Every finding on record at Old Jefferson Community Care Center

Based on interviews and record review, the facility failed to meet Hospice requirements by failing to maintain a system to ensure a resident's Hospice Binder contained the most recent Hospice Plan of Care for 1 (#12) of 2 residents reviewed for Hospice care. Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #12 was a patient of a local Hospice agency with an admission date of 02/20/2025. Review of Resident #12's Hospice Binder and Electronic Health Record revealed no current Hospice Plan of Care on file for current Certification Period of 03/05/2026 through 05/03/2026. An interview was conducted on 03/25/2026 at 11:55 a.m. with S1DON. S1DON stated she worked in collaboration with hospice representatives to coordinate care to the resident provided by the facility. S1DON reviewed Resident #12's Hospice Binder and Electronic Health Record. S1DON confirmed there was no current Hospice Plan of Care on file for the current Certification Period of 03/05/2026 through 05/03/2026. S1DON confirmed Resident #12's Hospice Binder should have contained the most current and up to date Plan of Care and did not.

46975 Based on observations, interviews, and record reviews, the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure: 1. Each resident received scheduled baths for 2 (#37 and #75) of 7 (#12, #23, #37, #45, #68, #75, and #92) residents reviewed for ADLs; and 2. Each resident received necessary perineal care after incontinent episodes and prior to application of a clean brief for 3 (#12, #23, and #92) of 7 (#12, #23, #37, #45, #68, #75, and #92) residents reviewed for ADLs. Findings: 1. Resident #37 Review of Resident #37's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Parkinson's Disease, Other Specified Anxiety Disorders, Age Related Osteoporosis, Age Related Physical Debility, and Spasmodic Torticollis. Review of Resident #37's Quarterly MDS with an ARD of 12/21/2024 revealed a BIMS of 15, which indicated she was cognitively intact. Further review of the MDS revealed she required substantial/maximal assistance with bathing. Review of Resident #37's current Care Plan revealed the following, in part: Problem: I have an ADL self-care performance deficit. Interventions: Bathing/showering: I require extensive assistance by one staff with bathing/showering. Review of Resident #37's Bath Documentation revealed she was scheduled to receive baths on Mondays, Wednesdays, and Fridays. Further review of the bath documentation dated 02/03/2025 revealed S12CNA documented not applicable for Resident #37's scheduled bath. An interview was conducted with Resident #37 on 02/03/2025 at 10:30 a.m. She stated she had not received a bath three times weekly. She explained she was unaware she had a bath schedule because she received baths inconsistently. She stated she wanted a bed bath three times weekly. An interview was conducted with Resident #37 on 02/04/2025 at 9:11 a.m. She stated she did not receive a bath on 02/03/2025 and wanted a bed bath. A telephone interview was conducted with S12CNA on 02/04/2025 at 12:40 p.m. She confirmed she was the CNA assigned to Resident #37 on 02/03/2025. She stated Resident #37's bath days were Monday, Wednesday, and Friday. She stated, on 02/03/2025, Resident #37 did not receive a bed bath. She confirmed Resident #37 did not refuse her bed bath. She stated Resident #37 should have received a full bed bath on her bath days. An interview was conducted with S10CNA on 02/04/2025 at 4:04 p.m. She confirmed she was the shower aide for Resident #37 on 02/03/2025. She stated Resident #37's bath days were Mondays, Wednesdays, and Fridays. She stated Resident #37's preferred bath method was a bed bath. She stated Resident #37 did not receive a bed bath on 02/03/2025, which was her scheduled bath day. An interview was conducted with S2DON on 02/05/2025 at 8:48 a.m. She stated Resident #37's bath days were Mondays, Wednesdays, and Fridays. She confirmed Resident #37's scheduled bath on 02/03/2025 was documented as not applicable. She reviewed Resident #37's Medical Record and confirmed there was no documented bath refusals for 02/03/2025. She confirmed if Resident #37 refused any services, it should have been documented. Resident #75 Review of Resident #75's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Other Cerebral Infarction, Unsteadiness on Feet, and Muscle Wasting and Atrophy. Review of Resident #75's Quarterly MDS with an ARD of 11/062024 revealed a BIMS of 15, which indicated she was cognitively intact. Further review of the MDS revealed she required partial/moderate assistance with bathing. Review of Resident #75's current Care Plan revealed the following, in part: Problem: I have an ADL self-care performance deficit related to generalized muscle weakness, impaired coordination, and poor endurance. Interventions: Bathing/showering: I require extensive assistance by 2 staff with bathing/showering. An interview was conducted with Resident #75 on 02/04/2025 at 2:38 p.m. She confirmed her shower was scheduled yesterday and she did not receive it. She stated she did not receive a shower today, and her next scheduled shower day was 02/05/2025. An interview was conducted with S11CNA on 02/04/2025 at 2:05 p.m. She stated Resident #75 was scheduled to receive a shower on 02/03/2024. She confirmed Resident #75 did not receive a shower on 02/03/2025. An interview was conducted with S10CNA on 02/04/2025 at 4:04 p.m. She confirmed she was the shower aide on 02/03/2025. She confirmed Resident #75 did not receive a shower on 02/03/2025. An interview was conducted with S2DON on 02/05/2025 at 8:48 a.m. She confirmed Resident #75's scheduled bath day was Mondays, Wednesdays, and Fridays. She stated Resident #75 should have received her bath or shower on 02/03/2025 since it was her scheduled bath day. She confirmed each resident should have been provided their preferred bath on their scheduled bath days. 2. Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Lack of Coordination and Lumbar Compression Fracture. Review of Resident #12's Quarterly MDS with an ARD of 01/14/2025 revealed a BIMS of 13, which indicated she was cognitively intact. Further review of the MDS revealed she required partial/moderate assistance with toileting hygiene and she was occasionally incontinent. Review of Resident #12's current Care Plan revealed the following, in part: Problem: I am at risk for potential impairment to skin integrity. Interventions: Keep my skin clean and dry. An observation was conducted on 02/05/2025 at 4:12 a.m. of S8CNA changing Resident #12's brief. S8CNA removed Resident #12's brief, which was soiled with urine. S8CNA applied a new clean brief without cleansing Resident #12's peri area. An interview was conducted with Resident #12 on 02/05/2025 at 10:00 a.m. She stated she wanted to be cleansed after each incontinent episode, and had never refused to be cleansed before. Resident #23 Review of Resident #23's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Lack of Coordination. Review of Resident #23's Quarterly MDS with an ARD of 11/20/2024 revealed a BIMS of 14, which indicated she was cognitively intact. Further review of the MDS revealed she required partial/moderate assistance with toileting hygiene and she was occasionally incontinent. Review of Resident #23's current Care Plan revealed the following, in part: Problem: I have bladder incontinence. Interventions: Clean my peri-area with each incontinent episode. An interview was conducted with Resident #23 on 02/04/2024 at 2:10 p.m. She stated a CNA came into her room between 4:00 a.m.-4:30 a.m. every morning to change her brief. She stated the CNA took the soiled brief off and put a clean one on without cleansing her peri-area. She stated she was unable to clean herself after she had an incontinent episode and wanted to be cleansed. She stated she never refused peri-care. An observation was conducted on 02/05/2025 at 4:38 a.m. of S8CNA changing Resident #23's brief. S8CNA removed Resident #23's urine saturated brief. The urine had soaked through Resident #23's brief. Four inches of the back of the resident's gown was wet, her cloth pad was wet, and the bed sheet was wet. There were visible drops of urine running down Resident #23's buttocks when the brief was removed. S8CNA applied a new clean brief and gown without cleansing Resident #23's skin or peri-area. Resident #92 Review of Resident #92's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. Review of Resident #92's Quarterly MDS with an ARD of 12/16/2024 revealed a BIMS of 14, which indicated she was cognitively intact. Further review of the MDS revealed she required substantial/maximum assistance with toileting hygiene and she was always incontinent. Review of Resident #92's current Care Plan revealed the following, in part: Problem: I have urge bladder incontinence. Interventions: Clean my peri-area with each incontinent episode. An observation was conducted on 02/05/2025 at 4:30 a.m. of S8CNA changing Resident #92's brief. S8CNA removed Resident #92's urine saturated brief. There were visible drops of urine running down Resident #92's buttocks when the brief was removed. S8CNA applied a new clean brief without cleansing Resident #92's peri-area. An interview was conducted with Resident #92 on 02/05/2025 at 7:00 a.m. She stated S8CNA did not provide peri-care to her when changing her brief this morning. She stated she wanted to be cleansed after each incontinent episode, and she could not do it herself. She stated she never refused peri-care. An interview was conducted with S8CNA on 02/05/2025 at 4:47 a.m. She stated Resident #23 was a heavy wetter and the last time she changed Resident #23's brief was at 1:30 a.m. She verified Resident #23's urine had soaked through the brief, gown, pad, and bed sheet. She stated rounds should be made every 2 hours. She confirmed the residents listed above were all soiled with urine and she did not provide peri-care. An interview was conducted with S2DON on 02/05/2025 at 11:00 a.m. She was notified of the above observations. S2DON confirmed staff should perform peri-care after each incontinent episode. She confirmed CNA's should perform rounds and incontinent checks every 2 hours on the residents.

Based on an observation and interviews, the facility failed to ensure drugs were stored in accordance with current accepted professional principles. The facility failed to ensure a medication cart was clean and free of loose pills for 1 (Med Cart B) of 3 (Med Cart A, B, and C) medication carts reviewed. Findings: Review of the facility's policy with a revised date of 11/2020, titled Storage of Medications, revealed in part, the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. On 02/04/2025 at 10:08 a.m., a review and observation was made of Med Cart B with S6LPN, which revealed the following: 4-Oval white colored tablets loose in cart. 3-Round white colored tablets loose in cart. 3-Oblong white colored tablets loose in cart. 2-Oblong white colored tablets loose in cart. 2-Small round white colored tablets loose in cart. 2-Round yellow colored tablets loose in cart. 1-Oblong yellow colored tablet loose in cart. 1-Large round white colored tablet loose in cart. 1-Half of a rectangle white colored tablet loose in cart. 1-Half of a round white colored tablet loose in cart. Totaling 18 whole tablets and 2 halves of tablets loose in medication cart. On 02/04/2025 at 10:25 a.m., an interview was conducted with S6LPN. She reviewed the aforementioned findings, and confirmed there was a total of 18 whole tablets and 2 halves of tablets loose in the medication cart, and they should not have been. On 02/04/2025 at 1:45 p.m., an interview was conducted with S2DON. She stated she expected staff to remove and dispose of any loose pills noted on medication carts. S2DON was informed of the aforementioned findings, and she confirmed there should have not been any loose pills on the medication cart.

Based on observations, interviews, and record review, the facility failed to store foods under sanitary conditions. The facility failed to ensure: 1. Food was dated after opening, and 2. Temperatures were documented on temperature logs daily. This deficient practice had the potential to affect 110 residents who were provided meals from the facility's kitchen. Findings: Review of the facility's policy titled, Food Receiving and Storage and dated 10/2017, revealed in part, the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Procedure: 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (received and/or open date). 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. During the initial tour of the facility's kitchen on 02/03/2025 at 8:22 a.m. with S3DM, the following observations were made: Snack/Nourishment Refrigerator: 1-opened gallon of mayonnaise was undated, 1/4 remained. Salad Bar Station: 1-opened container of chopped lettuce, undated. 1-opened container of chopped tomatoes, undated. 1-opened container of sliced cheese, undated. Review of the facility's temperature logs for the walk-in freezer, walk-in refrigerator, and snack/nourishment refrigerator revealed no documentation of temperatures for January 2025 to current. On 02/03/2025 at 8:25 a.m., an interview was conducted with S3DM. She confirmed the above aforementioned findings. She confirmed all opened items should be labeled with an open date. She confirmed the food items in the salad bar station should have been labeled with the dates they were placed on the salad bar station. She confirmed temperature logs for January 2025 to current were blank, and temperatures should have been documented daily. On 02/04/2025 at 1:31 p.m., an interview was conducted with S1ADM. He confirmed all opened items should have been labeled with an open date. He confirmed temperatures should have been documented daily, and all temperature logs should have been completed.

Based on interviews and record reviews, the facility failed to ensure the Minimum Data Set accurately reflected the residents' status for 1 (#49) of 4 (#33, #49, #214, and #414) residents by failing to ensure Resident #49 was coded correctly for infections. Findings: Review of Resident #49's Clinical Record revealed she was admitted to the facility on [DATE] with admission diagnoses of Sepsis and Pneumonia. Review of Resident #49's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2024 revealed a Brief Interview for Mental Status (BIMS) of 5, which indicated she was severely cognitively impaired. Further review revealed the following, in part: Section I-Active Diagnoses Active Diagnoses in the last 7 days-check all that apply Infections Section I1200. Pneumonia. Yes Section I1200. Septicemia. Yes Review of Resident #49's Physician Orders and Medication Administration Record (MAR) dated November 2024 revealed no orders for treatment of Pneumonia and Septicemia. Review of Resident #49's Nurse's Notes dated November 2024 revealed no noted related to the resident having Pneumonia and Septicemia. Review of the facility's Infection Log dated November 2024 revealed no infections, including Pneumonia and Septicemia for Resident #49. On 02/03/2025 at 12:05 a.m., an interview was conducted with Resident #49's family member. Resident #49's family member stated the resident did not have any infections including, Pneumonia and Septicemia, in November 2024. On 02/04/2025 at 12:15 p.m., an interview was conducted with S7LPN. She stated Resident #49 had not had any infections, including Pneumonia and Septicemia. On 02/05/2025 at 10:26 a.m., an interview was conducted with S4CCC. She stated she was responsible for completing Resident #49's MDS assessments. She reviewed Resident #49's Annual MDS assessment with an ARD of 11/14/2024. She confirmed Pneumonia and Septicemia were admit diagnoses, and should not have been coded under active diagnoses. On 02/05/2025 at 11:00 a.m., an interview was conducted with S2DON. She reviewed Resident #49's active diagnoses and Annual MDS with an ARD of 11/14/2024. She confirmed Resident #49 was coded for Pneumonia and Septicemia and should not have been.

Based on observation, interviews, and record review, the facility failed to ensure each resident received meals which accommodated preferences for 1 (#36) of 2 (#36 and #37) residents reviewed for food. Findings: Review of Resident #36's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Dementia and Protein-Calorie Malnutrition. Review of Resident #36's Meal Ticket dated 02/04/2025 for the breakfast meal revealed she should have received double portions. An observation was made of Resident #36's breakfast tray on 02/04/2025 at 8:44 a.m. She had one 9 ounce bowl mixed with grits, scrambled eggs, and sausage and one slice of French toast. Her meal ticket read regular diet with double portions. An interview was conducted with S9CNA on 02/04/2025 at 8:49 a.m. She confirmed she served Resident #36's breakfast tray. She reviewed Resident #36's breakfast meal ticket and confirmed it read Resident #36 should have been served double portions. She confirmed Resident #36's breakfast tray did not contain double portions. She confirmed Resident #36's breakfast tray contained a single portion of grits, scrambled eggs, sausage, and French toast. An interview was conducted with S13LPN on 02/04/2025 at 8:54 a.m. She stated Resident #36 should have received double portions with meals. An interview was conducted with S3DM on 02/04/2025 at 9:02 a.m. She confirmed Resident #36's meal preference of double portions was listed on her meal tickets for all meals. She confirmed Resident #36 should have received double portions with all meals. An interview was conducted with S2DON on 02/05/2025 at 8:48 a.m. She stated Resident #36's double portions listed on her meal ticket was a meal preference. She confirmed the double portions should have been provided.

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff donned proper Personal Protective Equipment (PPE) during feeding tube care for 1 (#41) of 3 (#15, #41 and #60) residents observed for Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy dated 04/2024, titled, Enhanced Barrier Precautions revealed the following, in part: Enhanced barrier precautions are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 2. EBP employ targeted gown and glove use during high contact resident care activities. a. Gloves and gown are applied prior to performing the high contact resident care activity. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP .include device care or use. 5. EBP are indicated for residents with indwelling medical devices. a. Examples of medically inserted devices may include .feeding tubes. Review of the facility's sign titled Enhanced Barrier Precautions revealed the following instructions, in part: Enhanced Barrier Precautions .providers and staff must wear gloves and a gown for the following high contact resident care activities: .Device care or use of .feeding tube, wound care: any skin opening requiring a dressing. Review of Resident #41's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Other Sequelae of Cerebral Infarction and Gastrostomy Status. Review of Resident #41's current Physician Orders revealed the following, in part: Start date - 10/26/2022 enteral feed order: every shift residual check. Start date - 10/26/2022 enteral feed order: every shift visually assess tube and site. Review of Resident #41's current Care Plan revealed the following, in part: Problem: At risk for developing multidrug resistant organism infections related to feeding tube. Require the use of EBP. Intervention: EBP per facility protocol. Resident #41 will have EBP PPE as required. An observation was made on 02/05/2025 at 8:50 a.m. of Resident #41's door to her room. A sign was noted near the door above the room number, which read EBP with the above instructions. An observation was made on 02/05/2025 at 8:50 a.m. of S14LPN providing care for Resident #41's Percutaneous Endoscopic Gastrostomy (PEG) tube site. S14LPN applied gloves and entered Resident #41's room without a gown. S14LPN lifted Resident #41's gown and visually assessed the gauze dressing at the PEG site. Then, S14LPN retrieved an empty syringe, grasped the PEG tube, and checked Resident #41's residual. After PEG site assessment and residual check, S14LPN cleaned Resident #41's PEG tube syringe. An interview was conducted on 02/05/2025 at 8:55 a.m. with S14LPN. S14LPN stated Resident #41 was on EBP related to her PEG tube. S14LPN confirmed she did not have a gown on during care of Resident #41's PEG tube site. S14LPN stated she would put on a gown for PEG tube feedings, dressing changes and medications administration, but not for PEG site assessment and residual check. S14LPN stated she was not sure the proper EBP protocol. An interview was conducted on 02/05/2025 at 2:15 p.m. with S2DON. S2DON confirmed Resident #41 was on EBP related to the PEG tube device. S2DON stated S14LPN had notified her that she did not have a gown on during Resident #41's PEG site assessment and residual check. She confirmed she would expect the staff to follow EBP PPE protocol and apply a gown and gloves during direct care of residents

Based on observation, interviews, and record review, the facility failed to ensure nurse staffing data was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 111 residents residing in the facility. Findings: Review of the facility's policy titled Posting Direct Care Daily Staffing Numbers, dated 01/2023 revealed in part, the following: Policy Statement: Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. A tour and observation was made on 02/03/2025 at 11:10 a.m. of the facility, and no staffing data sheets was observed. An interview was conducted on 02/03/2025 at 11:15 a.m. with S5CS. She stated she was responsible for posting staffing data sheets. She stated the staffing data information was not posted for 02/03/2025. An interview was conducted on 02/03/2025 at 11:16 a.m. with S1ADM. He stated S5CS was responsible for posting staffing data sheets. He stated the staffing data information was not posted for 02/03/2025 and should have been.

Based on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed for MDS. Findings: Resident #2: Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #1 had a diagnosis of Dysphagia. Review of Resident #2's Physician Orders revealed the following: Regular diet, mechanical soft texture, regular- thin liquids consistency. Start date: 08/22/2024 Regular diet, mechanical soft texture, regular-thin liquids consistency. Start date: 11/21/2023. Discontinued: 08/16/2024. Review of Resident #2's MDS with an ARD of 07/26/2024 revealed mechanically altered diet- require change in texture of food or liquids was coded as no in Section K0520 titled Nutritional Approach. Resident #3: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Physician Orders revealed the following: Regular diet, mechanical soft texture, regular- thin liquids consistency. Start date: 08/22/2024 Regular diet, mechanical soft with chopped meats texture, regular- thin liquids consistency. Start date: 03/15/2024. Discontinued: 08/16/2024. Review of Resident #3's MDS with an ARD of 06/26/2024 revealed mechanically altered diet- require change in texture of food or liquids was coded as no in Section K0520 titled Nutritional Approaches. On 08/27/2024 at 9:20 a.m., an interview was conducted with S3CCC. She stated she was responsible for completing the resident MDS assessments. She reviewed Resident #2's MDS dated [DATE] and confirmed section K0520C titled Nutritional Approaches - Mechanically altered diet was not accurately coded for Resident #2's ordered mechanical altered diet. S3CCC confirmed if a resident was ordered a mechanical soft diet, section K0520C of the MDS should have been coded as yes and was not for Resident #2. On 08/27/2024 at 2:50 p.m., an interview was conducted with S3CCC. She reviewed Resident #3's MDS dated [DATE] and confirmed section K0520C titled Nutritional Approaches -Mechanically altered diet was not accurately coded for Resident #3's ordered mechanical altered diet. S3CCC confirmed if a resident was ordered a mechanical soft diet, section K0520C of the MDS should have been coded as yes and was not for Resident #3. On 08/27/2024 at 1:50 p.m., an interview was conducted with S1DON. She stated if a resident had a mechanical soft diet ordered, section K0520C - Nutritional Approach - Mechanically altered diet of the MDS should be coded as yes to accurately reflect the resident's diet order. 49343

Based on observations, interviews, and record review, the facility failed to ensure there was a system in place to ensure facility residents received routine dental care and routine dental care was provided for 1 (#73) of 3 (#8, #73, and #82) residents reviewed for dental services. This deficient practice had the potential to affect any of the 107 residents residing in the facility. Findings: Review of the facility's undated policy titled, Dental Services revealed the following, in part: Purpose: Oral healthcare and dental care needs will be provided to each resident. Policy: Routine dental services are provided to the resident through either: a. A contract agreement with a local dentist. b. A contract agreement with a dentist that comes to the facility. c. Referral to the resident's personal dentist; or d. Referral to community dentist. Procedure: 6. Social services personnel are responsible for assisting the resident/family with dental services. Review of Resident #73's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Unspecified Protein-Calorie Malnutrition. Review of Resident #73's Quarterly MDS with an ARD of 12/22/2023 revealed she had a BIMS of 15, which indicated she was cognitively intact. An interview was conducted with Resident #73 on 03/11/2024 at 8:56 a.m. She stated she lost her dentures prior to admitting to the facility. She stated she did not have any teeth, and she would like to have teeth so she could eat fried chicken. She stated she had not seen a dentist or been offered to see a dentist since admission to the facility. She stated she talked to S6SW about six months ago about getting a set of dentures but had not heard anything about it since. She did not have any natural teeth or dentures. An interview was conducted with S7CNA on 03/12/2024 at 10:07 a.m. She confirmed Resident #73 did not have any natural teeth or dentures. An interview was conducted with S8LPN on 03/12/2024 at 10:31 a.m. She stated Resident #73 previously told her she was going to talk with S6SW about getting a set of dentures. An interview was conducted with S4DM on 03/12/2024 at 1:48 p.m. She stated she was responsible to perform oral assessments on the facility residents. She stated her assessment would include if the resident had natural teeth and/or dentures. She stated if she assessed Resident #73's oral status and determined she did not have any natural teeth and no dentures, she would let S6SW know so she could be scheduled with a dentist. She confirmed she did not identify Resident #73 did not have natural teeth or dentures and should have. An interview was conducted with S6SW on 03/12/2024 at 1:36 p.m. She stated she was responsible for referring residents to the dentist. She stated she did not recall speaking to Resident #73 regarding dentures. She confirmed Resident #73 had not seen a dentist since admission to the facility. She stated residents were referred to the dentist if they were having a dental issue. She stated the facility did not have a system in place for residents to have routine dental care and should have. She confirmed Resident #73 had been a resident of the facility for a long time and had not received dental care and should have. An interview was conducted with S1ADM on 03/12/2024 at 3:05 p.m. He confirmed Resident #73 had not been seen by a dentist since admission to the facility.

Based on observations, record review, and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure Dietary staff wore a hair restraint correctly while preparing food. There were a total of 106 out of 107 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of the facility policy titled, Preventing Food Borne Illness - Employee Hygiene and Sanitary Practices revealed the following, in part: 7. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and clean linens. During the follow up tour of the facility's kitchen on 03/11/2024 at 11:15 a.m., an observation was made of S5FS assisting with food preparation. S5FS was not wearing hair cover appropriately leaving large amounts of hair hanging and exposed. An interview was conducted on 03/11/2024 at 11:15 a.m. with S3ADM. She verified the above observations and confirmed all dietary staff must wear hair restraints correctly to prevent hair from contacting food, clean linens, utensils, and clean equipment.

Based on interviews, and record review, the facility failed to ensure notifications of change in a residents conditions were made for 1 (#101) of 2 (#68, #101) residents reviewed for hospitalization s. The facility failed to ensure clinical staff reported to the physician when Resident #101 had hallucinations and a change in behavior. Findings: Review of the Facility Policy titled, Change in a Resident's Condition or Status, dated March 2024, revealed, in part: Policy Statement: Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/or status in a timely manner. 1. The nurse will notify the resident's attending physician or physician on call when there has been a/an: d. significant change in the resident's physical/ emotional/ mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normal resolve itself without intervention by staff . Review of the Medical Record for Resident #101 revealed the resident was admitted to the facility on [DATE]. Diagnosis included Spinal Stenosis, age related physical debility, heart disease. Review of the most recent MDS for Resident #101 with an ARD of 03/08/2024, revealed a BIMS of 13, which indicated the resident was cognitively intact. Review of Resident #101's current Physician Orders revealed the following, in part: 03/01/2024- Send to hospital for evaluation/treatment for altered mental status Review of Resident #101's Nurse's Note, dated 03/01/2024 to 03/04/2024 revealed the following: 03/01/2024 at 11:00 a.m. - Increased confusion noted. Resident #101 noted speaking to himself and reaching for items not there. MD notified, received order to send resident to the hospital for evaluation and treatment. 03/04/2024 at 1:33 p.m. - Resident #101 returned back to facility via ambulance. Review of Resident #101's local hospital discharge summary dated 03/04/2024 revealed the following, in part: Discharge Diagnosis: Acute Urinary Retention secondary to Foley Dysfunction Hospital Course: Resident #101 presented to the emergency department on 03/01/2024 from NH for altered mentation over a few days course. On 03/13/2024 at 10:30 a.m., an interview was conducted with Resident #101's RP. He stated he visited Resident #101 every day and on 02/29/2024 at an estimated time of, 12:00 -1:00 p.m. He stated the nurse was aware Resident #101 had hallucinations, and was not his normal self. On 03/13/2024 at 11:00 a.m., an interview was conducted with S11LPN. She confirmed she worked the day shift on 02/29/2024, 03/01/2024 and was assigned to Resident #101. She stated on 02/29/2024, Resident #101 had episodes of hallucinations and she did not notify the physician on 02/29/2024. On 03/13/2024 at 11:40 a.m., an interview was conducted with S14LPN. She stated on the evening of 02/29/2024, Resident #101 was confused and talking to someone that was not there, which was not his normal behavior. S14LPN confirmed she did not notify the provider. On 03/13/2024 at 11:38 a.m., an interview was conducted with S13LPN. She stated on the night of 02/29/2024 and S14LPN reported Resident #101 was confused and talking to someone that was not there, which was not his normal behaviors. S13LPN confirmed she did not notify the physician. On 03/13/2024 at 1:20 p.m., an interview was conducted with S2DON. She confirmed she expected staff to report any change in condition from residents' baseline to the physician. She confirmed if Resident #101 had hallucinations the provider should have been notified immediately because that was not his normal behaviors. On 03/13/2024 at 1:53 p.m., an interview was conducted with S15NP. She stated she was familiar with Resident #101's care and he did not normally have hallucinations. She confirmed she should have been notified when Resident #101 began hallucinating because that was not his normal behaviors. On 03/13/2024 at 2:00 p.m., an interview was conducted with S16MD. She confirmed she was not notified Resident #101 had hallucinations on 02/29/2024 and if she had been notified she would have ordered labs.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#82) of 3 (#8, #73 and #82) residents reviewed for ADL's. The facility failed to trim and file fingernails for Resident #82. Findings: Review of the Facility Policy titled, Fingernail Care, Foot Care and Podiatry Referrals, dated 04/18/2017, revealed the following, in part: 1.1 Purpose- Provide guidelines for the delivery of safe, evidenced based, nail and foot care which promote good personal hygiene, prevent hand/foot/nail infections, soft tissue injury and foot ulcers. 1.5 Policy- Nail hygiene services/care are provided to residents as needed to promote personal health/hygiene and safety. LPN's and trained/designated CNA's (per facility protocol) may trim finger nails for residents that require assistance with finger nail grooming. *Caution is used with residents receiving anticoagulant. 3.0 Procedure-Fingernail Care 7. Trim nails straight across-nail is cut even with end of the finger, smooth/round edges of nail with file, apply lotion as needed. Review of the Medical Record for Resident #82 revealed the resident was admitted to the facility on [DATE]. Review of the most recent MDS for Resident #82 with an ARD of 02/09/2024 revealed the provider assessed the resident as having a BIMS of 6, which indicated the resident was severely cognitively impaired and he required extensive assistance with ADL's. On 03/11/2024 at 10:05 a.m., an observation was conducted of Resident #82. Resident #82's fingernails are noted to be long, jagged and approximately 0.25-0.5 cm from the tip of the fingers. He stated he had two fingernails that were getting stuck on his clothes and he would like his nails trimmed. On 03/12/2024 at 9:00 a.m., an observation was conducted of Resident #82. Resident #82's fingernails are noted to be long, jagged and approximately 0.25-0.5 cm from the tip of the fingers. On 03/12/2024 at 9:15 a.m., an interview was conducted with S9CNA. She stated the shower aid or the aides on the floor were responsible for trimming fingernails unless the resident is diabetic. She stated resident #82 required maximum assistance for ADL care and was not diabetic. On 03/12/2024 at 1:35 p.m., an observation and interview were conducted with S11LPN. She confirmed Resident #82's fingernails were long, jagged and approximately 0.25- 0.5 cm past the tip of the finger. She confirmed his nails should have been trimmed and filed. On 03/12/2024 at 2:30 p.m., an interview was conducted with S12CNA. He stated he showered all the men in the facility. He confirmed he showered Resident #82 on 03/11/2024 but did not trim his nails. On 03/12/2024 at 1:38 p.m., an interview was conducted with S2DON. She stated the nurse, CNA or wound care nurse can all trim fingernails but the assigned nurse would be responsible for making sure it is completed. An observation was conducted at this time with S2DON, she confirmed Resident #82's nails were long, jagged and approximately 0.25 to 0.5 cm past the tip of the finger.

Based on interviews and record reviews, the facility failed to ensure reportable incidents were reported to the State Survey Agency. The facility failed to ensure: 1. An allegation of physical abuse was reported within 2 hours after the allegations were made to the State Survey Agency for 1 (#65) of 34 residents reviewed for abuse in the initial pool. 2. Two incidents of neglect, which resulted in elopement, were reported to the State Survey Agency for 1 (#73) of 3 (#73, #80, and #93) residents reviewed for elopement. Findings: 1. Review of the facility policy titled Abuse Components Plan Elder Justice Act and Affordable Care Act revealed the following, in part: Purpose The purpose of this policy is to facilitate appropriate, screening, training, prevention, identification, investigation, protection and reporting/response of actual and/or suspected incidents of abuse, neglect, exploitation, major injuries of unknown source, misappropriation of property/funds, or a reasonable suspicion of crime in strict accord with the Federal Elder Justice Act, State & Federal regulations and in compliance with organizational policy. Definitions Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Reporting 1. All alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds or a reasonable suspicion of a crime and/or other reportable incidents will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. LDH online tracking incident system, Statewide Incident Tracking System (SIMS). Resident #65 Review of Resident #65's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #65 had diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side and Dysphagia following Cerebral Infarction. Review of Resident #65's most recent MDS with an ARD of 01/19/2023 revealed he had a BIMS of 5, which indicated he was severely cognitively impaired. Review of the facility's incidents reported to the State Agency revealed no incidents were reported for Resident #65. Review of Resident #65's Progress Notes revealed the following, in part: 12/17/2022 6:20 p.m. Incident Note .Resident #65 was asked what happened to his forehead, Resident #65 stated S19CNA came in and hit me in the head with the dinner plate cover. This nurse asked Resident #65 was he sure that was what happened, Resident #65 stated that S19CNA picked up a dinner plate cover from the floor and hit him with it. S20LPN Review of the Incident Report dated 12/17/2022 at 6:20 p.m. revealed the following, in part: Resident Description: .Resident #65 stated S19CNA came in and hit me in the head with the dinner plate cover. This nurse asked Resident #65 was he sure that was what happened, resident stated that S19CNA had picked up a dinner plate cover from the floor and hit him with it. On 03/21/2023 at 1:02 p.m., an interview was conducted with S20LPN. S20LPN recalled the incident with S19CNA and Resident #65. S20LPN stated she went into Resident #65's room on 12/17/2022 around 6:00 p.m. and he had a small, slight abrasion/scratch with no swelling to his head. S20LPN stated Resident #65 said he splashed water on S19CNA, she got upset, and then hit him with the cover of his plate. She confirmed she reported the allegation of physical abuse to a supervisor. On 03/22/2023 at 1:59 p.m., an interview was conducted with S2DON. S2DON stated S20LPN notified her of the incident on 12/17/2022 and S1ADM was notified. S2DON confirmed it was not reported to the state agency. On 03/23/2023 at 2:34 p.m., an interview was conducted with S1ADM. S1ADM confirmed staff hitting a resident in the head with a dinner plate was an allegation of abuse. S1ADM stated allegations of abuse should be reported to the state agency. 2. Review of the facility's policy titled, Wandering and Elopement Assessment/Management/Security revealed the following, in part: 2.0 Definitions: Elopement - a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure dehydration, and/or other medical complications, drowning, or being struck by a car. Review of the facility's policy titled, Abuse Components Plan Elder Justice Act and Affordable Care Act revealed the following, in part: 2.0 Definitions: Reportable Incident . resident found in potentially hazardous nonresident area, .elopement . Reporting: 1. All alleged violations involving abuse, neglect .and/or other reportable incidents will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. LDH online tracking incident system, Statewide Incident Tracking System (SIMS). (required) Resident #73 Review of Resident #73's Clinical Record revealed she admitted to the facility on [DATE] and was readmitted on [DATE]. Further review revealed Resident #73 had diagnoses which included Unspecified Dementia, Major Depressive Disorder, and Unspecified Psychosis Not Due to a Substance or Known Physiological Condition. Review of Resident #73's most recent MDS with an ARD of 03/05/2023 revealed, in part, she had a BIMS of 4, which indicated she was severely cognitively impaired. Review of the current Care Plan for Resident #73 revealed the following, in part: Problem: 10/21/2022 - I use a wander guard related to safety. Resident is able to go outside with staff supervision. Problem: I am an elopement risk/wanderer 02/11/2023 - I was seen walking outside on sidewalk adjacent to smoking patio. 02/13/2023 - I was seen walking in rear parking lot after exiting my room through the window. Review of the Incident Investigation for Resident #73 dated 02/11/2023 at 2:00 p.m. revealed the following, in part: Person preparing report: S6LPN Nursing Description: At approximately 2:00 p.m., Resident #73 was seen outside on sidewalk adjacent to smoking patio. Mobility: ambulatory without assistance Predisposing Situation Factors: Wanderer Review of the Incident Investigation for Resident #73 dated 02/13/2023 at 3:15 p.m. revealed the following, in part: Person Preparing Report: S7LPN Incident Description: Nurse informed by CNA that the resident was seen outside the facility wandering in the rear parking lot. Upon entering the resident's room, Nurse noted the resident's window open and noted the resident outside in the parking lot with 2 staff members. Nurse redirected the resident back inside the facility. Resident Description: Resident states she just wanted to get out of there. Mobility: Ambulatory without assistance. Predisposing Situation Factors: Active Exit Seeker, Wanderer Review of the Nurses Notes dated February 2022 for Resident #73 revealed the following, in part: 02/11/2023 at 2:00 p.m. by S6LPN: Upon further investigation, it was determined that at approximately 2:00 p.m., resident was seen walking outside on sidewalk adjacent to smoking patio. 02/13/2023 at 3:40 p.m. by S7LPN: Nurse informed by CNA that resident was seen outside the facility wandering in the rear parking lot. Resident states she just wanted to get out of there. Review of the current Physician Orders for Resident #73 revealed the following, in part: (02/28/2023) Wander guard - verify placement, inspect skin at left ankle and confirm (+) signal operation Review of the Risk of Elopement Wandering Review for Resident #73 dated 12/28/2022 revealed the following, in part: Category: At risk to wander Score: 9, which indicated the resident was at risk to wander The resident is ambulatory, has a history of wandering, and has wandered in the last month Review of the facility's incidents reported to the State Agency from August 2022 to March 2022 revealed no entries for Resident #73. On 03/21/2023 at 1:40 p.m., an interview was conducted with S13CNA. She stated she was assigned to Hall A on 02/11/2023, and she was providing care for another resident, when S14RN brought Resident #37 back inside. She stated she was unsure how Resident #73 got outside. She stated Resident #73 was at risk for elopement and could not be outside of the facility unsupervised. On 03/21/2023 at 1:53 p.m., an interview was conducted with S14RN. She confirmed she worked at the facility on 02/11/2023. She explained on 02/11/2023, she was leaving for the day, and she exited the facility at the end of Hall B. She stated she observed S9CNA and Resident #73 returning inside the facility. She stated S9CNA reported she found Resident #73 outside. She stated Resident #73 had a wander guard in place. On 03/22/2023 at 9:09 a.m., an interview was conducted with S9CNA. She stated she worked at the facility on 02/11/2023 and she saw Resident #73 outside. She explained her car was parked in front of the facility's generator outside of the smoking patio exit. She stated she got in her car, went to back out, and saw Resident #73 standing in the driveway of the parking lot between a row of parked cars and a post by the fire hydrant. She stated Resident #73 should not have been outside unsupervised so she put her car in park, and assisted her back inside the facility. On 03/22/2023 at 9:25 a.m., an interview was conducted with S6LPN. She confirmed she was assigned to Resident #73 on 02/11/2023. She stated on 02/11/2023, she was at the nurses' station when a CNA came to her and stated she found Resident #73 outside. She stated Resident #73 was ambulatory and she did not know how she got out. She confirmed Resident #73 could not go outside unsupervised because she was a wanderer and elopement risk. She confirmed Resident #73 was in an area that was not fenced in and had access to the ponds in the front of the facility and the highway. On 03/21/2023 at 12:12 p.m., an interview was conducted with S7LPN. She stated she was assigned to Resident #73 on 02/13/2023. She stated, on 02/13/2023, she was notified by S15CNA and S16CNA Resident #73 was found outside in the employee parking lot. She stated S17CNA was sitting at the resident's door and the door was cracked so she could check on the resident since she was one-on-one supervision. She stated after Resident #73 was brought inside the facility, she noticed Resident #73's room window was open very wide where Resident #73 could have fit through it. On 03/21/2023 at 12:47 p.m., an interview was conducted with S16CNA. She stated she was assigned to Resident #73's hall on 02/13/2023. She explained around 2:00 p.m., she was walking up Hall A and saw Resident #73 through the windows beside the hallway exit door. She stated when she got to Resident #73, she was walking in the parking lot by the light pole near the Hall A exit door. On 03/21/2023 at 1:17 p.m., an interview was conducted with S15CNA. She stated she recalled the incident with Resident #73 eloping on 02/13/2023. She stated she was going out to her car for her lunch break. She explained she exited the facility through the exit door to the smoking patio. She stated as she walked on the sidewalk, she saw Resident #73 standing outside in the parking lot on the edge of the grass and concrete by the light pole. She confirmed Resident #73 was unsupervised at that time. On 03/22/2023 at 11:20 a.m., an observation was conducted of the perimeter of the facility. The parking lot of the facility was not fenced in and had direct access to the road at the front of the facility. There was a pond on each side of the driveway entrance at the front of the facility. The rear of the facility was wooded with barbed wire fence lining the tree line. The employee parking lot was un-level and consisted of concrete and grass areas. On 03/22/2023 at 10:07 a.m., an interview was conducted with S1ADM and S2DON. S1ADM and S2DON both confirmed Resident #73 was at risk for elopement. S2DON stated she was not able to determine how Resident #73 got out of the facility on 02/11/2023. S1ADM stated he was unable to determine how Resident #73 got out of the facility on 02/11/2023. S2DON stated she determined on 02/13/2023, Resident #73 exited the facility through her room's window. S1ADM confirmed the parking lot, where Resident #73 was found, was not fenced in and she had access to the ponds in front of the facility and the road. S1ADM stated he did not submit a report to the State Agency for the incidents involving Resident #73 on 02/11/2023 and 02/13/2023 because Resident #73 did not leave the premises. S1ADM confirmed Resident #73 should not have been outside unsupervised. 44965

Based on observations, interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the use of a Wander Guard alarm for 1 (#80) of 3 (#73, #80, and #93) residents reviewed for elopement. Findings: Review of the Clinical Record for Resident #80 revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Unspecified Anxiety Disorder, Other Symptoms and Signs Involving Cognitive Functions Following Cerebral Infarction, and Epilepsy. Review of the MDS with an ARD of 01/24/2023 for Resident #80 revealed under section P0200: Alarms-An alarm is any physical or electronic device that monitors resident movement and alerts staff when movement is detected. E. Wander/elopement alarm was coded as not used. Review of the MDS with an ARD of 12/20/2022 for Resident #80 revealed under section P0200: Alarms-An alarm is any physical or electronic device that monitors resident movement and alerts staff when movement is detected. E. Wander/elopement alarm was coded as not used. Review of the MDS with an ARD of 09/27/2022 for Resident #80 revealed under section P0200: Alarms-An alarm is any physical or electronic device that monitors resident movement and alerts staff when movement is detected. E. Wander/elopement alarm was coded as not used. Review of the MDS with an ARD of 09/08/2022 for Resident #80 revealed under section P0200: Alarms-An alarm is any physical or electronic device that monitors resident movement and alerts staff when movement is detected. E. Wander/elopement alarm was coded as not used. Review of the MDS with an ARD of 06/08/2022 for Resident #80 revealed under section P0200: Alarms-An alarm is any physical or electronic device that monitors resident movement and alerts staff when movement is detected. E. Wander/elopement alarm was coded as not used. Review of the MDS with an ARD of 04/06/2022 for Resident #80 revealed under section P0200: Alarms-An alarm is any physical or electronic device that monitors resident movement and alerts staff when movement is detected. E. Wander/elopement alarm was coded as not used. Review of the current Physician Orders for Resident #80 revealed the following, in part: Order Date: 12/04/2021 Start Date: 12/04/2021- Wander Guard- verify placement, inspect skin at band location left leg, and confirm positive signal operation every shift. Review of the current Care Plan for Resident #80 revealed the following, in part: Problem Onset: 12/06/2021 Problem: I use a wander guard related to safety. Resident attempted to go outside without notifying staff. He has a wander guard to his left leg. Approaches: Anticipate and intervene for the potential causes of which have precipitated my prior falls or accidents. On 03/20/2023 at 9:00 a.m., an observation was made of Resident #80's Wander Guard to his left ankle. On 03/21/2023 at 6:45 a.m., an observation was made of Resident #80's Wander Guard to his left ankle. On 03/21/2023 at 11:58 a.m., an interview was conducted with S4LPN. She stated Resident #80 wandered, required a Wander Guard and had it on his left ankle for over a year. On 03/21/2023 at 1:02 p.m., an interview was conducted with S5CNA. He stated Resident #80 wandered, required a Wander Guard and had it on his left ankle for more than a year. On 03/23/2023 at 9:53 a.m., an interview was conducted with S3MDS. She reviewed Resident #80's clinical record and verified he was ordered a Wander Guard on 12/04/2021. She reviewed the MDS's for Resident #80 with an ARD of 01/24/2023, 12/20/2022, 09/27/2022, 09/08/2022, 06/08/2022, and 04/06/2022 and verified the resident was not coded for the Wander Guard. She confirmed the MDS under section P0200 was incorrect and she should have coded the Wander Guard alarm on the above MDS assessments for Resident #80. On 03/23/2023 at 11:26 a.m., an interview was conducted with S2DON. She confirmed Resident #80 was care planned for and ordered a Wander Guard on 12/04/2021. She reviewed the MDS under section P0200 with the above ARD's for Resident #80 and confirmed they were not coded for a Wander Guard alarm and should have been.

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision for a resident at risk for elopement for 1 (#73) of 3 (#73, #80, and #93) residents reviewed for elopement. Findings: Review of the facility's policy titled, Wandering and Elopement Assessment/Management/Security revealed the following, in part: 1.5 Policy: Facilities will maintain procedures to ensure that residents at risk for elopement do not wander away from the facility. 2.0 Definitions: Elopement - a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure dehydration, and/or other medical complications, drowning, or being struck by a car. Review of the Clinical Record for Resident #73 revealed she admitted to the facility on [DATE], was readmitted on [DATE], and had diagnoses which included Unspecified Dementia, Major Depressive Disorder, and Unspecified Psychosis Not Due to a Substance or Known Physiological Condition. Review of the Quarterly MDS with an ARD of 03/05/2023 for Resident #73 revealed, in part, she had a BIMS of 4, which indicated she was severely cognitively impaired. Review of the current Care Plan for Resident #73 revealed the following, in part: Problem: 10/21/2022 - I use a wander guard related to safety. Resident attempted to go outside without notifying staff/supervision. She had a wander guard to her left leg. Resident is able to go outside as she decides with staff supervision. Problem: I am an elopement risk/wanderer 02/11/2023 - I was seen walking outside on sidewalk adjacent to smoking patio. 02/13/2023 - I was seen walking in rear parking lot after exiting my room through the window. Approaches: 02/14/2023 - I have been placed on one-on-one supervision. Wander alert: Check function and skin around band every shift Review of the Incident Investigation for Resident #73 dated 02/11/2023 at 2:00 p.m. revealed the following, in part: Person preparing report: S6LPN Nursing Description: At approximately 2:00 p.m., Resident #73 was seen outside on sidewalk adjacent to smoking patio. Description: Resident was placed on one-on-one supervision. Mobility: ambulatory without assistance Predisposing Situation Factors: Wanderer Review of the Incident Investigation for Resident #73 dated 02/13/2023 at 3:15 p.m. revealed the following, in part: Person Preparing Report: S7LPN Incident Description: Nurse informed by CNA that the resident was seen outside the facility wandering in the rear parking lot. Upon entering the resident's room, nurse noted a CNA sitting outside of the room. Nurse noted the resident's window open. Nurse noted the resident outside in the parking lot with 2 staff members. Nurse informed by staff. Nurse redirected the resident back inside the facility. Resident Description: Resident states she just wanted to get out of there. Description: One-on-one care provided by staff. Mobility: Ambulatory without assistance. Predisposing Situation Factors: Active Exit Seeker, Wanderer Review of the Nurses Notes from October 2022 to March 2023 for Resident #73 revealed the following, in part: 10/21/2022 at 4:00 p.m.: Resident packing all her belongings and stating she was walking home. Staff unable to redirect resident as she continues to be very resistant towards staff offer to assist with unsteady gait balance. Resident observed pushing on exit door in attempt to leave. Wander Guard placed on left ankle. 02/11/2023 at 2:00 p.m. by S6LPN: Upon further investigation, it was determined that at approximately 2:00 p.m., resident was seen walking outside on sidewalk adjacent to smoking patio. 02/13/2023 at 3:40 p.m. by S7LPN: Nurse informed by CNA that resident was seen outside the facility wandering in the rear parking lot. Resident states she just wanted to get out of there. Review of the current Physician Orders for Resident #73 revealed the following, in part: Wander guard - verify placement, inspect skin at left ankle and confirm positive signal operation Review of the Risk of Elopement Wandering Review for Resident #73 dated 12/28/2022 revealed the following, in part: Category: At risk to wander Score: 9 The resident is ambulatory, has a history of wandering, and has wandered in the last month An observation was made of Resident #73 on 03/20/2023 beginning at 9:35 a.m. She was seated in a reclining chair in her room. There was no staff member present inside or outside of Resident #73's room. On 03/20/2023 at 9:41 a.m., S8CNA entered Resident #73's room. An interview was conducted with S8CNA on 03/20/2023 at 9:41 a.m. She stated Resident #73 was one-on-one supervision because she wandered and previously attempted to elope. S8CNA stated she had been out in the hall getting caught up on some other work. She confirmed Resident #73 had not been supervised while she was performing other duties. An observation was made of Resident #73 on 03/20/2023 beginning at 12:45 p.m. She was seated in a recliner chair in her room watching television. There was no staff member present inside or outside of Resident #73's room. During the duration of the observation, Resident #73 stood up out of her chair multiple times and independently ambulated to her television and toward the doorway of her room. Surveyor remained in Resident #73's room until S9CNA entered Resident #73's room at 1:16 p.m. An interview was conducted with S9CNA on 03/20/2023 at 1:16 p.m. She stated she was assigned to sit with Resident #73 one-on-one today. She reported she had just returned from her lunch break. She confirmed Resident #73 was left unsupervised while she took her break. She stated Resident #73 was an elopement risk and sometimes went to the exit doors of the facility. She stated one-on-one supervision meant being with the resident at all times. She stated when she took a break, she usually asked another CNA assigned to the hallway to supervise Resident #73. She explained the relieving CNA did not usually provide line of sight supervision for Resident #73. She explained if she was assigned to provide one-on-one care for Resident #73, and she took her scheduled medications, she would perform other duties on the hall and not provide line of sight supervision for Resident #73. An interview was conducted with S10CNA on 03/21/2023 at 10:19 a.m. She stated she frequently took care of Resident #73. She stated Resident #73 had previously exited the facility unsupervised. She stated Resident #73 required one-on-one supervision. She explained one-on-one supervision meant Resident #73 had to be in the line of sight of a staff member. She stated it was not acceptable to leave Resident #73 unsupervised. She stated if the one-on-one CNA assigned to Resident #73 needed to take a break, another staff member had to sit with Resident #73 until they came back. She confirmed on 03/20/2023 from 6:00 a.m. to 2:00 p.m., she and S11CNA were assigned to Resident #73's hallway, and S9CNA was assigned one-on-one to Resident #73. She stated S9CNA did not notify her she was taking a lunch break on 03/20/2023 so Resident #73 could have been supervised. She stated she was not aware Resident #73 was unsupervised from 12:15 p.m. to 1:16 p.m. on 03/20/2023. An interview was conducted with S11CNA on 03/21/2023 at 11:29 a.m. She stated she was assigned to Resident #73's hall. She stated on 03/20/2023 from 6:00 a.m. to 2:00 p.m., she and S10CNA were assigned to Resident #73's hall, and S9CNA was assigned one-on-one with Resident #73. She stated Resident #73 required one-on-one supervision because she wandered. She stated one-on-one supervision meant Resident #73 had to be in the line of sight of a staff member at all times. She stated when the assigned one-on-one CNA needed to take a break, a CNA assigned to the hall would supervise Resident #73. She stated S9CNA did not notify her when she was going to lunch on 03/20/2023 so she could supervise Resident #73. An interview was conducted with S12LPN on 03/21/20223 at 11:37 a.m. She confirmed she was the nurse for Resident #73. She confirmed Resident #73 required one-on-one supervision, which meant she had to be in the line of sight of a staff member at all times. An interview was conducted with S13CNA on 03/21/2023 at 1:40 p.m. She stated she recalled the incident when staff found Resident #73 outside of the facility on 02/11/2023. She stated she was assigned to Hall A that day, and she was providing care for another resident, when S14RN brought Resident #73 back inside. She stated she was unsure how Resident #73 exited the facility. She stated Resident #73 was at risk for elopement and could not be outside of the facility unsupervised. She stated Resident #73 was ordered one-on-one supervision after the incident. She stated one-on-one supervision meant Resident #73 had to be in the line of sight of the staff member at all times. An interview was conducted with S14RN on 03/21/2023 at 1:53 p.m. She confirmed she worked at the facility on 02/11/2023 and recalled an incident involving Resident #73. She explained she was leaving for the day, and she exited the facility at the end of Hall B. She stated she observed S9CNA and Resident #73 entering the facility through Hall B. She stated S9CNA reported she found Resident #73 outside unsupervised. She stated Resident #73 had a wander guard in place. She stated she became one-on-one supervision at that time. She stated one-on-one supervision meant the resident had to be in line of sight of the staff member at all times. An interview was conducted with S9CNA on 03/22/2023 at 9:09 a.m. She stated she worked at the facility on 02/11/2023 and she saw Resident #73 outside. She explained her car was parked in front of the facility's generator outside of the smoking patio exit. She stated she got in her car, went to back out, and saw Resident #73 standing in the driveway of the parking lot between a row of parked cars and a post by the fire hydrant. She stated Resident #73 should not have been outside unsupervised so she put her car in park, and assisted her back inside the facility. An interview was conducted with S6LPN on 03/22/2023 at 9:25 a.m. She confirmed she was assigned to Resident #73 on 02/11/2023. She stated on 02/11/2023, she was at the nurses' station when a CNA came to her and stated she found Resident #73 outside. She stated Resident #73 was ambulatory and she did not know how she exited the facility. She confirmed Resident #73 could not go outside unsupervised because she was a wanderer and elopement risk. She confirmed Resident #73 was in an area that was not fenced in and had access to the ponds in the front of the facility and the highway. An interview was conducted with S7LPN on 03/21/2023 at 12:12 p.m. She stated she was assigned to Resident #73 on 02/13/2023. She stated, on 02/13/2023, she was notified by S15CNA and S16CNA Resident #73 was found outside in the employee parking lot. She stated S17CNA was sitting at the resident's door with the door cracked open so she could check on the resident. She stated after Resident #73 was brought inside the facility, she noticed Resident #73's room window was open very wide where Resident #73 could have fit through it. An interview was conducted with S16CNA on 03/21/2023 at 12:47 p.m. She stated she was assigned to Resident #73's hall on 02/13/2023. She stated she observed Resident #73 lying in her bed around 1:00 p.m., and she told her she wanted out and she was going to find a way. She explained around 2:00 p.m., she was walking up Hall A and saw Resident #73 through the windows beside the hallway exit door. She stated when she got to Resident #73, she was walking in the parking lot by the light pole near the Hall A exit door. She stated S15CNA was in her car on her lunch break and was returning inside when she saw the resident. An interview was conducted with S15CNA on 03/21/2023 at 1:17 p.m. She stated she recalled the incident with Resident #73 eloping on 02/13/2023. She stated she was going out to her car for her lunch break. She explained she exited the facility through the exit door to the smoking patio. She stated as she walked on the sidewalk, she saw Resident #73 standing outside in the parking lot on the edge of the grass and concrete by the light pole. She confirmed Resident #73 was unsupervised at that time. She stated then, S16CNA and S7LPN came outside to assist Resident #73 back inside. An interview was conducted with S17CNA on 03/21/2023 at 1:30 p.m. She stated she was a full time CNA on Hall A. She stated one-on-one supervision meant the resident had to be within the staff member's line of sight at all times. An interview was conducted with S18CNAS on 03/22/2023 at 8:54 a.m. She confirmed Resident #73 had been on one-on-one supervision since 02/11/2023 and had to be in the assigned CNA's line of sight. An observation was made of the perimeter of the facility on 03/22/2023 at 11:20 a.m. The parking lot of the facility was not fenced in and had direct access to the road at the front of the facility. There was a pond on each side of the driveway entrance at the front of the facility. The rear of the facility was wooded with barbed wire fence lining the tree line. The employee parking lot was uneven and consisted of concrete and grass areas. An interview was conducted with S1ADM and S2DON on 03/22/2023 at 10:07 a.m. S1ADM and S2DON both confirmed Resident #73 was at risk for elopement. S2DON stated she was not able to determine how Resident #73 exited the facility unsupervised on 02/11/2023. S1ADM stated he was unable to determine how Resident #73 exited the facility unsupervised on 02/11/2023. S2DON stated Resident #73 was placed on one-on-one supervision after the incident on 02/11/2023. S2DON stated one-on-one supervision meant one staff member was assigned to only Resident #73. S2DON and S1ADM stated it was determined Resident #73 exited the facility through her room window on 02/13/2023. S1ADM confirmed the parking lot, where Resident #73 was found, was not fenced in and she had access to the ponds in front of the facility and the road. S1ADM stated Resident #73 should not have been outside unsupervised. S2DON stated Resident #73 should have been on one-on-one supervision and when the staff assigned to her took a break, they were to get another CNA to sit with her. S2DON stated Resident #73 should have been supervised at all times.

Based on observations, interviews and record review the facility failed to ensure a resident's comprehensive plan of care was implemented for 2 (#98 and #358) of 21 residents reviewed in the final sample. The facility failed to ensure: 1. Anti-roll backs were installed on Resident #98's wheelchair as identified on the care plan. 2. Staff notified Resident #358's physician when she had a weight gain of 3.0lbs overnight as identified on the care plan. Findings: Resident #98 Review of the clinical record for Resident #98 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS with an ARD of 01/01/2022 revealed Resident #98 had a BIMS of 9 which indicated moderate cognitive impairment. Further review revealed he needed extensive assistance/one person assist for bed mobility, transfer, walking in room, walking in corridor, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Mobility device was a wheelchair and Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan for Resident #98 revealed the following: Problem: 09/27/2021- I have had an actual fall with no injury. 11/09/2021- I have had a fall. 12/20/ - I have had a fall. Approaches: 09/27/2021- Anti-roll backs on wheelchair An observation was made on 01/24/2022 at 10:15 a.m. of Resident #98 sitting in his wheelchair. Resident #98 did not have anti-roll backs on his wheelchair. An observation was made on 01/25/2022 at 9:00 a.m. of Resident #98 sitting in his wheelchair. Resident #98 did not have anti-roll backs on his wheelchair. An observation was made on 01/26/2022 at 8:30 a.m. of Resident #98 sitting in his wheelchair. Resident #98 did not have anti-roll backs on his wheelchair. An interview was conducted on 01/24/2022 at 10:00 a.m. with S11CNA. She said she provided care to Resident #98. S11CNA said Resident#98 had falls since he had been admitted to the facility. She said she was unaware if Resident #98's wheelchair should have anti-roll backs. During this interview, S11CNA observed Resident #98's wheelchair and confirmed his wheelchair did not have anti-roll backs. An interview was conducted on 01/26/2022 at 9:00 a.m. with S12CNA. He said he provided care to Resident #98. He said the resident has had falls since he was admitted to the facility. During this interview, S12CNA observed Resident #98's wheelchair and confirmed his wheelchair did not have anti-roll backs. An interview was conducted on 01/26/2022 at 9:15 a.m. with S3MDS. She said Resident #98 had three falls since 09/27/2021. She reviewed Resident #98's plan of care and confirmed he should have anti-roll backs on his wheelchair. An interview was conducted on 01/26/2022 at 10:45 a.m. with S2ADON. She confirmed Resident #98 had several falls while residing in the facility. She reviewed Resident #98's plan of care and confirmed he should have anti-roll backs on his wheelchair to prevent falls. An interview was conducted on 01/26/2022 at 10:50 a.m. with S4MW. He said he was unsure of how long Resident #98's wheelchair did not have anti-roll backs present. Resident #358 Review of the clinical record revealed Resident #358 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most current care plan revealed the following, in part: Problem: I have Congestive Heart Failure. Approaches: Obtain weights daily x 2 weeks. Notify MD/RD of 3.0lb weight gain overnight or 5.0lb weight gain over a week. Problem: I have Hypertension. Approaches: I will be monitored for [CONDITION(S)], I will have [CONDITION(S)] documented. Notify MD. Problem: I have [CONDITION(S)]. Approaches: Monitor/document my extremities for excessive [CONDITION(S)]. Problem: I am at potential risk for unplanned/unexpected weight gain related to CHF/Kidney Disease. Approaches: If my weight is not within range, contact Physician. Perform my weight at same time of day and record. Review of the weight log for Resident #358 dated 01/21/2022 to 01/26/2022 revealed the following: 01/21/2022- 124.8lb 01/22/2022- 128.2lb 01/23/2022- 128.0lb 01/24/2022- 126.6lb 01/25/2022- 126.8lb 01/26/2022- 129.8lb On 01/24/2022 at 11:00 a.m., an observation was made of Resident # 358. She was observed to have [CONDITION(S)] to her bilateral lower extremities. An imprint was observed on Resident #358's lower legs from the elastic bottom of her pants. On 1/26/2022 at 8:22 a.m., an observation was made of Resident #358. She was observed to have [CONDITION(S)] to her bilateral lower extremities. On 01/27/2022 at 11:00 a.m., an observation was conducted on Resident # 358. She was observed to have [CONDITION(S)] to her bilateral lower extremities. On 01/27/2022 at 11:45 a.m., an interview was conducted with S8LPN. She reviewed Resident #358's weight log and confirmed the resident had a 3.0lb weight gain from 01/25/2022 to 01/26/2022. She said S10CNA should have notified the nurse or the ADON of Resident #358's weight gain. She confirmed she was not notified of the weight gain. During this interview, S8LPN confirmed Resident #358 had pitting [CONDITION(S)] to her bilateral lower extremities. On 01/27/2022 at 12:05 p.m., an interview was conducted with S2ADON. She said S10CNA weighed Resident #358 on 01/25/2022 and 01/26/2022. She said S10CNA did not notify her or the nurse of Resident #358's 3.0lb weight gain. She said S10CNA should have notified the nurse of the 3.0lb. weight gain overnight. On 01/27/2022 at 1:40 p.m., an interview was conducted with S10CNA. She said she was responsible for weighing Resident #358 daily. After reviewing the weight log for Resident #358, she confirmed there was a 3.0lb. weight gain from 01/25/2022 to 01/26/2022 and she did not notify the nurse or the ADON as she should have.

Based on interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (#67) of 29 residents reviewed. The facility failed to ensure Resident #67's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the facility's Policy titled Administering Medications revealed the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: Medications are administered in accordance with prescriber orders, including any required time frame. Review of the clinical record for Resident #67 revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS with an ARD of 12/09/2021 for Resident #67 revealed the resident had a BIMS of 13 which indicated the resident was cognitively intact. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Otic Drops, 4 drops to right ear twice a day for 10 days. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 12/23/2021 [MEDICATION(S)] Otic Solution, Instill 4 drops in right ear two times a day every 10 days for ear infection for 10 days. On 01/25/2022 at 2:00 p.m., an interview was conducted with S2ADON. She stated it was the responsibility of the staff nurse to transcribe Physician orders. She stated S3MDS is responsible for performing pharmacy checks daily to identify transcription errors. On 01/25/2022 at 2:14 p.m., an interview was conducted with S3MDS. She stated she obtained a pharmacy report every morning and assessed transcription of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/25/2022 at 2:42 p.m., an interview was conducted with S7LPN. She verified the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/27/2022 at 2:10 p.m., an interview was conducted with S1DON. She confirmed the resident should have received the medication for 10 consecutive days.

Based on observations, interviews, and record review, the facility failed to ensure safe and secure storage of Schedule III-V medications. The facility failed to ensure: 1. Schedule III-V medications, in the emergency kit safe, were stored in a permanently affixed compartment and 2. Schedule III-V medications, in the emergency kit safe, were stored in a single unit package drug distribution system. Findings: Review of the facility's policy titled, Storage of Medications revealed the following, in part: Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. On 01/25/2022 at 12:05 p.m., an observation was made of the Hall A medication storage room. The emergency kit safe containing Schedule III-V medications was placed on top of the Non-Scheduled medication emergency kit. The emergency kit safe measured approximately 9in x 7in x 7in and weighed approximately 7.2 lbs. The emergency kit safe, which contained Scheduled III-V medications, was not permanently affixed to a surface. Review of the Emergency Drug Kit Inventory sheet documented the following Schedule III-V medications inside of the safe: 1. [MEDICATION(S)] 0.25 mg tablet - Quantity 6 tablets 2. Lomotil tablet- Quantity 6 tablets 3. Tylenol/[MEDICATION(S)] #3 tablet - Quantity 6 tablets 4. Tylenol/[MEDICATION(S)] #4 tablet- Quantity 6 tablets 5. [MEDICATION(S)] 50 mg tablet- Quantity 8 tablets 6. [MEDICATION(S)]/Tylenol 37.5/325mg tablet - Quantity 6 tablets 7. [MEDICATION(S)] 0.5 mg tablet- Quantity 6 tablets On 01/25/2022 at 12:15 p.m., an observation was made of the Hall B medication storage room. The emergency kit safe containing Schedule III-V medications was placed on top of the Non-Scheduled medication emergency kit. The emergency kit safe measured approximately 9in x 7in x 7in and weighed approximately 7.2 lbs. The emergency kit safe, which contained Scheduled III-V medications, was not permanently affixed to a surface. Review of the Emergency Drug Kit Inventory sheet documented the following Schedule III-V medications inside of the safe: 1. [MEDICATION(S)] 0.25 mg tablet - Quantity 6 tablets 2. Lomotil tablet- Quantity 6 tablets 3. Tylenol/[MEDICATION(S)] #3 tablet - Quantity 6 tablets 4. Tylenol/[MEDICATION(S)] #4 tablet- Quantity 6 tablets 5. [MEDICATION(S)] 50 mg tablet- Quantity 8 tablets 6. [MEDICATION(S)]/Tylenol 37.5/325mg tablet - Quantity 6 tablets 7. [MEDICATION(S)] 0.5 mg tablet- Quantity 6 tablets On 01/25/2022 at 12:17 p.m., an interview was conducted with S1DON inside the Hall A medication storage room. She verified six nurses per shift had key access to the two medication storage rooms in the facility. She said one emergency kit safe, which contained Schedule III -V medications was stored in both the Hall A and Hall B medication storage rooms. She said the emergency kit safes in both medication storage rooms were not permanently affixed to a surface and could be removed. During this interview, S1DON was observed to pick up and hold the emergency kit safe, which contained Schedule III -V medications, within her hands. She verified there was no process in place requiring facility staff to document the presence of the emergency kit safes that stored Schedule III-V medications to ensure it was present in each medication storage room. She further confirmed the emergency kit safe, which contained Schedule III -V medications was light in weight and can easily be picked up and carried by one person. On 1/25/2022 at 1:00 p.m., a phone interview was conducted with S5RNS. She verified there was no documentation the emergency kit safe containing Scheduled III-V medications was checked daily to ensure it was present in each medication storage room. On 01/25/2022 at 2:00 p.m., an interview was conducted with the facility's Pharmacist. He said there was a minimal amount of controlled substances in each emergency kit safes therefore each safe did not need to be permanently affixed to a surface. On 01/25/2022 at 3:05 p.m., an observation was made of the interior of the emergency kit safe containing Schedule III-V medications. S1DON carried the emergency kit safe containing Schedule III-V medications from the medication storage room into the conference room. S1DON opened the emergency kit safe, which was observed to have only a single door. Further observation revealed there was only one compartment inside the safe that contained seven individual clear plastic containers with multiple tablets in each. The seven clear plastic containers were individually labeled and contained the following medications and amounts: [MEDICATION(S)] (6 tablets), Lomotil (6 tablets), Tylenol/[MEDICATION(S)] #3 (6 tablets), Tylenol/[MEDICATION(S)] 4 (6 tablets), [MEDICATION(S)] (8 tablets), [MEDICATION(S)]/Tylenol (6 tablets) and [MEDICATION(S)] (6 tablets). DON verified the nurse had access to all the medications inside the safe when it was open. She confirmed the emergency kit safe was not a single unit drug package dispensing system and once opened the nurse had access to all 44 controlled medication tablets within the safe.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced by the presence of 46 food items which were beyond the usage date and/or expired in the dry storage room and the refrigerator. Based on the Resident Census and Facility Matrix report the facility had a total census of 103 residents. There were 102 residents who were served food from the kitchen. Findings: On [DATE] at 9:09 a.m., a tour of the facility's kitchen was conducted with S6DM. The dry storage room was observed and revealed the following: 9 cartons of thickened lemon flavored water with a Use By date from the manufacturer of [DATE]. 16 cartons of thickened lemon flavored water with a Use By date from the manufacturer of [DATE]. 16 cartons of cranberry cocktail with a Use By date from the manufacturer of [DATE]. 1 bag of cereal with an expiration date from the manufacturer of [DATE]. The refrigerator was observed and revealed the following: 4 gallons of whole milk with an expiration date from the manufacturer of [DATE]. On [DATE] at 9:33 a.m., an interview was conducted with S6DM. She confirmed the 46 food items were beyond the usage date and/or expired and should have been discarded and removed from the dry storage area and the refrigerator. She verified these items were intended and available for resident consumption. She was unable to describe the process in which kitchen staff routinely checked food items for expiration prior to distributing them to residents. On [DATE] at 3:25 p.m., an interview was conducted with S1DON. She stated she was aware there were food items found during the kitchen tour on [DATE] which were beyond the usage date and she was informed of the additional food items which were expired. She confirmed the items should have been discarded.

Based on observations, interviews, and record review, the facility failed to implement interventions consistent with the resident's plan of care to prevent accidents for 1 (Resident #95) of 6 (Resident #22, #27, #31, #79, #90, #95) residents reviewed for accidents An actual harm occurred for Resident #95 on 11/19/2019 at 10:00 p.m. when S8CNA transferred the resident, who required two-person assistance, from her wheelchair to her bed without the assistance of another staff member. On 11/20/2019 at 6:00 a.m., Resident #95 screamed out in pain when the morning CNA staff attempted to change her disposable brief. The resident was admitted into the hospital and was diagnosed with a traumatic oblique fracture of the proximal right femoral shaft at the distal end of the prosthesis which required an open reduction internal fixation to repair the fracture. The facility implemented corrective actions prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility policy entitled Transfer and Lift Policy revealed the following, in part: Purpose: The purpose of the Resident Transfer and Lift Policy is to provide facility staff guidelines for the use of appropriate techniques for lifting, transferring, moving and repositioning residents in order to protect the well- being and safety of residents and staff. Policy: All staff are responsible for using the required number of assistants for resident transfer and lifts as per the resident's personal lift assessment. A color coded legend is use to designate the type of lift required per the residents lift assessment. Color coded stickers are placed at the head of the residents bed and/or noted on the computer kiosk. Green - independent, no mechanical lift required Yellow - CNA assist * if more than 1 person required, indicate number of staff required Orange - Stand up lift, 2 person Red - Total bed lift, 2 person. Review of Resident #95's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Acute [CONDITION(S)], Vitamin Deficiency, Muscle Wasting and Atrophy, Dementia without Behavioral Disturbances, History of Falling, Heart Failure, Type 2 Diabetes Mellitus, Major Depressive Disorder, Essential Hypertension, Age-related [CONDITION(S)], Peri-prosthetic Fracture around Internal Prosthetic Left Hip Joint. Review of Resident #95's Quarterly MDS with an ARD of 10/29/2019 revealed the resident had a BIMS score of 5 indicating severe cognitive impairment. Further review of the MDS revealed Resident #95 required extensive two+ person physical assistance with bed mobility and transfers. A review of the Care Plan revealed the following, in part: Problem: I have an ADL self-care performance deficit related to disease process. Goal: I will improve current level of function through the review date. Approaches: Transfer: I require extensive with (2) staff assistance for transfers. Date initiated 08/09/2019 revision date 11/20/2019. Transfer: I require total with (2) staff assistance for transfers per Hoyer lift; revision date 12/03/2019 Review of the Nurse's Note from 11/18/2019-11/21/2019 revealed the following, in part: 11/20/2019 6:51 a.m. - Upon initial rounds resident complained of severe pain to right hip and upper right leg. Assessed at 6:05 a.m. right knee turned outwards, right leg shorter than left and complained of severe pain upon any attempt to move. X-ray residents right hip and upper right leg. Signed: S3LPN. 11/20/2019 07:24 a.m. -Upon initial rounds observed resident with right knee rotated outwards to right and right leg shorter than the left. Also, resident in severe pain with any movements even of covers. X- ray called to come out and x-ray right hip and upper right leg. Shortly after x ray, confirmed fracture of right femur. Transfer out to hospital. Signed: S3LPN Review of Imaging from local hospital on 11/20/2019 revealed the following: Clinical history: fall, pain. Impression: There is a traumatic oblique fracture of the proximal right femoral shaft at the distal end of the prosthesis. Distal fragment is displaced medially. Review of hospital discharge summary from a local hospital revealed the following: admitted : 11/20/2019 discharge date : 11/24/2019 Discharge Diagnosis: Closed fracture of head of right femur S/P ORIF (open reduction internal fixation) fracture An interview was conducted on 12/03/2019 at 9:00 a.m. with Resident #95's responsible party. She said she was notified on 11/20/2019 at 9:00 a.m. by S3LPN that Resident #95 sustained a fracture to her right leg. She said S2DON informed her Resident #95 had been seen on video surveillance propelling herself around the nurse's station until 9:58 p.m. on 11/19/2019. She further explained S2DON said at 9:59 p.m. Resident #95 was observed on video being transported via wheelchair to her room by S8CNA. S8CNA exited the room alone at 10:10 p.m. She said on the morning of 11/20/2019 at 6:10 a.m., S6CNA and S7CNA attempted to change Resident #95's diaper when she started to cry saying her right leg was hurting. She said prior to the accident Resident #95 required 2 person assist. She said Resident #95 had not been strong enough to get out of the wheelchair/bed without assistance. She said Resident #95 had never complained of hip pain and had been able to propel herself around the facility prior to the incident on 11/19/2019. On 12/03/2019 at 9:10 a.m., an observation was made of S6CNA and S7CNA transferring Resident #95 from bed to wheelchair using a mechanical lift. The transfer was completed properly and no issues/concerns noted. An interview was conducted on 12/03/2019 at 9:30 a.m. with S6CNA. She said she worked 6am-2pm shift the day of 11/20/2019. She said she and S7CNA attempted to change Resident #95's disposable brief at 6:00 a.m. when she screamed out in pain and pointed to her right leg. She said she immediately notified S3LPN as this was unusual for Resident #95. She said prior to 11/20/2019, Resident #95 propelled herself around the facility in her wheelchair using her legs. She said since the accident, Resident #95 is total dependent with transfers. She said Resident #95 had never complained of right hip pain prior to 11/20/2019 at 6:00 a.m. She said Resident #95 could not transfer on her own and required 2-person assist. She said she had never witnessed Resident #95 attempt to get up on her own without assistance. An interview was conducted on 12/03/2019 at 9:45 a.m. with S7CNA. She said on the morning of 11/20/2019 at 6:00 a.m., she and S6CNA attempted to change Resident #95's diaper when she screamed out in pain and pointed to her right leg. She said she immediately reported to S3LPN. She reported prior to this incident, Resident #95 was a 2 person assist but could help with transfers to the bed/wheelchair. She said she propelled herself throughout the facility using her legs. She reported she had always been 2 person assist but now totally dependent on staff. She said Resident #95 never attempted to get up on her own and had not complained of pain to her right hip prior to 11/20/2019 at 6:00 a.m. An interview was conducted on 12/03/2019 at 10:14 a.m. with S3LPN. She said she worked 6am-2 pm shift on 11/20/2019. She said she received report from S5LPN and did not receive report of changes that occurred during the night regarding Resident #95. She said S6CNA and S7CNA notified her that Resident #95 had cried out in pain when they attempted to change her diaper. She said she immediately assessed the resident and noticed her right leg shorter than her left leg and her right knee was pointed outward. She reported Resident #95 had been transferred to a local hospital for evaluation of a right leg fracture. She said prior to this incident, Resident #95 was a 2 person assist but could assist with transfers by standing. She said Resident #95 is now total dependent on staff and she is transferred via mechanical lift. She said Resident #95 propelled herself throughout the facility via wheelchair using her feet and had not complained of pain on the day shift on 11/19/2019. An interview was conducted on 12/03/2019 at 3:15 p.m. with S4LPN. She reported she worked the evening shift (2pm-10pm) on 11/19/2019. She said Resident #95 propelled herself in her wheelchair around the facility and ate dinner in the dining room the evening of 11/19/2019. She said Resident #95 sat in her wheelchair next to the nurse's station for several hours with staff. She said at 10:00 p.m. S8CNA transported Resident #95 to her room to be put to bed for the night as Resident #95 had been sitting up in the wheelchair for most of the day. She said Resident #95 had not complained of hip pain to her during the hours she was seated at the nurse's station. She said Resident #95 was a person assist with transfers. She said the nursing staff were responsible for ensuring the CNAs were transferring residents according to the resident's personal lift assessment. An interview was conducted on 12/03/2019 at 3:40 p.m. with S9CNAS. She reported on the morning of 11/20/2019, she had been informed Resident #95 was sent to the hospital for a fractured right leg. She reported she called S8CNA to find out if anything unusual happened during her shift the night before. She said S8CNA said Resident #95 refused to have her diaper change and had complained of pain to her right hip at 5:00 a.m. on 11/20/2019. She said S8CNA failed to report this change in condition to the nurse. She said S8CNA confirmed she transferred Resident #95 from the wheelchair to bed without another staff member's assistance on 11/19/2019. She said Resident #95 had been a 2-person assist with transfers. She said she was responsible for ensuring the CNA staff followed transfer protocol according to the resident's personal lift assessment. An interview was conducted on 12/03/2019 at 3:50 p.m. with S10CNA. She said she worked the night shift (10pm-6am) on 11/19/2019. She said she worked the same hall as S8CNA the night shift on 11/19/2019. She said S8CNA had not asked for assistance to transfer Resident #95 to bed. She reported Resident #95 was a 2-person assist with transfers. An interview was conducted on 12/03/2019 at 5:30 p.m. with S8CNA. She reported she worked 2pm-10pm and 10pm-6am on 11/19/2019. She said Resident #95 had dinner in the dining room and had propelled herself around the facility during the evening shift. She said Resident #95 sat in her wheelchair at the nurse's station until 10:00 p.m. She said at 10:00 p.m., S5LPN requested she assist Resident #95 to bed for the night. She said she transferred Resident #95 to her room and assisted her from the wheelchair into the bed. She confirmed she transferred Resident #95 to bed by herself. She said honestly I did not look at the board behind the bed to see how many person assist Resident #95 was. She confirmed she knew S10CNA had been working on the same hall that night but did not ask her for assistance and that she transferred Resident #95 to bed several nights a week without assistance. She said I knew I could handle her by myself. She said she attempted to change Resident #95's diaper on 11/20/2019 at 5:00 a.m., and the resident refused. She said Resident #95 said Get out of my room, leave me alone, my hip is hurting. She said she did not report this incident to S5LPN. She confirmed she should have notified S5LPN that Resident #95 had refused to have her diaper changed and that she had complained of right hip pain at 5:00 a.m. on 11/20/2019. An observation was made on 12/04/2019 at 12:35 p.m. of the color coded legend, used to designate the type of lift required per residents lift assessment, posted at the head of the bed for Resident #95 revealed the following: Red dot - indicates total lift, 2 person An interview was conducted on 12/04/2019 at 3:00 p.m. with S5LPN. She reported she worked the night shift (10pm-6am) on 11/19/2019. She confirmed S8CNA did not inform her Resident #95 refused to have her diaper changed or that she complained of right hip pain at 5:00 a.m. on 11/20/2019. An interview was conducted on 12/04/2019 at 3:30 p.m. with S2DON. She said on 11/20/2019 at 7:00 a.m. she received a call from S3LPN informing her of an incident with Resident #95. She said the facility obtained an x-ray and sent Resident #95 to the hospital for evaluation of right hip/leg fracture. She said she called S8CNA who worked the evening shift the night before (2pm- 10pm) and the night shift (10pm-6am). She reported S8CNA said Resident #95 propelled herself around the facility in her wheelchair and visited with the nurses and other residents at the nurse's station on the evening of 11/19/2019. S2DON said according to video footage S8CNA transported Resident #95 in her wheelchair to her room at 9:58 p.m. She said S8CNA reported to her Resident #95 stood up with assistance next to the bed, held on to the night stand, pivoted, and sat on the edge of the bed. She said S8CNA admitted she transferred Resident #95 to the bed by herself, and she did not ask S10CNA for assistance. S2DON confirmed Resident #95 was a 2 person assist according to her personal lift assessment. She said S8CNA was immediately suspended pending investigation. S2DON reported S9CNAS was responsible to ensure the CNA staff were transferring residents per their plan of care. She said after the investigation, it was determined the injury was of unknown origin but probably occurred when Resident #95 was transferred from the wheelchair to the bed by S8CNA. An interview was conducted on 12/05/2019 at 10:05 a.m. with S1ADM and S2DON. Both stated they felt a thorough investigation had been done and the specific cause of the injury could not be determined until they received Resident #95's operative report from the orthopedic surgeon. S2DON stated the resident had [CONDITION(S)] with a history of fractures, and the operative report may indicate a pathological fracture. She stated the improper transfer was identified as a problem and was addressed with QA. A phone interview was conducted on 12/05/19 at 10:43 a.m. with Resident #95's orthopedic surgeon. He confirmed he was the operating surgeon for Resident #95 and confirmed a diagnosis of traumatic oblique fracture of the proximal right femoral shaft at the distal end of the prosthesis. He said there had been no evidence Resident #95's injury was the result of a pathological fracture and no indication this was an osteoporotic fracture. He said her injury was a spiral fracture, specifically a long spiral fracture of the femur, which is a result of a fall, injury or twisting motion with transfer. On 12/02/2019 to 12/05/2019, observations were made of residents being transferred according to their plan of care and facility policy. Interviews conducted with CNAs on each hall and different shifts revealed they were knowledgeable of the facility policy for transferring residents safely and according to their plan of care. Interviews with staff, residents, and a family member revealed there were no further issues involving incidents while transferring a resident. Record reviews included staff training, documents verifying corrective action plans had been implemented and ongoing monitoring was being performed. The facility had implemented the following actions to correct the deficient practice on 11/20/2019: 1. Corrective action for the issue identified as being deficient for Res #1400 was as follows: a. CNA in question was counseled in regards to improper transfer. b. CNA in question was educated/trained on 11/20/19 on proper/safe transfer technique. c. All residents were re-assessed on 11/20/19 to ensure their over bed care plans were accurate in regards to their transfer status. d. New User Defined Assessments regarding lift status was completed on all residents on 11/20/19. 2. Residents that had the potential to be affected by the alleged deficient practice were identified through transfer status assessments. 3. Steps to ensure that the deficient practice does not recur will be as follows: a. The nursing staff (including CNA in question) was in-serviced on 11/20/19 in regards to the following: proper lift and transfer with return demonstration, reporting changes in condition, following over bed care plan in regards to transfers. b. Continuous training will be held weekly for 4 weeks c. Incident reports will be reviewed during the stand- up meeting by Administrator and/or designee to ensure incidents of unknown origin are investigated timely. d. CNA in question will be monitored daily by CNA Supervisor to ensure proper transfers are performed according to the over bed care plan. 4. QA measures put into place to ensure the deficient practice will not recur will be as follows: a. DON and/or designees will conduct random audits for compliance with the lift/transfer policy. This will be accomplished by direct observation of 3 residents a day for 4 weeks and then randomly thereafter and results documented on a QA form. Issues noted will be addressed immediately and additional training/in-servicing done at this time. b. DON and/or designees will monitor nursing communication between CNAs and Nurses to ensure changes of condition are reported timely. This will be accomplished by direct interviews and/or review of the 24-hour report daily for 4 weeks and then randomly thereafter and results documented on a QA form. Issues noted will be addressed immediately and additional training/in-servicing done at this time. c. Failure to comply will result in disciplinary action. 6. Completions date for corrective action will be November 22, 2019