Every finding on record at Ozark Health Nursing and Rehab Center

Number of residents sampled:Number of residents cited: Based on record review, document review and interview, the facility failed to supervise, monitor and put interventions in place for residents with known exit seeking behaviors to prevent access to potentially hazardous areas without assistance for and prevent an elopement for two (Resident #100, and Resident #107) residents of four residents reviewed. It was determined the facilities non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to CFR 483.25(d)(2) at a scope and severity of K. The IJ began on 08/23/2025 at approximately 7:30 PM when Resident #100 left the facility without staff knowledge and was found approximately 150 yards from the facility per an online map program, in a connecting hospital parking lot at 7:42 PM. The temperature was high at 93 degrees per an online local weather report search. The Administrator was notified of the Immediate Jeopardy (IJ) on 08/05/2026 at 6:34 PM. A Removal Plan was requested. On 08/06/2026 an acceptable IJ removal plan was accepted by the State Agency and the IJ was removed. The findings include: Resident #100 Review of an admission Record revealed the facility admitted Resident #100 with diagnoses that included atherosclerotic heart disease, hypertension, type 2 diabetes, anxiety disorder, post-traumatic stress disorder, absence of left toes, absence of right leg below the knee, psychoactive substance abuse, and stimulant dependence. Review of Resident #100's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/2025, revealed Resident #100 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #100 had impairment to bilateral lower extremities and utilized a manual wheelchair for mobility.Review of Resident #100's Care Plan revealed a focus initiated on 09/11/2025 that Resident #100 was an elopement risk. Interventions revealed the resident was not an exit seeker but had confusion related to dementia and wanders, and that the resident would get turned around and try to go through doors. The Care Plan also revealed a focus initiated 08/26/2025 that Resident #100 would exit the building independently without staff awareness. Interventions initiated on 09/11/2025 included notify staff when going outside of building and two elopement bracelets were placed on the resident; one on left ankle and one on wheelchair. Review of Progress Notes date 07/07/2025 at 8:38 PM revealed Resident #100 was going to the cafeteria, [which is in the adjoining hospital building, approximately 0.1 miles from the facility per Google Maps], by self today. At supper Resident went to the [hospital] cafeteria but was later found by the front office. While resident was alert and oriented x4, resident does have some confusion and was asked to please stay in courtyard and cafeteria. Due to intermittent confusion, we may need to reiterate this request frequently and ask them to let us know when/where they are going for safety. Review of a facility Incident and Accident (I&A) Report dated 08/23/2025 at 7:42 PM, revealed Security called nursing station to inform them that Resident #100 was found in the parking lot of the adjoining hospital asking staff for a ride. The I&A revealed a nurse went to get the resident, and no injuries were noted at the time. The I&A revealed the Administrator spoke to Resident #100 via phone to counsel them on the dangers of leaving the facility without staff knowledge, including potential injury, exposure, and delayed medical response. Resident #100 stated they would not leave the facility again. Resident #100 was put on 15 minutes checks until the following Monday. During an interview on 08/04/2026 at 12:39 PM, the Licensed Practical Nurse (LPN) #3 stated that security called to notify staff that Resident #100 was in the emergency room (ER) parking lot. LPN #3 stated when she arrived to get Resident #100 they were close to the road. LPN #3 also stated that was the first time Resident #100 had gone outside alone. During an interview on 08/04/2026 at 1:00 PM, the Security Officer stated that Resident #100 was found in the ER parking lot by the helicopter pad. The Security Officer stated, I stayed with them to make sure Resident #100 would not roll out in the road until the nursing home staff arrived. Review of an Office of Long-Term Care (OLTC) I&A Report dated 09/11/2025, revealed Resident #100 was found outside the building without staff accompaniment. This marks the second occurrence the resident exited the building independently. The Resident returned safely without incident: no injury or distress were observed.Review of the local weather report for the city and state of the incident on 09/11/2025 revealed the temperature was high at 91 degrees. During an interview on 08/05/2026 at 13:45 PM, the Director of Facilities stated, he found Resident #100 on 09/11/2026 approximately 6.5 feet from the highway on the sidewalk. [Online maps program indicated this was 0.3 miles from the facility doors] He stated that he called the Administrator to the nursing facility, and they came down promptly to get Resident #100. During an interview on 08/06/2026 at 1:53 PM, the Administrative Assistant stated that at approximately 8:00 AM on 09/11/2025, the Administrator asked me to get the van because Resident #100 was by the highway. I met them at the pharmacy parking lot and brought Resident #100 back to the building. During an interview on 08/06/82026 at 2:09 PM, the Administrator stated that on 09/11/2025 the Director of Facilities called to report that Resident #100 was out of the facility. The Administrator stated, When I arrived Resident #100 had no apparent injuries. Resident #100 immediately apologized and returned to the facility. The Administrator also stated that she completed an internal report on the elopement for Resident #100 on 08/23/25, but did not report it to The office of Long-Term Care. I felt that this was an isolated incident due to [the resident's] cognition. Resident #107 Review of an admission Record revealed the facility admitted Resident #107on 07/22/2025 with diagnoses that included dementia, atrial fibrillation, osteoporosis, hypertension, anxiety disorder and depression. Review of a significant change MDS with an ARD of 01/19/2026 revealed Resident #107 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #107 was independent with mobility. Review of Resident #107's Care Plan revealed a focus initiated on 09/11/2025 that Resident #107 was an elopement risk. Interventions revealed the resident was not an exit seeker but had confusion related to dementia and wanders, that the resident would get turned around and try to go through doors and that the resident now had an elopement bracelet on for safety with an initiated date of 08/06/2025. The interventions also revealed Resident #107 now had two elopement bracelets, one on the right wrist and another on the left ankle, initiated on 10/30/2025. The Care Plan also revealed a focus of Resident #107 being an elopement risk/wander related to being disoriented to place and having impaired safety awareness. The focus stated the resident tended to wander aimlessly which could result in the resident intruding on the privacy of others. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Other interventions included to offer the resident ice cream, cookies, or crackers and that the resident enjoyed activities and exercise as well. Interventions had an initiated date of 10/27/2025. Review of a facility I&A Report dated 11/01/2025, revealed that at 7:40 PM the alarm went off, staff started looking for Resident #107 and found them outside by the loading dock near yellow hall, standing behind the door. Review of a Progress Note dated 11/01/2025, revealed Resident #107 was carrying a black bag and stating that they were going home to see kids. The Progress Note revealed that at 7:40PM the elopement bracelet alarm went off, and Resident #107 was found at 7:45 PM, by a CNA, outside by the loading dock near yellow hall, standing behind the door, no injury noted, confused with increased anxiety. The Progress Note revealed the elopement bracelets were in place on the right ankle and left wrist and that the Administrator was notified. During an interview on 08/06/2026 at 12:21 PM, LPN #3 stated that Resident #107 had an elopement bracelet on and that staff kept an eye on Resident #107 due to wandering behaviors. LPN #3 stated that on 11/01/2026 the elopement bracelet alarm went off, and an unknown CNA let Resident #107 in. During an interview on 08/06/2026 at 1:38 PM, LPN #4 stated that unknown staff helped Resident #107 get into the building. I instructed staff to keep Resident #107 by the nurse's station or in the day room in view and to implement 5-minute checks for 24 hours. LPN #4 also stated, Staff should have done a physical assessment because it was November and cold outside. Staff probably went over to the hospital to look for Resident #107 and did not think to look outside on the loading docks. Review of the local weather report for city and state of the incident indicated that on 11/01/2025the temperature was low at 43 degrees.During an interview on 08/06/2026 at 3:52 PM, CNA #5 stated that Resident #107 traveled the halls and staff were constantly having to redirect the resident. Resident #107 was determined to leave the facility, and staff had to keep redirecting the resident. CNA #5 stated, On 11/01/2025 Resident #107 'banged' against and got out of the door. During an interview on 08/06/2026 at 4:36 PM, the Director of Nursing (DON) stated that Resident #107 went down towards the door, they must have gotten out and staff followed. To my understanding the resident must have gotten out the double doors. My staff assessed Resident #100 for injury. The DON stated that she expected staff to observe the residents more closely to prevent further elopements. Review of a Written Statement dated 08/05/2026 and signed by the Administrator stated, Residents do not sign in and out when exiting the facility to go outside. Residents only sign out when leaving the facility grounds with family or friends. Review of facility policy titled Reporting Resident Abuse Neglect, Unusual Occurrences and Misappropriation of Resident Property Policy revised date in 09/09, revealed that all employees are responsible for taking the necessary steps to assure the safety of the residents. In a situation where the resident may be in imminent danger, employees must intervene to prevent further abuse or danger. Removal Plan The IJ was removed on 08/06/2026 after the survey team performed on-site verification that the Removal Plan had been implemented. On site verification of the removal plan began on 08/06/2026 at 1:15 PM when the sign in and out sheet was reviewed, Interdisciplinary Team In Service regarding staff responsibilities when a resident chose to leave the facility completed, by seven staff. Resident In- Service detailing the responsibility of residents to sign in and out of the facility with ten resident signatures. In- Service for the front-line staff verified with 20 staff signatures and employees unable to attend the initial education will complete education prior to assuming resident care responsibilities. During an interview on 08/06/2026 at 10:20 AM LPN # 10 indicated the sign in and out sheet was in use this morning by the residents leaving the facility. Ongoing monitoring will be provided by the charge nurse or designee will review the Sign-Out/Sign-In Log each shift to verify completion and identify residents who have not returned as expected. Any resident who has not returned within the expected timeframe will be assessed according to facility policy, including attempts to contact the resident and notification of the physician and responsible party as appropriate. The Director of Nursing or designee will audit the Sign-Out/Sign-In Log five days per week for four weeks, then weekly for two additional months to verify compliance. Audit results will be reviewed through the facility's Quality Assurance and Performance Improvement (QAPI) program. Trends, concerns, and opportunities for improvement will be addressed through additional education, observation, and corrective action as needed.

Number of residents sampled: Number of residents cited: Based on interviews, record review, and facility policy review, the facility failed to ensure elopements were reported to the Administrator and the State Agency (SA) within the required timeframe for two (Resident #100 and Resident #107) of four residents reviewed. The findings include: Resident #100 Review of an admission Record revealed the facility admitted Resident #100 with diagnoses that included atherosclerotic heart disease, hypertension, type 2 diabetes, anxiety disorder, post-traumatic stress disorder, absence of left toes, absence of right leg below the knee, psychoactive substance abuse, and stimulant dependence. Review of Resident #100's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/2025, revealed Resident #100 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #100 had impairment to bilateral lower extremities and utilized a manual wheelchair for mobility.Review of Resident #100's Care Plan revealed a focus initiated on 09/11/2025 that Resident #100 was an elopement risk. Interventions revealed the resident was not an exit seeker but had confusion related to dementia and wanders, and that the resident would get turned around and try to go through doors. The Care Plan also revealed a focus initiated 08/26/2025 that Resident #100 would exit the building independently without staff awareness. Interventions initiated on 09/11/2025 included notify staff when going outside of building and two elopement bracelets were placed on the resident; one on left ankle and one on wheelchair. Review of Progress Notes dated 07/07/2025 at 8:38 PM revealed Resident #100 was going to the cafeteria, [which is in the adjoining hospital building, approximately 0.1 miles from the facility per an online map program], by self today. At supper Resident went to the [hospital] cafeteria but was later found by the front office. While resident was alert and oriented x4, resident does have some confusion and was asked to please stay in courtyard and cafeteria. Due to intermittent confusion, we may need to reiterate this request frequently and ask them to let us know when/where they are going for safety. Review of a facility Incident and Accident (I&A) Report dated 08/23/2025 at 7:42 PM, revealed security called the nursing station to inform them that Resident #100 was found in the parking lot of the adjoining hospital asking staff for a ride. The I&A revealed a nurse went to get the resident, and no injuries were noted at the time. The I&A revealed the Administrator spoke to Resident #100 via phone to counsel them on the dangers of leaving the facility without staff knowledge, including potential injury, exposure, and delayed medical response. Resident #100 stated they would not leave the facility again. Resident #100 was put on 15 minutes checks until the following Monday. During an interview on 08/04/2026 at 12:39 PM, Licensed Practical Nurse (LPN) #3 stated that security called to notify staff that Resident #100 was in the emergency room (ER) parking lot. LPN #3 stated when she arrived to get Resident #100 they were close to the road. LPN #3 also stated that was the first time Resident #100 had gone outside alone. During an interview on 08/04/2026 at 1:00 PM, the Security Officer stated that Resident #100 was found in the ER parking lot by the helicopter pad. The Security Officer stated, I stayed with them to make sure Resident #100 would not roll out in the road until the nursing home staff arrived. Review of an Office of Long-Term Care (OLTC) I&A Report dated 09/11/2025, revealed Resident #100 was, found outside the building without staff accompaniment. This marks the second occurrence the resident exited the building independently. The Resident returned safely without incident: no injury or distress were observed. Review of the local weather report for the city and state of the incident on 09/11/2025 revealed the temperature was high at 91 degrees Fahrenheit. During an interview on 08/05/2026 at 13:45 PM, the Director of Facilities stated, I found Resident #100 on 09/11/2025 approximately 6.5 feet from the highway on the sidewalk. [online maps program indicated where the resident was found had been 0.3 miles from the facility doors] I called the Administrator to the nursing facility, and they came down promptly to get Resident #100. During an interview on 08/06/2026 at 1:53 PM, the Administrative Assistant stated that at approximately 8:00 AM on 09/11/2025 the Administrator asked me to get the van because Resident #100 was by the highway. I met them at the pharmacy parking lot and brought Resident #100 back to the building. During an interview on 08/06/2026 at 2:09 PM, the Administrator stated that on 09/11/2025 the Director of Facilities called to report that Resident #100 was out of the facility. The Administrator stated, When I arrived Resident #100 had no apparent injuries. Resident #100 immediately apologized and returned to the facility. The Administrator also stated that she completed an internal report on the elopement for Resident #100 on 08/23/25, but did not report it to The Office of Long-Term Care. I felt that this was an isolated incident due to [the resident's] cognition. Resident #107 Review of an admission Record revealed the facility admitted Resident #107on 07/22/2025 with diagnoses that included dementia, atrial fibrillation, osteoporosis, hypertension, anxiety disorder, and depression. Review of a significant change MDS with an ARD of 01/19/2026 revealed Resident #107 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #107 was independent with mobility. Review of Resident #107's Care Plan revealed a focus initiated on 09/11/2025 that Resident #107 was an elopement risk. Interventions revealed the resident was not an exit seeker but had confusion related to dementia and wandered, that the resident would get turned around and try to go through doors, and that the resident now had an elopement bracelet on for safety with an initiated date of 08/06/2025. The interventions also revealed Resident #107 now had two elopement bracelets, one on the right wrist and another on the left ankle, initiated on 10/30/2025. The Care Plan also revealed a focus of Resident #107 being an elopement risk/wander related to being disoriented to place and having impaired safety awareness. The focus stated the resident tended to wander aimlessly, which could result in the resident intruding on the privacy of others. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Other interventions included to offer the resident ice cream, cookies, or crackers, and that the resident enjoyed activities and exercise as well. Interventions had an initiated date of 10/27/2025. Review of a facility I&A Report dated 11/01/2025, revealed that at 7:40 PM the alarm went off, staff started looking for Resident #107 and found them outside by the loading dock near yellow hall, standing behind the door. Review of a Progress Note dated 11/01/2025, revealed Resident #107 was carrying a black bag and stating that they were going home to see kids. The Progress Note revealed that at 7:40PM the elopement bracelet alarm went off, and Resident #107 was found at 7:45 PM, by a CNA, outside by the loading dock near yellow hall, standing behind the door, no injury noted, confused with increased anxiety. The Progress Note revealed the elopement bracelets were in place on the right ankle and left wrist and that the Administrator was notified. During an interview on 08/06/2026 at 12:21 PM, LPN #3 stated that Resident #107 had an elopement bracelet on and that staff kept an eye on Resident #107 due to wandering behaviors. LPN #3 stated that on 11/01/2026 the elopement bracelet alarm went off, and a CNA let Resident #107 in. LPN #3 was unsure of which CNA let the resident back into the facility. During an interview on 08/06/2025 at 1:38 PM, LPN #4 stated that staff whom she could not recall the name of had helped Resident #107 get into the building. I instructed staff to keep Resident #107 by the nurse's station or in the day room in view and to implement 5-minute checks for 24 hours. LPN #4 also stated, Staff should have done a physical assessment because it was November and cold outside. Staff probably went over to the hospital to look for Resident #107 and did not think to look outside on the loading docks. Review of the local weather report for city and state of the incident indicated that on 11/01/2025 the low temperature was 43 degrees Fahrenheit. During an interview on 08/06/2026 at 3:52 PM, CNA #5 stated Resident #107 traveled the halls, and staff were constantly having to redirect the resident. Resident #107 was determined to leave the facility, and staff had to keep redirecting the resident. CNA #5 stated, On 11/01/2025 Resident #107 'banged' against and got out of the door. During an interview on 08/06/2026 at 2:23 PM, the Administrator stated, I did not take witness statements for the elopement on 11/01/2025, I just did verbal statements over the phone. The Administrator stated one CNA who's name she could not recall had told the Administrator that the resident did not make it to the loading dock. The Administrator stated, I was under the assumption that eyes were on Resident #107 the entire time. Review of facility policy titled Reporting Resident Abuse Neglect, Unusual Occurrences and Misappropriation of Resident Property Policy revised date in 09/09, revealed that all employees are responsible for taking the necessary steps to assure the safety of the residents. In a situation where the resident may be in imminent danger, employees must intervene to prevent further abuse or danger. The policy also revealed that the facility must investigate each allegation- if any change in patient assessment, report to law enforcement and OLTC.

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure staff/volunteers performed hand hygiene during meal service to prevent the spread of infection and cross contamination. This failed practice had the potential to spread infection to all residents eating in the dining room observed for independent and dependent dining. The findings include: During an observation of the dining areas on 08/03/2026 that began at 11:47 AM, a volunteer used his bare hands to touch the outside of the drinking cups then scooped the cup into an ice chest to fill it with ice and did not use the ice scoop. The volunteer did not perform hand hygiene between approximately 12 resident cup deliveries or between scooping ice from the ice chest for any of the residents in the dining room. The volunteer also filled and delivered drinks to an unknown number of residents in the dining area across the hall without performing hand hygiene. Certified Nursing Assistant (CNA) #6 placed their bare hand on the top of a cup while transporting the cup to a resident. CNA #7 delivered a tray to a resident and sat up the tray, with bare hands. CNA #7 did not perform hand hygiene before touching a residents roll with their contaminated bare hands. Medication Assistant-Certified (MAC) #8 was also observed to have delivered a tray to a resident, contaminating their bare hands; without performing hand hygiene, MAC #8 then unwrapped the resident's straw and touched the bottom of the straw before it was placed in the beverage. During an interview on 08/06/2026 at 1:06 PM, CNA #6 stated, I should carry the cup by the bottom of the cup to prevent the spread of germs. CNA #6 also stated they were the one to train the male volunteer on passing drinks. She stated, I demonstrated how to get ice from the ice chest, and he has already been retrained on performing hand hygiene and passing drinks. During an interview on 08/06/2026 at 1:19 PM, MAC#8 stated, When passing trays, I should perform hand hygiene before touching the trays. I usually use a knife or fork to put butter on the rolls. During an interview on 08/06/2026 at 11:37 AM, Certified Nursing Assistant (CNA)#1 stated, when scooping ice for a resident, you must use the scoop then place the scoop back in the bag to cover it. She stated hand hygiene should be performed before and after helping a resident and if hand hygiene was not performed it could cause infection and contamination. During an interview on 08/06/2026 at 11:46 AM, CNA #2 stated that hand hygiene should be performed between residents, before going in and out when serving the tray and when necessary. CNA #2 stated a cup, or bare hands should not be used to scoop ice out of ice chest, the scoop should be used to prevent cross contamination and sickness. During an interview on 08/05/2026 at 9:29 AM, the Medical Director (MD) stated hand hygiene should be performed with every resident interaction especially, if serving meals and drinks to residents because it could spread bacteria and germs to the residents. During an interview on 08/06/2026 at 10:40 AM, Infection Preventionist (IP) stated she randomly checks or audits staff for hand hygiene daily. The IP revealed the volunteer had been monitored and educated about hand hygiene specifically handling the trays and cups. She stated, we verbally told him what to do and when we would see something, we would tell him. The IP stated the process for filling cups with ice was to use the scoop by the handle, fill the cup and not put the scoop back into the ice chest but to place it in the box. She stated, hand hygiene should be performed after every drink cup and/or tray delivery and if the scoop handle was not used to scoop the ice it could contaminate the whole ice chest and spread to the whole building. During an interview on 08/06/2026 at 2:00 PM, the Director of Nursing (DON) stated that when staff or volunteers scoop ice from the ice chest, the scoop should be used and not the cup. The DON stated hand hygiene should be performed before and after every delivery and/or setup of meals. The DON stated that when bare hands were used to scoop ice from the ice chest with a cup and not the scoop, it could cause cross contamination. The DON also stated that she expected staff to perform hand hygiene before delivering meal trays and after the tray had been delivered and before delivering a tray to another resident. The DON stated dietary staff should not handle drink cups by the rim of the glass and should never touch a resident's food with bare hands as this could spread germs. During an interview on 08/06/2026 at 2:35 PM, the Administrator stated she expected staff and volunteers to perform hand hygiene between each passing of a tray and to use safe food handling practices. The Administrator also stated she did participate in providing in-services to staff with nurse supervisors monitoring hand hygiene during mealtimes. She stated, the one volunteer we have, completed an in-service on hand hygiene and was monitored by the nurse supervisor. The Administrator stated a scoop should be used to fill drinking cups for residents, not their bare hands. She stated that when hand hygiene was not done, it could cause cross contamination. A review of the in-service titled, Hand Hygiene dated July 2026, revealed hand hygiene is the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. Any health-care worker, caregiver or person involved in direct or indirect patient care needs to be concerned about hand hygiene and should be able to perform it correctly and at the right time. The use of gloves does not replace the need for cleaning hands. Hand hygiene must be performed regardless of the indications for glove use. This in-service was for auxiliary personnel. A review of the in-service titled, Handwashing, dated June 2026, revealed disposable gloves are used for handling ready-to-eat food. Reusable gloves may be used for handling raw foods and non-food items, such as cartons, rubbish and in cleaning activities. It is important to note that gloves cannot replace hand washing for food production and preparation. Disposable glove use in food businesses include to use disposable gloves for handling read-to-eat food, wash hands before donning gloves, change gloves between tasks, and wash hands after doffing gloves.A review of a facility policy titled, Hand Hygiene revised 11/20, revealed all staff in the facility are responsible for following hand hygiene policies and procedures, including but not limited to Registered Nurses (RN), Nurse Practitioners (NP), Licensed Practical Nurses (LPN), Physicians (MD), Environmental Services (ES), Dietary Services, and Volunteers. They should perform hand hygiene before each resident encounter, before applying gloves, after coming in contact with resident's intact skin, and after removing gloves. Indications for handwashing using Alcohol Based Hand Rub (ABHR) if assisting more than one resident with meals, sanitize between each resident, always after removing gloves or facemask, before and after assisting a resident with meals, and any other time it is felt necessary to perform hand hygiene. A review of a facility policy titled, Infection Prevention and Control Plan, effective 07/2020, revealed the goals of the Infection Prevention and Control Plan shall improve compliance with hand hygiene, preventing foodborne illnesses, and directing, encouraging and monitoring staff adherence to recommended infection prevention and control practices.

Based on observation, record review, and interview, it was determined that the facility failed to report to the Office of Long-Term Care (OLTC), an allegation of sexual abuse of one (Resident #46) by another (Resident #34) resident within two hours of the allegation being made. The findings are: 1. A review of an Admission Record indicated Resident #34 was admitted to the facility with diagnoses that included: congestive heart failure, cognitive communication deficit, and dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/15/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment for daily decision making. Section E - Behaviors, indicated: Resident #34 did not have verbal, physical, or other behaviors symptoms directed toward others. Review of Resident #34's Care Plan initiated 08/25/2022, and revised on 01/16/2024, revealed the resident had a behavior problem related to being sexual with others. Interventions included: Resident currently taking [Name Brand Antidepressant] for depression, to encourage the resident to eat meals with spouse and to get out of the room more often. The resident is married and sometimes thinks another resident is spouse or reminds resident of spouse and resident may try to hold their hands or touch them inappropriately. The resident does not understand/remember that they have dementia or other residents do. (revised 08/10/2023). 2. A review of an Admission Record indicated Resident #46 was admitted to the facility with diagnoses that included: neurocognitive disorder with Lewy bodies, vascular dementia with behavioral disturbances, and anxiety disorder. The admission MDS with an ARD of 01/22/2025, revealed Resident #46 had a BIMS score of 1, which indicated severe cognitive impairment for daily decision making. In Section E - Behaviors, indicated: Resident #46 had verbal and physical behaviors symptoms directed toward others, rejection of care and wondering. A review of Resident #46's Care Plan initiated 11/07/2023 and revised 02/09/2024, revealed the resident was at risk for elopement/wandering around building and getting turned around. Interventions included: Resident was not an exit seeker but had confusion related to dementia and wandered. The resident may get turned around and try to go through doors. The resident wore an elopement bracelet for safety. A review of an OLTC Witness Statement Form, dated 08/30/2024 and completed by the Director of Nursing (DON), indicated the resident ' s family member had come to the DON ' s office and stated that another resident had alleged Resident #34 had placed a hand down Resident #46 ' s pants in the dining room. During a phone interview on 04/15/2025 at 10:47 AM, a family member of Resident #46 stated sometime last year during a visit with the resident, another resident approached them and told the family member that Resident #34 was observed seated in the dining room in a wheelchair beside Resident #46 and was touching Resident #46 inappropriately. The family member said it was after hours, so they reported it the following Monday. The family member was informed by the DON that an investigation would be conducted. The family member said the DON later contacted them and informed the family member the investigation was completed and it was determined it did not happen. During an interview on 04/17/2025 at 9:02 AM, the Administrator stated an internal investigation was completed and the allegation was unfounded, due to negative findings during the body audit and the interviews with the cognitive witnesses. The Administrator stated she felt the internal investigation was all that was needed and felt comfortable the incident did not happen. The Administrator stated there was no documentation for the internal investigation, and no documentation in (electronic charting program). The Administrator stated the internal investigation paperwork was on her desk, but after returning from vacation, she purged her office and accidentally threw the investigation paperwork away. During an interview on 04/17/2025 at 10:06 AM, Registered Nurse (RN) #5 was asked if the abuse allegation should have been reported. She said she thought it should have been. During a phone interview on 04/17/2025 at 10:14 AM, Licensed Practical Nurse (LPN) #7 was asked if the abuse allegation should have been reported. She said based on who said it happened, when, where, and having a witness around who really cared for Resident #46, I thought it was a lie from the start, so no. During an interview on 04/17/2025 at 10:38 AM, the DON stated on August 30th, Resident #46's family member came to the DON and stated a couple weeks before, a resident told her Resident #46 was raped, and Resident #34 touched Resident #46 inappropriately. The DON said she called the Administrator, interviewed the resident who made the accusation, and the residents who were sitting at the table with Resident #46. She asked two nurses to do an exam on Resident #46. Nothing was found during the body audit and the witnesses stated it never happened. The DON was informed Resident #34 was seated at the table in the big dining room, and Resident #46 was sitting at another table in the small dining room. She stated Resident #46 was acting normal after the body audit. The DON said she contacted Resident #46's family member, and the family member was good with the outcome of the investigation. The DON said the interventions placed were to ensure Resident #34 was in a separate dining room, and time checks were placed for staff to know where the resident was at all times. The DON said staff was able to interview everyone, complete a body examination, and there was nothing to report. A witness stated Resident #46 was seated next to them and did not see anything suspicious, so she felt an internal investigation was appropriate in this situation. The DON said, anytime an allegation is made, however, everyone complains so, that is where judgment comes into play. We used our experience, investigated in a timely manner, and presented it to the Administrator. She said there was not any documentation in PCC, because witness statements were made. During a phone interview on 04/17/2025 at 11:50 AM, the Medical Director said they should investigate any allegation and come up with the conclusion to report or not.

Based on observation, record review, and interview, it was determined that the facility failed to ensure evidence of an investigation for an allegation of sexual abuse was maintained after the investigation was conducted and failed to report to the Office of Long Term Care (OLTC) the results of the investigation to enable the state agency to provide the necessary oversight of the facility's efforts to investigate for two (Resident #34 and Resident #46) of two residents reviewed for abuse. The findings are: 1. A review of an Admission Record indicated the facility admitted Resident #34 with diagnoses that included congestive heart failure, cognitive communication deficit, and dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident # 34 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment for their daily decision making. In Section E - Behaviors, indicated: Resident #34 did not have verbal, physical or other behaviors symptoms directed toward others. Review of Resident #34's Care Plan initiated [DATE] and revised [DATE], revealed the resident had a behavior problem related to being sexual with others. Interventions included: Resident currently taking [name brand medication name] for depression, to encourage the resident to eat meals with spouse and to get out of the room more often. The resident is married and sometimes thinks another resident is spouse or reminds resident of spouse and resident may try to hold their hands or touch them inappropriately. The resident does not understand/remember that they have dementia or other residents do. (revised [DATE]). 2. A review of an Admission Record indicated the facility admitted Resident #46 with diagnoses that included: neurocognitive disorder with Lewy bodies, vascular dementia with behavioral disturbances, and anxiety disorder. The admission MDS with an ARD of [DATE] revealed Resident #46 a BIMS score of 1 which indicated severe cognitive impairment for their daily decision making. In Section E - Behaviors, indicated: Resident #46 had verbal and physical behaviors symptoms directed toward others, rejection of care and wondering. A review of Resident # 46's Care Plan initiated [DATE] and revised [DATE], revealed the resident was at risk for an elopement/wandering around building and getting turned. Interventions included: Resident was not an exit seeker but had confusion related to dementia and wandered. The resident may get turned around and try to go through doors. The resident wore an elopement bracelet for safety. During a phone interview on [DATE] at 10:47 AM, a family member of Resident #46 said that sometime last year during a visit with Resident #46, another resident approached them and told the family member that Resident #34 was observed seated in the dining room in a wheelchair beside Resident #46 and was touching Resident #46 inappropriately. The family member said it was after hours, so they reported it the following Monday. The family member was informed by the Director of Nursing (DON), that an investigation would be conducted. The family member said the DON later contacted them and informed the family member that the investigation was completed and it was determined the incident did not happen. During an interview on [DATE] at 9:02 AM, the Administrator said she was familiar with the abuse allegation between Resident #34 and Resident #46. She was on vacation and was notified by the DON of the allegation that allegedly happened two weeks prior, from Resident #46 ' s family member. She informed the DON to start an investigation to find out what happened and complete a body audit on Resident # 46. She said that approximately 20 to 25 minutes later, she received a call back from the DON informing her that the DON had spoken with the resident who told the allegation to Resident #46's family member and that resident said they did not see anything. It had been told to that resident by another resident. The Administrator said it would be impossible for anyone to witness because Resident #46 sat in one dining room and Resident #34 sat on the opposite side of the dining room and there were two walls between each side. Resident #46 did not like to be touched and often rejected care and would scream, if touched. The Administrator said an internal investigation was completed and the allegation was unfounded, due to negative findings during the body audit and the interviews with the cognitive witnesses. She felt the internal investigation was all that was needed and felt comfortable the incident did not happen. The Administrator said there was no documentation for the internal investigation and no documentation in (electronic charting software name). The internal investigation paperwork was on her desk, and after returning from vacation, she purged her office and accidentally threw the investigation away. The Administrator said she had never seen or heard Resident #34 physically touch or verbally say anything inappropriate to another person, before or after the incident. She stated Resident #34 was friendly to others but never touched anyone in that way. [The reporting resident] dislikes Resident #34. During an interview on [DATE] at 8:48 AM, Registered Nurse (RN) #6 said she was working the day of the allegation. Around 4:30 PM the DON informed the RN of the situation and asked her to help the floor nurse complete a head-to-toe assessment, including a pubic area assessment. Resident #46 was combative during the assessment, which was normal because Resident #46 did not like to be touched. Resident #46 finally calmed down and RN #6 said the assessment was completed. No signs of abuse, scratches, bleeding or bruising were seen. RN #6 said that after the assessment, no behaviors were observed from Resident #46. RN #6 said that Resident #34 was a flirt , but she had never seen Resident #34 touch or say anything inappropriately to another resident, before or after the incident. RN #6 said some of the interventions in place were Resident #34 was to be in line of sight, and first to be served in the dining room, then moved to the resident's room. During a phone interview on [DATE] at 9:50 AM, the Ombudsman said that she was aware of one resident that touched another resident inappropriately, but that the resident no longer resided in the facility. During an interview on [DATE] at 10:06 AM, RN #5 said she was informed of the situation on that day. She spoke with a resident (who had since expired), and the resident stated it did not happen. RN #5 said the intervention was putting Resident #34 in an area where staff could always observe the resident. RN #5 said that she thought it should be reported to the OLTC. During a phone interview on [DATE] at 10:14 AM, Licensed Practical Nurse (LPN) #7 said she was working the South Hall at the time of the alleged incident and was informed to provide a witness statement. She witnessed the body audit performed on Resident #46. There were no findings, no bruising, redness, or scratches. LPN #7 said she had never seen Resident #34 inappropriately touch or say anything, before or after the incident. She stated, I would be surprised if Resident #34 did anything, due to failing health. The LPN said, checks were in place, but I am not sure if they were [DATE]-minute checks on Resident #34. LPN #7 said she thought the incident should have been a reportable to OLTC. She said based on who said it happened, when, where, and having a witness around who really cared for Resident #46, I thought it was a lie from the start. During an interview on [DATE] at 10:38 AM, the DON stated on [DATE], Resident #46's family member came to me and stated a couple weeks before, a resident told her that Resident #46 was raped, and that Resident #34 touched Resident #46 inappropriately. The DON said she called the administrator, interviewed the resident who made the accusation, and the residents who were sitting at the table with Resident #46. She asked two nurses to do an assessment on Resident #46. Nothing was found during the body audit and the witnesses stated it never happened. She was informed Resident #34 was seated at the table in the big dining room, and Resident #46 was sitting at another table in the small dining room. She stated Resident #46 was acting normal after the body audit. The DON said she contacted Resident #46's family member, and the family member was good with the outcome of the investigation. The DON said the interventions placed were to ensure Resident #34 was in a separate dining room, and time checks were placed for staff to know where resident was at all times. The DON said we were able to interview everyone, complete a body examination, and there was nothing to report. A witness stated Resident #46 was seated next to them and did not see anything suspicious, so she felt an internal investigation was appropriate in this situation. The DON said anytime an allegation is made, however, everyone complains so that is where judgment comes into play. We used our experience, investigated in a timely manner and presented it to the Administrator. She said there was not any documentation in PCC because witness statements were made. During a phone interview on [DATE] at 11:50 AM, the Medical Director said he was aware of the incident but could not remember the details. He said they should investigate any allegation and come up with the conclusion to report or not.

Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to perform proper hand hygiene, don proper personal protective equipment (PPE), and follow standard infection control procedures for one (Resident #74) of three residents reviewed for isolation precautions. The findings are: A review of the Admission Record noted Resident #74 was admitted to the facility on [DATE], for diagnoses which included aftercare following joint replacement surgery. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2025 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14 (13-15 suggest cognitively intact). A review of the Physician Order Summary revealed Resident #74 was on enhanced barrier precautions (EBP), due to the peripherally inserted central catheter (PICC) line in their right arm and an order to receive antibiotics intravenously, via PICC line for a diagnosis of osteomyelitis (infection in the bone) of the hip. A review of the Transmission-Based Precautions (Isolation Precautions) policy, last revised 05/2024, noted For residents for whom EBP are indicated, EBP is employed, and gown and gloves should be worn when performing the following high-contact resident care activities. The policy noted Device care or use (PICC line is an indwelling device). A review of the undated Medication Administering policy, effective 09/2019, noted Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) On 04/16/2025 at 8:00 AM, this surveyor observed Licensed Practical Nurse (LPN) #1 donning gloves in the medication room located on the 800 Hall, while she prepared the antibiotics for administration. LPN #1 retained the left glove on her hand and walked down the hall to Resident #74 ' s room, which was approximately 25 feet. LPN #1 did not perform hand hygiene and did not don a gown prior to entering Resident #74 ' s room. LPN #1 applied a glove to her right hand and cleaned the hub (the connection point where the end of the PICC line connects to the intravenous line [IV tubing] to deliver the medication) with an alcohol pad for approximately 10 seconds and allowed the hub to air dry, holding the end of the PICC line with her thumb and finger. LPN #1 then touched the hub with her left thumb multiple times. LPN #1 started to connect the IV tubing to the hub of the PICC line. LPN #1 was told she touched the hub so she cleaned the hub of the PICC line again and then connected the IV tubing to the hub of the PICC line and administered the medication. During an interview on 04/16/2025 at approximately 8:30 AM, LPN #1 stated, I was supposed to dress out for that, because the resident is on EBP. LPN #1 confirmed she wore the same glove on her left hand from the medication room to Resident #74's room and did not perform hand hygiene. LPN #1 also confirmed she did not don a gown to perform the medication administration. During an interview on 04/16/2025 at approximately 9:45 AM, the Director of Nursing (DON) confirmed Resident #74 was placed on EBP due to having a PICC line. She stated, It's especially important to be cautious with PICC lines since they go straight to the heart. An infection would be dangerous. She also confirmed hand hygiene should be completed, new gloves applied, and a gown per the EBP for direct care or use of an indwelling device such as a PICC line.

Based on record review, observations, interview, the facility failed to ensure that hands were washed between clean and dirty task to prevent food borne illness. The failed practice had the ability to affect 35 residents who receive their meals from 1 of 1 kitchen. The findings are: A. On 01/08/24 at 12:20 PM, Dietary Aide #1 was observed to be wearing black gloves while serving trays from the steam table in the main dining room. Dietary Aide #1 was observed touching utensils, trays, plates, the counter, and a large clear trash bag of refuse during lunch service. Dietary Aide #1 continued to use contaminated gloves while using a scoop to serve homestyle French Fries. Dietary Aide #1 scooped up the french fries to serve and touched them with their right thumb to hold them into the scoop. Dietary Aide #1 continued to serve trays in the main dining room, did not switch gloves or wash hands between tasks. Dietary Aide #2, while wearing black gloves was observed putting trash in a large clear trash bag on the counter behind the serving line. Dietary Aide #1 reached into a stainless-steel bin with white bread slices, using her right hand to retrieve the bread slice. Dietary Aide #1 put the bread slice onto the tray and continued serving to main dining room. Dietary Aide #2 continued to put trash from lunch service into a large clear trash bag. Dietary Aide #1 asked Dietary Aide #2 for a white bread slice. Dietary Aide #2 used contaminated gloves to retrieve the white bread slice to hand to Dietary Aide #1. They continued to finish serving trays to the main dining room, did not switch gloves or use hand hygiene until lunch service was finished. B. On 01/10/24, Dietary Aide #3 was observed to be buttering rolls with a brush for lunch while wearing black gloves. After finishing the task and without changing gloves they continued to prepare to process mandarin oranges for puree. Dietary Aide #3 used contaminated gloved hands to put the bowl on, add the blade, retrieve utensils, and stainless-steel bins. Dietary Aide #3 removed gloves and did not wash hands then began to scoop mandarin oranges into the food processing bowl. Dietary Aide #3 pureed the mandarin oranges with thickener and used a rubber spatula to scoop it out of the food procession bowl and into stainless steel bins. Dietary Aide #3 put plastic wrap on top of the pureed mandarin oranges and moved them for service. Dietary Aide #3 took the food processing equipment to the dishwasher and then began the process to puree green peas. Dietary Aide #3 reassembled the food processing equipment and then went to get a 1/3 steam table pan of cooked green peas. Dietary Aide #3 was observed to be scooping green peas into the food processor. Dietary Aide #3 pureed the green peas and scooped them out into stainless-steel bins with a rubber spatula. Dietary Aide #3 was observed to be reassembling the food processor to finish the rest of the green peas. Before putting on the lid Dietary Aide #3 touched the top of the blade to push it down and proceeded to process the last of the green peas. Surveyor observed the left index finger touch the pureed mixture before putting the lid on. Dietary Aide #3 then pureed the green peas and scooped out the rest with a rubber spatula. Dietary Aide #3 continued to prep for the next puree and still was not observed to wash hands. C. On 01/11/2024 at 10:04 AM, the administrator provided a policy for hand hygiene. On page 1, under section A the policy states Decontaminate hands before donning gloves. Decontaminate hands after removing gloves. Decontaminate hands after contact with inanimate objects D. On 01/11/24 at 1:30 PM, the Dietary Manager was asked when hands should be washed. The Dietary Manager described hands needing to be washed upon beginning of shift, in between clean and dirty tasks, in between glove usage, and when hands appear to be soiled. The Dietary Manager was asked when do you change gloves? The Dietary Manager described that gloves should be changed in between tasks, when touching a different surface, utensils. The Dietary Manager was asked why it is important to change gloves and wash hands between clean and dirty tasks. The Dietary Manager stated, To prevent cross contamination.

Based on observation, interview and record review, the facility failed to ensure 2 Residents (#5 and #35) of 13 sampled residents who required assistance with hand hygiene, were assisted with hand hygiene prior to feeding self during meal to prevent contamination and illness. The findings are: Resident #5 had a diagnosis of Schizophrenia. The Quarterly Minimum Data Set (MDS)with an Assessment Reference Date of 10/11/2023 documented the Resident scored 09 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required partial/moderate assistance with her Activity of Daily Living (ADL's.) The Comprehensive Plan of care included the need for assistance with ADLS with an intervention revision on: 01/23/2017 stating Resident #5 requires partial to moderate assistance of one person for personal hygiene; an intervention dated 4/25/23 indicates the resident wants staff to provide all care at times with staff to encourage and assist as needed to ensure daily needs are being met. On 01/08/24 at 9:03 AM Resident #5 was observed sitting in her wheelchair in her room, her fingernails were approximately 1/2 inch past the tips of her fingers. A dark substance, brown in color was observed under her fingernails. On 1/8/24 at 12:34 PM Resident #5 was feeding herself in the dining room. Her fingernails were proximately 1/2 inch past the tips of her fingers. A dark substance, brown in color was observed under her fingernails. On 1/9/24 at 02:35 PM Resident #5 was sitting in her wheelchair in her room, her fingernails were approximately 1/2 inch past the tips of her fingers. A dark substance, brown in color was observed under her fingernails. On 1/9/24 at 2:45 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4 can you describe Resident #5 ' s fingernails. CNA #4 stated, They're long, yellow with dry skin behind her nails, and dark in color. The Surveyor asked CNA #4 when the hands should be washed for meals. CNA #4 said, stated, Before every meal and before they touch their food. The Surveyor asked, how are hands cleaned. The CNA #4 stated, With hand sanitizer. On 1-12-24 at 8:32 AM, during an interview Licensed Practical Nurse (LPN) #2, the Surveyor asked when hand hygiene should be performed. LPN #2 stated, Before and after meals, toileting, and when contaminated with bodily fluids and germs. The Surveyor asked when hands are looked at closely to know if any hand care is needed. The LPN #2 said, stated, On shower days, nails should be clipped and cleaned. Resident #35 had a diagnosis of Cerebral infarction. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10-10-2023 documented set up or clean up assistance, severely impaired for daily decision making according to a Staff Assessment for Mental Status. On 1/8/2024 at 11:30 AM, Resident #35 was observed in her room, sitting up in bed fingernails are 1/2 in long with a dried dark substance under her nails, she was observed eating with her hands placing her fingers in her mouth. On 1/9/2024 at 12:46 PM, Resident #35 was observed in her room, sitting up in bed fingernails are 1/2 in long with a dried dark substance under her nails, she was observed eating with her hands licking her fingers. On 1/9/2024 at 2:34 PM, the Surveyor asked CNA #4 can you please describe what you see under Resident #35's fingernails. CNA #4 said, They're long, yellowish, jagged, and dirty. The Surveyor asked CNA #4 are the residents hands cleaned before their meals. CNA #4 said The residents hands are cleaned with hand sanitizer, before meals. On 1-10-2024 at 9:10 AM The Administrator supplied a policy on Hand Hygiene .Residents Hand Hygiene: Keeping resident's hands clean is the number one way to prevent the spread of infection. Clean their hands after using the bathroom; after sneezing, blowing their nose, or coughing; before eating; or whenever their hands are dirty .

Based on observation, interviews and record review, the facility failed to ensure physician orders were followed to maintain a medication error rate of less than 5%, to prevent potential complications for 2 (Resident #13 and #61) of 25 residents that could potentially receive medication observed during the medication pass. This failed practice has the potential to inhibit maximum therapeutic outcomes. The medication error rate was 8.00%, based on observations of 25 medications administered. The findings are: a. On 01/09/24 at 3:22 PM, the Surveyor observed the 4:00 PM medication pass with the Licensed Practical Nurse (LPN) #1. The LPN #1 administered Nystatin 100000 suspension 5 ml being given by mouth four times a day X 7, order written 1/4/2023. The LPN #1 failed to shake the bottle before administration as listed on the bottle, to Shake Well. b. The MAR (Medication Administration Record) documented Resident #13 was to receive Nystatin Suspension 100000 UNIT/ML Give 5 ml by mouth four times a day for 7 Days swish and swallow. c. 01/10/24 03:07 PM, in an interview with LPN #1, in response to the question, are you aware Nystatin suspension is to be shaken before administration? LPN #1, stated, I thought about shaking the bottle afterwards. The bottle indicates prior to administration to shake the bottle. Shaking the bottle mixes the suspension. d. On 01/10/24 at 8:15 AM, the Surveyor observed the 8:00 AM medication pass with LPN #1. LPN #1 administered Fluticasone Propionate Suspension 50 MCG/ACT 2 spray in each nostril to Resident #61. LPN #1 failed to shake the bottle gently before administration as listed on the bottle and the manufacture's insert. e. The MAR (Medication Administration Record) documented Resident #61 was to receive Fluticasone Propionate Suspension 50 mcg 2 spray each nostril one time a day. f. 01/10/24 03:40 PM, in an interview with the LPN #1, in response to the question, Are you aware Fluticasone nasal spray, should be shaken gently before administration? LPN #1 stated, I was not aware, but it is clearly written on the bottle, to shake gently before administration. g. On1/11/2024, at 10:59 AM, with the Director of Nurses (DON), in response to the question, is it necessary to require adequate shaking during the preparation of medications prior to each dose of the administration and what would be the outcomes of not following instructions on the medication bottle or the medication insert? The DON stated, The LPN told me about the medication error, and had not looked at the bottle for instructions, and it should be followed as indicated on the bottle on the insert. If it is not given correctly, it can cause the medication to not be delivered properly. h. On 01/10/2024, at 10: 15 AM, the DON provided a policy titled, Medication Errors (Revised 4/2017) read in part .It is the policy of [Facility] to ensure that the Residents are free of any significant medication errors and the facility is free of medication errors of 5% or greater. Medication Errors due to failure to follow Manufactures Specifications or accepted Professional Standards include Failure to Shake Well. In addition, the policy Medication Administering (Effective: 9/2019) provided by the DON on 01/11/2024 at 10:16 AM, read in part .The individual administering the medication must check the label three (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving medication.

Based on observation and interview, the facility failed to ensure accommodation of needs were met by not ensuring the call light was within reach for one (Resident #8) of 16 residents (Resident #2, #3, #5, #8, #15, #16, #22, #24, #33, #35, #40 #42, #45, #49, and #62) sampled residents. The findings are: Resident #8 has a diagnosis of TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY and ACQUIRED ABSENCE OF LEFT LEG ABOVE KNEE. On the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/29/23, the Resident received a score of 15 on the Brief Interview for Mental Status (BIMS). On the annual MDS with an ARD of 7/05/23 the resident is an extensive assist with bed mobility, personal hygiene, transfer, dressing, and toilet use. A. On 01/08/24 at 11:39 AM, Resident #8 was observed to be lying in bed. The call light was observed to be in the top drawer of nightstand and appeared to be out of reach of the resident. The Surveyor asked Resident if he could reach the call light. Resident #8 responded that he could not reach the call light. B. On 01/08/24 at 11:45 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 where a residents call light should be located. CNA #3 stated, Next to the resident. The Surveyor asked how long the Resident has been without the call light. CNA #3 responded for about thirty minutes. C. On 01/11/24 at 2:15 PM, the Director of Nursing (DON) was asked why a Resident would need a call light within reach. The DON said so the Resident can call for assistance. D. On 01/11/24 at 10:04 AM, the Administrator provided a call light policy that states When leaving the room, place call light within easy reach of resident if in bed. If out of bed, stretch call light cord across bed so resident is able to reach it.

Based on observation, interview and record review, the facility failed to ensure Resident's catheter bag was secured and off the floor to prevent cross contamination for 1 of 1 sampled Resident #40 who have has a physician's order for an indwelling catheter according. The findings are: Resident #40 has a diagnosis of OBSTRUCTIVE AND REFLUX UROPATHY. On the Quarterly Minimum Data Set (MDS), dated [DATE] the resident received a score of 15 on the brief interview for mental status. On the discharge/return anticipated MDS the resident was noted to be dependent for Chair-bed transfer, sit to stand, lying to sitting and sit to lying. On 1/8/24 at 11:28 AM, the Resident #40 was observed to be sitting in his recliner. Resident's catheter bag was observed to be lying on the floor in front of the recliner, next to the Resident ' s foot. On 1/08/24 at 3:06 PM, Resident #40 ' s catheter bag was observed to be lying on the floor, just to the left side of the recliner. Resident's feet are elevated by the chair's footrest On 1/11/24 at 2:10 PM the Director of Nursing (DON) was asked where a urinary catheter bag should be located. The DON stated, It should always be below the bladder. When asked if the bag should ever be placed on the floor the DON stated, no. On 1/12/24 at 8:26 AM, Certified Nursing Assistant (CNA) # was asked where a Resident's catheter bag should be placed. CAN #4 stated, If they are in a wheelchair then underneath the seat, if they are in the bed, on the bottom of the bed frame and if they are in a recliner then I hang it on the pocket. When asked if a catheter bag should ever be put on the floor CNA #4 stated, No, absolutely not.

Based on record review and interview the facility failed to ensure residents had ready and reasonable access to funds managed by the facility for 1 (Resident #49) of 17 (#1, #5, #8, #11, #12, #17, #23, #25, #27, #31, #36, #39, #44, #47, #49, #98, and #153) sampled residents who had a trust fund managed by the facility as documented on a list provided by the Administrator on 10/18/22 at 8:10 AM. The findings are: Resident #49 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/3/22 the resident received a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 13-15 implies that the resident is cognitively intact. a. On 10/18/22 at 9:13 AM, Resident #49 stated, I am unable to obtain money for a family birthday. I was told that I had to have a receipt. b. On 10/19/22 at 8:05 AM, The Surveyor asked the Billing Coordinator, Can Resident #49 access her money? She answered, She is known to ask for large sums of money .maybe $100 or $200, that is a large sum to me. She wants to gift cash to family members. When this happens, of course there is no receipt and I have told her that this could get us both into trouble when it came time to reapply for her Medicaid. c. On 10/19/22 at 2:50 PM, Resident #49 stated, I used to send my kids $100 for Christmas. I can't do that anymore. I have two children with birthdays in March and I am unable to send them money as a gift. The Billing Coordinator told me that Social Security changed the way they do it. A staff member goes to [Retail Store] every other week and I am allowed to purchase things that way or the billing coordinator will order things for me because that way there is a receipt. d. On 10/19/22 at approximately 3:15 PM, The Administrator reported that she was unable to locate any policies or procedures relating to trust accounts. e. On 10/20/22 at 9:30 AM, The Surveyor asked the Administrator, What expectation she had when a resident requested money? She stated, We give the requested amount. She added that she had spoken to the billing coordinator and expressed that, it is not our position to decide if its gifting or not.

Based on observation, record review and interview, the facility failed to review and revise the resident care plan to meet the residents' needs for 2 (Resident # 23 and #8) of 16 (Residents #28, 54, 48, 44, 12, 14, 23, 39, 27, 8, 49, 54, 17, 24, 36, 153) sampled residents whose care plans were reviewed. The Findings are: 1. Resident #23 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She received oxygen, care of a PICC (Peripheral inserted central catheter) line and antibiotics while a resident. a. On 10/17/22 at 11:38AM Resident #23 was in bed with oxygen in use at 1.5 liter per minute (via nasal cannula) dated 10/17/22. A portable oxygen cylinder was on the back of her wheelchair. The PICC line was in place. An IV (intravenous) pole was at the bedside. b. On 10/18/22 at 08:15 AM, Resident #23 was in bed with Oxygen in use. PICC Line in left arm and IV pole at bedside. c. On 10/18/22 at 11:40AM, Resident #23 was in bed with Oxygen in use. PICC Line in left arm and IV pole at bedside. d. On 10/18/22 at 2:00PM, Resident #23 was in the bed with Oxygen in use. PICC Line in left arm and IV pole at bedside. e. On 10/19/22 at 1:30 PM, Resident #23 was sitting in her wheelchair in her room with portable oxygen via nasal cannula running at 1.5 liters per minute. PICC Line and IV pole noted. f. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 1-4 LPM (liters per minute) via (by way of) n/c (nasal cannula) prn (as needed for) SOB (shortness of breath) . g. On 10/19/22 at 11:01 AM, Review of Resident #23's Care Plan with a revised date of 12/6/19 revealed no documentation of the use of oxygen or IV antibiotics. h. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . i. On 10/20/21 at 5:20 PM of Section 4.7 of the RAI (Resident Assessment Instrument) Manual documented, . The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving . j. On 10/20/22 at 11:40 AM, the Surveyor asked the MDS Coordinator, Will you look at the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes there is The Surveyor asked, does Resident # 23 have a care plan for IV antibiotics, PICC Line management and Oxygen? She answered, Yes she does for the PICC Line, I put it on their yesterday. The Surveyor asked, when was it ordered? She stated, 10/14/22. The Surveyor asked, should she have a Care Plan for these needs? She answered, Yes. The Surveyor asked, who is responsible for making sure It's on the care plan? She answered, Me. 2. Resident #8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/22/22 documented a score of 8 (7-11 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). He used Anticoagulant medications 7 days during the lookback period. a. On 10/20/22 at 11:40 AM, the Surveyor asked the MDS Coordinator, Will you look at physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes there is. The Surveyor asked, does Resident #8 have a Care Plan for an anticoagulant? She answered No. The Surveyor asked, should she have a Care Plan for anticoagulant? She answered, Yes. The Surveyor asked, who is responsible for making sure it I s on the Care Plan? She answered, Me. 3. A policy provided by the Administrator on 10/20/22 at 11:45AM Titled CARE PLAN documented, .This plan of care will be modified to reflect the care currently required/provided for the resident .

Based on observation, record review and interview, the facility failed to ensure oxygen signage was displayed in accordance with professional standards of practice when oxygen is in use for 5 (#14, #23, #36, #44, #49)of 9 (5, #8, #14, #23, #31, #36, #39, #44, #47, #49) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident # 23 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She received oxygen. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 1-4 LPM (liters per minute) via (by way of) N/C (nasal cannula) PRN (as needed for) SOB (shortness of breath) . a. On 10/17/22 at 11:38 AM, Resident # 23 was in bed with O2 [oxygen] on via N/C [Nasal Canula] @ [at] 1.5 liter per minute dated 10/17/22. There was no Oxygen in use sign on the door. b. On 10/18/22 at 8:15 AM, 11:40 AM and 2:00 PM, Resident #23 was in the bed with Oxygen in use with no sign that oxygen was in use on the door. c. On 10/19/22 Resident #23 was sitting in her wheelchair in her room with portable oxygen via nasal cannula running at 1.5 Liters per Minute without an oxygen sign on the door. 2. Resident # 44 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum DATA SET with an Assessment Reference Date of 9/23/22 documented a score of 8 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. She received oxygen while a resident. A Care Plan documented OXYGEN: . CANNULA MAY BE PLACED IN MOUTH Due to (D/T) PAIN IN RIGHT NOSTRIL . I am on oxygen therapy, 2-3 liters per minute (LPM) via nasal cannula every shift for shortness of breath related to [CONDITION(S)] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cannula may be placed in mouth D/T pain in right nostril every shift. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 10/17/22 at 11:39 AM, R#44 had O2 on by nasal cannula in her mouth at 2.5 LPM. There was no oxygen in use sign on door. b. On 10/18/22 at 8:45 AM, R#44 was sitting in her recliner with her oxygen on at 2.5 LPM. The Oxygen sign was not displayed on door. c. On 10/19/22 at 2:45 PM, R#44 was in bed with Oxygen On via nasal canula at 2.5 LPM with no oxygen sign posted on door. 3. Resident # 49 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 10/17/22 at 10:48 AM, Resident #49 was in recliner with O2 on via N/C at 2 LPM. No oxygen sign on the door. b. On 10/18/22 at 11:50 AM, Resident #49 was in recliner with oxygen on at 2 LPM via nasal cannula. There was no sign about oxygen in use. c. On 10/19/22 at 2:30 PM, R# 49 was in recliner with no sign posted about oxygen in use. Oxygen in use via nasal cannula at 2 LPM. d. Care Plan documented .O2 at 2 LPM via N/C [nasal canula] q [every] 24 hours PRN [as needed] S.O.B [Shortness Of Breath] . e. On a POLICY labeled OXYGEN provided by the administrator on 10/20/22 at 9:40 AM documented .Oxygen will be delivered in a safe manner and with clean and functioning equipment f. At 10/20/22 The Surveyor asked LPN # 1, why should an oxygen in use sign be posted? She stated, Because its flammable and people need to know when it's in use. The surveyor asked LPN # 1, What could happen if it isn't posted? She stated, I'm not exactly sure. They need to be on it and that alerts staff to make sure it's on cause shoes need to be on due to static electricity. g. At 10/20/22 The Surveyor asked the Assistant Director of Nursing (ADON), Why should an oxygen in use sign be posted? She stated, First, most importantly to make sure it's in place and that no one from the public accidently smokes. The Surveyor asked the ADON, What could happen if it isn't posted? She stated, Obviously the resident could get hypoxic without oxygen so this helps alert staff and staff will not do anything they aren't supposed to do. 4. Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set [MDS] with as Assessment Reference Date [ARD] of 09/02/22 documented a Brief Interview of Mental Status [BIMS] of 12 (Indicated Cognition Intact), required extensive assistance with activities of daily living self-performance skills with one-to-two-person physical assist. Oxygen-Yes. a. 10/19/22 at 2:18 PM, The resident was in bed and receiving wound care. The oxygen was on at 2 LPM [Liters Per Minute] per NC [nasal cannula]. There is no signage on the door to alert that oxygen is on in the room. b. On 10/20/22 at 10:32 AM, the Resident was asleep in bed, with the O2 still on at 2LPM/NC. There was still no sign on the door that Oxygen was in use. 5. Resident #36 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 09/12/2022 documented a BIMS of 12 (Indicated Cognition Intact), required supervision to limited assistance with activities of daily living self-performance skills with one-person physical assist. Oxygen-Yes. a. On 10/18/22 at 11:09 AM, the resident was in her room sitting in the recliner with oxygen going at 2 LPM/NC. There was no sign on the door to alert Caution Oxygen in Use, or No Smoking. b. On 10/19/22 at 1:24 PM, the resident still had her oxygen on at 2LPM/NC, there's still no oxygen in use sign. c. On 10/20/22 at 12:39 PM, the resident was sitting in her recliner with oxygen still going at 2LPM/NC. There was still no sign that oxygen was in use.

Based on record review and interview the facility failed to ensure resident funds were refunded promptly after discharge/death for 11 (#104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114) sampled residents who had trust funds, as documented on a list provided by the Billing Coordinator on [DATE] at 8:19 AM. The findings are: 1. On [DATE] at 8:05 AM, The Surveyor asked the Billing Coordinator, Why are there 65 residents listed with trust accounts and only 54 residents in the facility? She answered, Some of the residents have been discharged and had received an interest payment after the account was closed out. One resident who was on the books when I took this position. Some of the residents had a balance of as little as a penny and, the people who write the checks downstairs don't know where to send it. Some of the residents had no family or representatives with whom to leave the money. 2. On [DATE] at 8:19 AM, The Billing Coordinator highlighted 11 residents on the list of trust account holders who were discharged but still had a balance in the trust account. 3. On [DATE] at 11:35 AM, a list of the residents with trust accounts was provided by the Administrator. The list revealed a total of 65 residents with balances in the trust account. According to the Administrator on [DATE] at 10:20 AM, the census of the facility was 54. 4. Resident #111 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated [DATE] documented, .Resident is now Hospice . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] at 8:19 AM documented Resident #111 had a balance of $0.01 in the trust fund. 5. Resident #112 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Return Not Anticipated MDS with an ARD of [DATE] documented the resident discharged to the community. A Progress Note dated [DATE] documented, .Resident discharged with all medications . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #112 had a balance of $15.79 in the trust fund. 6. Resident #104 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated [DATE] documented, .discharged to home with Granddaughter . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #104 had a balance of $1.62 in the trust fund. 7. Resident #105 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Progress Note to in the record to document the resident's death. a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #105 had a balance of $0.03 in the trust fund. 8. Resident #106 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated [DATE] documented, . Stayed with family till breathing ceased . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #106 had a balance of $0.20 in the trust fund. 9. Resident #107 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Discharge Status .Other . A Progress Note dated [DATE] documented, .All of personal belongings were taken with resident and family . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #107 had a balance of $0.03 in the trust fund. 10. Resident #108 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated [DATE] documented, .Resident has had a decline. The resident was unable to eat, drink or take any PO (oral) meds. unable to obtain an O2 (oxygen) attempted by multiple people but last night was staying between 40's and 60's. resident on 3 LPM (liters per minute) via mask due to labored mouth breathing with short periods of Apnea. Hospice and family and provider notified, and family is at bedside . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #108 had a balance of $1.62 in the trust fund. 11. Resident #109 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated [DATE] documented, .Note Text: Report on this resident called to [Named at Nursing Facility] at 0850. Transportation from that facility arrived at approximately 0825 . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #109 had a balance of $1.67 in the trust fund. 12. Resident #110 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated [DATE] documented, .Coroner pronounced resident deceased . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #110 had a balance of $0.01 in the trust fund. 13. Resident #113 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Acute Care Hospital .A Progress Note dated [DATE] documented, .resident will need to go to hospital due to abnormal CT (Computed Tomography) of chest . a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #113 had a balance of $0.02 in the trust fund. 14. Resident #114 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Progress Note that documented the resident death. a. The Trust-Current Account Balance sheet as of [DATE], which was provided by the Billing Coordinator on [DATE] documented Resident #114 had a balance of $0.03 in the trust fund. 15. On [DATE] at 12:45 PM, The Surveyor asked the Administrator, to provide the form which is signed when a resident elects to open a facility managed trust account. The Administrator reported that there is not a form signed by the resident concerning the opening of a trust account, just the Beneficiary Designation Form. The Surveyor asked, What takes place when a resident has no one to name as beneficiary? She stated, .I have reached out to a consultant from another facility to discuss what their practice is . 16. On [DATE] at 1:06 PM, The Administrator reported that she was pulling the paperwork for the residents who are discharged but still have a balance in the trust account. She stated, .There is not a beneficiary notice in the ones I am pulling so far. I will also find out when they changed to this new Admission Packet. 17. On [DATE] at 1:25 PM, The Administrator stated the new Admission Packet was adopted by the facility on [DATE]. As a result, Resident #107 is the only resident who was admitted using the new Admission Packet. The Administrator stated that she was still looking for a policy.

Based on record review and interview the facility failed to ensure the resident and resident's representative were notified in writing of the reason for the transfer/discharge to the hospital in a language they could understand for 2 (Resident #14 and #28) of 6 sample selected Residents who were hospitalized from 07/02/2022 to 10/05/2022. This failed practice had the potential to affect 26 Residents who were transferred/discharged to hospitals since 07/02/2022 according to a list provided by the Administrator on 10/20/2022 at 11:49 am. The findings are: 1. Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set [MDS] with as Assessment Reference Date [ARD] 07/29/22 documented a Brief Interview Mental Status [BIMS] of 12 (Indicated Cognition Intact), required extensive assistance with activities of daily living self-performance skills with one-to-two-person physical assist. A Notice of Unplanned Transfer/Discharge and Bed Hold documented. On this date 07/16/22, the resident has been transferred/discharged to .due to Change of Condition. The Notice of transfer did not give details in language the resident or representative could understand. a. On 10/20/22 at 11:30 am, The Surveyor asked the Medical Records Clerk, Is this the only documentation that you sent out to the resident or representative? She stated, Yes, it is, I just scan them, and the Activity Director sends them out. The Administrator sends the monthly report of notices to the Ombudsman. 2. Resident #28 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the Quarterly (MDS) with an ARD 8/26/22 showed his BIMS documented a 3. a. A Discharge Return Anticipated MDS with an ARD of 8/21/22 documented discharge to an acute care hospital. b. A Progress Note dated 8/21/22 documented, . resident is being sent [Medical Facility] for altered mental status . c. Review of Resident #28's record did not reveal a notice of transfer/discharge which would have been sent to the representative with a reason for transfer in writing.

Based on record review and interview, the facility failed to ensure a tamper resistant band was provided on a Secure Care Alarm System bracelet for 1 (Resident #262) of 2 (Residents #262 and #24) sampled residents who had broken their Secure Care Alarm System bracelet and staff were trained to stop a resident from leaving the building for 1 of (Resident #262) sampled resident who exited the people unaccompanied. These failed practices resulted in Immediate Jeopardy for Resident #262 who exited the building on 2 occasions without being accompanied by staff. The Immediate Jeopardy was removed on June 19, 2021 when the resident was placed on one-on-one and a wander guard bracelet was placed on the resident's wheelchair, but other deficient practices remained. The Director of Nursing (DON) was informed of the Immediate Jeopardy removed on July 1 at 2:39 p.m. The findings are: Resident #262 had diagnoses of Dementia, Anxiety, and Major Depressive Disorder. The Admission Minimum Data Set with an Assessment Reference Date of 6/23/21 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and was at significant risk of wandering and getting to a potentially dangerous place. a. Resident #262 was admitted on [DATE] and the Baseline Care Plan documented the resident was an elopement risk. b. An Admission Wandering Risk assessment dated [DATE] documented, .Resident states she wants to go home and has made at least one attempt to leave out the front hall. Wander guard in place to alert the staff when she is out of her room and trying to leave . c. The Comprehensive Plan of Care documented, . MOOD/BEHAVIOR: I have some hx [history] of [CONDITION(S)] and general confusion at times. Date Initiated: 06/18/2021 .I tried to get out of my room and wanted to leave after admitting. I have an elopement bracelet on to aide in my safety. Date Initiated: 06/18/2021 . I am new to the facility and don't want to be here. I want to go home. I do not think my health care proxy will take me back home. Date Initiated: 06/18/2021 . Please Monitor/record my mood to determine if problems seem to be related to external causes, i.e. [such as] medications, treatments, concern over diagnosis . d. A Progress Note on 6/19/2021 at 10:30 a.m. documented, Late Entry: .resident removed elopement bracelet and wheelchair elopement alarm and exited building. Staff stopped at edge of parking lot and returned to building. Explained again reason for stay and resident voices understanding. Resident has scant short term memory and needs reminding often. e. A Progress Note on 6/19/2021 at 11:36 a.m. documented, .Resident went to south Hall and exited through double doors despite elopement bracelet and door alarming. Staff noted resident in front parking lot and returned to hall and notified this nurse. Staff member will be assigned to monitor resident. f. On 7/1/21 at 10:30 A.M., the Director of Nursing (DON) was asked to explain about resident's elopement and how she was able to remove the wander guard. She stated, She pulled it off, she's not the only one. She was asked, How did she get it off? She stated, She just pulled it until it broke. She was asked, What type of material is the strap made of? She stated, It's just like a hospital bracelet, it's plastic. She was asked, After she broke the first bracelet, why didn't you get a different type of strap? She stated, I don't know, this is the only kind I've ever used. It's the one that comes with the unit. She was asked if the progress notes documented one time, she left the faciity on [DATE]. She stated, .that was two separate occurrences. The first was at 10:30 [A.M.] and the second was 11:30 [A.M.]. g. On 07/01/21 at 10:50 A.M., Resident #262 was asked how long she had been in the facility. She stated, 2 days. She was asked why she was in the facility. She stated, I don't know, it was not my choice. She was asked, Have you tried to leave the facility? She stated, No, I've not had any problems. Everybody has been real nice. She was asked if the facility staff had put a bracelet on her that would alarm if she tried to leave. She stated, No, I don't need that. I'm not a child. I'm not going anywhere. The wanderguard was under her wheelchair. h. On 07/01/21 at 11:22 A.M., Licensed Practical Nurse (LPN) #2 was asked if she was working on 6/19/21 and if she could tell me about what happened with Resident 262. She stated, She didn't want to stay, she had just come in and when she would go to the door the alarm would sound and we would have to talk her into coming back to her room. She was asked if she (Resident #262) had exited out of the building. She stated, One time, there is a fire safety on the door if you push it long enough it will release. So, we talked her into coming back in. She was asked if she exited the building a second time that day. She stated, .I'm just going by what I was told. One of the aids brought her back in. She was asked what she did after the first time the resident got out of the building. She stated, I placed someone at the end of the hall to watch closer. She was asked what interventions were placed after the second time. She stated, The same thing, and explained again to the resident, she has a very short term memory. She was asked if the wander guard was on the resident. She stated, She kept pulling it off, I finally put it under the wheelchair, out of sight out of mind . She was asked if the resident was able to ambulate. She stated, She can transfer, but not ambulate. She was asked if the resident was put on one on one. She stated, I don't know, I'm old, that's been awhile. i. On 7/1/21 at 12:17 P.M., the Director of Nursing (DON) was asked for a Training/Monitoring report. The DON stated no training was initiated that she was aware of after Resident #262 eloped on 6/19/2021. At 12:19 P.M. the DON verified there was no training/communication provided after Resident #262 eloped on 6/19/2021 either time. j. On 07/01/21 at 1:14 P.M., CNA #1, who was working on 6/19/21 stated, It was maybe her [Resident 262] 2nd or 3rd day, she kept saying she wanted to go home, we would try to redirect her, but she wanted to go home. When she got out, the screener came to the hall and told me she got out. I went to get the weekend supervisor and my partner went to get [Resident #262] and bring her back in. The supervisor had me sit with her, I stayed with her. CNA #1 was asked, Did you document that you were with her and where she was? He stated, No, no one gave me anything to document. CNA #1 was asked, How long did you stay with her? He stated, Until about 7:15 P.M. or 7:20 P.M. at the end of my shift. CNA #1 was asked, Did anyone take over for you? He stated, No, I was told they would figure it out. CNA #1 was asked, Did [Resident #262] have a wander guard? He stated, Yes, she had one on her body then we put one on her wheelchair. CNA #1 was asked, Was she able to walk and or ambulate? He stated, Not that I know of. She could transfer from chair to bed and toilet. CNA #1 was asked, Since the resident eloped on that day, are you aware of any other times she tried to get out the door or did get out of the facility? He stated, Not that I know of. CNA #1 was asked, How do you check the wander guard to ensure they are working properly and that they are on the resident? He stated, They didn't check them as far as I know. CNA #1 was asked, What about the doors? He stated, I have no knowledge of anyone checking the doors. k. On 07/01/21 at 2:55 P.M., Registered Nurse (RN) #1 was the weekend supervisor, she was asked to review what happened the day Resident #262 got out of the facility. She stated, The first time she went around the south hall and circled around by the cafeteria, [the screener] didn't know she was a resident at the time. She [Resident #262] had only been here for 2 days. We got her back in and she was settled. I didn't think there would be any more problems. Then about an hour later [the screener] came to the hall and said she [Resident #262] was outside. She was out in the drive through area. We got her back in and she had pulled her alert bracelet off, we replaced that, and I had [CNA #1] sit with her. RN #1 was asked, Did you have him document during his one on one with her? She stated, No, it wasn't like we were doing neuro checks. RN #1 was asked, Did you notify the Administrator? She stated, Yes, I wanted to know what the screener was allowed to do and why she couldn't stop the resident from going out. He said she could stop the resident from going out, she just couldn't provide care. I also told him she was wanting to go home, but it wasn't possible. We tried to redirect and tell her there wasn't any way to get her home today, she didn't have a ride. RN #1 was asked, So he was aware that the resident got out of the facility and into the drive through area? She stated, Yes, when I called him about the screener, I told him. RN #1 was asked, Did you document in the resident ' s record about the occurrence? She stated, No, my understanding was that the nurses documented in the chart when they did the incident report. RN #1 was asked, Did you ask the screener why she didn't stop the resident? She stated, Yes, she said it was because the resident had behaviors. RN #1 was asked, Did she come through the double doors onto the floor? She stated, Yes, she came to the hall and told the aides. l. A Secure Care Test Log Elopement Book provided by the DON on 07/01/21 at 2:09 P.M. contained the residents that were an elopement risk with the secure care alarm system wander guards. For each resident a page with their picture, name, room number, bracelet expiration date, location of bracelet, and daily nurse initials. The DON was asked what the nurse were initialing that they did. She stated, The nurses initial that the alarm is in place, they have a handheld wand and they check it to see if it's working. She was asked if the policy and procedures in the back of the binder, were the current policies and procedures. She stated, They are the current policies they use. m. A Wandering: Resident Assessment Identification and Response policy copied from information provided by the DON on 07/01/21 documented, .Resident wandering is defined as when a cognitively impaired resident with impaired safety judgement leaves the facility without staff observation or knowledge of the resident's departure .

Based on observation, interview, and record review, the facility failed to ensure food was dated, tightly resealed after opening, stored properly, promptly discarded before expiration date, and maintain kitchen equipment and ice machines in a sanitary manner to prevent the potential of food borne illness. These failed practices had the potential to affect 60 residents, (total census 61) who received meals from the kitchen and 55 residents who received ice from the kitchen and the 700 hall ice machine based on a list provided by Dietary Employee #1 on 7/2/2021 at 10:00 A.M. The findings are: 1. On 06/28/21 at 11:30 A.M., during initial rounds with Dietary Employee #1, the following observations were made: a. A half full box of frozen Mozzarella sticks were on a shelf in the freezer beside the short order grill. The bag was not dated. b. An open box of frozen Breakfast Burritos was on a shelf in the same freezer. Inside the box, the bag containing multiple breakfast burritos was not completely reclosed after opening leaving the items exposed to air. c. A box of Grey Poupon mustard containing 11 unopened jars was located on a shelf in the walk in refrigerator. One opened jar was also on the shelf. All 12 jars had an expiration date of 05/31/2021. d. An open box of Kosher Salt was on a shelf in the kitchen and was not placed in a sealed bag 2. On 06/30/21 at 11:08 A.M., during follow-up rounds of the kitchen for rounds, the following observations were made: a. A half full 32-ounce jug of 100% lemon juice with a received date of 2/19 and an open date of 6/1, was on the cook's table near the ovens. Dietary Employee #2 was asked if she had used the juice today. She said, No. Does it need to be thrown out? She was asked how long it had been out of the refrigerator. Dietary Employee #2 replied, Between Sunday and Tuesday. I'm going to go ahead and throw it out. On the side of the bottle the manufacture's guidelines documented, REFRIGERATE AFTER OPENING. Dietary Employee #1 was asked if lemon juice should be refrigerated after opening. She said, Yes. b. There was a large ice machine near the Dietary Office. A fuzzy blackish residue was on the interior lip of the bin's door. Employee #1 lifted the lid and looked at this area and said, Whollie [NAME]! When the employee wiped the area with a white napkin there was a blackish clump on the napkin. Employee #1 was asked to describe what she saw. She said, Lint build up. Employee #1 was asked how often the bin was cleaned. She replied, Weekly as far as wiping it down. Maintenance is the one that empties it and sanitizes it. Employee #1 was asked how often maintenance cleans it. She said, I don't know. I don't know the last time it was cleaned. c. On 7/2/2021 at 12:25 P.M., Maintenance Employee #1 was asked how often the ice machines were cleaned. She replied, Once a month. Maintenance Employee #1 was asked what the process was. Maintenance Employee #1 said, I follow the guidelines, it includes emptying the ice from the bin, sanitizing the bin and the coils. Then we run it and let ice form. We dump the first three dumps. Maintenance Employee #1 was asked when the last time the machine was cleaned. Maintenance Employee #1 said, 6/16/2021. 6. Next to the ice machine there was a blue ice scoop holder mounted to the wall that contained an ice scoop. There was a slimy substance on the inside of the scoop near the bottom. Dietary Employee #1 took a disposable white towel and wiped the substance. A pinkish substance transferred to the towel. Dietary Employee #1 was asked to describe what she saw on the towel. She said, A little bit of pinkish red substance. Dietary Employee #1 was asked how often the scoop and holder were cleaned and when was the last time they were cleaned. Dietary Employee #1 said, It should be running through the dish machine daily. I'm not here at the end of the day so I don't know when the last time it was cleaned. 7. There was an ice machine on the 700 Hall. A blackish and pinkish residue was on the internal shield. Dietary Employee #1 wiped the internal shield of the ice bin with a towel. There was a small spot of pink slimy substance on the towel. 8. In the Rusty Bucket Kitchen's freezer there was a bag containing four individual pizzas that was not resealed exposing the pizzas to air.

Based on record review and interview, the facility failed to ensure potential neglect was prevented, investigated and reported to the Office of Long Terms and other state officials in accordance with state law for 1 of 1 (Resident #262) sampled resident who left the building without staff intervening. The findings are: Resident #262 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 6/23/21 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and was at significant risk of wandering and getting to a potentially dangerous place. a. The Resident #262 was admitted on [DATE] and the Baseline Care Plan documented the resident was an elopement risk. b. An Admission Wandering Risk assessment dated [DATE] documented, .Resident states she wants to go home and has made at least one attempt to leave out the front hall. Wander guard in place to alert the staff when she is out of her room and trying to leave . c. A Progress Note on 6/19/2021 at 10:30 a.m. documented, Late Entry: . resident removed elopement bracelet and wheelchair elopement alarm and exited building. Staff stopped at edge of parking lot and returned to building. Explained again reason for stay and resident voices understanding. Resident has scant short-term memory and needs reminding often. d. A Progress Note on 6/19/2021 at 11:36 a.m. documented, .Resident went to south Hall and exited through double doors despite elopement bracelet and door alarming. Staff noted resident in front parking lot and returned to hall and notified this nurse. Staff member will be assigned to monitor resident. e. On 7/01/21 at 11:50 A.M., received An OLTC [Office of Long Term Care] Witness Statement Form provided by the Assistant Administrator on 07/01/21 at 11:50 A.M. from the screener that was working on 6/19/21 at the time of the 2 elopement occurrences that documented, .Date 7/1/2021 Time 1145 [11:45 A.M.] Witness Full Name [Screener #1] . she came out of the locked double door in front of me and managed to get outside again, I then ran to double door and grabbed CNA [Certified Nursing Assistant], who then took off running out of the building to retrieve resident from parking lot . f. On 07/01/21 at 1:14 P.M., Certified Nursing Assistant (CNA) # 1, who was the CNA who worked the 7:00 p.m. to 7:00 a.m. shift on 6/19/21 was asked about the resident elopement. He stated, It was maybe her [Resident 262] 2nd or 3rd day, she kept saying she wanted to go home, we would try to redirect her, but she wanted to go home. When she got out, the screener came to the hall and told me she got out. I went to get the weekend supervisor and my partner went to get [Resident #262] and bring her back in. g. On 07/01/21 at 2:55 P.M., Registered Nurse (RN) #1 who was the weekend supervisor, was asked to review what happened the day that Resident #262 got out of the facility. She stated, The first time she went around the south hall and circled around by the cafeteria, [the screener] didn't know she was a resident at the time, she [Resident #262] had only been here for 2 days. We got her back in and she was settled. I didn't think there would be any more problems. Then about an hour later [the screener] came to the hall and said she [Resident #262] was outside. She was out in the drive through area. We got her back in and she had pulled her alert bracelet off, we replaced that, and I had Certified Nursing Assistant [CNA #1] sit with her . RN #1 was asked, Did you ask the screener why she didn't stop the resident? She stated, Yes, she said it was because the resident had behaviors. RN #1 was asked, Did she come through the double doors onto the floor? She stated, Yes, she came to the hall and told the aides. h. On 7/2/21 at 2:38 P.M., the DON was asked, When should a reportable to the state agency be done? She stated, Depends on what kind it is. 2 hours for abuse. She was asked, Were the elopements on 6/19/21 reported to the state agency within the required time limit? She stated, No. i. The facility ' s Abuse, Neglect, Unusual Occurrences and Reporting Misappropriation of Resident Property dated 11/2020 did not address reporting and investigating suspected neglect.

Based on observation, interview and record review the facility failed to ensure a medication cart was kept locked and stored, in accordance with State law and accepted standards of pharmacy practice, when unsupervised to prevent the potential access by residents. The findings are: 1. On 7/2/2021 at 11:44 A.M., the Southeast medication cart was sitting out in the hallway just past the nurse's station unlocked. There were 3 residents sitting around the nursing station within 10 feet of the cart. No licensed staff was with the cart at this time. 2. On 7/2/2021 at 11:46 A.M., Licensed Practical Nurse (LPN) #1 was exiting a resident's room [ROOM NUMBER] doors down from where the cart was stationed. When LPN #1 approached the cart, she was asked how the medication cart should be left when unattended. She stated, It should be locked when not within eyesight and I left it unlocked. LPN #1 was asked, What is the purpose for locking the medication cart? She stated, The cart should be locked for safety so the residents can't get into the medications. LPN #1 was asked, Is there a risk for confused residents to get into the cart? She stated, Yes, if it's left unlocked, they are at risk for getting into it. 3. On 7/2/2021 at 11:47 A.M., the Director of Nursing (DON) was asked if the medication cart should be locked when not in the presence of licensed staff. She dropped her head and stated, Yes. The DON was asked, Is it the facilities policy to ensure the medication carts remain locked when not in the presence of licensed staff? She stated, Yes, it is. 4. On 7/2/2021 at 12:10 P.M., A Storage of Medications policy provided by the DON on 7/2/2021 at 12:10 P.M. documented, . Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended . All controlled drugs are stored under double-lock and key.

Complaint # (AR 335) was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure post fall interventions were planned and implemented to reduce the potential for further falls for 3 (Residents #2, #6 and #16) of 7 (Residents #2, #4, #6, #9, #10, #13 and #16) case mix residents with a history of falls; a system of routine checks of personal safety alarms was developed and implemented that included frequency to ensure the alarms were functioning to reduce the potential for fall related injuries for 3 of 3 (Residents #2, #6 and #16) case mix residents that used safety alarms; and the extremities were supported during transportation in a shower chair to prevent injury for 1 (Resident #11) of 3 (Residents #1, #7 and #11) case mix residents who were unable to hold their legs and feet above the surface of the floor when in a shower chair without foot rests. The failed practices resulted in a pattern of actual harm for Resident #2 who suffered a fractured hip on 3/30/14, Resident #11 who suffered distal fractures of the tibia and Resident #16 who suffered a fracture to the Thoracic vertebral body (T-10). The failed practices also had the potential to cause more than minimal harm to 32 residents with a history of falls in the past 6 months; 27 residents at risk for falls; 10 residents who used shower chairs and were unable to hold their legs; and 14 residents who used safety alarms as documented on lists provided by the Director of Nursing (DON) on 8/1/14 at 10:30 a.m. The facility also failed to ensure two person manual transfers were conducted in a manner to lessen potential for injury for 2 (Residents #2 and #6) of 7 (Residents #2, #3, #6, #7, #8, #11 and #12) case mix residents who required 2-person manual transfers; planned interventions to prevent skin tears were implemented to prevent further injury for 1 of 1 (Resident #6) of case mix resident who required padding of bed frames; and handrails were securely affixed on 1 of 3 halls to reduce the potential for accident hazards for residents who were independent for mobility. The failed practices had the potential to cause more than minimal harm for 31 residents who required two-person manual transfers; 2 residents who used mattresses on the floor (as documented on a list provided by the DON on 8/1/14 at 8:53 a.m.); 1 resident with planned use of sheep-skin padding to a bed frame (as documented on a list faxed by the DON on 8/5/14 at 8:18 a.m.); and 46 residents who were independent for mobility throughout the facility (as documented on a list faxed by the DON on 8/4/14 at 3:11 p.m.). The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/14 documented the resident was admitted [DATE]; scored 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS); required extensive assistance of two people for bed mobility and transfers; had no pain; experienced a fall in the last month prior to admission and had a fracture related to a fall in the 6 months prior to admission. a. A Fall Risk assessment dated [DATE] documented the resident had a total score of 22. The form further documented a score greater than 21 indicated the resident was at high risk for falls. b. An Occurrence and Analysis (O&A) Report dated 2/20/14 at 3:30 a.m. documented, "(Resident) observed sitting on (mat) leaning back on recliner. (Resident) unable to voice what he was doing ...Staff heard him holler 'hey' and checked on him. (No) injury (no) distress noted... Corrective action by nursing staff at the time of incident to prevent further occurrences: fall (mat) in place, restorative to be consulted for an alarm." A Fall Risk assessment dated [DATE] documented the resident had a total score of 28. The form further documented a score greater than 21 indicated the resident was at high risk for falls. c. An O&A report dated 2/23/14 at 6:15 a.m. documented, "Alarm sounded to room resident in floor laying on stomach on mat ...(no) injuries noted ...Corrective Action by nursing staff at the time of incident to prevent further occurrences: Provide reassurance, (check) often, and keep alarm on (at) all (times)... Any other comments can be added here: Pt. (patient) had tried numerous times to get up. Staff in the room cont. (continually) off (and) on all night. Antianxiety meds (medications) (and) pain (medications) used to attempt to settle him more." There was no specific documentation on the O&A form of what 'check often' meant. d. An O&A report dated 3/30/14 at 3:15 a.m. documented, "Nurse making rounds, found (resident) in floor with c/o (complaint of ) (left) hip pain... Corrective Action by nursing staff at the time of incident to prevent further occurrences: "will contact restorative for pressure alarm request (in reference to the 'clip' magnet alarm the resident had been using)... Any other comments can be added here: Alarm was not in place." The O&A report documented the resident was sent to a local emergency department for evaluation. 1) A hospital Operative Report dated 3/31/14 documented, "Pre-op Diagnosis: [REDACTED]." 2) A Re-Admission Nursing assessment dated [DATE] at 4:20 p.m. documented the resident was readmitted to the facility with 2 dressings over surgical incision sites on the left hip and left upper outer thigh. e. A Physical Therapy (PT) Assessment Report dated 4/7/14 documented, "...History of Present Condition... Pt.(Patient) fell at NH (nursing home). He was recovering from total hip (ORIF) and refx (re-fractured) same hip... Assessment... Pt. will benefit from skilled PT at this time to continue strengthening, gait training and balance training to improve safety. Pt. goal is to return home as soon as possible." f. An O&A report dated 4/20/14 at 12:45 a.m. documented, "Heard resident yell. Went to check on him (and) he had gotten himself out of bed (and) was laying on the floor ...Found skin tear to (left) upper back... Corrective Action by nursing staff at the time of incident to prevent further occurrences: ...Gave him call light (and) reminded him to use if needing to get OOB (out of bed)... Will check on res (resident) frequently. Body alarm was removed by resident. Reattached it in back to keep resident from pulling off." g. An O&A report dated 5/19/14 at 9:10 a.m. documented, "Resident was in the floor in front of his w/c (wheelchair). Resident stated that he needed to go to the restroom and got up and fell . His alarm had been removed and wasn't going off. Abrasion noted to (left) hip incision and bilateral gluteal folds... Corrective Action by nursing staff at the time of incident to prevent further occurrences: Make sure that resident's alarm is attached to resident at all times." h. The Quarterly MDS with an ARD of 5/21/14 documented the resident required extensive assistance of two people for transfers and was not steady when moving from a seated to a standing position and only able to stabilize with staff assistance. i. The resident's Care Plan dated 5/29/14 (copied on 7/31/14 at 8:45 a.m.) documented, "Mobility... Ambulation: I am not walking at this time...Transfers: I need assist (times) 2 with transfers..." The resident's CNA Closet Care Plan (copied on 7/31/14 at 8:45 a.m.) documented, "Assist: Assist (times) 2... Alarms Body (at) all times." j. An O&A report dated 7/12/14 at 1:30 a.m., documented, "(Resident) in room yelling help ...(Resident) in floor. (Right) elbow has blood running down arm. (Resident) stated he tried to stand up and fell ...(Resident) had taken off body alarm ...Corrective Action by nursing staff at the time of incident to prevent further occurrences: Had aides put resident in w/c (wheelchair) and sit (resident) at nurses station." k. An O&A report dated 7/19/14 at 10:45 p.m. documented, "(Resident) in floor next to roommate's Geri chair ...(Resident) stated he had crawled out of bed. S/T (skin tear) to (right) (upper) arm on inside of arm. 4 cm (centimeter) (by) 3 cm ...stated he had fallen and hit his head. Neurochecks done. All within normal limits ...Resident had removed alarm from self... Corrective Action by nursing staff at the time of incident to prevent further occurrences: Continue previous plan of care. (Resident) to nurses station in w/c... How could this have been prevented? Pressure Alarm and Body Alarm and Motion Alarm... Any other comments can be added here: Resident removes Body Alarm (clip - magnet type)." l. A Resident Profile Report (Certified Nursing Assistant Care Plan on computerized kiosk) was received from the DON on 7/31/14 at 11:58 a.m. and documented, "07/21/2014... low air loss mattress... Body alarm at all times. Fall mat... Safety Notes: My mattress is on the floor to reduce my risk of injury if a fall occurs..." m. On 7/29/14 at 12:00 p.m., The resident was on a mattress in the floor. CNA #8 and CNA #9 placed a gait belt around the resident's body and pulled the resident up from the mattress, while each CNA held the gait belt and one of the resident's arms. The resident's feet were on floor and the resident attempted to straighten, but could not. The resident's hips were at approximately a 90-degree angle to his legs and his knees were flexed at approximately a 120-degree angle, which allowed pressure to the resident's torso / ribs. n. On 7/30/14 at 5:05 p.m., the resident was in a wheelchair at the nurse's station on the South Hall. A clip / magnet safety alarm was attached to the resident's clothing, as had been removed by the resident prior to falls on three previous occasions. 2. Resident #11 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 5/14/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS; required extensive assistance of two people for bed mobility and transfers; and had functional limitation in range of motion of an upper extremity and a lower extremity on one side. a. The resident's Care Plan with a review date of 2/20/13 documented, "Mental Wellness... I do have some pain and muscle spasms related to my stroke. I have medication for this... Mobility: Ambulation: I am not able to walk because of my stroke... Personal Care: Bathing: I need assist (times) 2 for transfers and help with my shower... Safety Notes: I wear a foot brace on my left leg and a left shoulder sling prn (as needed) 5/8/13." b. The July 2014 Active Orders sheets documented, "01/14/2014 ...Left foot / ankle CVA (cerebrovascular accident) day splint daily when out of bed." c. The Nurses Notes entry dated 6/13/14 at 11:00 a.m. documented, "Resident's daughter ...stated, 'What happened to Momma (resident)?' ...(CNA #10) drug her leg going to the shower room. Shower aide (CNA #11) stated that left leg got caught in the shower chair and was drug just a little before the CNA noticed it. She (resident) c/o (complained of) pain (at) this time. She declined an x-ray. (Physician) was notified and a new order given for Flexeril 10 mg (milligram) (one) PO (by mouth) prn (as needed). (Resident's daughter) was notified of the new order." d. The Nurse's Notes entry dated 6/13/14 at 10:00 p.m. documented, "(Resident) awake in bed. C/O pain to (left) leg. Gave prescribed 50 mg Tramadol. Asked if wanted x-ray, (resident) stated, 'not tonight, but will in the morning.' Will notify nurse in the morning to get x-ray." e. An O&A report dated 6/13/14 documented, "Date: 6/13/14 Time: 6:30 a.m. ...found out by this nurse (Registered Nurse (RN) #1) (11:00 a.m.)... Describe Event: ...daughter reported to this nurse that her mother stated, '(CNA #10) drug her leg going to the shower room. Shower aide (CNA #11) stated that the left leg got caught in the shower chair and was drug just a little before the CNA noticed it. She c/o pain... Corrective Action by nursing staff at the time of incident to prevent further occurrences: Educate CNAs on watching for (paralyzed) limbs with transfers and when in chair that doesn't have foot pedals; educate Charge Nurse to complete I&A (Occurrence / Analysis Report) form... How could this have been prevented? (blank). " There was no documentation in the Nurse's Notes or on the O&A report that the resident's left leg / ankle brace was in place as ordered at the time of the incident. f. A computerized ADL (activities of daily living) Detailed Entry Report dated 6/13/14 for Shift 2 had entries entered for 9:02 a.m. and signed by CNA #11 that documented, "Note ...While night shift CNAs was bringing resident to me in shower chair apparently her left ankle got caught up in the chair while she was being pushed down the hall, because when I was getting her dressed resident started complaining about her ankle hurting, and she told me what happened. Resident was crying and asked if I would ask the nurse if she could have a pain pill. We told the nurse (Licensed Practical Nurse (LPN) #5). Her ankle seemed to be a little swollen." g. The Nurse's Notes entry dated 6/14/14 at 10:00 p.m. documented, "...Still c/o pain in (left) ankle and (lower) leg - called (physician) - left mess (message) for him to call..." h. The Nurse's Notes entry dated 6/14/14 at 11:00 p.m. documented, "(Resident) in bed. No c/o pain or discomfort. Asked about foot. (Resident) said it felt fine..." i. The Nurse's Notes entry dated 6/15/14 at 7:30 a.m. documented, "...Called (physician). Left mess (message) to call." j. The Nurse's Notes entry dated 6/15/14 at 8:00 a.m. documented, "(Physician) called (with) new order to x-ray foot (and) ankle. Transferred to x-ray per gurney." k. A hospital Radiology report dated 6/15/14 for a 3-view left ankle X-ray documented, "Impression: Posterior and medial malleolar fractures of the distal tibia." l. A Division of Medical Services (DMS)-762 form dated 6/24/14 documented, "(resident) had an appointment with Ortho (orthopedic physician) on 06/18/2014, her injury was evaluated and resident was placed in a hard cast." m. On 7/31/14 at 9:25 a.m., the resident was asked about the incident of 6/13/14. The resident stated, "Yes, very well. They were taking me to the shower in the shower chair. They were going fast." The resident was asked what happened after her left foot was injured. The resident stated, "They (CNAs) took me into the shower. I was crying and screaming. They didn't give me a choice." n. On 7/31/14 at 10:00 a.m., LPN #6 was asked about the resident's accident of 6/13/14. LPN #6 stated, "The CNAs know (Resident #11) can support her left foot if you pick it up and put it on top of her right foot." LPN #6 stated the resident and the resident's family had refused x-rays two times. The LPN stated, "...until the pain was worse, then she asked for one." o. On 7/31/14 at 3:59 p.m., the Director of Nursing (DON) was asked what the facility's response was, after the incident, to attempt to prevent further occurrences. The DON stated initial training was in Abuse / Neglect prevention, "all staff," due to LPN #5's lack of response to reports from CNAs on the morning of 6/13/14. The DON was asked if any training was provided to CNA staff about use of shower chairs for residents. The DON stated, "Not 'til this week after (state agency) called us (facility)." p. On 8/1/14 at 8:53 a.m., the DON provided evidence of in-service records dated 7/28/14 and 7/29/14 (the first and second days of the survey) that documented for the topic, "Choosing the Proper Shower Chair for Residents." The in-service record documented, "It is very important that the proper chair be used to prevent injury to the resident. We have chairs without foot pedals that can be used for most residents ...if the shower chair with foot pedals is not available, you must have another CNA elevate the resident's lower extremities during transfer to shower room." q. On 8/1/14 at 10:00 a.m., the DON provided a computerized print-out from the kiosks dated 7/29/14 at 12:00 a.m. titled, "Message Compliance Report," that documented, "...IMPORTANT ...Please note that any resident who is transferred with a Shower Chair and has lower extremity weakness OR whose cognition is such that they cannot remember to hold their feet up should be transferred to the Shower Room in the Hospice Shower Chair WITH Foot Pedals and not the regular Shower Chair which DOES NOT have Foot Pedals. This is to prevent injury to the resident." r. On 8/1/14 at 10:07 a.m., the DON provided a listing of all types of shower chairs in the facility. The listing documented a total of 7 shower chairs in the facility, with 4 shower chairs that had foot rests and 3 that did not. 3. Resident #16 had [DIAGNOSES REDACTED]. a. An Occurrence / Analysis Report dated 7/31/13 at 8:00 p.m. documented, "...Type of Occurrence... fall / slip... Describe event: Walked by room (and) saw resident in room in floor. Appears to have been trying to take off shoes (and) slid into floor from w/c (wheelchair). Noted large abrasion to (right) upper back. (No) bleeding noted. (No) treatment needed... Nature of injury... Abrasion (right) upper back... Corrective Action / Intervention: Try to catch Resident before putting self to bed... to assist him (with) dressing." The planned intervention lacked guidance on the frequency of when the intervention was to be implemented. 1) The Nurse's Note entry dated 7/31/13 at 8:00 p.m. documented, "...Resident in floor in his room when this nurse walked by... denies pain... Large abrasion noted to (right) upper back... ROM (Range of Motion) WNL (within normal limits) for Res. (resident)..." 2) The resident's Fall Protocol Interventions form documented, "7/31/13 (Description of Fall) ...fell trying to take shoes off from w/c... (Intervention) ...Isolated Incident..." b. The Quarterly MDS with an ARD of 8/28/13 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on the BIMS; required limited physical assistance of one person for transfers; required the extensive physical assistance of one person for dressing; did not walk, was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position and during surface-to-surface transfer; and had experienced two or more falls since admission or prior assessment. c. An Occurrence / Analysis Report dated 8/28/13 at 9:30 p.m. documented, "...Type of Occurrence... fall / slip... Describe event: ...Resident found in floor by bed. Resident states that he was trying to get back in bed from the w/c... Found large bruise on (left) elbow (and) superficial abrasion to (right) shoulder blade... Corrective action / Intervention: CNAs reported res had 3 episodes of loose BM (bowel movement). Resident had just returned from the bathroom per resident has been up to bathroom more due to BMs (and) has weak knees possibly causing fall. Will look in on Resident (and) assist if he is up trying to use bathroom tonight..." This planned intervention had no frequency specified. 1) The Nurse's Notes entry dated 8/28/13 at 9:30 p.m. documented, "...Resident was found in floor by bed. Resident states that he was trying to get back in bed from the w/c... found large bruise on (left) elbow (and) superficial abrasion to (right) shoulder blade... Instructed CNAs to frequently check on Resident (and) assist if needed..." The planned intervention had no frequency specified. 2) The resident's Fall Intervention Protocol form documented, "8/28/13 (Description of Fall) ...In floor beside bed ...(Intervention) ...episodes of loose BMs, frequent check for assistance to bathroom..." The planned intervention had no frequency specified. d. The resident Care Plan dated 6/6/13 and updated 9/5/13 documented, "...Mobility: ...Transfers: I am able to transfer myself but I am unsteady. I need assistance (times) 1 staff member to ensure my safety during transfers and ambulation... Safety Notes: ...Please make sure my call light is within my reach ...This can make me at a higher risk for falling ...I've fallen in the past..." e. An Occurrence / Analysis Report dated 9/17/13 at 7:15 p.m. documented, "...Type of Occurrence... fall / slip...Describe event: ...(Resident) observed kneeling in front bed. (Resident) states going from wc (wheelchair) to be(d) legs gave out ...Corrective action / Intervention: restorative consult requested for sensor by bed..." 1) The Nurse's Notes entry dated 9/17/13 at 7:30 p.m. documented, "(at)1915 (7:15 p.m.) (resident) observed kneeling in front of bed... (resident) states going from wc to bed and legs gave out.(no) injury noted..." 2) The resident's Fall Intervention Protocol form documented, "9/17/13 (Description of Fall) Resident found on the floor between wc (and) bed... (Intervention) ...Bed sensor..." 3) The Resident Profile Report dated 9/18/13 documented, "...Equipment: ...Infrared alarm on closet door ...Mobility: Assist (times) 1-2 with transfers..." f. The resident's November 2013 physician's orders [REDACTED]. g. An Occurrence / Analysis Report dated 11/10/13 at 7:00 p.m. documented, "...Type of Occurrence ...fall ...Describe Event: ...(resident) observed lying on floor by staff. (resident) stated tried to stand up from wc and legs gave out and wc moved. bruising to (right) elbow (and) (right) back noted. ROM (range of motion) to (right) extremity WNL's (within normal limits), (no) c/o pain voiced (at) this time... Corrective action by nursing staff at the time of incident to prevent further occurrences: ...sensor alarm was off, (resident) had just returned from dinner. Staff educated to keep sensor alarm on (at) all times. restorative to be notified of change... How could this have been prevented? ...Alarm turned on (and) facing forward ...If interventions such as alarms are used, were they on and functioning? ...No." 1) The Nurse's Notes entry dated 11/10/13 at 7:00 p.m. documented, "...Resident observed lying on floor by staff. (resident) stated tried to stand up from wc (and) legs gave out and wc moved. bruising to (right) elbow (and) (right) back. (no) c/o pain..." 2) The resident's Fall Intervention Protocol form documented, "11/10/13... (Description of Fall) ...(Resident) found on floor... (Intervention)... Bed sensor was off, now on..." 3) The Nurse's Notes entry dated 11/12/13 at 8:08 a.m. documented, c/o lower back pain. 2 APAP (acetaminophen) po (by mouth) (one) mucinex po (with) a.m. meds (medications) for slight cough (and) congestion. (no) temp (temperature)..." 4) The Nurse's Notes entry dated 11/13/13 at 2:00 a.m. documented, "Resident c/o back pain to (right) mid back near where he is bruised from fall. Gave Tylenol 325 mg (two) tabs po (and) faxed (name of clinic)." 5) The Nurse's Notes entry dated 11/13/13 at 10:45 a.m. documented, "Resident c/o shoulder, back pain, requesting to lay down. Tylenol 650 mg (two) po given at this time." 6) The Nurse's Notes entry dated 11/13/13 at 10:55 a.m. documented, "...MD's (Medical Doctor's) office notified via faxed of (increased) complaints pain shoulders, mid back and hips, bi-lat (bilateral) sides... Heat applied at this time." The Nurse's Notes entry dated 11/13/13 at 11:10 a.m. documented, "Heat removed, stated 'little effective' requesting to stay in bed." 7) The Nurse's Notes entry dated 11/13/13 at 1:30 p.m. documented, "...New order received for flexeril 5 mg (one) po BID (twice daily) PRN pain, x-ray bi-lat shoulders, bi-lat hips (and) back for pain / post fall on 11/10/13. Radiology notified..." 8) The Nurse's Notes entry dated 11/13/13 at 3:40 p.m. documented, "Resident to radiology for x-rays." 9) The hospital Radiology Report dated 11/13/13 at 3:43 p.m. and documented at 4:05 p.m. documented, "...Procedure: Thoracic Spine... Recommend CT (computed tomography) of the lower thoracic spine to further evaluate this atypical lower thoracic fracture, presumptively at level of T (thoracic) 10..." 10) The Nurse's Notes entry dated 11/13/13 at 4:10 p.m. documented, "...New order received from (nurse practitioner) to (send) resident to ER (emergency room ) for evaluation for possible thoracic spine fx (fracture) (at) T10..." 11) The hospital Emergency Physician Record dated 11/13/13 documented, "...CT Scan... TH (thoracic) 10 (unstable) fracture... Progress... Transfer to ER (metropolitan area hospital) ...Clinical Impression... Low back pain... 1. Fall... 2. Unstable TH10 fracture... 3. Obesity... 4. Advance Alzheimer's Disease... 5. Non Ambula (Ambulatory) Today... 6. Diab (Diabetes) Mellitus... 7. Coumadin Tx (treatment)... 8. A (Atrial) Fibrillation... 9. Parkinson's Disease..." h. On 7/28/14 at 3:10 p.m., Medical Records Staff #1 provided a list of residents discharged from the facility between 11/1/13 and 7/28/14 that documented Resident #16 was discharged from the facility "...11/21/2013 at 23:10 (11:10 p.m.)..." i. On 7/31/14 at 10:15 a.m., Licensed Practical Nurse (LPN) #3 was asked if she worked with Resident #16. LPN #3 stated, "Yes ma'am." LPN #3 was then asked, Do you recall how (Resident #16) transferred? LPN #3 stated, "Well, he kind of, he tried to do it himself, we had to anticipate him..." LPN #3 was asked if the resident ambulated or transferred himself safely. LPN #3 stated, "We did therapy, his legs were in bad shape, he could short transfer safely like commode to wheelchair, had unsteady gait, and strength in his legs was not good." j. On 7/31/14 at 10:30 a.m., Certified Nursing Assistant (CNA) #14 was asked if she worked with Resident #16. CNA #14 stated, "Yes." CNA #14 was asked how Resident #16 transferred. CNA #14 stated, "Good; standby assist." k. On 7/31/14 at 11:23 a.m., Restorative Certified Nursing Assistant (RCNA) #2 was asked if she worked with Resident #16. RCNA #2 stated, "Yes." RCNA #2 was asked if Resident #16 had any alarms or other fall or accident prevention interventions. RCNA #2 stated, "He had an infrared alarm on closet door that pointed in front of bed so when his feet hit the floor it sounded." 4. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/3/14 documented the resident was admitted [DATE]; scored 5 (0-7 indicates severe cognitive impairment) on the BIMS; required extensive physical assistance of two people for bed mobility and transfers; was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, when walking, when turning around while walking, while moving on and off the toilet and during surface-to-surface transfer; had an active [DIAGNOSES REDACTED]. a. The Resident Plan Report dated 6/12/14 (copied on 7/29/14 at 10:45 a.m.) documented, "...General Information... Fall Risk... Mobility... Transfers: I need assistance of two people for transfers ...Safety ...I have a padded bed frame..." b. A Nursing assessment dated [DATE] documented, "...Transfers...(with a mark to indicate) 2 person assist..." c. The undated Closet Care Plan for CNA was provided on 7/30/14 at 5:15 p.m. by the DON and documented, "...Assist: Assist (times) 2..." d. An Occurrence / Analysis Report dated 4/7/14 at 8:40 p.m. documented, "...Type of Occurrence... fall... Severity... No apparent injury... Describe Event: Resident found in floor on her right side on fall mat. (resident) stated, 'I guess I was trying to get up out of bed.' (resident) denies any pain. ROM WNL... Corrective action by nursing staff at the time of incident to prevent further occurrences: ...bed alarm in place..." e. An Occurrence / Analysis Report dated 5/5/14 at 2:20 a.m. documented, "...Type of Occurrence... fall and Equipment malfunction ...Nature of injury ...skin tear... Describe event: ...(resident) saying help, help ...(resident) in floor by door ...skin tear on (right) elbow ...(resident) pressure alarm on bed and on, But not going off..." f. An Occurrence / Analysis Report dated 6/13/14 at 5:10 p.m. documented, "...Type of Occurrence ...fall ...Describe event: Resident sitting in floor on mat large skin tear from elbow to forearm on (right) arm-measured 10 cm (centimeter) (by) 1 cm; 3 other small skin tears distal to that area ...appears that resident tore skin on bed frame ...Corrective action by nursing staff at the time of incident to prevent further occurrences: Sheep skin to bed frame..." 1) The Nurse's Notes entry dated 6/13/14 at 5:10 p.m. documented, "...Resident sitting in floor on mat large skin tear from elbow to forearm on (right) arm. Measured 10 cm (by) 1 cm; 3 other small skin tears distal to that area ...Area 4 just proximal to knuckle ...Appears that resident tore skin on bed frame..." 2) The resident's July 2014 Active Orders documented, "6/13/14 ...Cleanse skin tears to right arm from elbow to knuckle with wound cleanser, pat dry, apply steri strips, apply TAO (triple antibiotic ointment), nonadherent dry dressing and wrap with kerlex every day until healed then DC (discontinue)..." A Physician's Telephone Order dated 7/4/14 documented, "...D/C cleanse S/T's (skin tears) to (right) arm from elbow to knuckle (with) wound cleanser pat dry apply steri-strips, apply TAO, non-adherent dry drsg (dressing) (and) wrap (with) Kerlix qd (every day) until healed d/t (due to) resolved..." g. The Nurse's Notes entry dated 6/16/14 at 12:15 p.m. documented, "...Called (physician) office to report bruising and continued pain in (right) hand..." 1) The Nurse's Notes entry dated 6/16/14 at 2:55 p.m. documented, "...(physician) office called (with) new orders for X-ray of (right) hand (and) wrist..." 2) A Radiology Report dated 6/16/14 documented, "...Procedure: Two view Right Forearm ...History: Trauma. Right arm pain. Impression: ...Incidental note of distal right 5th metacarpal bone fracture..." 3) A Radiology Report dated 6/16/14 documented, "...Procedure: Three-view Right Hand... History: Right hand trauma. Pain... Impression: Distal right 5th metacarpal bone fracture..." 4) A physician progress notes [REDACTED]. 5) On 7/30/14 at 4:00 p.m., the DON was asked how the resident's finger was fractured around the middle of June 2014. The DON stated, "I don't remember." On 7/30/14 at 5:10 p.m., the DON returned to this surveyor and stated, "About (Resident #6)'s finger fracture, initially she had no swelling to hand after falls on 6/12/13 and 6/13/14, but as the weekend progressed the weekend nurse noticed the hand was swollen and bruised. They got order for X-ray and found out it was broke. Doctor had no new orders." As of this time, there was no documentation from 6/16/14 through 7/

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to serve food at the consistency to meet an edentulous resident's needs for 1(Resident #1) of 7 case mix residents (Residents #1, #2, #3, #4, #5, #6 and #8) who were at risk for choking. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who choked in the dining room on [DATE] at 6:15 p.m. and expired at 6:30 p.m. and had the potential to affect 12 residents who were at risk for choking as identified by a list provided by the Director of Nursing (DON) on [DATE] at 12:00 p.m. The Immediate Jeopardy was removed by the facility on [DATE] when the facility identified the issue and initiated corrective action, however the facility had not corrected the underlying deficient practice at the time of the survey. The facility was informed of the Immediate Jeopardy Removed on [DATE] at 11:25 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. A physician order [REDACTED]." The Admission Nursing assessment dated [DATE] documented, "Resident has dentures, diet= ground with gravy, liquids consistency= honey thick, has a chewing problem." a. The Dietary Nutrition assessment dated [DATE] documented, "Chewing problem, swallowing problem." b. An Initial Minimum Data Set ((MDS) dated [DATE] and Quarterly MDS dated [DATE] documented the resident had long and short term memory problems, was moderately impaired in cognitive skills for daily decision making, required extensive assistance from staff in most activities of daily living but required set-up only with eating, had a swallowing and chewing problem and required a mechanically altered and therapeutic diet. c. A Nursing assessment dated [DATE] documented, "No teeth. Has dentures. Needs assist eating and has swallowing difficulty." d. A Nursing assessment dated [DATE] documented, "Resident needs assist, swallowing difficulty, Nectar thick liquids." e. The Resident Plan of Care, updated [DATE], documented, "Problem: At risk for poor nutritional status... Approaches:... Diet as ordered by physician. Assist with meals as needed. Set up meal tray so that it is readily accessible. Problem: Gastrointestinal Reflux Disease: Observe, document, report to doctor: (Belching, coughing, choking when lying down, dyspepsia, regurgitation, swallowing problems.) Approach: Upright with all po (oral) intake due to difficulty swallowing. Nectar thicken liquids ([DATE]). Problem: High risk for aspiration, complications due to dysphagia secondary to history of stroke and subdural hematoma.... Approaches:... Assess/record/report to MD (medical doctor) signs and symptoms of aspiration or complications. Choking/strangling on liquids. Coughing during or after meals. Swallowing precautions as recommended by ST (speech therapy) or MD. Diet/thicken fluids to nectar thick consistency. If assisting resident to eat, feed slowly, stop for signs of choking and notify nurse ASAP (as soon as possible). Feed in upright position and maintain for 1 hour after eating when possible to reduce aspiration risk." f. The [DATE] Physician order [REDACTED]." g. A Nursing assessment dated [DATE] documented, "Resident has dentures, refuses to wear them, likes to eat in dining room, needs assist with set up and assist feeding at times. h. A Nursing assessment dated [DATE] documented, "Dentures, swallowing difficulty, Resident feeds self most of the time." i. Nurses notes dated [DATE] at 6: 15 p.m. documented, "Nurses called to help with resident in Dining Room. I arrived at 6:16 p.m. nurse was doing [MEDICATION NAME] Maneuver on Resident #1 who was sitting upright in wheelchair. Face was already turning blue... I did [MEDICATION NAME] we were told Resident #1 was full code. We proceeded with resident in wheelchair to North Hall. We laid the resident on the floor-preceded with CPR (cardiopulmonary resuscitation), Ambu bag from crash cart... continued compressions... lifted resident onto gurney, and continued down hall to emergency room . Continued compressions until emergency room staff took over." 1) The menu for the [DATE] at the evening meal documented, "BBQ Pork on a Bun, Onion Rings, Coleslaw, Cream Pie, Milk." 2) A witness statement completed on [DATE] by the Evening Cook on [DATE] at the supper meal documented, "The pulled pork is BBQ and is very fine. I have worked here for over 3 years and served it to mechanical soft every time we have it. I have been told by my manager that it is fine to serve to mechanical soft because it is so fine." On [DATE] at 1:30 p.m., the Evening Cook stated, "It (BBQ Pork) is already prepared, take it out, put it in pan, warm it up. We don't touch it or grind it." 3) A witness statement dated [DATE] at 6:10 p.m. by Certified Nursing Assistant (CNA) #1 documented, "We were done feeding. I was taking residents out of the dining room. Resident #1 was eating by himself doing very well. I came back into the dining room and noticed Resident #1 chin and mouth were blue. I asked him if he was ok. Got no response. I asked him if he was choking-he nodded yes. I yelled, 'I've got one choking' and started the [MEDICATION NAME] on him." On [DATE] at 3:20 p.m. CNA #1 stated, "The meat was not ground up. It was long, pulled pork.--very stringy. It was the size of my finger (made gesture) at least 3 inches long. I have questioned several of the products that we give the residents on ground meat. The kitchen always says it is an acceptable product for them. (Resident #1) ate really fast, he always ate too fast. There were 25 residents on that side that night with 5 aides. It could happen anytime. I think he was already gone because his bladder emptied before they got him to the hall." j. The Medical Center Resuscitation Record dated [DATE] at 6:20 p.m. documented, "CPR was continued. 6:27 p.m. MD intubating. Unable to intubate. 6:28 p.m. MD suctioning airway. MD manually removed foreign body from esophagus. 6:30 p.m. CPR held. Patient remains pulseless. Patient pronounced dead." The Code Blue History and Physical dated [DATE] documented, "Attempted to intubate, removed [MEDICATION NAME] of food from trachea approximately 10 centimeter piece of meat removed manually." (10 centimeters multiplied by 0XXX 08 = 3.9 inches) k. The County Coroner Report dated [DATE] documented apparent cause of death, "Asphyxiation secondary to Aspiration." l. A Surgical Pathology Report dated [DATE] documented, "Foreign body removed from esophagus consists of a 7.0 x 2.8 x 2.5 centimeter foreign body suggestive of a large piece of meat. ((7.0 x 2.8 x 2.5) x 0XXX 08 = 3 cubic inches) The National Dysphagia Diet: Standardization for Optimal Care, American Dietetic Association 2003 defines a Level 3: Mechanical Soft Diet : "Thin-sliced, tender, small chunks of meat or poultry. Level 2: Mechanically Altered- Ground Diet: Meat pieces should not exceed ,[DATE] inch cube and should be tender." m. The Immediate Jeopardy was removed on [DATE] and the scope and the severity reduced to a "G" when the following corrective actions were taken by the facility prior to surveyor entrance: 1) The facility policy on Nursing Home Diets was changed. The policy on [DATE] documented: Regular ground: Diet designed for those who are unable to chew meat. It is a regular with mechanically modified meat. Raw fruits and vegetables are limited to soft or shredded varieties. This diet is interchangeable with the mechanical diet." The policy on [DATE] documented Ground Meat: This diet is the same as mechanical soft with the exception of meat being more finely ground. 2) The product that was identified by a Surgical Pathology Report as the foreign body from Resident #1's esophagus was a pulled pork meat in barbecue sauce. A facility report of Actions Taken, dated [DATE] documented, "The Dietitian removed the BBQ pork from the menu on [DATE]." (On [DATE] at 9:00 a.m. the freezer and refrigerator of the facility were checked per surveyor. None of the product had been kept in the facility.) 3) On [DATE] and [DATE], the facility in-serviced the Dietary staff on the new policy. On [DATE] through [DATE] the facility in-serviced the nursing service on therapeutic diets and meal cards. The importance of the identification of meals and meal cards being the same was stressed. 4) The Dietitian and Food Managers from [DATE] through [DATE] had monitored the ground foods on the tray line for each meal served. n. As of [DATE], while the facility had removed the Immediate Jeopardy the underlying deficient practice was not corrected: 1) The policy was not standardized for optimal care according to the National Dysphagia diet : The National Dysphagia Diet: Standardization for Optimal Care, American Dietetic Association 2003 defines a Level 3: Mechanical Soft Diet : "Thin-sliced, tender, small chunks of meat or poultry. Level 2: Mechanically Altered- Ground Diet: Meat pieces should not exceed ,[DATE] inch cube and should be tender." On [DATE] at 12:00 p.m., the Dietitian was asked for the facility policy on Diets. She provided a page from the Dietary Manual titled: "Nursing Home Diets." The page documented, "Regular Ground-Diet designed for those who are unable to chew meat. It is a regular diet with mechanically modified meat. Raw fruits and vegetables are limited to soft or shredded varieties. This diet is interchangeable with the mechanical soft diet. She was asked if this was her current policy (the policy that was revised on [DATE]) and she stated it was. She was asked the difference between a mechanical soft and ground diets. She stated the 2 are interchangeable as the definition states of a regular ground and the mechanical soft diet. 2) The employees responsible for the corrective action did not voice understanding of the policy changes: On [DATE] the Evening Cook was shown the facility's current policy on Regular Ground/Mechanical diet, she stated: "We make no difference between the two. No change after last Thursday night ([DATE]) is no different - it is the same. It's always been that way." On [DATE] at 3:20 p.m., CNA #1 stated when asked what information she was given in the in-service, "Nothing different. They didn't say anything new, just watch it." 3) The Dietitian and Food Managers from [DATE] through [DATE] had monitored the ground foods on the tray line for each meal served. There was no documented monitoring of the individual tray as it was delivered to the resident to ensure the resident actually received the correct consistency.