Every finding on record at Paris Health And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a safe and sanitary manner. Specifically, the facility failed to maintain kitchen equipment free of debris, failed to prevent potential cross-contamination from personal electronics in food preparation areas, and failed to ensure staff avoided bare-hand contact with a resident's food for one of one kitchen reviewed for food service. The findings include: During an observation on 03/02/2026 at 9:05 AM, this surveyor and Dietary Manager (DM) #4 observed the grease trap located under the griddle, which revealed an accumulation of approximately two inches of black sludge and debris. DM #4 stated the grease trap should be cleaned weekly but estimated the current accumulation had been present for a very long time. The DM was unable to state exactly when the grease trap had last been cleaned, as it was not listed on the cleaning schedule. During a concurrent observation and interview on 03/02/2026 at 12:10 PM, Certified Nursing Assistant (CNA) #1 was observed delivering a meal tray to a resident. CNA #1 opened a package of crackers, contaminating their hands, removed the crackers with their bare hands, and placed the crackers directly into the resident's bowl of chili. CNA #1 stated the belief was that bare-hand contact with food was acceptable if hand sanitizer was used between residents. During an observation on 03/02/2026 at 2:50 PM, this surveyor observed the food preparation area and saw a personal cellphone, which belonged to [NAME] #2 laying on a food prep counter. DM #4 confirmed the device belonged to [NAME] #2. During an interview on 03/04/2026 at 10:25 AM, [NAME] #3 stated that failure to clean grease traps could lead to bacteria buildup and pest attraction. [NAME] #3 further noted that personal items must be stored away from food preparation areas to avoid contamination. During an interview on 03/04/2026 at 12:59 PM, [NAME] #2 stated that grease traps should be cleaned during stovetop maintenance, but could not recall the last time this specific trap was cleaned. [NAME] #2 acknowledged that accumulated grease was a fire hazard and that personal items on prep tables caused cross-contamination. [NAME] #2 then claimed ownership of the phone that was left on the food prep table and confirmed that all personal belongings were to be kept out of the kitchen, because of the risk of contamination. During an interview on 03/04/2026 at 1:35 PM, DM #4 stated that uncleaned grease traps could eventually cause a pest issue and confirmed that personal items in preparation areas could lead to cross-contamination. During an interview on 03/05/2026 at 1:22 PM, the Administrator stated that grease traps should be cleaned daily, or frequently, depending on use. The Administrator confirmed that dirty grease traps were fire hazards and that personal cellphones on food preparation tables created cross-contamination risks. During an interview on 03/05/2026, Registered Dietician #9 stated the facility did not have a specific policy or procedure regarding safe food handling and personal items in food preparation areas. A review of CNA #1's annual performance evaluation on 03/05/2026 at 8:30 AM, confirmed CNA #1 received training on the serving and removing of trays on 12/15/2025. A review of the facility's Kitchen Cleaning Schedules from 02/09/2026 to 03/01/2026, revealed no specific cleaning tasks for grease traps. An in-service titled Job Duties dated 01/05/2026, did not indicate specific cleaning for drip pans and grease traps. A review of the facility policy titled Hand Hygiene dated 06/11/2020, revealed instructions for reducing infection risks, but failed to address specific hand hygiene requirements for food service or the prohibition of bare-hand contact with ready-to-eat food. A review of policies and procedures for Cleaning Schedules dated 02/01/2002 and 08/10/2018 were provided by the Administrator, and neither contained specific cleaning instructions or frequency regarding drip pans and grease traps. A review of the policy and procedure titled, Cooking Guidelines effective 08/15/2009, indicated that staff should wash hands before handling foods and after becoming contaminated and wear gloves when handling all foods.

Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to revise the comprehensive care plan as needed and after changes were made on the resident's 01/05/2026 quarterly Minimum Data Set (MDS) for one (Resident #99) of three residents. The findings include: A review of Resident #99's quarterly MDS with an Assessment Reference Date (ARD) of 07/30/2025, revealed the resident had active diagnoses, which included depression, insomnia, and non-Alzheimer's dementia. Resident #99's MDS also revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment. A review of Resident #99's quarterly MDS with an ARD of 01/05/2026, revealed a BIMS score of 03, which indicated the resident had severe cognitive impairment. A review of a Witness Statement dated 12/13/2025, regarding an incident on 08/13/2025, revealed Resident #99 was found in Resident #13's bed with their arms on Resident #13 back, with Resident #13 trying to climb on top of Resident #99 while kissing. Resident #13 had nothing on from the waist down and Resident #99 had their pants around their knees. Resident #99 was care planned for this behavior after the incident. A review of Resident #99's Care Plan on 03/03/2026 at 2:27 PM, revealed Resident #99 was care planned for 'Sexual Expression' on 08/15/2025, with a goal to allow the resident to engage in sexual behavior with other consenting residents, after an incident that occurred on 08/13/2025. Resident #99's Care Plan also specified interventions of ensuring appropriate consent was obtained between residents, provide privacy if the resident was found engaging in activity, and observe for changes in mood or cognition, per policy. During an interview on 03/04/2026 at 10:59 AM, Resident #99's Responsible Party stated Resident #99 was not capable of consent related to sexual relationships or activity and had not been in a long time. Resident #99's Responsible Party revealed they were the decision maker for the resident. During an interview on 03/05/2026 at 11:22 AM, Licensed Practical Nurse (LPN) #10 stated that the Care Plans should be updated as needed. LPN #10 reported being familiar with Resident #99, and that the resident could not express their needs or wants. LPN #10 stated she did not believe Resident #99 was ever capable of making a decision on a sexual relationship, although it was noted on the care plan. During an interview on 03/05/2026 at 11:45 AM, LPN #11 was notified of changes in conditions which needed to be care planned, then assessed if there was a change. The Medical Director and Interdisciplinary Team were notified as necessary. LPN #11 stated Resident #99's current care plan was not accurate for the resident's care needs due to the steady decline. During an interview on 03/05/2026 at 10:02 AM, the Social Services Director stated we discussed the incident of when Resident #99 and Resident #13 where found in Resident #13's bed, in the morning meeting on 08/13/2025 (sic). The Social Services Director confirmed she did the sexual consent forms with Resident #99 and Resident #13 at that time and determined they were able to consent. The form was not triggered to repeat on the next quarterly assessment and was not a preventive measure. During an interview on 03/05/2026 at 12:25 PM, the Director of Nursing (DON) stated Sexual Expression was care planned for Resident #99 after an incident between Resident #99 and Resident #13. After this incident, the Social Director completed the sexual questionnaires on 08/13/2025, that was used to determine if residents could consent to intimate relationships. The resident's BIMS were reviewed, and the resident's responsible parties were notified. At the time of the incident in August of 2025, neither resident wanted a sexual relationship. A review of Resident #99 and Resident #13's Sexual Questionnaire's indicated both residents answered questions concerning their understanding of intimate relationships. The forms were dated 08/13/2025, signed by the Social Services Director with the word consent written on the page. During an interview on 03/05/2026 at 1:25 PM, the Medical Director stated a Care Plan for sexual activity a resident with a BIMS score of 03 was not appropriate, because the sexual knowledge would be low. During an interview on 03/05/2026 at 1:47 PM, the Administrator revealed the Care Plan was very important, because it was resident focused and centered to identify the needs of the resident. The facility cared for behaviors, treatment, and protocols. The Administrator confirmed that Care Plans were updated as needed and when the MDS reflected a change, he then stated, I expect to have care plans updated quickly.

Based on facility record review, interview, facility policy review, it was determined that the facility failed to ensure quarterly statements were provided to three (Resident #8, Resident #68, and Resident #82) of three residents, or their representative, reviewed for personal funds. The findings include: Resident #8 A review of Resident #8's Face Sheet indicated the facility admitted the resident on 08/21/2024, with diagnoses which included schizoaffective disorder, bipolar disorder, and depression. Resident #8's Face Sheet also revealed the resident's representative was listed as the Primary Financial responsible party. A review of Resident #8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/2025, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. During an interview on 03/04/2026 at 1:56 PM, Resident #8's representative reported that Resident #8 was supposed to receive their own quarterly resident trust statements, and that Resident #8 only added Resident #8's representative as a backup emergency contact. Resident #8's representative reported that they had never received a quarterly statement from the facility related to Resident #8's resident trust account. During an interview on 03/05/2026 at 10:11 AM, Resident #8 reported they had never received an account statement from their resident trust account from the facility, and if they had, it would be on their bedside table. Resident #68 A review of Resident #68's Face Sheet indicated the facility admitted the resident on 04/04/2019, with diagnoses which included dementia with psychotic disturbance. Resident #68's Face Sheet also revealed the resident's representative was listed as the Primary Financial responsible party. A review of Resident #68's quarterly MDS with an ARD of 02/23/2026, revealed a BIMS score of 03, which indicated the resident had severe cognitive impairment. During an interview on 03/04/2026 at 1:40 PM, Resident #68's representative confirmed they were the person responsible for Resident #68's financial affairs and further confirmed that Resident #68 had their money in a trust account through the facility. Resident #68's representative reported that during the entirety of Resident #68's admission of more than six years, they had never received a quarterly statement from the facility. They reported receiving a bill every month, but no quarterly statement. Resident #68's representative confirmed that no other document came with the bill, nothing like a statement of account. Resident #68's representative then confirmed the address listed on Resident #68's Face Sheet was correct. Resident #82 A review of Resident #82's Face Sheet indicated the facility admitted the resident on 07/21/2025, with diagnoses which included cognitive communication deficit and dysphagia. Resident #68's Face Sheet also revealed the resident's representative was listed as the Primary Financial responsible party. A review of Resident #82's quarterly MDS with an ARD of 01/26/2026, revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. During an interview on 03/03/2026 at 9:06 AM, Resident #82's representative reported that the facility handled the money for Resident #82, but they have never received an account statement from the facility, only a bill. During an interview on 03/05/2026 at 9:57 AM, the Financial Specialist confirmed they were responsible for the resident trust accounts and sending out the quarterly statements to both the residents and responsible parties listed on the face sheets. The Financial Specialist reported that the statements were emailed to the facility from the corporate office on a quarterly basis. Once the facility received the statements, the Financial Specialist verified the address listed on each statement prior to mailing them to the responsible party, or hand delivering them to the resident, if they were their own person. The Financial Specialist then revealed there was no documentation of the statements being sent either through the mail or being delivered to the resident. The Financial Specialist was unable to confirm if the quarterly financial resident trust statements had been provided to the resident representative, either by mail or in person. The Financial Specialist reported the last quarterly resident trust statements that were supposed to have been sent out were from 12/31/2025. During an interview on 03/05/2026 at 10:25 AM, the Administrator confirmed it was their expectation that staff followed the policies of the facility, and if there was confusion, then it was expected that the staff came to the Administrator for clarification. The Administrator confirmed quarterly trust account statements were expected to be sent to the resident's representative or the resident. The Administrator confirmed the process of receiving the statements (the facility received the statements electronically), they were then printed and mailed or provided to the residents. During an interview on 03/05/2026 at 11:42 AM, the Administrator was unable to provide verification that the statement had been mailed or delivered to the resident's representative or to the residents and stated, our process was not good enough. The Administrator reported the facility did not have a system in place to ensure the quarterly statements were provided to the residents' representative. A review of a facility policy titled Resident Trust with an effective date of October 2022 read in part that the responsibilities of the facility included providing each resident or legally responsible designee a statement of the account activity quarterly.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to maintain an environment free of hazards and failed to provide supervision for one (Resident #1) of three residents reviewed. Specifically, an electronic locking door known to have issues was not monitored or properly reported for repairs, allowing Resident #1 to elope from the facility and walk down the city street in traffic. The findings include: A review of the Resident Face Sheet, indicated the facility admitted Resident #1 on 07/11/2025 with diagnoses that included dementia, expressive language disorder, cognitive communication deficit following a stroke, muscle weakness, and unsteady on their feet. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/2025, revealed Resident #1 had a Brief Interview of Mental Status score of 0 which indicated the resident was had severe cognitive impairment. No wandering behaviors were identified. A review Resident #1's Elopement Evaluation recorded 07/13/2025 at 11:56 AM revealed, the resident was ambulatory or independent in wheelchair locomotion, was a new admission who had made statements questioning the need to be in the facility and displayed behaviors which may indicate an attempt to leave like body language, etc. which indicated an elopement may have been forthcoming. The resident was found to be at risk for elopement, but no care plan was initiated at that time per comments, Has not exit-seeked. A review of Resident #1's Care Plan, initiated on 07/28/2025, revealed the resident's dementia which effected their decision making and caused cognitive communication issues which greatly impacted their communication and analysis of cognition difficult. Interventions included assistance with decisions as needed, provided cues, prompts, and reminders as needed, and speech therapy to find the best communication method. Resident #1 was at risk for falls related to impulsiveness; the approach was to assist with transfers and ambulation as needed. Behaviors were noted to interfere with care and increase risk for complications, interventions were if the resident refused care to attempt at a later time or with different staff, observe and document behaviors, and the resident calms with her child. On 10/09/2025 the care plan was edited to include elopement behaviors, interventions included an electronic monitoring device applied to the right ankle, listening for door alarms, and one-on-one observations. No elopement plan was initiated prior to Resident #1's 10/07/2025 elopement. A review of October 2025 General Administration History, revealed Resident #1 had an order placed on 10/08/2025 to check the functioning of the right ankle electronic monitoring device and the surrounding skin's integrity. During a concurrent observation and interview on 10/10/2025 at 11:26 AM, Resident #1 was seen in their room ambulating with a walker. Resident #1's response to all questions was unintelligible, although the resident made eye contact and verbalized a response there was a minimal number of actual words and no communication took place. During an interview on 10/10/2025 at 8:17 AM, the City Police Department [NAME] stated he was in contact with the responding officer to the elopement because there was another incident happening simultaneously. The responding officer worked from noon until midnight and was not available at the time of the interview. The [NAME] reported the officer responded to a 9-1-1 call where a citizen reported an elderly person walking alone down a city street approximately 200 yards away from the nursing facility, going south out of town. A citizen came by and reported to the officers that they were the ones who called it in because they almost hit the person in the street. The [NAME] reported the street had streetlights, but it was dimly lit and did not adequately illuminate the area. The person found walking in the street could not formulate a sentence and was unable to provide their name. The responding officer contacted the dispatch who placed a call to the nursing facility, and they reported they did not have any missing residents. Dispatch contacted the local hospital with the same results. The officer called for Emergency Medical Services (EMS). The [NAME] stated prior to EMS arriving the responding officer was called for emergent backup to a priority situation. The officer asked the citizen to walk with the unidentified person until he could return because the officer was worried the person (Resident #1) would be struck by a car. The other scene was less than a mile away and the officer had to yell from the corner for EMS to come to the 2nd scene before they could assess the person. The [NAME] stated at some point the nursing facility realized they were missing someone and called dispatch back. The nurses arrived with the facility van and took Resident #1 back. A review of the police report from Resident #1's elopement revealed the responding officer located a person walking down the city street with a walker. A motorist stopped and stated they had placed the 9-1-1 call because they had almost hit the person. The responding officer was unable to understand the person's verbal communications. After the nursing facility and the hospital denied any missing residents, the responding officer asked for EMS. Prior to EMS' arrival the officer had to respond to another incident and when EMS arrived to the first scene, the officer also instructed EMS to move further south to the second incident leaving the person walking down the road. While the responding officer was at the local hospital a second 911 call came in reporting the person again walking in the same road. Dispatch was instructed to contact the County Sherriff's Office for further assistance. By this point the facility was aware Resident #1 had eloped and was the person walking in the street through traffic. The staff utilized the facility's transport van to return Resident #1 to the facility. Resident #1's identity was not known to the police department until Wednesday 10/08/2025 when the responding officer did his follow-up with the facility. A review of the City Police Departments redacted radio log from 10/07/2025 3PM-11PM shift revealed, at 8:07 PM a citizen called in and reported a person with a walker walking on a public street by the facility. An officer made contact with the person at 8:11 PM. Dispatch contacted the facility at 8:13 PM to inquire about any missing residents. At 8:16 PM it was reported to the officer that the facility was not missing any residents. At 8:28 PM the local hospital was contacted and reported back at 8:28 PM they had no missing patients. At 8:32 PM the officer requested dispatch to send EMS. At 9:28 PM two different citizens called in and reported the person with the walker was further down the road and was now blocking traffic. At 9:32 PM dispatch was instructed to contact the County Sheriff's office for assistance to remove the person from the road. EMS reported the person was alert and oriented and known to walk every night around that time. A review of a progress note from 10/08/2025 at 11:10 AM LPN #4 notified Resident #1's family/representative of the elopement. The representative stated it was only a matter of time, the resident was an escape artist and did this at their last facility. During an interview on 10/10/2025 at 12:42 PM, Resident #1's family stated they were not sure how the resident got out of the facility's secure unit. To their knowledge, someone found the resident two blocks away and the paramedics brought the resident back to the facility. The family reported that while in another facility, Resident #1 got out and was found across the highway at the movie theater. The family reported the resident was not in a locked unit previously and believed the resident was secure because at the current facility every door seemed to have a different code on it. A nurse reported to the representative that maybe the door was faulty, and the resident followed someone out who was not paying attention. The family did not believe Resident #1 was in any danger now, since the application of the electronic monitoring ankle bracelet. The family stated they believed the staff were doing what they could, but they must be more careful with residents. During an interview on 10/10/2025 at 9:24 AM, the Maintenance Director (Maintenance) stated he checked the doors including the electronic monitoring system and the electronic door locks every Tuesday. Maintenance stated his wife worked here in therapy and sometimes she took one of the residents outside and let the alarm go off so they could do a mock elopement with a resident. Maintenance reported after Resident #1's elopement he came in and checked the door on the 500-Hall secure unit where the resident got out. He said he tried it three times then a buzzing noise started. He stated the keypad showed red like it was locked but it opened right up. Maintenance called a repair business, and they came and changed out the keypad. Maintenance believed it was shorting out since it was not doing it every time and took 3 times to recreate the scenario. Maintenance stated he had worked here about 26 years and had checked the doors weekly. Maintenance stated he gets handwritten work orders and after he addresses it, he signs, dates the bottom with the resolution and sticks it in his desk drawer. A review of hand-written maintenance work orders from 06/01/2025-10/10/2025 provided by the facility revealed no work orders for the 500-Hall secure exit doors. A review of the computerized maintenance tracking system for six months from 10/10/2025 provided by the facility revealed on 10/03/2025 the Maintenance Director completed a test operation of doors, locks, gates, and alarms as well as a facility inspection of secure doors and mag door check. There were no notations made. A review of a witness statement dated 10/07/2025 at 10:00 PM revealed Medication Assistant Certified (MAC) #9 was assisting Resident #1, who asked for some underwear, which was provided. At around 7:00 PM snacks were provided, Resident #1 retrieved some snacks and went and sat by the back door. MAC #9's second statement from 10/08/2025 revealed the resident always had a change of clothes on their walker. A review of a witness statement dated 10/07/2025 at 11:00 PM revealed, MAC #8 last saw Resident #1 at 7:30 PM and thought the resident had gone to bed. MAC #8 reported no door alarms went off. A review of a witness statement dated 10/08/2025 revealed MAC #3 last saw the resident between 7:30 PM- 8:00 PM, the resident had clothes on their walker and was sitting in a chair at the end of the hallway. Resident #1 put clothes on the floor beside the chair. This was not new or unusual behavior for the resident. The resident was not trying the doors or pacing. During an interview on 10/11/2025 at 11:40 AM, Certified Nursing Assistant (CNA) #1 was at the 500-Hall secure exit door past the dining room were Resident #1 went out and stated, the staff had issues with door prior to the elopement. CNA #1 stated, sometimes it would not open from the inside and when it closed you had to make sure it closed behind you or it left a gap. The problem had been reported to nurses over the last two to four weeks. CNA #1 stated she did rounds on evening shift every two hours at 4PM, 6PM, 8PM, and 10PM. She gathered briefs for everyone needed and went to each room starting at the end of the hall. She saw everyone she changed and checked the roommate as she went. The check for residents was more of a mental thing no documentation was done. CNA #1 reported that since the secure doors keypad had been changed there had been no other issues. Tuesday, 10/07/2025, the evening of the elopement, CNA #1 left the facility prior to dinner and was not in the building at the time of the elopement. During an interview on 10/10/2025 at 11:57 AM, Central Supply Tech (CST) #2 stated it had been at least a month since the 500-Hall door had issues with not working. CST #2 stated he did not report the issues but knew it had been mentioned before. CST #2 stated the facility did not have an active Administrator and some things get forgotten, we are all just helping each other out. CST #2 reported before the door was fixed you could hear it making a mechanical winding sound. When he heard the winding sound, he would pull it until it stopped. You can tell people that, but they don't listen. I just think some employees get too comfortable. During an interview on 10/10/2025 at 12:04 PM, MAC #3 stated she worked Tuesday night 10/07/2025 the night Resident #1 eloped. MAC #3 reported Resident #1 had no issues at dinner and later they were roaming in the hallway, but it was not unusual behavior. MAC #3 reported, sometimes Resident #1 packed clothes up but after they walked around, they put them away. MAC #3 was unaware when Resident #1 left the facility stating she goes to another hall to pass medications from 8PM-9PM, about 15-20 mins before she left the 500-Hall Resident #1 was sitting in the hallway on their walker. MAC #3 was vaguely aware of the door locking issues but had not thought about it in a while and thought it had been fixed. During an interview on 10/10/2025 at 12:31 PM, Licensed Practical Nurse (LPN) #4 stated she had worked on the secure unit for two weeks during the day. She stated there was a situation where the 500-hall secure exit door would open but it would not catch back with the magnet. LPN #4 stated, You had to push it again and make sure it closed. LPN #4 stated CNA #7 told her to be careful with the door and CNA #7 said she made a report of it. LPN #4 reported no issues with the door now that the keypad had been replaced. LPN #4 stated the CNAs round every two hours looking at the census and each room at the resident. LPN #4 stated she also will go around with the med pass and lay eyes on them. During an interview on 10/10/2025 at 12:54 PM CNA #7 stated, the door 500-Hall secure exit door shuts but it does not lock tight, and you must push it again or it will open. CNA #7 reported the door had been that way a couple months and she reported it to Maintenance. I told him when he came back a couple of months ago and they did look at it. Not sure if they did anything or replaced anything at that time. I haven't noticed it for a while. I work back there and make sure the door shuts and locks when I am back there, It's my habit. CNA#7 stated she was not on duty when Resident #1 eloped. During an interview on 10/10/2025 at 1:01 PM, LPN #5 stated the last time she saw Resident #1 on 10/7/2025 at 7:50 PM. I was in the room across the hall, and [pronoun] told me good night. LPN #5 stated after the encounter she took a break and left the facility. At about 8:20 PM the facility staff got a call, and the police asked if they were missing a resident, dispatch said they had a person and described them. LPN #5 stated, she looked up and asked a few staff if we were missing a resident. Since everyone told her no, she told dispatch no. LPN #5 stated nothing else was done at that time. At 9:40 PM, Floor Tech (FT) #6 called and reported seeing Resident #1 on the street while driving to the facility. Staff were sent down there. LPN #5 stated an alarm never went off and she thought the 500-Hall side door by the dining room because it has been known to be faulty. Resident #1 had put clothes under a chair by the door. LPN #5 reported after Resident #1 had returned to the facility they pointed to the 500-Hall door and said, I got out. LPN #5 stated the staff tested the door several times at about 11, and it opened. They facility put one on one staff to the 500-Hall exit door at that time. During an interview on 10/10/2025 at 1:14 PM, FT #6 stated he was driving to work down the city street when he met a car with their flashers on and got in behind them. Resident #1 had their walker with dining cups with stuff in them and was booking it. He knew it was Resident #1 right away. A county officer and EMS arrived, and I called the facility. The nurse came down and called the girls to bring the transport van down there. It took 5 staff to get Resident #1 in the van. A couple in the car behind Resident #1 said they called it in. The staff had to calm down Resident #1, then they loaded up and brought them back. The Regional Administrator told me the next day Resident #1 walked them to the exit door past the dining room on 500-hall. The resident took her walker and pushed the door open. The resident would have had to walk along the side of the facility by the therapy room. The other side had creek and was muddy. Resident #1 was scared to death. It was at least a half a mile down the highway. During an interview on 10/10/2025 at 1:53 PM the Medical Director (MD) stated the facility had a policy and procedure on elopement, but he did not know the specifics. The MD stated Resident #1 eloped and walked about 3/4 of a mile then was picked up and brought back to the facility unharmed. He stated he saw Resident #1 Wednesday and assessed no harm to the resident. The MD stated he was aware the facility had a plan to fix the door the resident went out, but had no idea what happened stating, It just came open. During an interview on 10/10/2025 at 2:02 PM the Director of Nursing (DON) stated a resident saying they wanted to go home, packing a bag, or door checking were all considered resident exits seeking behaviors. The DON stated she would have to check but she believed Resident #1 was care planned as an elopement risk. Resident #1 resided on the secure unit, but the electronic monitoring system had not been initiated prior to the 10/07/2025 elopement. There were 2 CNAs and a MAC working the Secure unit the night of the elopement. The DON stated she was notified by the charge nurse that Resident #1 had an elopement. The facility staff took the transport van to pick Resident #1 up and returned to the facility. The DON stated she in-serviced LPN #5 about elopements and doing the census for a room-by-room search. The staff did a facility census, body audits, and notifications. They notified Resident #1's family, The MD, Myself and she notified the Regional Administrator. After Resident #1 was returned they checked the door. LPN #5 checked the 500-Hall secure exit door and said it was not locking. Once they figured out the door was malfunctioning a staff member was assigned to sit and monitor it. The DON stated she was unaware of any issues with the 500-Hall exit door and maintenance request are put in through a computerized tracking program which the charge nurses have access to but did not know if the CNAs did. Maintenance then got alerted to it, but Maintenance was known to check the system on a regular basis. The system had been in place for at least 7 years since she had been employed there and stated the staff should know about it. The DON stated the staff also wrote down maintenance work orders, but the computerized tracking system was the official system. The DON stated there were no work orders that were in the computerized system for any locking doors issues. During an interview on 10/10/2025 at 2:41 PM the Regional Administrator stated anytime a resident gets out of the facility, off the property, and out of line of sight, it is an elopement. She stated she was notified by the DON when Resident #1 eloped on 10/07/2025 somewhere around 9:45PM-9:50PM. They made sure the resident was on route back to the facility. Resident #1 was placed one-on-one and was assessed for the electronic monitoring system. She stated Resident #1 was not care planned for an elopement risk prior to the 10/07/2025 event because Resident #1 had been in the facility since July 2025 and there has been no exiting seeking or door checking behaviors. The Regional Administrator stated she was not aware of Resident #1's elopement from another facility. The Regional Administrator stated the facility did not know 100% for sure how Resident #1 got out but stated one of the MAC asked and Resident #1 rolled to the door and pointed to it. The staff checked it 3 times and it was not working. A staff member was stationed there, and the repair company came out the next day, a keypad had to be replaced. They thought it might have gone bad during the rainstorm. Everything has been working since then. The next day the DON and Regional Administrator asked Resident #1 again how they got out, Resident #1 walked right to the same door. The staff have been checking all the doors and keypads to see if any have issues. The Regional Administrator stated some maintenance work orders are made in the computerized tracking system and some are handwritten. The written ones were given directly to the Maintenance Director unless they were emergent than he was called. The Regional Administrator stated the computerized tracking system was just being implemented for maintenance work orders this week but had no knowledge of any issues with that door prior to the event. The Regional Administrator stated she told the Maintenance Director to give her the computerized tracking system in-service, and she would personally go around to everyone. The slips of papers and sticky notes we have are not a system. It's just not going to cut it. During an interview on 10/10/2025 at 3:15 PM 3:15 PM the repair technician who responded to the facility and replaced the keypad stated that the lock had failed and would intermittently release. He stated there was no obvious defect found, and the Maintenance Director stated he did a check every Tuesday. There were storms in the area, it is a possibility it was the weather, but he wrote in his report the exact cause was unknown. He stated he was able to replicate the problem by releasing the door 3 times and it started to make a humming sound. The repair technician stated if the sound was the same as the staff was reporting it could be indicative of an ongoing problem. He stated the repairs were completed and he tested it about twenty times. A review of a facility policy titled, Elopements and Wandering Residents, dated 01/23/2020, indicated, the purpose of the policy was to identify residents who wander so appropriate interventions can be put in place in an effort to provide adequate supervision and safety. The Standard was, during the admission process residents should be evaluated by reviewing their history and interviewing the family/representative to determine a history of wandering. A resident evaluation for elopement should be completed. The resident's care plan should address the elopement potential and risk. The facility should be equipped with door locks/alarms to help avoid elopements. If an alarm on an exit door is noted to be malfunctioning, maintenance should be notified immediately, and visual monitoring should be implemented until repair or replacement is confirmed. New staff will be informed of the alarm protocols and then they should be included in routine in-services. A one-year review of the facility in-services on wandering/elopement revealed the facility's used a variation of a 01/23/2025 Elopement Policy, a 10/30/2017 Elopement Policy, Tips for Preventing Elopement, Door Alarm Response Protocols, and Missing Resident Timeline to provide training to 23 staff members on 12/27/2024, 50 staff members on 05/09/2025, 32 staff members on 06/27/2025, 164 staff members on 07/16/2025, and 16 staff members on 09/05/2025.

Based on observation, interview, and facility policy review, the facility failed to ensure foods stored in the freezer and dry storage area were covered, and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen;1 of 1 ice machine in the kitchen was maintained in clean and sanitary condition to prevent food and beverage contamination and staff washed their hands between dirty and clean tasks and before handling clean equipment to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 96 residents who received meals from the kitchen. The findings are: 1. On 08/06/24 at 4:17 PM, an opened box of salt was on the shelf above the food preparation counter, the box was not covered. 2. On 08/06/24 at 4:37 PM, the ice machine in the kitchen had an accumulation of wet, black, slimy appearing residue around the area where ice forms before dropping into the ice collector. It was pointed out to the Dietary Manager and asked if the residue build up could be wiped off. She used tissue paper and wiped it off. The wet black residue easily transferred to the tissue. The Dietary Manager was asked if she could describe what was found on the panel. She stated, It was slimy black. The Dietary Manager was asked who used the ice from the ice machine and how often they cleaned it. We have a company that come s every 3 months to clean it. We use it in the kitchen to fill beverages served to the residents at mealtimes. 3. On 08/06/24 at 4:45 PM, an opened box of vegetable blend was on a shelf in the walk-in freezer. The bag was not covered or sealed. 4. On 08/06/24 at 5:02 PM, Dietary Aide (DA)#1 opened the refrigerator and removed trays that contained beverages and placed them on the counter, picked a maker and placed it in a container on the counter, contaminating her hands. Without washing her hands, she picked up glasses that contained beverages to be served to the residents for supper meal by the rims and placed them in a deep pan. She then pours ice around the drinks to keep them chilled before serving them to the residents at the supper meal. 5. On 08/06/24 at 5:30 PM, DA #1, who was on the tray assisting with the supper meal, was observed to pick up cartons of supplements and placed them on the trays, contaminating her hands. Without washing her hands, she picked up glasses and cups that contained beverages by the rims and placed them on the trays to serve to the residents with their meal. 6. On 08/06/24 at 5:36 PM, DA #1 on the tray line serving supper meal, was observed to pick up cups of juice and cartons of milk and placed them on the trays, contaminating their hands. Without washing their hands, she picked up glasses that contained beverages by the rims and placed them on the trays to serve the residents. At 5:53 PM, DA #1 was asked what she should have done after touching dirty objects and before handling clean equipment? DA #1stated, I should have washed my hands. 7. On 8/06/24 at 5:39 PM, DC #2 was on the tray line serving supper meal. DC#2 picked up cartons of juice and cartons of sherbets and placed them on the trays. Without washing her hands, she picked up clean plates from the plate warmer and placed them on the trays with her fingers inside the plates. She then portioned food items on the plates and served them to the residents for supper meal. 8. A review of a facility policy titled, Handwashing Guidelines with effective date of February 1, 2002, provided by the Dietary Manager on 8/07/24 at 5:51 PM, indicated, Frequency of Handwashing .After hands have touched anything unsanitary, i.e., garbage, soiled utensils or equipment, and dirty dishes.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure that physician's orders for medications were followed during medication administration for 2 (Resident #24 and #92) of 6 residents reviewed for medication administration. The surveyor observed 31 medication opportunities with 2 errors noted, which was a 6.45% error rate for the facility. Findings include: A review of a facility policy titled, 6.0 General Dose Preparation and Medication Administration, dated 01/01/2013, indicated, Facility staff should verify that the medication name and dose are correct. During an observation on 08/07/2024 at 7:45 AM, Registered Nurse (RN) #4 administered multivitamin/multimineral 1 tablet to resident #92. During an observation on 08/07/2024 at 7:54 AM, RN #4 administered calcium with vitamin D3 600 milligrams (mg)/5 micrograms (mcg). 1 tablet to resident #24. A review of Physician Orders, revealed Resident #92 had an order for multivitamin tablet, 1 tablet by mouth daily this order was ordered on 12/18/2023. A review of Physician Orders, revealed Resident #24 had order for calcium with vitamin D 600 mg/ 10 mcg tablet. 1 tablet by mouth daily this order was ordered on 07/02/2024. During an interview on 08/07/2024 at 4:47 PM, the surveyor asked RN #4 to compare the medication that was given to Resident #92 and #24 to the medication administration record (MAR). RN #4 stated a multivitamin with minerals was given but the order was for a multivitamin for Resident #92 and vitamin D3 was not the accurate amount with Calcium for Resident #24. RN #4 stated both variations of the medications are the only available dose in the building. Surveyor asked, What is the importance of following physician's orders during medication administration? RN #4 stated, Follow physician's orders to make sure the resident is getting the correct medication ordered. During an interview on 08/08/2024 at 7:10 PM, the Director of Nursing (DON) Resident #92 should have received a multivitamin but a multivitamin with minerals was received and Resident #24 was not given the correct strength of Vitamin D. The DON stated it is important to give the correct medications and dosages to ensure that Physician's orders are followed.

Based on observation, interview, and facility policy review, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 8 residents who received pureed diets. The findings are: 1. On 8/06/24 at 5:15 PM, a pan of pureed chicken alfredo to be served to the residents who required pureed diets was on the steamtable. The consistency of the pureed chicken alfredo was lumpy and not smooth. There were pieces of intact pasta visible in the mixture. 2. On 8/07/24 at 8:08 AM, the following observations were made on the steamtable during the breakfast meal service: a. A pan of pureed sausage. The consistency was gritty and not smooth. b. A pan of pureed bread. The consistency was thick. c. On 8/06/24 at 8:17 AM, the surveyor asked the Dietary Manager to describe the consistency of the pureed sausage and pureed oatmeal served to the residents at the breakfast meal. She stated, Pureed bread was thick and pureed sausage was not completely pureed. 3. On 8/07/24 at 10:33 AM, Dietary [NAME] (DC) #3 used a #8 scoop to put 10 servings of Spanish rice into a blender, added a can of tomato juice and pureed. At 10:41 AM, DC #3 poured the pureed Spanish rice into a pan, covered the pan with foil and place it in the oven. The consistency of the pureed rice was gritty. At 12:42 PM, the Dietary Manager was asked if she could describe the consistency of the pureed Spanish rice. She stated, It was gritty. 4. On 08/07/24 at 11:19 AM, DC #3 used a 2 -ounce spoon to place 12 servings of shredded lettuce and 12 servings of diced tomatoes into a blender, added 2 tablespoons of thickener and pureed. She poured the pureed salad into a pan. The consistency of the pureed salad was not formed and had tomato seeds in the mixture. At 2:19 PM, DC#3 was asked to describe the consistency of the pureed salad. DC #3 stated, The seeds are hard to puree. 5. A review of a facility policy titled, Pureed Foods Process #2 Preparing Pureed Foods, with an effective date of August 23, 2017, indicated whole foods should be pureed in a blender or a food processor to a semi-solid consistency, the consistency of applesauce or mashed potatoes.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to change contaminated gloves and perform hand hygiene during medication administration with a resident on enhanced barrier precautions (EBP) for 1 (Resident #26) of 1 resident reviewed for percutaneous endoscopic gastrostomy (PEG) tube medication administration. Findings include: A review of a facility policy titled, Hand Hygiene, dated 06/11/2020, indicated, The following is a list of some situations that require hand hygiene. Before and after direct resident care. Before and after entering isolation precaution settings. After handling soiled or used linens. A review of a facility policy titled, Enhanced Barrier Precautions, dated 04/29/2024, indicated, EBP requires donning of gown and gloves during high-contact resident care activities. EBP is employed while performing high-contact resident care activities including device care or use: feeding tube. A review of the Face Sheet, indicated the facility admitted Resident #26 with diagnosis of artificial openings of gastrointestinal tract. A review of Resident #26's Care Plan revealed the resident had potential for infection related to PEG- enhanced barrier precautions. Interventions included gown and gloves during high-contact care areas with an initiation date of 07/30/2024. A review of Physician Orders, revealed Resident #26 had an order enhanced barrier precautions ordered on 07/22/2024. During an observation on 08/07/2024 at 8:13 AM, Registered Nurse (RN) #4 was observed by the surveyor preparing Resident #26's medications in hallway on medication cart with gloves in place on both hands. RN #4 entered resident's room filled 3 large medicine cups with water in the bathroom and placed on resident's bedside table. RN #4 then pulled back the resident's linens and exposed the PEG tube. RN #4 then used the bed controller to raise the height of the resident's bed. All of this occurred while RN #4 was wearing the same pair of gloves. RN #4 then applied a gown prior to administering the resident's medications and left the same pair of gloves in place. During an interview on 08/07/2024 at 6:10 PM, the surveyor asked RN #4, Is Resident #26 on any precautions? RN #4 stated there were enhanced barrier precautions for PEG tube. The surveyor asked what personal protective equipment (PPE) is required for EBP, and RN #4 stated gown and gloves for extra precaution to prevent infection from transmission of a healthcare worker. The surveyor asked RN #4, What should have been done in between the preparation of Resident #26's medication and administration? RN #4 stated that gloves should have been changed and hand hygiene performed. During an interview on 08/07/2024 at 6:20 PM, the surveyor asked the Director of Nursing (DON), Is Resident #26 on any precautions? The DON stated EBP for PEG tube. The surveyor asked what personal protective equipment (PPE) is required for EBP? DON stated gown and gloves. It should be applied when walking into the room for PEG tube medication administration. Surveyor asked the DON, Should a glove change be performed in between medication preparation and PEG tube medication administration? The DON stated yes, the gloves should have been changed. The surveyor asked, What is the reasoning for EBP? DON stated, To protect the resident with an extra layer of protection from healthcare staff.

Based on observation, interview and record review, the facility failed to ensure foods stored in the freezer, refrigerator, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; kitchen vents were cleaned to provide a sanitary environment for food preparation; kitchen walls and door frames were free of chips, debris, dirt, grease, grime, rust, stains, and spills; wall tiles were replaced; expired dairy products and food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; refrigerator temperatures were maintained at 41 degrees Fahrenheit or below, and cold dairy products were maintained at 41 degrees Fahrenheit or below to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 85 residents who received meals from the kitchen (total census: 86), as documented on a list provided by the Assistant Administrator on [DATE] at 1:42 PM. The findings are: 1. On [DATE] at 10:44 AM, during the initial rounds with the Assistant Dietary Supervisor the following observations were made on a shelf above the food preparation counter, on the shelf above the steam table: a. An opened container of onion powder was congealed and was not dated. The Assistant Dietary Supervisor stated, It has been there too long. I will throw it away. b. A container of Italian seasoning had no received date. c. A container of celery salt had no received date. d. A container of pumpkin pie spices had no received date. e. A container of multi-mix seasoning was not dated. f. A container of seasoning salt had no received or opened date. g. Two bags of bread were not sealed. h. An opened bag of coffee on top of the coffee maker did not have a received date. 2. On [DATE] at 10:51 AM, Dietary Employee (DE) #1 was wearing gloves on her hands when she picked up a box of plastic wrap and placed it on the counter. Without changing gloves, and washing her hands, she picked up clean utensils by their tips and placed them in individual bags for the residents to be used in eating their lunch meal. 3. On [DATE] at 10:58 AM, the walk-in refrigerator temperature was 45 degrees Fahrenheit. At 11:00 AM, the Surveyor asked the Assistant Dietary Supervisor to check the temperature of the milk. She did so, and stated, It was 43.2 degrees Fahrenheit. 4. On [DATE] at 11:02 AM, the following observations were made in the walk-in freezer. a. An opened box of Smithfield pork riblets dated [DATE] was not covered or sealed; the meat had ice cycles on it. The Dietary Supervisor stated, It doesn't look good. b. An opened box of sausage links was not covered or sealed. c. An opened box of breakfast squares dated [DATE] of turkey sausage, with mozzarella cheese was not covered or sealed. 5. On [DATE] at 11:23 AM, the following observations were made in the kitchen areas: a. Two poles attached to the steam table had rust. b. The legs of the preparation counter where the can opener was attached had rust on them. c. The door frames leading to the dry storage room were chipped. The areas that were chipped were covered with rust. d. The floor corners leading to the dry storage room had accumulation of black corroded residue on it. e. The door seams leading to the walk-in refrigerator had rust on them. The area had an accumulation of dirt and debris. f. The metal legs of the food preparation counter and the metal legs of the conventional oven were rusty. g. The airway attached to the back of the deep fryer where heat escapes had an accumulation of greasy caked on food in it. h. The back of the deep fryer air flow had greasy dust in it. i. The left side of the oven had grease build up on it. j. The door of the oven had greasy stripes on it. k. The wall above the shelf where clean pans were stored was chipped. The areas that were chipped were covered with black residue. l. The shelf below the clean side of the dish washing machine where clean racks were stored was covered with rust matter. m. A package of cookies were out of the box but sealed in the package with no received date. No box was found. The Acting Dietary Manager and Surveyor was unable to tell what kind of cookies they were or when the cookies were received. 6. On [DATE] at 11:33 AM, the Bread Rack contained 40 bags of white bread, one rack contained 3 bags of wheat bread, one contained 3 bags of hamburger buns and one bag of hot dog buns. There was no received date on the bags of bread. The Assistant Dietary Supervisor stated, We just received them today. 7. On [DATE] at 11:58 AM, DE #1 picked up a can of pear halves and placed it on the counter. She picked up a can of thickener and placed it on the counter. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She then used her contaminated gloved hands to pick up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets for lunch. 8. On [DATE] at 12:02 PM, DE #2 was wearing gloves on her hands when she opened the refrigerator door. Without changing gloves and washing her hands. She picked up cups by their rims and placed them on the counter to be used in serving beverages to the residents at the lunch meal. At 1:30 PM, the Surveyor asked DE #2 what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 9. On [DATE] at 12:18 PM, a cart that had pans containing cartons of whole milk and cartons of mighty shakes was pushed out of the walk-in refrigerator into the kitchen. There was no ice on either pan to chill the beverages before serving to the residents. The pans were on the cart at room temperature. At 12:34 PM, the Assistant Dietary Supervisor took a carton of mighty shake out of the pan and a carton of whole milk to prepare fortified shake. The Surveyor asked the Assistant Dietary Supervisor to check the temperature of the chocolate milk, the mighty shake, and the whole milk. She did and stated, The carton of chocolate milk 46.6 degrees Fahrenheit, the carton of chocolate mighty shake 49.4 degrees Fahrenheit, the carton of whole milk 43.3 degrees Fahrenheit. The Surveyor asked the Assistant Dietary Supervisor what the instructions on the chocolate mighty shake stated, There were supposed to have them on ice. She read the instructions on the carton and stated, Store frozen, thaw, then store at 40 degrees or below. 10. On [DATE] at 12:20 PM, DE #1 was on the tray line assisting with the noon meal service. She picked up condiments and placed them on the trays. Without washing her hands, she picked up clean plates from the plate warmer and placed them on trays to be used in portioning food items to be served to the residents for lunch. At 1:29 PM, the Surveyor asked what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have removed gloves and washed my hands. 11. On [DATE] at 1:12 PM, the following observations were made in the refrigerator of the Pantry on the 500 Hall (Unit): a. An opened package of extra hot beef sticks had no opened date, no received date, and no name to whom it belonged to. b. A bowl of pudding had no name or date when stored. 12. On [DATE] at 1:14 PM, the following observations were made in the freezer of the Pantry on 500 Hall (Unit): a. A box of chicken pot pie had no name and no received date. b. A gallon of vanilla ice cream, yellow in color with ice cycles on top of it, had no received date or opened date on the container. The Assistant Dietary Supervisor stated, It has been there too long. c. One chocolate ice cream bar had no name and no received date on it. d. An opened box of chocolate chip cookies dated [DATE] was on the counter by the refrigerator. 13. On [DATE] at 3:58 PM, a gallon of whole milk that contained a small amount of milk was on the food preparation counter. At 4:11 PM, when DE #4 was about to add the milk that had been setting on the counter since 3:58 PM to the lasagna she was immediately stopped and was asked to check the temperature of the milk. She did so and stated, It is 56.9 degrees Fahrenheit. 14. A facility policy titled, Hand-washing Guidelines, provided by the Assistant Administrator on [DATE] at 1:40 PM documented, I. Frequency of Hand-washing: . After hands have touched anything unsanitary, i.e., garbage, soiled utensils or equipment, and dirty dishes .

Based on observation, interview, and record review, the facility failed to ensure resident personal care equipment was properly labeled and stored to prevent the potential for cross-contamination between residents for 1 (Resident #26) of 5 (Residents #19, #26, #27, #33 and #37); failed to maintain a clean, safe, and sanitary environment to help prevent the development and transmission of communicable diseases and infection for 3 (Residents #66, #67 and #288) of 10 sampled residents (Residents #3, #12, #22, #27, #37, #48, #53, #66, #67 and #84) sampled residents who used the resident bathrooms and failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to sanitize hands between residents during medication administration. The failed practices had the potential to affect 14 residents on the 200 Hall who required assistance with oral care as documented on a list provided by the Assistant Administrator on 08/02/23 at 2:00 PM; 60 residents who use the resident bathrooms according to a list provided by the Assistant Director of Nursing [ADON] on 08/03/23 at 11:00 AM, and 36 residents who received medications on halls 3C (300 Hall) and 4D (400 Hall) by Licensed Practical Nurse (LPN) #1 according to a list provided by Medical Records on 08/02/23 at 3:11 PM. The findings are: 1. Resident #67: a. On 07/31/23 at 12:51 PM, Resident #67 was lying in bed. The Surveyor opened the bathroom door to the shared bathroom. There was a black and brown substance on the floor under the sink, and around baseboard tiles. Three fourths of the baseboard tiles were missing. An open urinal was hanging on the handrail. There was a brief lying on top of the Sharps Container in the bathroom and a used glove in the wash basin sitting on top of the back of the toilet. An unidentified toothbrush was lying on the sink behind the chrome fixtures resting on an area of a brown substance, dark facial hairs, and dark strands of human hair. b. On 08/01/23 at 9:03 AM, Resident #66 was out of the room. The Surveyor observed human feces in the bathroom toilet in Resident #66 and Resident #67's shared bathroom. Two toilet plungers were next to the toilet on the floor, one on each side with bits of toilet paper and human waste stuck to the plunger sitting to the right of the toilet. An open urinal was hanging over the handrail next to the toilet. An unlabeled toothbrush was sitting on the back of the sink. On the sink were strands of dark colored human hair, dark facial hairs, two open packets of skin protectant ointment, and a tube of toothpaste. 2. On 08/02/23 at 7:48 AM, LPN #1 did not sanitize or wash his hands prior to or after administering medication to Resident #10. a. On 08/02/23 at 8:29 AM, LPN #1 did not sanitize or wash his hands prior to or after administering medication to Resident #288. b. On 08/02/23 at 8:33 AM, the Surveyor asked LPN #1 if there was any sanitizer on his medication cart. LPN #1 answered No, we did, but I don't know where it is. The Surveyor asked if there was anything he should have done differently after giving medications to Resident #10. LPN #1 answered, I thought about it and wanted to sanitize my hands, but I couldn't find any. Some of these rooms have it and some don't. There is usually some sitting on the med [medication] cart. It's supposed to be here. Somebody must have used it and not brought it back. The Surveyor asked who was responsible for stocking sanitizer on medication carts. LPN #1 answered, Central Supply I believe, and she's not here right now. She's the one who orders the OTC's (over the counter). The Surveyor asked who stocks when Central Supply isn't here or unavailable. LPN #1 answered, I'm not sure. The Surveyor asked what can happen if hands are not sanitized between residents when doing a medication pass. LPN #1 answered, Infections and spread of germs. The Surveyor asked what should you do when there is no sanitizer on the cart or in the resident rooms. LPN #1 answered, Wash hands, or find a room that has some and use that. The Surveyor asked if it was up to standard of practice to not sanitize or wash hands between residents during medication pass. LPN #1 answered, No, it's not there, so I didn't think about it. c. On 08/02/23 at 3:20 PM, the Surveyor asked the ADON who was responsible for facility infection control. The ADON answered, I am. The Surveyor asked if it was standard of practice to not sanitize or wash hands between residents on a medication pass. The ADON answered, No it isn't. The Surveyor asked what could happen if hands are not sanitized or washed between residents. The ADON answered, Spread of Infection. The Surveyor asked if the nurses were trained on infection control. The DON answered, We do it as needed and quite often. The Surveyor asked what specifically indicated whether-or-not training was needed quite often. The ADON answered, I also do the tracking and trending and use that. They do go over infection control during hiring and we do it yearly. The Surveyor asked if the facility kept sanitizer on the medication carts and who was responsible for stocking it. The ADON answered, The charge nurse. d. A policy titled, 6.0 General Dose Preparation and Medication Administration, provided by the ADON on 08/08/23 at 3:42 PM, documented, .This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications . 2. Prior to preparing or administering medications. authorized and competent facility staff should follow facility's infection control policy (e.g. handwashing) . e. A policy titled, Hand Hygiene, provided by the Assistant Administrator on 08/03/23 at 10:08 AM, documented, Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections . Standard: Hand washing should be performed between procedures with resident/guest(s) . Process: I. Handwashing .5. As an adjunct to routine hand washing, hand sanitizer may be applied to the hands between tasks . II. Hand Sanitizer If hands are not visibly soiled, use an alcohol-based hand sanitizer . 47916 3. Resident #26: a. On 07/31/23 at 11:44 AM, the Surveyor observed an opened cream-colored toothbrush lying on left side of Resident #26's sink with the bristles touching the sink, resting in residue. b. On 07/31/23 at 2:35 PM, the Surveyor observed an opened cream colored toothbrush lying on the left side of the sink with the bristles touching the sink in residue with the bristles in Resident #26's bathroom. c. On 08/02/23 at 11:40 AM, the Surveyor showed Certified Nursing Assistant (CNA) #5 the toothbrush resting on the left side of the sink and asked if she could tell the Surveyor which resident the items belonged to, and who was responsible for assisting with oral care and storage. CNA #5 said, I do not know. I cannot tell. The CNAs are responsible for oral care. During the interview CNA #5 said, The toothbrush should be covered. I do not know where it should be stored. It can have cross contamination due to the toilet over there and flushing. The Surveyor asked if the sink appeared clean. CNA #5 said, No. d. On 08/03/23 at 10:31 AM, the Surveyor asked the ADON who was responsible for the storage of personal care items. The ADON said, CNAs are responsible. Toothbrushes and personal care items are supposed to be labeled and stored by resident preference, a bag, container. The Surveyor asked what the consequences of improper storage of personal care items was. The ADON said, Residents are at risk for infection, or cross contamination. 4. Resident #288 had diagnoses of Pressure Ulcer of Unspecified Heel, Stage III, and Osteomyelitis Unspecified. a. On 07/31/23 at 1:14 PM, Resident 288 was wearing gray flex [heel proctor] boots. Resident #288 said, I have pressure ulcers on my sacrum/back, and both heels. Water gathers at the bottom of my toilet and dries. A brown substance was on the floor around the toilet. Resident #288 said, I put paper towels in the floor and wipe it up using my heel to scrub the floor. They told me at the wound clinic to try to avoid getting an infection in my heel. The grout on the left side, right side, and front of the toilet, and around the doorway baseboards was dark brown. b. On 08/01/23 at 10:05 AM Resident #288 said, Stuff is still seeping from the bottom of my toilet. It is so slippery, I have to take my boots off when I am in the bathroom, but then my socks get dirty. The Surveyor asked if his heels get wet when he wipes the brown substance off the floor with a paper towel. Resident #288 said, Yes, it does. The Surveyor observed a brown, wet substance around the bottom of the toilet. c. On 08/02/23 at 11:55 AM, the Surveyor observed a clear fluid seeping from below the toilet. The grout behind the toilet was white. The grout to the sides and front were brown. The Surveyor asked LPN #1 to describe the substance in the bathroom floor. LPN #1 said, Well, it looks like the toilet is leaking around the seal and drying. I am not sure about the brown stuff. The Surveyor discussed with LPN #1 about Resident #288 cleaning the wet floor using his socks and having to remove his heel protectors and asked if this was appropriate. LPN #1 said, This is not appropriate, and resident is at risk for further skin breakdown and infection. d. On 08/02/23 at 12:28 PM, the Surveyor observed a brown substance around the bottom of the toilet, and white fluid seeping from below the toilet that had spread out approximately 12 inches from the toilet. The floor grout was white behind and to the right and left back side of the toilet. The grout on the left, and right side and the front of the toilet to the baseboards around the door were brown. A Maintenance Assistant entered Resident #288 ' s room and the Surveyor asked him to describe the bathroom floor. He said, It looks like water. I am not sure what the brown stuff is. The grout is supposed to be white, but it is brown, dark brown. There is no caulking around the toilet, it looks like the toilet is leaking around the seal. e. A policy titled, Cleaning - Patient Room - Occupied, provided by the Assistant Administrator on 08/02/23 at 2:00 PM documented, .Clean the bathroom as per procedure. Place wet floor signs at the door to the room. Damp mop floor with an EPA [Environmental Protection Agency] approved disinfectant/detergent solution. Begin at the farthest corner of room working backwards toward door including the bathroom and closet. Be sure to disinfect baseboards . f. On 08/02/23 at 2:30 PM, the Surveyor asked the ADON the process for keeping resident rooms clean and reduce the risk for infections. The ADON said, Housekeeping provides cleaning services, and residents with compromised skin are placed on enhanced barrier precautions. Unclean rooms have a risk for cross contamination, and infection.

Based on interview and record review, the facility failed to ensure residents were aware of how to file a grievance and how to contact the Ombudsman. The failed practices had the potential to affect all 87 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 07/31/23 at 3:10 PM. The findings are: 1. On 08/02/23 at 9:28 AM, the Surveyor attended a meeting with the Resident Council. The Surveyor asked the Resident Council members, Do you know how to file a grievance? The Council members agreed that they did not know how to file a grievance. The Surveyor asked, Do you know how to contact the Regional Ombudsman? The council members agreed that they did not know how to contact the Ombudsman. 2. On 08/02/23 at 10:26 AM, The Assistant Administrator stated, Social Services is who the Residents report grievances to. The Surveyor asked, Who does the staff report resident grievances to? She stated, They report it to Social Services, she is everyone's grievance contact. The Surveyor asked the Assistant Administrator to provide the policy for filing grievances and the policy for notification of the Ombudsman. The Assistant Administrator stated, We do not have a policy to notify the Ombudsman, but the contact information is on the wall by my office. 3. A facility policy titled, Resident and Family Grievances, provided by the Assistant Director of Nursing (ADON) on 08/02/23 at 3:10 PM documented, Residents and their family members may voice grievances through a verbalized complaint to a facility staff member or through a written grievance process .

Based on observation, interview, and record review, the facility failed to provide a clean bathroom, toileting, and showering facility for residents to promote a safe, clean, comfortable, and homelike environment for 6 (Residents #3, #5, #65, #66, #67 and #288) sampled residents. This failed practice had the potential to affect 87 residents based on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 07/31/23 at 3:12 PM. The findings are: 1. Resident #66: a. On 07/31/23 at 12:19 PM, Resident #66 was lying in bed. The Surveyor asked if he had any concerns. Resident #66 stated, The showers have black mold in the stalls. I don't know if it's turd [feces] or what. It has been that way since I've been here. The Surveyor asked Resident #66 how long he had been in the facility. Resident #66 answered, A couple months if not longer. The Surveyor asked how often he got a shower. Resident #66 answered, I'm supposed to get one 2 times a week, but that doesn't always happen. The shower is so dirty. The Surveyor then opened the door to the restroom. There was a strong odor of human waste, and an open urinal hanging on the handrail next to the toilet. b. On 08/01/23 at 9:51 AM, Resident #66 was sitting up in a wheelchair in his room. The Maintenance Assistant was working on the toilet in the bathroom. The Surveyor asked if the toilet had been running continuously. The Maintenance Assistant answered, Yes. The Surveyor asked why there was only 1/3 of the baseboards tiled. The Maintenance Assistant answered, I think tile has been ordered. It looks unfinished and unclean because they ran out of tile when they were putting in the baseboards. The Surveyor asked if the baseboard tiles had been ordered and when. The Maintenance Assistant answered, I don't know. The Surveyor asked if the facility kept a maintenance log, or documented what was on order. The Maintenance Assistant answered, I'm just the assistant and I'm sure [name] keeps track of it somehow, but I don't know of any log or book. I'm just the one that fixes everything. [name] is the brains, and I'm sure he has a way of keeping up with things. c. On 08/01/23 at 10:51 AM, observed the shower on the 300 Hall. There was a black substance on the wall tiles, grout between the tiles and between the tiles on the shower floor. There were rusted metal hangers on the wall, and chipped tiles with sharp, jagged edges on the baseboard tiles on the corner wall of the shower. There was a shower wand hanging over a shower grab bar with the water left running, and a used washcloth on the floor of the shower. There were no residents or staff in the shower area. d. On 08/02/23 at 12:50 PM, the Surveyor accompanied the Housekeeping (HK) Supervisor to the shower on the 300 Hall. The Surveyor asked the HK Supervisor to describe what she saw on the floors and walls of the shower. The HK Supervisor answered, We don't know what that is. It was a black mess. We used bleach and [a Commercial-strength disinfectant]. Some of it came off, but this is the cleanest we could get it. We've tried to talk to maintenance, we call it mold. The Surveyor asked what maintenance said when she talked to them. The HK Supervisor answered, He's on vacation. When he gets back, he will come up with a [NAME] idea. The Surveyor asked how long the shower had looked like that. The HK Supervisor answered, One year. I've been here thirteen or fourteen years. I wouldn't say it looked like this; it's collected over time. The Surveyor asked if there was a reason why the water continuously runs from the shower wand hanging over the grab bar in the shower. The HK Supervisor answered, It won't turn off. I don't think [name] knows this is going on. Some of the aides don't know to report this. The Surveyor asked what the reporting process was. The HK Supervisor answered, We fill out the paper report hanging on the maintenance door. They are not reporting it like they need to. 2. Resident #67: a. On 07/31/23 at 12:51 PM, Resident #67 was lying in bed. The Surveyor opened the bathroom door and saw that the toilet was running continuously and had a black and brown substance on the floor under the sink and around the baseboard tiles, 3/4 of the tiled baseboard was missing. There was an open urinal hanging on the handrail. There was a brief lying on top of the Sharps Container in the bathroom and a used glove in the wash basin sitting on top of the back of the toilet. An unidentified toothbrush was lying on the sink resting on an area with a brown substance and dark strands of human hair. b. On 08/01/23 at 8:58 AM, Resident #67 was lying in bed awake. The Surveyor asked if he knew the toilet was continuously running and if it bothered him. Resident #67 answered, It's been that way over a year, it's filthy. The Surveyor opened the door to the bathroom and observed the toilet was full of brown water close to the top edge, and there was a pungent odor of human feces. Resident #67 stated, I went in there yesterday and the seat was covered with filth. The boy that used it messed on it and didn't tell anybody. I almost fell . 3. Resident #3: a. On 07/31/23 at 1:42 PM, Resident #3 was sitting up in a motorized wheelchair. The Surveyor opened the bathroom door and saw the toilet was running continuously and needed to be cleaned. There was a deep scratch in the wall into the sheetrock next to baseboard approximately 2 feet by 4 inches long and 1/2 inch deep. The walls had multiple patched areas where there was no paint. b. On 08/01/23 at 8:55 AM, observed the toilet running continuously in the bathroom. 4. Resident #5: a. On 07/31/23 at 11:07 AM, Resident #5 was lying in bed. There were pillows and bolsters stacked in a wheelchair pushed into the corner between the left side of the resident's bed and the wall. The floor had visible dirt, debris, and sunflower seed hulls on the floor behind the wheelchair. There was paint peeling from the walls across from the residents' bed on the corner by the chest of drawers. The bathroom had a deep scratch in the wall below the baseboard. The Surveyor asked Resident #5 if he liked the way his walls looked in his room. Resident #5 answered, I would like to have these things fixed. b. On 08/01/23 at 9:20 AM, Resident #5 was lying in bed. The floor behind the wheelchair in the corner had sunflower seed hulls, debris and a dead insect lying on the surface. c. On 08/02/23 at 11:36 AM, Resident #5 was sitting up in a motorized wheelchair. The floor where the wheelchair had been had bolsters stacked up against wall, lying on floor. Sunflower seed hulls and a dead insect were visible on the floor behind the bolsters. A small piece of paper, small brown debris, and the imprints of the wheels of a wheelchair were visible on the floor in front of where the bolsters were stacked. 5. Resident #65: a. On 07/31/23 at 1:05 PM, Resident #65 was sitting in a recliner in the room. The Surveyor observed light brown spots of a dried substance on the floor in the room in front of the recliner. There were 3 empty sugar substitute packets lying on the floor in front of a trash can sitting next to the recliner. The bedside table had a sticky clear dried substance on the surface with 3 empty styrofoam cups, one lying on its side and 3 plastic lids, 2 packets of sugar substitute, and an unidentified white powder in various areas. The trash can in the bathroom was overflowing with paper towels spilling out onto the floor. There was paint peeling off the wall in the bathroom directly behind sink area measuring the length of the sink and approximately 3 inches wide. There was a shiny, dried, brown substance on floor in bathroom around the bottom of toilet with an emesis basin lying upside down on the floor between the wall and the right side of the toilet. The bathroom had a strong odor of urine and human waste. b. On 08/01/23 at 9:14 AM, Observed dried brown spots on the floor in front of the recliner. The bedside table remained the same with a sticky, clear substance on the surface, an unidentified white powder was scattered randomly on the surface and 5 styrofoam cups were sitting on floor beside Resident #65's recliner. c. On 08/02/23 at 9:24 AM, Resident #65 was sitting in a recliner in the room. Multiple spots of dried brown substance remained on the floor in front of the recliner. The bedside table surface was covered with a sticky, clear looking substance. 4 pink empty packages of sugar substitute were lying on the floor next to the recliner. The trash can next to the recliner was over full. The brown, shiny substance remained around the base of the toilet in the bathroom. There was a strong odor of urine. d. On 08/02/23 at 12:24 PM, the Surveyor asked the Housekeeping Supervisor how often resident rooms were cleaned. The HK Supervisor answered, They are cleaned, it depends on the rooms. It's different on different days. The Surveyor asked how she knew which rooms got cleaned on a daily basis. The HK Supervisor answered, We know the residents that need to be cleaned more than once daily. The Surveyor accompanied the HK Supervisor into Resident #65's room. Resident #65 was sitting in a recliner listening to music. The HK Supervisor stated, This is one that we do two times daily. I have a CNA [Certified Nursing Assistant] designated. The Surveyor asked which CNA was designated. The HKS answered, I don't know. I have one that's supposed to be there today. The Surveyor asked what the process was for cleaning resident rooms. The HK Supervisor replied, We clean the whole room and bathroom. We don't leave anything out. We sweep, mop, knock down cobwebs, dust windowsills, and empty trashcans. The Surveyor asked if they cleaned bedside tables. The HK Supervisor answered, We do it all. Housekeeper #2 was walking by in the hallway pushing a cleaning cart and entered Resident #65's room. The Surveyor asked Housekeeper #2 how often she cleaned Resident #65's room. Housekeeper #2 answered, I've cleaned it every day this week. The Surveyor asked what her process was for cleaning. Housekeeper #1 answered, The normal. The Surveyor asked what the normal was specifically. Housekeeper #2 answered, Surfaces, countertops, and bedside table. The Surveyor asked how often the floor was mopped. Housekeeper #2 answered, I've mopped every day this week. The Surveyor accompanied the HK Supervisor and Housekeeper #2 into Resident #65's bathroom. The HK Supervisor pointed to the area around the toilet, under the sink and moved the empty trash can to find trash underneath. The Surveyor asked Housekeeper #2 to describe what was on the floor. She answered, I don't know what that is, and it won't come up. I've mopped around the toilet, and it just comes back. I think it needs to be caulked. 47916 6. Resident #288: a. On 07/31/23 at 1:14 PM, Resident #288 said, Water gathers at the bottom of my toilet and dries. He pointed out a brown substance on the floor around the toilet to the bottom of the doorway baseboards. b. On 08/01/23 at 10:05 AM, Resident #288 said, [NAME] stuff is still seeping from the bottom of my toilet. It is so slippery; I have to take my flex [heel proctor] boots off when I am in the bathroom. The Surveyor observed a brown substance, with a clear, wet substance around the bottom of the toilet. c. On 08/02/23 at 11:55 AM, the Surveyor observed a clear fluid seeping from below the toilet. The grout behind the toilet was white, and grout to the sides and front of the toilet to the door baseboards were very dark brown. The Surveyor asked Licensed Practical Nurse (LPN) #1 to describe substance in the bathroom floor. Well, it looks like the toilet is leaking around the seal and drying. I am not sure about the brown stuff. This is not appropriate, and resident is at risk for further skin breakdown and infection. I will contact maintenance. d. On 08/02/23 at 12:28 PM, the Surveyor observed a brown substance around the bottom of the toilet, and the white fluid seeping from below the toilet had spread out approximately 12 inches from the toilet. The floor grout was white behind and to the right and left back side of the toilet. The grout on the left side, right side, and the front of the toilet to the baseboards around the door was very dark brown and the floor was moist. The Maintenance Assistant entered the room, and the Surveyor asked him to describe the bathroom floor. It looks like water. I am not sure what the brown stuff is. The grout is supposed to be white, but it is brown, dark brown. There is no caulking around the toilet, it looks like the toilet is leaking around the seal. We have a resident flushing stuff down the toilet and are having issues with the toilets backing up across the facility. During the interview the Maintenance Assistant said, Someone could slip and fall, infection. The Performance Improvement Project provided by the Assistant Administrator on 07/31/23 at 3:33 PM documented, Project: Housekeeping/Maintenance - Maintain the upkeep of facility Date Identified: 6/14/2023 . Housekeeping/Maintenance 6/14/2023 Implementation To maintain the upkeep of the facility and ensure a homelike clean environment . Plan for House Keeping Maintenance: Daily cleaning of the floors. Floors to be re-stripped and waxed, one hall a month until facility is done. And then re-start. 7. A facility policy titled, Cleaning - Patient Rooms - Occupied, provided by the Assistant Administrator on 08/02/23 at 2:00 PM stated, .Policy: All patient rooms will be cleaned daily. Procedure: Empty all waste containers . Dust all fixtures, ledges and surfaces in the room and bathroom. Begin at the door and work clockwise around the room. Damp dust overbed tables, bedside tables, telephone, chairs, stools, ledges, light switches, lamps and spots on walls or cabinets with an EPA approved disinfectant/detergent solution. Clean the bathroom as per procedure . Place wet floor signs at the door to the room. Damp mop floor with an EPA [Environmental Protection Agency] approved disinfectant/detergent solution. Begin at the farthest corner of the room working backwards toward door including the bathroom and closet. Be sure to disinfect baseboards .

Based on interview, observation, and record review, the facility failed to ensure nail care was regularly provided to maintain good hygiene and prevent potential injuries or infections for 2 (Residents #67 and #84) of 18 (Residents #3, #5, #11, #12, #19, #22, #26, #27, #33, #37, #48, #53, #66, #67, #70, #79, #84 and #190) sampled residents who required assistance with nail care and failed to provide mouth care for 1 (Resident #26) of 5 (Residents #19, #26, #27, #33 and #37) of 5 sampled residents on the 200 Hall who were dependent on staff for oral care. The failed practices had the potential to affect 45 residents on the 300 and 500 Halls who required staff assistance for nail care as documented on a list provided by the Assistant Director of Nursing (ADON) on 08/02/23 at 8:55 AM and 14 residents on the 200 Hall who were dependent or required staff assistance with oral care as documented on a list provided by the ADON on 08/02/23 at 2:00 PM. The findings are: 1. Resident #67 had a diagnosis of Non-Alzheimer's Dementia. a. A Care Plan dated 10/14/22 documented, Nail care as needed. b. On 07/31/23 at 12:41 PM, Resident #67 was lying in bed. His fingernails were approximately 1/4 inch past his fingertips with a dark brown substance under his fingernails on both hands. c. On 08/01/23 at 3:30 PM, Resident #67 was lying in bed. His fingernails remained approximately 1/4 inch past his fingertips with a brown substance under them. d. On 08/02/23 at 11:47 AM, Resident #67 was lying in bed with his hands folded across chest. His fingernails remained approximately 1/4 inch past his fingertips with a dark brown substance under the fingernails on his right hand, and light brown substance under the fingernails on his left hand. e. On 08/02/23 at 11:57 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #2 into Resident #67's room. The Surveyor asked LPN #2 to describe what was seen under Resident #67's fingernails. LPN #2 answered, He's got dirt under his fingernails. Those actually look pretty good for him. He's Hospice and frequently refuses showers and care. Hospice gives him bed baths and does his nailcare. Hospice is supposed to do it, but we do nailcare prn [as needed]. The Surveyor asked what could happen if nail care was not done. LPN #2 answered, He could get infections. That's the biggest. The Surveyor asked how often Resident #67's nails got checked. LPN #2 answered, I honestly don't know if we have a policy when he gets checked. When I do meds [medications] sometimes I check. f. On 08/02/23 at 12:07 PM, the Surveyor asked the ADON who was responsible for resident nail care. The ADON answered, As long as it's not a Diabetic, typically CNAs [Certified Nursing Assistants]. The Surveyor asked how often resident nails were checked and how often nail care was done. The DON answered, They should be checking every shift and as needed. The Surveyor asked why resident nail care was important. The ADON replied, Infection Control. The Surveyor asked what could happen if nail care was not done on a regular basis. The ADON answered, They can get infections in several places, or could get a skin tear. 2. Resident #84 had diagnoses of Alzheimer's Disease, Hypertension, and Atrial Fibrillation with other Dysrhythmias. a. A Care Plan dated 07/05/23 documented, Nail care as needed. b. On 07/31/23 at 3:48 PM, the Surveyor observed Resident #84 lying in bed. Her fingernails were approximately 1/4 inch past her fingertips with a dark brown substance visible underneath her fingernails. c. On 08/01/23 at 10:12 AM, the Surveyor observed Resident #84 lying in bed. Her fingernails remained approximately 1/4 inch past her fingertips. The right thumbnail was more than 1/4 inch long. A Dark brown substance was visible underneath the fingernails. The Surveyor also observed a scab below Resident #84's left eye. d. On 08/02/23 at 8:57 AM, the Surveyor observed Resident #84 lying in bed. LPN #2 walked into the room. The Surveyor asked LPN #2 to describe Resident #84's fingernails. LPN #2 answered, They are disgusting. The Surveyor asked who was responsible for nail care. LPN #2 answered, Actually everybody, the aides do it with their showers, and we have nail care. I don't remember what day it is. The Surveyor asked how often should nails be checked and nail care given. LPN #2 answered, They should be checked daily. The Surveyor asked why nail care was important. LPN #2 answered, Because it's disgusting and you can get germs and nasties under there. She's a picker, so it could cause her to get skin infections. e. A facility policy titled, Nail Care, provided by the Assistant Administrator on 08/02/23 at 8:35 AM documented, Purpose: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well being for the resident. Standard: Nail care is a routine part of grooming each day . f. A facility policy titled, Documentation of Routine ADL [Activities of Daily Living] Care, provided by the Resident Care Nurse on 08/02/23 at 12:21 PM documented, .Standard: Activities of Daily Living (ADL) Care services are considered routine care services . Process: .The charge nurse should be informed of a resident's refusal of care or any condition that prohibits the provision of care. Plans of care for residents are accessible to all staff . 47916 3. Resident #26 had a diagnosis of Vascular Dementia, Severe. a. On 07/31/23 at 11:44 AM, the Surveyor observed a cream colored toothbrush lying in residue on left side of Resident #26's sink by an unreadable labeled green denture cup. The toothbrush was resting on its side with the bristles touching the sink. An unlabeled pink denture cup, an unlabeled tube of denture adhesive was on the right side of the sink. b. On 07/31/23 at 2:35 PM, the Surveyor observed a cream colored toothbrush lying in residue on the left side of Resident #26's sink by an unreadable labeled green denture cup, an unlabeled pink denture cup, an unlabeled tube of toothpaste and denture adhesive was resting on the right side of the sink. The Surveyor asked the roommate if she wore dentures and she said, No, them must belong to [Resident #26]. I do not wear dentures, and that is not my toothbrush. I don't have a toothbrush. The toothbrush was resting on its side with the bristles touching the sink in the same position as earlier. The Surveyor observed Resident #26 with her mouth open, and her breath had a sour odor. c. On 08/02/23 at 11:40 AM, the Surveyor accompanied CNA #5 into Resident #26's room and pointed out the unlabeled pink denture cup, unlabeled green denture cup, unlabeled cream toothbrush resting on its back, the denture adhesive and toothpaste resting on Resident #26's sink. The Surveyor asked CNA #5 if she could tell the Surveyor which resident those items belonged to, who was responsible for assisting with oral care and storage of items, and if the resident was receiving oral care. CNA #5 said, I do not know. I cannot tell. I cannot even read that denture cup. The CNAs are responsible for oral care. During the interview CNA #5 said, The toothbrush should be covered. I do not know where it should be stored. d. The Care Plan dated 05/16/17 documented, .Assistance with brushing teeth/oral care . e. A facility policy titled, Hygiene and Grooming, provided by the Resident Care Nurse on 08/02/23 at 12:21 PM documented, Purpose: Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity . Process: .II. A.M. Care Should Include: .e) Gather oral hygiene supplies and take to bedside for the resident to brush teeth. Assist the resident as needed . III. P.M. Care Should Include: .f) Gather oral hygiene supplies and take to bedside for the resident to brush teeth. Assist the resident as needed . The policy did not address labeling and storage of personal care items. f. On 08/03/23 at 10:31 AM, the Surveyor asked the ADON who was responsible for oral mouth care, and the storage of personal care items. The ADON said, CNAs are responsible. Toothbrushes and personal care items are supposed to be labeled and stored by resident preference . a bag, container. Residents are at risk for infection. g. A facility policy titled, Brushing the Resident's Teeth, provided by the ADON on 08/03/23 at 12:39 PM documented, PURPOSE: Oral hygiene is provided to clean and freshen the resident's mouth and teeth, lessen the potential for infections of the mouth or gums and to stimulate the gums and remove food particles from between the teeth. Standard: Oral hygiene is provided twice daily, unless documented by the physician as medically contraindicated or the resident desires more frequent hygiene .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance that was acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practice had the potential to affect 85 residents who received meals from the kitchen (total census: 86), as documented on a list provided by the Assistant Administrator on 08/01/23 at 1:24 PM. The findings are: 1. On 07/31/23 at 12:09 PM, the following observations were made on the steam table: a. A pan of ground polish sausage had the edges burnt. b. The polish sausage was not completely ground. There were chunks of polish sausage visible in the mixture. The Surveyor asked Dietary Employee (DE) #3 to describe the appearance of the mechanical soft diets. She stated, Mechanical soft meat was dark in color. I put them in the oven at 10:00 AM at the temperature of 350 degrees Fahrenheit. I had them in the oven too long but lowered the temperature down to 250 degrees Fahrenheit. 2. On 07/31/23 at 12:40 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the appearance of the ground meat served to the residents who required mechanical soft diets. She stated, Ground polish sausage was dark and was cooked too long. 3. On 07/31/23 at 12:41 PM, the Surveyor asked CNA #2 to describe the appearance of the ground meat served to the residents on mechanical soft diets. She stated, Ground meat looked dark, like it had been cooked too long. 4. On 07/31/23 at 1:05 PM, the Surveyor asked the Assistant Dietary Supervisor to describe the appearance of the ground polish sausage served to the residents on mechanical soft diets. She stated, It was done too early and was left in the oven too long. 5. On 08/01/23 at 12:01 PM, the Surveyor asked the Assistant Dietary Supervisor to describe the appearance of the sauerkraut served to the residents at the lunch meal on 07/31/23. She stated, It was okay, but it was dark. 6. On 08/01/23 at 12:04 PM, the Surveyor asked DE #3 how long she cooked the sauerkraut. She stated, I cooked it for 2 hours. The Assistant Dietary Supervisor stated, Two hours that was too long. Canned foods are already cooked, it just needs to be heated up.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who received pureed diets, as documented on the List provided by the Assistant Administrator on 08/01/23. The findings are. 1. On 07/31/23 at 12:09 PM, the following observations were made on the steam table: a. A pan of pureed polish sausage, the consistency was thick, lumpy, and not smooth. b. Pureed sauerkraut, the consistency was runny and was not formed and the edges were burnt. c. A pan of pureed bread with milk, the consistency was thick and sticky. 2. On 07/31/23 at 12:40 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the consistency of the pureed food items served to the residents who required pureed diets. She stated, Pureed meat was gritty, pureed bread was like a paste, mashed potatoes were runny, and pureed pear was runny. 3. On 07/31/23 at 12:46 PM, the Surveyor asked CNA #3 to describe the consistency of the pureed foods served to the residents on pureed diets. She stated, The meat was between pureed and mechanical soft, and pureed sauerkraut was a mixture of pureed and mechanical soft. 4. On 07/31/23 at 1:05 PM, the Surveyor asked the Assistant Dietary Supervisor to describe the consistency of the pureed foods served to the residents on pureed diets for lunch. She stated, Pureed meat was gritty and supposed to be more of pink. It looks more like mechanical soft, instead of pureed. Pureed is supposed to be more of mashed potatoes consistency. The pureed bread was too hard and thick, set for too long, more of a rock and too thick. Pureed sauerkraut should have been pureed more and pureed pear halves needs to be a little thicker. 5. On 07/31/23 at 3:35 PM, Dietary Employee (DE) #4 pureed broccoli florets to be served to the residents on pureed diets. The consistency was runny. 6. On 07/31/23 at 4:04 PM, DE #4 pureed lasagna for the residents who required pureed diets. The consistency was runny with pieces of noodles visible in the mixture. 7. On 07/31/23 at 4:54 PM, DE #4 pureed bread sticks for the residents who received pureed diets. The consistency was runny and not formed. 8. On 07/31/23 at 5:34 PM The surveyor asked the Assistant Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed bread was too runny, pureed broccoli was too thin and pureed lasagna was not thick, she used too much liquid and it has lumps.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with maintaining a clean, comfortable homelike environment, with the provision of nail care, with distributing and serving food in a sanitary manner, and with the implementation of Infection Control procedures. These failed practices had the potential to affect all 87 residents who resided in the facility as identified on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 07/31/23 at 3:12 PM. The findings are: 1. A Recertification and Complaint survey was conducted on 2/12/21 at the facility. During this survey, the team identified concerns with housekeeping, maintenance services, providing fingernail care to dependent residents, food storage, preparing and serving food in a sanitary manner and concerns with infection control and prevention during medication observations. a. A review of the facility's Plan of Correction, with a completion date of 3/12/21 indicated the Administrator/Designee would monitor 1. housekeeping services to ensure they were consistently provided to maintain sanitary and orderly bathrooms by observing and documenting on a monthly calendar 3 times a week for 8 weeks or until compliance is verified. 2. Maintenance services were consistently provided to maintain a comfortable homelike environment by observing and documenting on a monthly calendar 3 times a week for 8 weeks or until compliance was verified. b. The Plan of Correction for fingernail care, with a completion date of 3/12/21 indicated all residents were evaluated, and nails were trimmed as needed. The DON/Designee to observe and document nail care three times a week for 8 weeks or until compliance was verified. c. The Plan of Correction for food storage, repairing and serving in a sanitary manner, with a completion date of 3/12/21 indicated staff were provided with additional education related to the deficient practices and the Certified Dietary Manager (CDM) or designee would monitor three times a week for 8 weeks or until compliance was verified that staff wash hands and change gloves as required, staff did not touch food without gloves, leftover food items were not used in preparation for future meals, stored food would be sealed, covered and dated, and ice scoop holder was clean and sanitary. d. The Plan of Correction for infection control and prevention, with a completion date of 3/12/21 indicated the Director of Nurses (DON) would monitor for medications not being placed back in the original container, hands were sanitized, and gloves were worn, and staff sanitized hands when delivering laundry to residents. The DON would monitor three times a week for 8 weeks or until compliance was verified; all findings would be reported to the Quality Assurance committee monthly. 2. A Recertification survey was conducted on 4/15/22 at the facility. During this survey, the team identified concerns with maintenance services, concerns with providing fingernail care to dependent residents, concerns with food storage, preparing and serving food in a sanitary manner and concerns with infection control practices when handling laundry from the isolation rooms. a. A review of the facility's Plan of Correction, with a correction date of 5/6/22 indicated the Administrator/Designee would monitor 5 resident rooms per week to ensure there was a process in place to preventing beds from scraping and cutting into the wall. A review of the facility ' s plan of correction for fingernail care, with a correction date of 5/6/22 indicated the DON/Designee would ensure nails were cleaned, trimmed, and filed and would monitor by observing and documenting 3 times a week for 8 weeks or until compliance is verified. b. A review of the Performance Improvement Project (PIP), for project Housekeeping/Maintenance-Maintain the upkeep of the facility, identified on 6/14/23 indicated daily cleaning of the floors, floors to be re-stripped and waxed one hall a month until the facility is done, then will repeat. The document noted the dementia unit hallways, dining room and all rooms have been waxed except for rooms 502. 504, 506, 518 and 519. c. A review of the facility's Plan of Correction, with a correction date of 5/6/22 indicated the CDM or designee would monitor for cleanliness in the kitchen, monitored stored food was sealed and covered, leftover food was discarded after 3 days, and dietary staff wash hands per protocol three times a week for 8 weeks or until compliance was verified. The CDM would present findings to the Quality Assurance Committee for further review and recommendations. d. A review of the facility's Plan of Correction, with a completion date of 5/6/22 indicated the Administrator or designee would monitor three times a week for 8 weeks that staff followed infection control practices for isolation laundry, and laundry was not contaminated when staff folded the laundry. The Administrator to present findings to the monthly Quality Assurance Committee monthly. 3. A Recertification survey was conducted on 8/4/23. During the survey the team identified concerns with housekeeping, maintenance, concerns with providing fingernail care to dependent residents, concerns with food storage, preparing and serving food in a sanitary manner and with infection control practices. Cross Reference F 584, F677, F812 and F880. 4. A policy titled, Quality Assurance/Quality Assurance Performance Improvement, provided by the Assistant Administrator on 08/3/23 at 8:19 AM documented, .Our facilities have a Performance Improvement Program which systematically monitors data, analyzes and improves its performance to improve resident/guest outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care, services and cost . 5. On 08/03/23 at 9:55 AM, the Surveyor asked the Assistant Administrator, How does the QAA Committee know when an issue arises in any department? She answered, We have stand up meetings every day, we discuss grievances and complaints. We add those to the meetings. The Surveyor asked, How does the QAA Committee know when a deviation from performance or a negative trend is occurring? She answered, We have tracking and trending and then we do a plan of correction. The Surveyor asked, How does the QAA Committee decide which issues to work on? She answered, They look at quality measures, grievances, and complaints and decide. The Surveyor asked, How long will the QAA Committee monitor an issue that it has been corrected? She answered, We normally look at it for 6 to 8 weeks at a time and then follow monthly. We never stop just because we are in compliance. The Surveyor asked, Is the QAA Committee aware of repeated survey deficiencies? She answered, Yes. The Surveyor asked, If aware, did the Committee implement corrective action? She answered, Yes. If we are cited in a survey, we do normal monitoring to get back into compliance and discuss in our meetings. The Surveyor asked, Is the Committee monitoring to ensure corrective action has been implemented? She answered, We have been in compliance up to this point.

Based on observation, record review and interview, the facility failed to maintain an effective pest control program to ensure the facility was free from flies. This failed practice had the potential to affect all 87 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Minimum Data Set (MDS) Coordinator on 07/31/23. The findings are: 1. On 07/31/23 during initial rounds, the following observations were made: a. 11:22 AM, the resident in Resident room [ROOM NUMBER]A had two flies on the overbed table. The resident had her own flyswatter. b. 11:27 AM, the resident in Resident room [ROOM NUMBER]B, had a fly on the bed and a flyswatter on the overbed table. c. 12:27 PM, the resident in Resident room [ROOM NUMBER]B, had a fly flying around in the room. d. 11:38 AM, the resident in Resident room [ROOM NUMBER]A, had 3 flies on the bed. e. 12:27 PM, the resident in Resident room [ROOM NUMBER]B had a fly strip hanging from the ceiling with dead flies on it. f. 12:30 PM, the resident in Resident room [ROOM NUMBER]B had three fly strips and a fly trap hanging from ceiling, all with dead flies on them. The resident also had a fly swatter. The Surveyor asked the resident, Have you had problems with flies? Resident answered, Oh lord, we buy the bait, and they hang it up. It was a plague of roaches. Then it was a plague of ants. Now we have a plague of flies. g. 1:35 PM, the resident in Resident room [ROOM NUMBER]B, had two fly strips hanging from the ceiling with flies on them. 2. On 08/02/23 at 8:52 AM, the [Pest Elimination Company] Binder contained the following invoices: a. A Customer Service Report dated 06/23/23 documented, .Large Fly Program serviced. Glue boards were 25% full. Glue boards replaced. Performed exterior fly treatment. Exterior fly bait stations serviced. Performed interior spot treatment for large flies . b. A Customer Service Report dated 07/21/23 documented, .Large Fly Program serviced. Glue boards were 25% full. Glue boards replaced. Performed exterior fly treatment. Exterior fly bait stations serviced. Performed interior spot treatment for large flies . 3. On 08/02/23 at 9:28 AM, the Surveyor met with members of the Resident Council. The Council members reported, This place has a lot of flies in the rooms. They just lay flyswatters on the tables or give us fly catchers which is nasty. Flies are a problem. We've seen them in the dining hall and in our rooms. We would like to have something done about the flies. 4. On 08/02/23 at 12:09 PM, the Surveyor asked the Maintenance Assistant, Are you in charge of maintenance while the Maintenance Director is out? He answered, Yes. The Surveyor asked, I checked the [Pest Elimination Company] Binder that shows they came in June and July to address the large flies. Are large flies the same as a common house fly? He answered, I don't know. I think so. The Surveyor asked, I also noticed that some residents have their own flyswatters, some residents have fly strips hanging from the ceiling in their rooms, and I noticed quite a few flies in the resident rooms. Would you say that this facility has an effective pest control program? He answered, No. 5. A policy titled, Insect and Rodent Control, provided by the Assistant Administrator on 08/02/23 at 9:08 AM documented, Insects and rodents carry harmful bacteria . The facility should have a pest control program intended to minimize the presence of . flies .

Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. This failed practice had the potential to affect 15 residents who use tobacco products as documented on a list provided by the Assistant Administrator on 07/31/23 at 11:00 AM. The findings are: 1. On 08/01/23 at 8:51 AM, Resident #11 stated, You have to be on time to smoke or they won't let you go out to smoke. The Surveyor asked, If you are two minutes late will they let you smoke? Resident #11 stated, Not with [Certified Nursing Assistant (CNA) #4], but the others will. 2. On 08/01/23 at 9:29 AM, the Surveyor asked Resident #17, If you arrive late, do they still let you smoke? Resident #17 stated, If it is [CNA #4], she won't let us out to smoke. 3. On 08/02/23 at 8:15 AM, the Surveyor asked CNA #4, Do you take the residents out to smoke? CNA #4 answered, Yes. At 9:00 AM. The Surveyor asked, Have you ever told a resident if they are late for the smoke break, they can't smoke? CNA #4 answered, Yes. They are supposed to be on time. I've done this for years. We only have twenty minutes to smoke two cigarettes. The Surveyor asked, Who told you they only have twenty minutes? CNA #4 answered, When we first started this, we were told that. The Surveyor asked, Have you told a resident that if they were two minutes late, they can't smoke? CNA #4 answered, I don't think so, but they know they aren't supposed to be late. The Surveyor asked, Would you consider that to be a violation of their rights, to tell them they can't smoke if they are late? CNA #4 answered, I don't think so. They have twenty minutes. 4. On 08/02/23 at 8:20 AM, the Surveyor asked Resident #11, Do you remember when you told us that [CNA #4] won't let you smoke if you are late? Resident #11 answered, Yes. The Surveyor asked, Did you ever tell anyone about this? The Administrator or anyone? Resident #11 answered, No. I just accepted it. 5. On 08/02/23 at 8:23 AM, the Surveyor asked Resident #17, Do you remember when you told us that [CNA #4] won't let you smoke if you are late? Resident #17 answered, Yes. The Surveyor asked, Did you ever tell anyone about this? Resident #17 answered, No. But [CNA #4] won't let us smoke if we are even one minute late. 6. On 08/02/23 at 9:11 AM, a document titled, Facility Resident Smoke Times provided by the Assistant Administrator on 07/31/23 at 11:00 AM documented, .Staff may only take you out at the allotted Smoking times . Any violation of the facility Smoking Policy may result in loss of smoking privileges . The document did not address a twenty-minute time limit or that residents would lose privileges if they were late to a scheduled smoke break. 7. A facility policy titled, Supervised Smokers, provided by the Assistant Administrator on 08/01/23 at 1:40 PM documented, The resident . has the right to smoke, if desired . There was no mention of a twenty-minute time limit or that residents would lose privileges if they were late to a scheduled smoke break. 8. On 08/02/23 at 9:54 AM, the Surveyor met with the Resident Council. The Council Members were asked, If you are late to a smoke break, do you still get to smoke? The Council Members stated, If smokers are late, they are not going out. 9. A facility policy titled, Federal Rights of Residents/Guest(s), provided by the Assistant Administrator on 08/02/23 at 10:20 AM documented, All resident/guest(s) in long term care facilities have rights guaranteed to them under Federal and State law . (e) Respect and dignity. The resident/guest has a right to be treated with respect and dignity . 10. On 08/02/23 at 1:52 PM, the Surveyor asked the Assistant Administrator, Are you aware that you have a staff member who will not allow the residents to smoke if they are late to smoke break? The Assistant Administrator answered, No. I wish we had enough staff for each resident to have their own individual staff member to take them out to smoke all day long, but we don't. Sometimes residents are fifteen to twenty minutes late for smoke break. The Surveyor asked, Could it be considered a violation of their rights if they are not allowed to smoke? The Assistant Administrator did not answer. The Surveyor asked, Do you remember the document you gave me early in the survey with the smoke break times? The Assistant Administrator answered, Yes, it was in the survey stuff. It had smoke times at the top and verbiage at the bottom. The Surveyor asked, Did you realize that it said any violation of the facility Smoking Policy may result in loss of smoking privileges? The Assistant Administrator answered, I don't know. I was just told to give it to you.

Based on observation, and interview, the facility failed to maintain air conditioning equipment to prevent leaks with the potential to result in accidents and hazards for 1 of 1 air conditioners observed. The findings are: 1. On 08/02/23 at 12:00 PM, the Surveyor entered Resident room [ROOM NUMBER] and observed a moderate amount of clear fluid on the floor next to the air conditioning unit under the window. 2. On 08/02/23 at 12:10 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 to Resident room [ROOM NUMBER]. LPN #1 was shown the the clear fluid on the floor next to the air conditioner under the window and called maintenance. 3. On 08/02/23 at 12:30 PM, the Maintenance Assistant stated that the clear fluid on the floor did not come from the air conditioner, as he ran his hands under the window unit and indicated that they were dry. The Surveyor asked if the dried clear stains were from the air conditioner. The Maintenance Assistant pulled off the air conditioner cover exposing the filter, the filter was caked in a black substance. The Maintenance Assistant stated, It's filthy, and this dirty filter could leak water and cause it not to cool. I'll get that taken care of right away. During the interview the Maintenance Assistant said, Housekeeping is responsible for cleaning air filters. 4. On 08/02/23 at 1:00 PM, the Housekeeping Supervisor stated, Air conditioner filters should have been cleaned by housekeeping. 5. On 08/03/23 at 10:30 AM, the Surveyor asked the Assistance Director of Nursing (ADON) when the residents have their window air conditioners filters cleaned, who was responsible to clean them, and would there be any concerns if not serviced. The ADON stated, They are checked every day and cleaned by housekeeping, if needed. If the filters are not cleaned, they will not cool and if leaking inside it could cause falls and compromise wounds.

Based on observation, and interview the facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 1 (Resident #19) of 10 sampled (Residents #3, #11, #19, #26, #37, #48, #53, #79, #84 and #190) who eat in the Dining Room. This failed practice had the potential to affect 61 residents who eat in the Dining Room according to a list provided by the Assistant Administrator on 08/02/23 at 2:00 PM. The findings are: 1. Resident #19 had diagnoses of Alzheimer's and Type 2 Diabetes. a. On 07/31/23 at 12:33 PM, during the lunch meal, the Surveyor reviewed Resident #19's meal slip and observed she was missing ice cream from her lunch tray. The Surveyor asked Certified Nursing Assistant (CNA) #1 to review the meal ticket and she agreed that ice cream was missing from the tray. The Surveyor asked if there were consequences of food missing from a resident's meal trays. CNA #1 said, No, it just means something did not get put on their tray. b. The July 2023 Physicians Orders documented, Puree diet, order date 11/11/22; and Ensure Plus 1 can PO [by mouth] TID [three times per day] between meals as supplement., order date 08/05/21. c. A Care Plan with a start date of 06/23/23 documented, My significant weight loss will be stabilized x [times] 90 days AEB [as evidenced by] my wt [weight] record . Notify MD [Medical Doctor] of significant weight loss . Weigh per schedule and PRN [as needed] .fortified foods to breakfast, lunch, and dinner . ice cream to lunch . Assisted diner. d. On 08/03/23 at 2:20 PM, the Surveyor asked the Assistant Director of Nursing (ADON) what process staff followed when a meal tray is missing food. The ADON said, Staff are expected to review the meal ticket, and notify the kitchen if something is missing. The resident can choose a replacement if it's something they do not want. It could cause weight loss.

Based on observation, interview and record review, the facility failed to ensure transportation into was done in a safe manner to prevent an injury for 1 of 1 (Resident #62) sampled resident who required transportation into the shower in a shower chair. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious harm, injury, or death to Resident #62, who was tipped out of the shower chair and sustained a left pelvic fracture and had the potential to cause more than minimal harm to 15 residents who received showers in the B Hall shower room and were transported in a shower chair to the shower room according to a list provided by the Administrator on 4/15/22 at 8:50 AM. The Administrator was informed of the Immediate Jeopardy on 4/14/22 at 3:35 PM. The findings are: 1. Resident #62 had diagnoses of [CONDITION(S)], Heart Failure, [CONDITION(S)] and Generalized Muscle Weakness. The Quarterly Minimum Data Set with an Assessment Reference Date of 3/11/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required extensive physical assistance of two plus persons with bed mobility, transfers, dressing and toilet use, independent with set up only with locomotion on and off the unit, extensive physical assistant on one person with personal hygiene and in part of bathing activity. a. The Nurses Note dated 3/3/22 at 4:54 PM documented, . 9:50 AM Writer summoned to A/B shower room, resident in doorway of B side into shower room up in shower chair. Another nurse reported resident had been on the floor and was assessed and assisted back to chair by staff with gait belt. ROM [range of motion] in normal limits. CNA [Certified Nursing Assistant] reports she was wheeling the resident in the shower chair and was walking in backwards pulling resident in the shower chair and hit lip of doorway and resident fell out of shower chair. Nurse staff report resident laying on left side when arrived. Resident reports bumped right side of head towards back. no lump or discoloration noted to area. Resident reports tail bone and hip sore. Neuro checks started and in normal limits. Resident showered by different CNA. D.O.N. [Director of Nursing] and MD [Medical Doctor] notified. Resident talking with wife on the phone with writer present and wife notified. After lunch resident demanding to have left hip xrayed because it's sore. When asked became upset then reported it is not any worse but it ' s not any better and it's sore. I want it xrayed. [MD] notified and new order for left hip xray via mobile xray obtained. Wife notified. b. An x-ray of the HIP W (With)/PELVIS (2-3 V (VIEW)) AP (Anterior Posterior), LAT (Lateral) AP Pelvis dated 3/3/22 documented, .Fixation of the left hip by metallic hardware is seen with adequate alinement. Osteopenia. Normal visualization of the superior and inferior pubic rami and ischial tuberosities . Impression: Fixation of the left hip by metallic hardware is seen with adequate alignment. Osteopenia . c. The Nurses Note dated 3/5/22 at 2:57 PM documented, .Resident reports hip not sore anymore but further down leg is and wants to have his pain medication every 4 hours exactly not about every 4 hours. Resident has no redness warmth or discoloration anywhere to hip or leg . d. The Nurses Note dated 3/6/22 at 1:36 PM documented, .Reports left leg still sore . ROM Remain in normal limits. Resident has no redness warmth or discoloration anywhere to hip or leg . e. The Nurses Note dated 3/7/22 at 5:55 AM documented, . 3P [3:00 PM] to 7A [7:00 AM] Resident CO [complained of] upper leg pain post fall. Want scheduled pain medication given as soon as due. Resident noted to have increased agitation with staff. No acute distress or changes in vitals . f. The Nurses Note dated 3/7/22 at 12:26 PM documented, .IDT [Interdisciplinary Team] review of incident dated 3/3/22 at 9:50 AM . Xray results show no ill effects. POC [Plan of Care] updated. MD, RP [Responsible Party], DON aware. No evidence of abuse or neglect noted . g. The Nurses Note dated 3/7/22 at 1:40 PM documented, .Resident reports left leg sore/hurts shows area to the side of the leg below hip approx [approximately] handbreadth. Resident request more pain meds [medications]. MD notified and reports will keep the same for now is on quite a bit of [MEDICATION(S)] [pain medication] now. Resident offered to ask for Bio freeze, Icy Hot or something along those lines order. Resident became very hateful, reporting I told you its sore and that is all you can tell me. I hope you all live in pain. You don't even know what it's like to hurt every. You all should suffer. I don't care how much I take now. I want more my leg is sore. Left leg has no redness, swelling discoloration noted. Residents left buttock has fading bruise, but resident reports buttock does not hurt . h. The Nurses Note dated 3/9/22 at 11:59 PM documented, . Nurse spoke with resident regarding the time he takes his pain medication. Resident states if he takes it at 8/12/4 etc. [etcetera] every 4 hours these times work better for him. Times of administration changed, and resident was happy . i. The Nurses Note dated 3/10/22 at 2:33 PM documented, .Resident after given noon routine pain med demanding Tylenol. Informed had no order and would ask MD. Resident reports it's only Tylenol. Writer began to explain can only have so much Tylenol in 24 hours. Resident interrupted and writer reporting in hateful voice I'm not stupid and can add. Its Tylenol and I want it. Resident reports it shouldn't matter why he wants it (Tylenol) or whatever else he asks for if he wants it, he should get it . New orders received for 325mg [milligrams] Tylenol 1 PO [per oral] Every 8 Hours PRN [as needed] between routine pain meds. When informed, resident said only 325mg why not extra strength. Well, that won't do anything, but I guess I will take what I can get . j. The Nurses Note dated 3/11/22 at 7:33 AM documented, . Late Entry for 3/9/22 new skin issue charted previously by CNA and bruising to left buttock/hip area and this is consistent with recent incident resident had . k. The Administration Record dated 3/11/22 at 9:13 AM documented, .Tylenol 325mg 1 PO every 8 hours . Resident reports right outer upper thigh pain sharp in nature but then says dull and constant, then reports do you not know what pain is. Of course, you don't, I'm telling you its sore and hurts . l. The Nurses Note dated 3/11/22 at 3:36 PM documented, .Resident refused to get up after breakfast reports cannot shower or get up as cannot walk. Resident reports hatefully you let me lay here knowing I'm hurting . When writer touch outer thigh where resident says its sore no flinch grimace or other s/s [signs or symptoms] of pain or discomfort noted . Resident demanding nurse to promise would be there exactly at 12 with pain medication . m. The Nurses Note dated 3/14/22 at 8:20 AM documented, . Entered room to give am meds . resident then reached up with right hand and took pill cup, shook it asked what was in it. Writer listed meds that were in cup, resident then said so is there a pain pill or not, writer reported yes. Resident responded what about Tylenol. Writer responded no . resident reported huh, then put cup to mouth . then stated so what are they going to do about this pain. Writer informed is going to have therapy eval. [evaluation] today that x-rays were good, and therapy can help with muscle. Resident responded so no one is going to do anything to find out. I have nerves coming out of my spine and no one is going to do anything about those nerves coming out of spine. Resident then made shooing motion with hand and writer left the room . n. The Nurses Note dated 3/15/22 at 11:30 AM documented, . APN [Advanced Practice Nurse] in facility today and seen resident due to having increased discomfort since fall to left leg and radiates around his back. New order for [MEDICATION(S)] 500 QID [four times daily] for muscle pain and pelvis and left hip xray to be scheduled . o. The X-ray of the Pelvis 3+ [plus] vw [view] dated 3/16/22 at 10:46 AM documented, .Impression: Suspected left inferior pubic ramus [pelvic] fracture. Consider a CT [Computed Tomography] scan for closer evaluation . p. The CT scan of the Pelvis WO [Without] Contrast dated 3/16/22 at 11:41 AM documented, . Impression: Minimally displaced fracture of the left inferior pubic ramus . q. The Nurses Note dated 3/17/22 at 12:54 AM documented, .Spoke with Resident/RP regarding CT results and new orders for bed rest. Res [Resident] and RP voice their understanding . r. The Post Incident Actions form dated 3/3/22 at 9:50AM provided by the DON on 4/14/22 at 10:00 AM documented, .Immediate Post Incident Action: Staff verbally inserviced to ask for help when assisting shower chair over ledge . s. On 4/14/22 at 11:50 AM, the DON was asked, How many staff members transfer [Resident # 62] when he is being taken to the shower? The DON stated, The transfer is two person assist to the shower chair and one person would push him down the hall to the shower. The DON was asked, Who is responsible for taking the residents to get a shower? The DON stated, The Aides on the floor. We do not have shower aides. The DON was asked, Was [Resident # 62] usually taken in the shower chair to the shower? The DON stated, Yes. The DON was asked, What did the CNA say happened the morning of the incident? The DON stated, I did not interview her, but she was a new aide and she actually pushed him forward into the shower room and the shower chair hit the lip at the entrance and he fell forward. She (the aide) no longer works here, but it has nothing to do with the incident. The DON was asked, Is the nurse that was working on the day of the incident working today? The DON looked at the schedule and stated, She is off the next couple of days, but the nurse [Staff Development Nurse] who first responded to the fall is here. t. On 4/14/22 at 12:00 PM, Resident #62 was asked, How many staff take you to the shower in the shower chair? Resident #62 stated, One person takes me to the shower. Resident #62 was asked, Can you tell me what happened on March 3rd when you were being taken to the shower? Resident #62 stated, The aide was pushing me to the shower and when she got to the door, she pushed me forward and the chair tilted forward, and I was tipped out. Resident #62 was asked, How do staff usually push you through the doorway to the shower? Resident #62 stated, Normally they wheel me backwards into the shower room. That is what they should do. Resident #62 was asked, Did you hurt after the incident? Resident #62 stated, Yes. Resident #62 was asked, Where did you hurt? Resident #62 pointed to his left upper leg in the region of the inner thigh and groin and stated, In the upper left thigh in the pelvic region. The resident was asked, Did the facility do anything to try and determine if you had injured yourself? Resident #62 stated, Yes. They did X-rays. They had a difficult time finding the fracture. They eventually did a CT scan of the pelvis. Resident #62 was asked, Where did they determine the fracture was? Resident #62 stated, It's in the pelvis. Resident #62 was asked, What did they do once they determined that you had a fractured pelvis? Resident # 62 stated, I was put on bed rest. Resident #62 was asked, Was that the only time anyone pushed you in the forward position in the shower chair through the doorway into the shower room? Resident #62 stated, That was not the only time, but it was the only time we had an accident. u. On 4/14/22 12:20 PM, the Staff Development Nurse was asked, Were you the nurse that first responded on 3/3/22 when [Resident #62] fell out of the shower chair? The Staff Development Nurse stated, Yes, because I was the closest. I was at the nurse's station, and it happened in the B hall shower room. The Staff Development Nurse was asked, Can you tell me what happened? The Staff Development Nurse stated, I did not see what happened. [CNA #3] came and reported the resident had fallen. [CNA #2] stated that she had the resident in the shower chair, and she pushed him forward into the shower room and the shower chair caught the lip formed by the tile and he flipped out of the chair. The Staff Development Nurse was asked, How are staff supposed to push the residents in the shower chair into the shower room? The Staff Development Nurse stated, They all know to go backwards, so that does not happen. The aide taking the resident to the shower had only worked at the facility for 2 or 3 days. The Staff Development Nurse was asked, How do the aides know to take the residents backwards in the shower chair into the shower room? The Staff Development Nurse stated, Usually the more experienced aides tell the new aides to go backwards when they are training them. The Staff Development Nurse was asked, Did [Resident #62] complain of pain when the incident happened? The Staff Development Nurse stated, Initially no. I checked range of motion. He had no complaints, and we used a gait belt and got him up. He does not have feeling on one side. The Staff Development Nurse was asked, Which side does he not have feeling in? The Staff Development Nurse stated, I believe it is the left leg. We always have to pick that leg up for him. The Staff Development Nurse was asked, How long was it before the resident did complain of pain? The Staff Development Nurse stated, [LPN #3] was his nurse. She would know when that happened. I just helped when it initially happened. v. On 4/14/22 at 12:30 PM, the Staff Development Nurse accompanied the surveyor to the B hall shower room and pointed out the area of tile across the entrance way to the shower room that was raised higher than the rest of the tile that she referred to as the lip. The Staff Development Nurse demonstrated what occurred at the time of the incident and stated, The aide pushed the chair forward while she was behind the resident. The chair hit the lip and the momentum caused by her pushing the chair forward caused the resident to fall out. I usually tell staff to go backwards while standing in front of the resident, so the chair does not tip. w. On 4/14/22 at 12:45PM, LPN #3 was interviewed by telephone and was asked, Where you the nurse caring for [Resident # 62] when he fell out of the shower chair? LPN #3 stated, Yes. LPN #3 was asked, Did you see what happened when the incident occurred? LPN #3 stated, I was not the first nurse to go to the shower room. I had to come from the back of the building. Another nurse had already got there when I arrived. LPN #3 was asked, Can you tell me what happened to cause the incident? LPN #3 stated, The aide was taking him into the shower backing in and the chair hit the lip and he fell out. LPN #3 was asked, What way was the resident facing? LPN #3 stated, She had him facing forward and she was pulling him forward is what I was told happened, but I was not there, so I did not witness it happen. LPN #3 was asked, Who told you that was what happened? LPN #3 stated, The staff that were there, but I cannot remember specifically who. When I got there, they had checked him out and were getting him up. LPN #3 was asked, When did the resident first complain of pain? LPN #3 stated, I cannot remember specifically when he first complained. I would have to look at my notes. We did do an x-ray to make sure he had not injured himself and the x-ray did not show any injury. LPN #3 was asked, Did the resident continue to complain of pain? LPN #3 stated, Yes he did continue to complain of pain. He complained sometimes on my shift but not always. He may have developed a bruise a day or two after the incident. I discussed with him that you can have discomfort after a fall. He takes routine pain medication for chronic conditions. We adjusted the times of the pain medication to try and make him more comfortable. He will get upset if he misses a dose of his scheduled pain medication. We have to wake him up for the medication if he is sleeping. LPN #3 was asked, How long was it before it was identified that the resident had a fracture? LPN #3 stated, We had him seen by the Nurse Practitioner. X-rays had already been done, but when the pain moved, we got more x-rays done. He was started on [MEDICATION(S)]. We got PT [Physical Therapy] consulted. He did not want PT. He wanted stronger pain medication. At the time we were not sure if the pain was muscular and thought therapy would help. LPN #3 was asked, How was it determined that he had a fracture? LPN #3 stated, The CT showed that he had a pelvic fracture I believe. LPN #3 was asked, What was ordered when it was determined he had a fracture? LPN #3 stated, After we got the x-ray results, we got orders for bed rest, but he was none compliant with that. LPN #3 was asked, Is there usually just one person to take a resident to the shower? LPN #3 stated, Yes. LPN #3 was asked, What is the correct way to take a resident in a shower chair into the shower? LPN #3 stated, I don't know that we have a policy on that. I was always taught to back through the door, but I don't know that is how it happened because I did not see it happen. LPN #3 was asked, Was there any in-service given to the CNA involved in the incident the day that the incident happened? LPN #3 stated, Not that I was involved in. x. On 4/14/22 at 1:05 PM, the DON was asked, Did you in-service the aide that transported [Resident # 62] incorrectly into the shower room after the incident on 3/3/22? The DON stated, Yes, she was given a one-on-one in-service. The DON was asked, Did you in-service the other CNA staff after the incident occurred? The DON stated, We did not because it had not been a pattern and she was a new CNA. y. The One-on-One Inservice, provided by the Director of Nursing on 4/14/22 at 1:10 PM documented, . DATE 3/3/22 . TOPIC: Shower chair entering shower room . BRIEF SUMMARY OF DISCUSSION: Ensure when entering shower room with resident in shower chair always pull resident into shower room with resident facing outward due to lip of tile . z. On 4/14/22 at 2:45 PM, the DON was asked, Have you had any in-services on the correct way to transport residents in the shower chair? The DON stated, Not specifically on that. We have had in-services on resident transfers. We have had in-services telling staff to be mindful of their surroundings when transferring residents so as not to cause accidental injury by bumping into something, but the incident with the shower was an isolated incident. The DON was asked, How long have you worked at the facility? The DON stated, I have worked at the facility 7½ years. The DON was asked, Have you had any other incidents where a resident has tipped out of the shower chair? The DON stated, We have had people fall from the shower chair, but not because of going through the door frame and tipping forward. aa. On 4/14/22 at 2:50 PM, CNA #1 was asked, How long have you worked for the facility? CNA #1 stated, I have worked at the nursing facility since August 2021. CNA #1 was asked, How do you take a resident into the B hall shower if they are in a shower chair? CNA #1 stated, Oh, on that one you have to pull the resident in backwards due to the little ledge going into the room. CNA #1 was asked, How do you know that? CNA #1 stated, I just figured it out. bb. On 4/14/22 at 2:53 PM CNA #4 was asked, How long have you worked at the facility? CNA #4 stated. I have worked at the nursing facility since August 2021. CNA #4 was asked, How do you take a resident into the B hall shower if they are in a shower chair? CNA #4 stated, To get a resident into the B hall shower I have to pull the resident backwards into that shower. CNA #4 was asked, How do you know to do that? CNA #4 stated, It is really just common sense. cc. On 4/14/22 at 2:55 PM, CNA #5 was asked, How long have you worked at the nursing facility? CNA #5 stated, I have worked at the nursing facility for 6 and a half years. CNA #5 was asked, How do you take a resident in a shower chair into the B hall shower? CNA #5 stated, I cover them up and pull them through the door backwards due to the ledge going into that shower and some of the residents are heavier than others and with that ledge it is just for safety really. 2. The Immediate Jeopardy (IJ) was removed on 4/14/22 at 4:50 PM, when the facility implemented the following Plan of Removal, and the s/s severity was lowered to a D: a. On 04/14/2022, upon learning of the IJ the facility in-serviced all nursing staff present how to properly assist resident into all shower rooms or any door with a raised area with return demonstration to maximize safety. b. Facility will in-service all other nursing staff prior to the start of their shift as well as new hires prior to providing care how to properly assist residents into all shower rooms or any door with a raised area with return demonstration to maximize safety. c. Facility will monitor by observation 5 times a week for 6 weeks. Followed by 3 times a week until substantial compliance is met. d. Facility will present all findings to the QA [Quality Assurance] Committee for further review and recommendations.