant (NC), and Registered Nurse (RN#1) to the area outdoor where the resident was found. While walking to the location, the NC made the statement while walking by the 200 Hall door, See this curb, that is why we have a wander guard on that door, because it has a high curb. We proceeded to the back end of the parking lot on the right side of the building. There was a curb approximately 6 inches high, then a steep hill leading downward into a small, wooded area. There was a large piece of broken asphalt sticking up out of the ground approximately 1 foot on the path leading down where Resident #1 was found. o. On 10/18/22 at 4:20 pm, The Surveyor asked the DON, There were 11 staff here according to the Nurse Schedule and the CNA assignment sheet you provided to me, where are the witness statements from the other staff members that were present when the elopement occurred? She stated, The statements I gave you are from the staff who were pertinent to the investigation. She was provided a list of 7 staff that did not provide witness statements and were working the night of the elopement and was asked if she has statements from those staff members. She replied, No but I can call them and see if I can get them in her to write one. p. On 10/18/22 at 4:46 pm, The Surveyor conducted a telephone interview with CNA #1. The Surveyor asked to explain her experience of the events regarding the elopement of Resident #1. She stated, It was almost 1am he [Resident #1] was at the nurse's station eating jello. When he finished that he said, I'm [NAME] [going] to walk around and he walked away. I do my rounds at 1 so I got up to go make sure everyone was doing rounds. Once I got to 300 Hall, I heard a beeping sound, so I went to see where it was coming from. It was the door in the dining room, so I looked out and didn't see anyone. I went to his [Resident #1] room, and he was not there. I went to the nurse and told her he was not in his room and the alarm had been going off and she said, he was just here. I went and got another CNA [CNA #2] and we went outside. While I was outside, I called another nurse [LPN #1] and asked if she had seen [Resident #1]. We were looking everywhere and calling his name. The Surveyor asked, Then what happened? She replied, We just kept doing that, walking around in the woods until finally we called the Director of Nursing (DON) and she told me that he was found by police. q. On 10/18/22 at 4:55 pm, The Surveyor asked the Administrator, What time were the Authorities notified that a resident was missing? The Administrator replied, I'll have to look at the police report. He went and got the police report and stated, The police report shows it was 2:52am. The Surveyor asked, Why was there a delay from the time that it was determined that a resident was unaccounted for at 1:30 am until the police were notified at 2:52 am? The Administrator stated, I wanted be sure that the resident could not be found. I didn't want to call the police and then he be here. r. On 10/18/22 at 7:20 pm, The Surveyor asked the NC, Why was the door he eloped from not equipped with a wander guard detector? The NC replied, It is a central area off the dining room where residents gather and have activities. The wander guard has about a 150 feet perimeter for the alarm. It would limit those residents on participation in activities, dining, and social gatherings, things they do in that area. We have exit doors all over the facility, midway in some of the halls. The wander guard system is on the front door because it is high a traffic area and 200 Hall door has one on it because it has a high curb outside the door. She was shown the statement made in the Incident and Accident Next Day Reporting form 7734 where it was documented that an interior search was conducted, then an exterior search and the Surveyor asked, Why did staff not search outside grounds for a resident immediately while doing the headcount? She stated, That report was rushed we have so little time to get it reported. I think that internal meant internal as in internally referring to facility staff. The Surveyor asked, Why wasn't the police notified when it was discovered that the resident was unaccounted for? She replied, Honestly, we knew he was here somewhere on the property. The Surveyor asked the NC, So, he was outside for 2 and a half hours before he was found. She stated, He wasn't going anywhere. He said he wasn't trying to leave. He said he just wanted to go outside and watch the sunrise. The surveyor asked the NC, Did he tell you he fell 2 or 3 times. She replied, Yeah, he did, but he refused medical treatment. We did a skin assessment, and he was ok. The Surveyor asked, Why wasn't the police notified sooner, when it was discovered that the resident was unaccounted for? She replied, It wasn't like the police came and saved the day. He was found by [RN #1], it just so happened it was after the police arrived. She was walking with the police and they [the police] had flashlights, they [RN #1 and the police] went to the only place she hadn't been, and he was there. s. On 10/19/22 at 1:39 pm, The DON provided 2 additional Witness statements. CNA #3 documented, .After I clocked in for the night, I went to the first dining room to sit my things down and I see [Resident #1] coming from 200 hall. A few minutes later I seen him again coming from 200 hall again went down 700 halls then I was notified [LPN #1] that [Resident #1] I went down 300 then 400 and a few rooms on 600 to look for resident and then I notified the nurse that I looked for the resident . CNA #4 documented, . [Resident #1] was walking down 400 halls. I walked behind him. He went to the front. I went to the break room. When they said he was missing I looked for him inside . t. On 10/19/22 at 3:15 pm, The Surveyor asked the DON, Why weren't the police notified at 1:30am when it was determined that [Resident #1] was missing? She replied, We honestly thought we were going to find him. He has never done this before. The Surveyor asked, What could have happened? She replied, That night, I was praying, please let him be ok. u. On10/21/22 The Administrator was shown a copy of CNA #1 witness statements that were provided to the Surveyor and asked to review it. The Surveyor asked, Does the witness statement indicate that there was an immediate search outdoors when the door was found unlocked? He replied, I believe she searched the immediate area and then came back in and did the head count while others were searching outside. The Surveyor asked, Where are the witness statements that say that? He stated, I don't have any. He was shown the witness statement from CNA #2 and was asked to tell the surveyor what CNA #2 documented occurred when he was told [Resident #1] was missing. The Administrator stated, He finished up what he was doing. The Surveyor asked, What does it say he was doing, rounds? He replied, Yes. The Surveyor asked, Do you see how that corresponds with the statement from CNA #1? He replied, Yes, I see what you are saying. He was asked to look at the witness statement from CNA #3 and was asked, Would you agree that documentation reflects that the resident was having wandering behavior? He replied, Yes, but that is not uncommon for him. He wanders around at night. The Surveyor asked the Administrator to review the witness statement from CNA #4 and was asked to clarify, So he went to the front, and she went to the breakroom? He replied, Yes, they would have had to come through the dining room, and she stopped and the breakroom on 300 hall and he would have continued down toward the 1st [first] nurse's station. He was shown a witness statement from LPN #2 and was asked to review. After reviewing the witness statements with the Administrator, he was shown the policy for Elopement and Wandering that was provided to the surveyor. The Surveyor asked the Administrator to read the policy statement. He read aloud, Appropriate measures will be implemented to identify and respond promptly to elopement and wandering. The Surveyor asked, What measures were taken to respond to the wandering that was observed by the staff? He replied, That was his normal, he did that every night. The Surveyor asked, Okay but what was the response by your staff? What did they do to prevent the elopement that night? He stated, They gave him some jello. The Surveyor asked, What does the Care Plan state for [Resident #1]? He replied, That he is at risk for elopement. The Surveyor asked, What were they supposed to do to prevent the elopement? The Surveyor asked, What does it say? He sat in silence. The Surveyor asked, So you don't know? He shook his head side to side and mumbled indicating no. Again, the Surveyor asked the Administrator, What did the staff do to prevent the elopement? He stated, They gave him a jello. I feel like the staff responded appropriately. v. On 10/18/22 at 3:30 pm, The Administrator provided a copy of the Elopement policy which documented, Appropriate measures will be implemented to identify and respond promptly to elopement and wandering . Interventions will be developed according to the resident's specific needs .It is the responsibility of all employees to immediately report to the Charge Nurse or Director of Nursing any attempt by a resident to leave the premises, or suspicion that a resident is missing from the facility .Make a thorough search of the building and premises. If not located, Call the appropriate code, notify law enforcement, Notify the physician. Complete the wandering Elopement Risk information sheet, Make an extensive search of the surrounding area .

Complaint # (AR 447) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided for a newly admitted resident with a recent history of gastrointestinal hemorrhage and hepatic [MEDICAL CONDITION], as evidenced by failure to consistently conduct and document bowel assessments, failure to promptly identify and intervene to correct a prolonged lack of sufficient bowel movements and failure to accurately transcribe admission physician orders [REDACTED].#5) of 1 case mix resident who had a history of [REDACTED].#5, who experienced a recurrence of hepatic [MEDICAL CONDITION] and required hospitalization due to rising serum ammonia levels, and had the potential to cause more than minimal harm to on other residents who had physician orders [REDACTED]. The Administrator was notified of the Immediate Jeopardy condition on 9/14/17 at 4:36 p.m. The findings are: 1. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 8/29/17 documented the resident scored 9 (8-12 indicated moderately impaired) on a brief interview for mental status, required extensive assistance of one person for bed mobility, transfer, ambulation, locomotion, dressing, toilet use and personal hygiene, was occasionally incontinent of urine and frequently incontinent of bowel. a. A hospital Discharge Medication List dated 8/23/17 at 2:22 p.m. documented, .[MEDICATION NAME] 20 grams/30 ml (milliliters) soln (solution). Take 45 ml 30 g (grams) total by mouth every 8 (eight) hours as needed for less than 3-4 BMs (Bowel Movements) a day. 1.) The above [MEDICATION NAME] order was transcribed to the facility's Physician order [REDACTED].[MEDICATION NAME] Solution 20 GM/30ML give 45 ml by mouth every 8 hours as needed for constipation related to End Stage [MEDICAL CONDITION] . The remainder of the order, to administer the [MEDICATION NAME] if the resident had less than 3 to 4 bowel movements daily, was not transcribed to the facilty's Physician Orders. The orders were signed as confirmed by Licensed Practical Nurse (LPN) #1. 2.) The August 2017 Medication Administration Record (MAR) documented the same incomplete [MEDICATION NAME] order, [MEDICATION NAME] solution 20 gm (gram)/30 ml (milliliters) give 45 ml by mouth every 8 hours as needed for constipation related to End Stage [MEDICAL CONDITION]. The remainder of the order, to administer the [MEDICATION NAME] if the resident had less than 3 to 4 bowel movements daily, was not transcribed to the MAR. b. The Activities of Daily Living (ADL) - Toileting sheet documented one small bowel movement on 8/23/17; no bowel movements on 8/24/17; no bowel movements on 8/25/17; one large bowel movement on 8/26/17; no bowel movement on 8/27/17; one small formed bowel movement on 8/28/17; and no bowel movements on 8/29/17. According to the hospital physician orders, the [MEDICATION NAME] should have been given every 8 hours, since the resident only had one or zero bowel movements on each of the above dates; however, according to the August 2017 MAR, the [MEDICATION NAME] was given only on one occasion between 8/23/17 and 8/29/17. Nurses' initials were documented on 8/25/17 to indicate one dose of [MEDICATION NAME] was administered on that date. c. Between 8/23/17 and 8/29/17 when the [MEDICATION NAME] was not administered as ordered, the following Nurses' Notes were documented: 1.) A Nurse's Note dated 8/27/17 at 11:35 a.m. documented, At 1040 (10:40 a.m.) resident was resting in bed, but difficult to arouse. Respirations E/U (even, unlabored). Responds appropriately to verbal stimuli. FSBS (Finger Stick Blood Sugar): 93. 6 oz (ounces) of Orange Juice administered. Resident took 5-6 bites of pudding. Re-checked FSBS. FSBS:127. WCTM (will continue to monitor). There was no documentation of an assessment of bowel sounds on this date or that the lack of bowel movements on this date was identified and addressed. 2.) A Nurse's Note dated 8/29/17 at 9:40 a.m. documented, resident request to sleep longer this am (morning). po (by mouth) (meds) taken whole w/o (without) difficulty. Resident noted more drowsy than normal this shift. Van driver stated well it's time to go to [MEDICAL TREATMENT]. Resident answering some questions. Resident stated that she wasn't just feeling good. This nurse notified resident's daughter at (phone number) and rang and went to voicemail this nurse left a detailed message concerning the change on resident and to notify this nurse and left phone # (number) to return call as soon as she got this message. Still awaiting return call at this time. There was no documentation of an assessment of bowel sounds on this date or that the lack of at least 3 to 4 bowel movements per day over the past 7 days was identified and addressed at this time. 3.) A Nurse's Note dated 8/29/17 at 11:28 a.m. documented, Got a call from (name) stating resident was going to (hospital name) from [MEDICAL TREATMENT] . called [MEDICAL TREATMENT] to find out what was going on they stated would have to call back . immediately called (name) responsible party to make sure they knew resident was going to hospital and to see if they had information since [MEDICAL TREATMENT] hasn't called back (name) stated mother was not usual self and was going to hospital stated ok would check on notes and told resident blood sugar was 150 at 06:18 (6:18 a.m.) per records she then stated was coming to get belongings notified (name) APN (Advance Practice Nurse) resident was going to (hospital) from [MEDICAL TREATMENT]. d. A handwritten statement signed by the transport driver of the facility van documented, On August 29, 2017 I (name) transported (Resident #5) to [MEDICAL TREATMENT] and I ask for a nurse to look at her because she wasn't looking good. The RN (Registered Nurse) charge nurse directed me to take her to the emergency room . I put her back on the van and called dispatch and my supervisor told me not to transport her to call 911 so I did and then (Resident #5) started to slide out of the chair so I put my legs against hers until (ambulance service) comes. e. The Hospital Progress Note dated 8/29/17 at 12:11 p.m. documented, Presents to emergency room with chief complaint of altered mental status. Patient has GCS (Glascow Coma Scale) 7 with glucose of 49. Glucose corrected with D ([MEDICATION NAME]) 50 but no response to increase in mental status. Patient intubated for airway protection. ET (Endotracheal) tube in appropriate position on chest x-ray. No other abnormalities noted on chest x-ray. CT (Computed Tomography) head negative for bleed or infarction. EKG (Electrocardiogram) shows normal sinus rhythm. No signs of infection but patient's ammonia is elevated, concerning for hepatic [MEDICAL CONDITION]. Patient was previously admitted with ammonia of 80 and diagnosed with [REDACTED]. A laboratory report dated 8/29/17 at 7:39 p.m. documented, .Ammonia: Value: 124 (H) Ref (reference) range; 11-35 uMol/L(micromole per liter) . f. The Hospital Critical Care Attending Admission Note dated 8/29/17 at 1:05 p.m. documented, .History of Present Illness: The patient underwent a recent TIPS (transjugular intrahepatic portosystemic shunt) procedure during hospital stay 8/8-8/23. Her daughter says that she only received [MEDICATION NAME] x (times) 2 at her nursing home and that she was becoming increasingly confused, such that she could not follow physical therapist's instructions and eventually became quite altered. She was sent to the ED (Emergency Department) from [MEDICAL TREATMENT] because of her mental status, where she was intubated for airway protection. Yesterday she was quite somnolent but today is responding more . Altered mental status 2/2 (secondary to) hepatic [MEDICAL CONDITION], suspect due to not getting [MEDICATION NAME]. No clear signs of infection. No ascites on US (Ultrasound) . g. The MICU (Medical Intensive Care Unit) Note dated 8/31/17 at 11:20 a.m. documented, .Assessment and Plan: .PMHx (Past Medical History): [MEDICAL CONDITION] and [MEDICAL CONDITIONS] (End Stage [MEDICAL CONDITION]) on HD ([MEDICAL TREATMENT]) TTS (Tuesday, Thursday, Saturday), [MEDICAL CONDITION], DM (Diabetes Mellitus),[MEDICAL CONDITION](Hypertension), GAVE (gastric antral vascular ectasia), s/p (status [REDACTED]. Morning of 8/29 (sic) patient was not moving any extremities and would not respond to painful stimuli, but after stool output of ~ (approximately) 1500cc (cubic centimeters) patient became more alert (moving extremities, responding to voice). Mental status as of 8/31 AM (morning) is stable . h. A Hospital Progress Note dated 8/31/17 at 1:11 p.m. documented, .Subjective and 24 Hour Events: Had about 4 liters of stool out and initially thought not to be improving from mental status perspective but more interactive on rounds this AM . Altered mental status 2/2 (secondary to) hepatic [MEDICAL CONDITION], suspected initially due to not getting [MEDICATION NAME] . i. A Nephrology Consult note dated 8/31/17 at 2:19 p.m. documented, .Pt (patient) on [MEDICATION NAME] having lots of loose stools - output ~ 4.2 lts (liters) . j. On 9/15/17 at 4:53 p.m., the facility's Registered Nurse Consultant was asked, How are physician orders [REDACTED]. The Admit Nurse who checks the order for correct transcription from the original to the computer was not here. Their system for double checking or transcribing orders was not completed. The DON (Director of Nursing) thought the Admit Nurse did it and the Admit Nurse, upon return, thought the DON did it. k. On 9/15/17 at 12:03 p.m., the DON was asked, to review the hospital physician orders [REDACTED].? She stated, Yes, correct. The DON was then asked to review the orders that were transcribed by LPN #1 and was asked if portion of the order regarding administration of [MEDICATION NAME] for less than 3 to 4 bowel movements per day was included. The DON stated, No, I don't see it. The DON was then asked to review the administration of the medication on the MAR and was asked, Do you see the 3 to 4 BMs per day (portion of the order) on the MAR and stated, No. The DON was asked, Would you say these orders were transcribed correctly from the original admit orders to the facility physician orders [REDACTED]. The DON was asked, On the 25th, she was given [MEDICATION NAME]; is there any documentation that the [MEDICATION NAME] was effective or not? She stated, No. l. As of 9/13/17 at 1:57 p.m.,, there was no documentation in the Nurses' Notes to indicate complete assessments of the resident's gastrointestinal (GI) status were conducted during the 7 days she resided in the facility (8/23/17 through 8/29/17). 2. The Immediate Jeopardy was removed and the scope/severity reduced to H on 9/14/17 at 6:43 p.m. when the facility implemented the following Plan of Removal: a. On 09/14/17 upon notification of deficient practice of facility failure to translate and administer medications as ordered and facility failure to assess, monitor and identify lack of bowel movements in a newly admitted resident with complicated GI (Gastrointestinal) history, the DON /Designee immediately began in-servicing the charge nurses on duty of proper protocol for transcribing and administering medications as ordered as well as assessing GI system and BMs to include supportive documentation. This in-servicing to be done shift to shift by DON/Designee before charge nurses are allowed to begin shift and care for residents. This in-servicing to be done shift to shift and with all newly hired charge nurses as well as PRN (as needed) charge nurses until all employed charge nurses are in-serviced and in-service sign in sheets are signed by all the nurses. Beginning 09/14/2017 DON/Designee began assessing all 114 residents, identified by current census, for evidence of active bowel sounds through GI assessment, as well as documentation of BM within last 3 days. Any resident noted to have abnormal GI assessment or lack of BM in last 3 days, physician will be notified and orders obtained and implemented at that time. b. Beginning 9/14/17 the DON/Designee to review all new admission orders [REDACTED]. Any negative findings will be reported to the physician for further orders or instruction. This monitoring of admission orders [REDACTED]. c. Beginning 9/14/17 to continue until P(NAME) (Plan of Correction) is implemented and compliance achieved DON/Designee to review all new admission and newly written telephone orders every day until compliance achieved to ensure all medications are transcribed and administered as ordered. Any negative findings to be reported to the physician immediately for further orders and instructions. d. Beginning 9/14/17 and to continue until P(NAME) implemented and compliance achieved the DON/Designee to monitor BM documentation and GI assessments every day until compliance achieved on all residents with orders for laxatives to ensure proper assessment, monitoring, and physician notification. Any negative findings will be reported to the physician immediately for further orders or instruction. e. Any concerns with medication transcription and/or administering as well as GI assessments, monitoring and BM documentation will be brought to every Monday-thru-Friday morning QA (Quality Assurance) meeting by the DON/Designee for review, revision or implementation by ICP (Interdisciplinary Care Plan) teams. These concerns to be followed up on at the quarterly QA meeting as well.