Every finding on record at Robinson Nursing and Rehabilitation Center LLC

Based on record review and interviews, the facility failed to ensure Resident Assessment and Minimum Data Set [MDS] were coded correctly to ensure residents were provided with individualized treatment plans and goals for six (Resident #1, #31, #45, #51, #67, and #79) of six residents reviewed.The findings include:Resident #31Review of the admission Record for Resident #31 revealed the facility admitted Resident #31 with diagnoses that included fracture of left patella, sprain of anterior cruciate ligament of left knee, effusion, pain, hypertension, anxiety, and diabetes mellitus.Review of end of PPS Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed this was Resident # 31's most recent MDS.Review of a Progress Note dated [DATE] indicated Resident #31 discharged to a nursing home closer to family.During an interview on [DATE] at 3:12 PM, MDS #2 reported that Resident #31's most recent resident assessment did not accurately reflect the resident's status. She indicated that Resident #31 should have had a discharge MDS completed. MDS #2 stated I guess I just did not complete that one. Resident #45Review of the admission Record for Resident #45 revealed the facility admitted Resident #45 on [DATE] with diagnoses that included volvulus, depression, and tachycardia.Review of the Order Summary Report for Resident #45 revealed an order dated [DATE] for transfer to hospital due to possible ileus (decreased bowel motility).Review of a Progress Note dated [DATE] at 9:55 PM, revealed Resident #45 was transported via ambulance to the emergency department at a hospital due to abdominal x-ray results.Review of the most current discharge MDS with an ARD of [DATE], revealed resident return was anticipated.During an interview on [DATE] at 3:12 PM, MDS #2 reported that Resident #45's resident assessment did not accurately reflect the resident's status. She also stated, maybe I thought the resident was going to return. She indicated a discharge, return not anticipated should have been completed. Resident #67Review of Resident #67's Medical Diagnosis revealed diagnoses which included seizure disorder, depression and pain.Review of Resident #67's quarterly MDS with an ARD of [DATE], revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment.Review of Progress Notes dated [DATE] revealed Resident #67 discharged home with family.During an interview on [DATE] at 2:17 PM, MDS #1 confirmed Resident #67 was discharged from the facility and stated, I missed putting in the Discharge MDS. MDS #1 also stated, Discharges should be coded on the MDS because it was used to track the residents. Resident #79Review of Resident #79's Medical Diagnosis revealed diagnoses which include polyneuropathy (causes nerve damage in multiple areas), anemia, and anxiety.Review of Resident #79's MDS Assessment Transmittal History revealed there was a quarterly MDS with ARD of [DATE] and an entry MDS with an ARD of [DATE].Review of a Progress Notes dated [DATE], indicated Resident #79 transferred to the emergency room (ER) and passed away in less than 24 hours.During an interview on [DATE] at 2:17 PM, MDS #1 stated, Resident #79 died in the hospital and I forgot to do the discharge, return not anticipated. When a resident dies at the hospital in less than 24 hours it is considered a death in the facility. MDS #1 revealed the process was to call and check on residents that were hospitalized , or a family member might call the facility to let staff know. MDS #1 stated, I was aware Resident #79 passed and forgot to code Resident #79's discharge. Review of a Daily Checklist for MDS Coordinators undated, revealed MDS coordinators should complete discharge assessments if [resident] admitted to hospital for inpatient or observation.Review of documentation from the Resident Assessment Instrument [RAI] Manual revealed if a resident is discharged and not expected to return to the facility must be completed in 30 days. It must also be completed in 30 days if a resident is expected to return to the facility. Death in facility must be completed when a resident dies in the facility or when on leave of absence [LOA]. Must be completed within 7 days.Resident #1Review of the admission Record revealed the facility admitted Resident #1 on [DATE] with diagnoses that included bipolar disorder and unspecified intellectual disabilities.Review of an annual MDS with an ARD of [DATE], revealed Resident #1 was not currently considered by the State Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.Review of Resident #1's Care Plan revised [DATE], revealed Resident #1 had a mood problem related to unspecified mood [affective] disorder and obsessive-compulsive disorder (OCD) and had a PASRR.Review of a [company name] document dated [DATE], revealed that Resident #1 did not require specialized services for their mental illness, intellectual disability, and/or developmental disability beyond the capabilities of a nursing facility.During an interview on [DATE] at 10:59 AM, MDS #1 stated the annual MDS with an ARD of [DATE] was not correct due to Resident #1 did have a [company name] PASSRR in the EHR. She stated this was something she should have caught. MDS #1 stated she did receive training in 2024 when she started. She stated the MDS coordinator, who was no longer employed at facility, at the time of her hire taught her how to fill out the MDS and she had been to several trainings but was unable to find a copy of a certificate.Resident #51Review of Resident #51's Medical Diagnosis revealed the facility admitted Resident #51 with diagnoses which included paranoid schizophrenia, bipolar disorder and diabetes.Review of Resident #51's annual MDS with an ARD of [DATE], revealed Resident #51 had a BIMS score of 13, which indicated the resident was cognitively intact. Section A1500 did not show that Resident #51 has a PASRR II.Review of Care Plan for Resident #51 revealed Resident #51 was a level II PASRR ([DATE]) and to report significant findings and perform behavioral health consults as needed.Reviewed a [company name] document dated [DATE] that stated Resident #51 would require a level II PASRR.Reviewed a [company name] document dated [DATE] that revealed Resident #51 was approved for nursing home placement, must contact the state designated authority with client's admission date to receive a completed PASRR evaluation.Reviewed [company name] document dated [DATE] revealing an evaluation was completed and determined Resident #51 did not require specialized services. Provision of a structured environment was recommended at the facility. During an interview on [DATE] at 11:40 AM, MDS #1 reviewed Resident #51's EHR and stated Resident #51 had a PASRR II and then looked at the MDS and stated, It looks like I missed that one. MDS #1 stated, it should be coded correctly to ensure Resident #51 is getting the right services. During an interview on [DATE] at 9:27 AM, MDS #2 indicated the MDS coordinators use Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 dated [DATE].During an interview on [DATE] at 1:53 PM, MDS #1 provided information from the RAI manual showing that a resident with a level II PASRR, serious mental illness and/or intellectual disability should be coded 1 to indicate yes the resident had a PASRR II.During an interview on [DATE] at 11:16 AM, the DON stated the facility did not have a policy for the Minimum Data Set (MDS) and that the facility uses the Resident Assessment Instrument (RAI) manual, she also provided an undated facility document titled Daily Checklist for MDS Coordinators that the MDS staff utilize.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure a resident who had not been assessed to safely self-administer medications was not left alone while receiving medications via nebulizer for one (Resident #100) of one resident reviewed. The findings include:A review of facility policy Medication, General Administration of item 1. Stated Drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, or other personnel wo are duly authorized to perform such services under state law. Item 9. Self-administration of drugs is permitted when approved by the interdisciplinary team and with a physician's order. A review of Resident #100 Medical record did not show an assessment for self-administering of the nebulizer/breathing treatment.A review of Resident #100 Care Plan does not identify the resident to receive Nebulizer treatments.During a concurrent observation and interview on 06/03/2026 9:45 AM, this surveyor observed Resident #100 receiving a breathing treatment. The resident was holding the plastic nebulizer hose mouthpiece in their mouth. There were no staff in the resident's room. The surveyor observed the Medical Aide Certified (MA-C) in the hallway two doors down with the medication cart preparing another resident's medications. The MA-C stated she had started the nebulizer treatment on Resident #100 and was going in and out of the room checking on the resident. The MA-C stated they are allowed to start and stop the breathing treatments for residents and that she had received the additional training allowing them to administer the nebulizer treatment. The MA-C then went into another resident's room, two doors down the hall from Resident #100.During a concurrent observation and interview on 06/03/2026 at 3:10 PM, this surveyor observed Resident #100 in bed with the nebulizer treatment running. There were no staff in the resident's room. The resident was observed laying the nebulizer pipe, while still running with white vapor coming from the end of the tubing indicating medication was being administered, on their lap. The surveyor stepped out into the hallway and spoke to Certified Nursing Assistant (CNA) #3, who stated they had just assisted with dressing Resident #100 after their bath and assisted in situating Resident #100 in their bed. CNA #3 stated they saw MA-C give Resident #100 an updraft and turn their breathing treatment on, and then the MA-C left. CNA #3 said the MA-C had left work a little after 3:00 because her shift was over. During an interview on 06/03/2026 at 3:14 PM, CNA #4 stated they saw the MA-C do the updraft and start the breathing treatment and then the MA-C left the room and left work for the day. On 06/03/2026 at 3:18 PM during an interview Licensed Practical Nurse (LPN) #5 stated they were not aware Resident #100 was receiving a breathing treatment because it was ordered for noon, but they had put it off because the resident wanted to take a shower. LPN #5 stated Resident #100 was due their next breathing treatment at 4:00 PM. LPN #5 stated the nurse, or the MA-C can start a breathing treatment. LPN #5 stated they did not talk to the MA-C prior to the MA-C leaving for the day because they had been tied up on another hall. On 06/03/2026 at 3:23 PM during an interview, CNA #6, stated when Resident #100 was finished with the breathing treatment the resident would take it off and push their call light for someone to come in and turn it off and take it. CNA #6 stated either the nurse or the MA-C will come in and turn it off. CNA #6 stated when they came into Resident #100's room the resident was already on the machine and Resident #100 can do their own breathing treatment. CNA #6 stated the MA-C, or the LPN will start the treatment and then they will let the resident do their treatment and then they will come back and turn it off when the resident has finished. CNA #6 stated the treatments were timed and they know when to come back and turn the machine off. CNA #6 stated there are other residents that get them too. On 06/03/2026 3:26 PM, this surveyor observed Resident #100 with the nebulizer pipe in her mouth and vapor coming from end of plastic tube. Resident #100 stated they had a little more left in the tube. CNA #6 was in the resident's room and provided the resident with a wet washcloth and then left the room. During a concurrent observation and interview on 06/03/2026 at 3:27 PM, LPN #7 entered Resident #100's room and turned off the nebulizer. The surveyor asked LPN if they were aware that the MA-C had started the breathing treatment. LPN #7 stated a CNA, but did not give a name, had told him that the MA-C had started it before leaving for the day. LPN #7 then left the room and retrieved a bag for the nebulizer tubing. LPN #7 stated they had other residents on breathing treatments and that either the LPN #7 or the MA-C can start the updraft and then monitor for 10 - 15 minutes, checking in and out. LPN #7 stated they check the residents' oxygen at the end of the treatment but check on them periodically during the treatment. LPN #7 stated that was the proper way to monitor a resident while they receive a breathing treatment. LPN #7 stated they had been trained in their nursing program and at the facility but could not remember when the last training was at the facility.On 06/03/2026 at 3:58 PM during an interview, the Director of Nursing (DON) stated the facility policy on updrafts requires a doctor's order. The DON stated if a resident requested an updraft, due to short of breath, the nurse should assess the resident and using their nursing judgement and they should do the updraft. The DON stated only LPN, or Registered Nurses (RN) can administer an updraft. The MA-C cannot administer the updrafts. The nurse was required to stay in the room with the resident the entire time the updraft was running. The nurse could not leave the room or leave the resident unsupervised during the treatment because anything could go wrong, and some residents would take it off. The DON stated they want to make sure the resident received all the medication as ordered. The DON stated a negative outcome could be the machine could stop working properly, the resident could become short of breath, and the treatment may not be helpful. The DON also indicated that the nurse was required to be in the room to assess the resident should something go wrong. The DON stated the nursing staff were trained by their contracted pharmacy group prior to the DON hiring in March of 2026. The DON stated the updraft/nebulizer treatments were treated like any other medication and were covered in their medication policy. The DON stated there were no residents assessed to self-administer their own updrafts and MA-Cs are not permitted to perform an updraft treatment because they cannot assess a resident, and it was beyond their scope of practice in this facility.On 06/04/2026 the Director of Nursing (DON) provided a statement stating MA-Cs are not permitted to administer nebulizer treatments and it is performed by a licensed nurse only.On 06/04/2026 at 8:35 AM during an interview with MA-C, they said they had administered the breathing treatment for Resident #100 on 06/03/2026. MA-C said they had been trained on administering updrafts and monitoring of residents during the updrafts when they increased the MA-Cs scope of practice. The MA-C indicated they monitor things like if a resident was on oxygen they should not have lip balm, if they smoke, they cannot be around a tank, when transporting a tank to put it in a rolling cart, always look for signs on the person, checking the O2 levels, checking the tank for oxygen levels, check for discoloration of the resident. Follow the five steps when administering any medication, make sure it is the right person, the right medication, the right dose, make sure there is no food in their mouth, make sure the whole session has been completed and then tell the nurse. The MA-C stated they did not realize they did not stay in the room on 06/03/2026 to make sure the treatment was completed. The MA-C stated they went in the room two or three times, but the resident had to have a shower and was meticulous about how you handle them. The MA-C looked at the Medication Administration Record and stated they had started the updraft at 3:05 PM and stated it was at the end of their workday, and it had slipped their mind to stay in the room while the resident took the treatment. The MA-C stated they were not in the room when the treatment finished because they had left work, but it normally takes about 15 minutes. The MA-C indicated it was important to stay in the room with the resident to make sure they get all of the dosage. The MA-C said the dangers or concerns of leaving the room while the treatment was running would be the resident wouldn't get all the medicine or there may be a malfunction of the machine. The MA-C stated, prior to retraining on 06/03/2026, they did not know the facility policy on MA-Cs administering breathing treatments, but they are sure the facility would have told them. The MA-C stated they know they should have stayed in the room, notified the nurse, let the nurse know what they were doing, let the nurse know if a resident doesn't take it, if they fight against it, if any slight change to notify the nurse, if they had to coach the resident into taking it, if a resident said they were tired of the medication. The MA-C stated, I notify the nurse of everything. The MA-C stated prior to them leaving work on 06/03/2026 they did not notify the nurse [of the ongoing nebulizer treatment]. The MA-C stated she had been trained [on administering nebulizer treatments] by the Infection Preventionist right after they changed a MA-Cs scope of practice but could not remember when.On 06/04/2026 at 9:30 AM the MA-C reviewed Resident 100's MAR for 06/03/2026 and stated they had started the resident's morning breathing treatment at 9:31 AM and had not stayed in the room with the resident while the treatment was going but was going in and out of the room monitoring the resident. On 06/04/2026 at 10:00 AM during an interview the Administrator stated MA-Cs were not permitted to administer nebulizers to residents in this facility because a MA-C cannot assess a resident for effective breathing, especially if it was a PRN breathing treatment. The Administrator indicated the nurse has to remain with the resident while the treatment was being rendered to make sure the medication was being administered. The Administrator stated if the nurse was not there they cannot know if the resident had the treatment on the entire time and received the medication as ordered, if they suffered from shortness of breath, had increased anxiety, had a critical situation occur like shortness of breath that could lead to death because the resident was needing the treatment to open the airways so they could breathe better.On 06/04/2026 at 11:40 AM the Nurse Consultant stated their employee trainings were online, and they could not provide a copy of those in-services. On 06/04/2026 at 11:41 AM DON stated they did not have a functional job description for the MA-C.

Based on record review and interview, the facility failed to ensure a significant change Minimum Data Set (MDS) was completed within 14 days from the effective date of hospice service election for one (Resident #84) of four residents reviewed.The findings include:Review of the Centers for Medicare and Medicaid Services' (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual version 1.20.1 dated October 2025, revealed a Significant Change in Status Assessment (SCSA) is required when a terminally ill resident enrolls in a hospice program, or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice service election.Review of an admission Record revealed the facility admitted Resident #84 on 10/11/2024 with diagnoses that included malignant melanoma of skin.Review of Resident #84's Order Summary Report revealed an order dated 01/20/2025 for [name of hospice] to eval [evaluate] and admit.Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2026 revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated Resident #84 had severe cognitive impairment. The MDS also revealed Resident #84 had hospice care while a resident.Review of the MDS section of the electronic health record (EHR) for Resident #84 did not indicate a significant change MDS was completed after Resident #84 was admitted to hospice services on 01/20/2025. According to the RAI manual timeframe, 14 days after the effective date of the hospice service election indicates the assessment was due to be completed by February 3, 2025.During an interview on 06/04/2026 at 9:27 AM, MDS Coordinator #1 stated she used the RAI Manual version 1.20.1 dated October 2025 for guidance when completing assessments. She stated Resident #84 was receiving hospice services as of January 2025. She reviewed Resident #84's EHR and stated she did not see a time when the resident was discharged from hospice services and readmitted . She confirmed a significant change MDS was not completed for Resident #84 to address the resident enrolling in hospice. She stated a significant change MDS should have been completed for Resident #84 so many days after the significant change but she was not able to state when this should have been completed. She stated the significant change MDS was not completed for Resident #84 because, [It] just got missed.During an interview on 06/04/2026 at 11:16 AM, the Director of Nursing (DON) was interviewed and stated the MDS Coordinators used the RAI manual in the MDS office. She provided a Daily checklist for MDS Coordinators.Review of the Daily Checklist for MDS Coordinators undated, revealed admission and significant change assessments only have 14 days to complete from admission date or change noted date.

Based on observations, record review, interviews, and facility policy review it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet one (Resident #100) of one residents reviewed. Specifically, the resident's care plan did not identify the resident as receiving medications via nebulizer (a medical device that turns liquid medication into a breathable mist, delivering it directly to the lungs). The findings include: Review of an admission Record revealed Resident #100 had diagnosis of type 2 diabetes mellitus, acute embolism and thrombosis, dementia, chronic obstructive pulmonary disease, asthma, tachycardia, depression, anxiety disorder, and edema. Review of Resident #100's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. The MDS did not indicate Resident #100 received oxygen therapy. Review of the resident's Progress Notes effective date range 05/04/2026 – 06/04/2026, revealed the resident had a physician's order to inhale one application (of medication) using a nebulizer three times a day for asthma. Review of Resident #100's Electronic Medical Record (EMR) revealed there was no assessment completed for self-administering a nebulizer/breathing treatment. Review of Resident #100's Care Plan last reviewed on 03/20/2026, revealed the Care Plan did not identify that Resident #100 received nebulizer treatments. During an observation and concurrent interview on 06/03/2026 9:45 AM, Resident #100 was holding a plastic nebulizer hose mouthpiece in their mouth. There were no staff present in the resident's room. This Surveyor observed the Medical Aide Certified (MAC) in the hallway two doors down preparing another resident's medications. During an interview, the MAC stated she had started the nebulizer treatment for Resident #100 and was going in and out of the room checking on the resident. The MAC stated MACs were allowed to start and stop the breathing treatments for residents and that she had received additional MAC Expanded Scope training that allowed a MAC to administer the nebulizer treatment. The MAC then went into the room to administer the other resident's medications. On 06/03/2026 at 3:10 PM, this Surveyor observed Resident #100 in bed with the nebulizer treatment running. There were no staff present in the resident's room. The resident was observed laying the nebulizer pipe, while still running with white smoke coming from the end of the tubing, on their lap. During an interview on 06/04/2026 at 10:30 AM, the Minimum Data Set Coordinator (MDS) reviewed Resident #100's care plan and stated it did not reflect the updraft/nebulizer treatment and stated it should be on the care plan. MDS stated, The care plan tells staff how to care for the resident, how to watch for signs and symptoms of a problem, and what to look for related to a specific area. The MDS stated if a breathing treatment was left off the resident's care plan, the nurse or other staff may not know what to look for, as far as signs, symptoms, warnings, and know why the breathing treatment was needed for that specific resident. The MDS stated it was their responsibility to ensure a resident's breathing treatment was on the care plan. The MDS was looking in their computer software and stated Resident #100 started breathing treatments in February of 2026, that this resident had their initial care plan done in February of 2026 with an updated care plan done on March 8, 2026, and their quarterly was due now, but these assessments did not have the nebulizer/breathing treatment on them. During an interview on 06/04/2026 at 10:44 AM, the Administrator stated if a resident was receiving a breathing treatment, it should be on the resident's care plan because the care plan directed staff on how to take care of a resident. The Administrator stated the nebulizer was an order of medication, and it should be on the care plan. The Administrator stated the MDS Coordinator, and each department reviewed their own sections of the care plan. The Administrator stated, all orders should be added [to the care plan] within seven days and that was actual regulation. During an interview on 06/04/2026 at 10:48 AM, the DON stated the Unit Manager completed the medication section of the care plan, but the MDS coordinator was responsible for ensuring the medications were on the care plan and the nebulizer should be on the care plan so, we know the resident was receiving nebulizer/breathing treatments/oxygen. During an interview on 06/04/2026 at 11:40 AM, the Nurse Consultant stated the facility's employee trainings were online, and they could not provide a copy of those in-services. During an interview on 06/04/2026 at 11:41 AM, the DON stated they did not have a functional job description for the MAC. During an interview on 06/04/2026 at 12:16 PM, MDS stated the Minimum Data Set is a guide for the development of the resident's care plan. They stated the facility uses the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 Manual for completing the MDS, dated [DATE]. During an interview on 06/04/2026 at 12:29 PM, the Nurse Consultant stated they do not have a care plan policy and stated they used the RAI manual for developing the care plan. Review of a facility policy titled Medication, General Administration of, with a revised date of 11/22/2026, revealed that drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, or other personnel who are duly authorized to perform such services under state law and that self-administration of drugs is permitted when approved by the interdisciplinary team and with a physician's order.

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a comprehensive care plan was revised to include the signs, symptoms, and adverse reactions staff were to monitor for related to the use of a diuretic medication for one (Resident #84) of one resident reviewed. The findings include: Review of Resident #84's admission Record revealed the facility admitted Resident #84 on 10/11/2024 with diagnoses that included acute kidney failure. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2026, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #84 was taking high-risk drugs including a diuretic. Review of Resident #84's Care Plan with a last reviewed date of 04/17/2026, revealed Resident #84 was on diuretic therapy related to kidney failure. Interventions included to administer diuretic medication as ordered by the Physician and monitor for side effects, but did not include what signs, symptoms or adverse reactions staff were to monitor the resident for. Review of the Order Summary Report for Resident #84 revealed a diuretic medication to be given one tablet by mouth one time a day with an order date of 03/13/2025. The Physician's Order did not include what signs, symptoms, or adverse reactions staff were to monitor the resident for. Review of the Food and Drug Administration (FDA) Label revised in 09/2010 for the diuretic medication revealed for precautions, all patients receiving [drug name] therapy should be observed for signs or symptoms of fluid or electrolyte imbalance, which included dryness of mouth, thirst, weakness, fatigue, hypotension, and oliguria. During an interview on 06/04/2026 at 9:27 AM, MDS Coordinator #1 stated she updated the resident care plans. She was asked to review Resident #84's care plan for signs and symptoms or adverse reactions to monitor for the use of a diuretic and she stated she did not see this information. She stated she could not state why this information was not care-planned. She stated the signs, symptoms and adverse reactions for use of a diuretic should be included on the care plan so all staff caring for the resident would know what signs to look for. She stated the nurses know how to provide the necessary care to residents by looking at the care plan and the Certified Nursing Assistants (CNAs) have the closet care plans to reference. During an interview on 06/04/2026 at 11:16 AM, the Director of Nursing (DON) stated the nurses and CNAs know how to care for residents by reviewing the care plan or the closet care plan. She stated the staff should review the care plan every day in case something changes. She stated upon hire, CNAs complete competencies and were taught how to read and review the care plan in CNA school. The DON also stated the facility did not have a policy on care plans.

Number of residents sampled: Number of residents cited: Based on observation, interviews, and record reviews, the facility failed to ensure a physician's order for a sensor device to check blood sugar results was placed on the physician orders and the medication administration record of a resident's electronic health record for one (Resident #99) of one resident reviewed. The findings include: Review of Resident #99's admission Record revealed that the facility admitted the resident on 06/11/2024 with diagnoses that included diabetes mellitus. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 03/21/2026, revealed Resident #99 had a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. Review of a Care Plan with a revised date of 03/20/2026, revealed that Resident #99 was resistant to care as evidenced by refusing blood sugar checks and that Resident #99 refused finger pricks in the event the sensor device to check blood sugar results was not available. Review of Resident #99's Order Summary Report June 2026, did not indicate that the resident had an order for a sensor device to check blood sugar results. Review of Resident #99's Medication Administration Record dated June 2026, did not have a sensor device to check blood sugar results on the record. During an interview on 06/01/2026 at 12:05 PM, a sensor device patch was observed to Resident #99's left upper arm. During an interview on 06/02/2026 at 12:15 PM, a sensor device patch was observed to Resident #99's left upper arm. During an interview on 06/03/2026 at 11:15 AM, a sensor device patch was observed to Resident #99's left upper arm. During an interview on 06/03/2026 at 12:34 PM, Licensed Practical Nurse (LPN) #8 indicated that she started working at the facility in 9/2024. LPN #8 indicated that she did not see an order in Resident #99's chart on how the residents' blood sugars should be taken. LPN #8 indicated that the resident checked blood sugars using a sensor device and the results show up on the resident's phone. LPN #8 indicated that she would obtain the blood sugar results from Resident #99's phone. LPN #8 indicated that the sensor device patch was changed every 10 days. LPN #8 indicated that she did not know who the doctor was that wrote the original order for the sensor device. LPN #8 called the pharmacy and was informed that the sensor device was ordered by Doctor #9. LPN #8 indicated that Resident #99 would get a notification on the resident's phone when it was time to order the sensor device. LPN #8 indicated that sensor devices should be on the Physician Orders. During an interview on 06/03/2026 at 12:40 PM, LPN #10 indicated that she had been employed at the facility for two years. She indicated that the Endocrine Doctor wrote the order for the sensor device. LPN #10 indicated that she thinks that the Sensor device should be on the Physician Orders. LPN #10 indicated that Resident #99 informed her that blood sugars are checked by using the sensor device. During an interview on 06/03/2026 at 12:50 PM, Pharmacy Staff #11 indicated that Resident #99 had the sensor device filled on 11/10,2025, 12/10/2025, 1/09/2026, 2/16/2026, 3/17/2026, and 5/12/2026. Pharmacy Staff #11 indicated that each refill had three sensors, and each sensor lasted for 10 days. Pharmacy Staff #11 indicated that the order for the sensor device was written by Doctor #9. During an interview on 06/03/2026 at 2:29 PM, Resident #99 indicated they had the sensor device for over eight months. During an interview on 06/03/2026 at 2:57 PM, LPN #10 indicated that it was a habit to give Resident #99 the sensor without having a Physician Order. She indicated that Resident #99 handled their own affairs. During an interview on 06/04/2026 at 9:10 AM, the Director of Nursing (DON) indicated that she started in March of 2025, and Resident #99 had the sensor device then. The DON indicated that Resident #99 received the order for the sensor device from an outside physician. The DON indicated that the Medical Director did not have to review orders from outside doctors before they were added to the Physician Orders. The DON indicated that she was not sure how the nurses knew when to change the sensor device since it was not on the medication administration record, or on the Physician Orders. During an interview on 6/04/2026 at 11:35 AM the Medical Director indicated that he doesn't directly take care of Resident #99. The Medical Director indicated that he was not aware Resident #99 was using a sensor device. The Medical Director indicated that if Resident #99 was using a sensor device then it should be on the Physician Orders. During an interview on 6/04/2026 at 12:15 PM the Administrator indicated that the facility does not have a policy for quality of care. Review of a facility Inservice Education Report titled [Name Brand] Orders and Blood Glucose Monitoring dated 06/03/2026, revealed that staff responsibilities were to verify a current Physician/Provider order was present before applying or utilizing a sensor device. Do not initiate sensor device monitoring based solely on resident or family request. Review of a facility Inservice Education Report titled Blood Glucose Monitoring dated 06/03/2026 indicated that blood glucose checks must be performed as ordered by the physician. Review of a facility policy titled Physician Services with a revised date of 11/22/2026 revealed that medications, diets, specialized rehabilitation, therapy, or any other treatment may not be administered to the resident without the written approval of the attending physician. The policy also revealed that the residents' total program of care should be reviewed at each physician visit.

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a written plan of care included both the most recent hospice plan of care and a description of the services provided by the long-term care (LTC) facility to maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #84) of one resident reviewed. The findings include: Review of the admission Record for Resident #84 revealed the facility admitted the resident on 10/11/2024 with diagnoses that included malignant melanoma (cancer) of skin. Review of Physician's Orders for Resident #84 revealed an order dated 01/20/2025 for [name of hospice] to eval [evaluate] and admit the resident. There was no information in the orders to indicate the diagnosis for admission to hospice services or contact information for the hospice agency. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/2026, revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment. The MDS also revealed the resident received hospice care while a resident. Review of Resident #84's Care Plan last reviewed on 04/17/2026, revealed the care plan did not include any information for hospice services to be provided to the resident or any contact information for the hospice agency. Review of a Hospice Agreement revealed the facility entered into an agreement with the hospice provider on September 1, 2013. The agreement was signed by the facility Administrator on 01/21/2014. The hospice agency's director signed the form on 09/04/2014. During an interview on 06/04/2026 at 9:27 AM, MDS Coordinator #1 stated that Resident #84 was receiving hospice services as of January 2025. She reviewed Resident #84's electronic health record (EHR) and stated she did not see a time when the resident was discharged from hospice services and readmitted to the facility. MDS #1 was asked to review Resident #84's care plan for hospice services provided and she stated she did not see any information. She stated hospice information should be care planned because, The care plan is for us to be able to take care of the resident and for the aides to see. She stated she updated resident care plans and hospice services was not care planned because, It just got missed. During an interview on 06/04/2026 at 11:16 AM, the Director of Nursing (DON) stated the nurses and Certified Nursing Assistants (CNAs) know how to care for residents by reviewing the care plan or the closet care plan. She stated the staff should review the Care Plan every day in case something changed with the care provided. She stated upon hire, CNAs completed competencies and were taught how to read/review the care plan in CNA school. She stated the MDS Coordinator was responsible for adding hospice information to the residents' care plans. The DON was asked to provide a policy for hospice care and informed the survey team that the facility did not have a policy.

Based on observation, interview, and record review, the facility failed to ensure personal hygiene, as related to proper nail care, was not provided to residents who were dependent on nail care for 2 (Residents #83 and #87) of 2 residents reviewed for activities of daily living (ADL) care. The findings include: 1. A. Review of Resident #83 ' s Care Plan identified: i. Resident needs secured/special care neighborhood due to behaviors/psychosocial/dementia/ other psychiatric issues, initiated: 07/22/2024. ii. Resident has an ADL self-care performance deficit, initiated: 02/27/2024. iii. Resident has potential/actual impairment to skin integrity r/t (related to) fragile skin, incontinence of bowel and bladder, Dx (Diagnoses) of: Dementia, schizophrenia, and iron deficiency anemia. Initiated: 10/15/2024. B. Review of Resident #83 ' s Minimum Data Set (MDS) dated Dec. 5, 2024, reflects resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #83 had severe cognitive impairment. C. MDS dated Dec. 5, 2024, reflected Resident #83 to have diagnoses of: Dementia, anxiety disorder, psychotic disorder, post-traumatic stress disorder. 2. A. Review of Resident #87 ' s Care Plan identified: i. Resident #87 needs secured/special care neighborhood due to behaviors/psychosocial/Dementia/wandering/elopement risk; Initiated: 06/17/2024. ii. Resident #87 had an ADL self-care performance deficit r/t Dementia; Initiated: 06/04/2024. iii. Resident #87 had impaired cognitive function/dementia or impaired thought processes as evidenced by BIMS score; Initiated: 06/13/2024. iv. Resident #87 had potential to be physically aggressive: hitting, kicking, pushing, pinching, scratching, etc. related to: Dementia; Initiated: 06/04/2024. B. Review of Resident #87 ' s MDS dated Dec. 3, 2024, reflected resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #87 had severe cognitive impairment. C. Review of a Physician ' s Order dated 01/06/25, identified Resident #87 to have diagnosis of: Alzheimer's Disease Vascular Dementia, and Behavioral Disturbance. 3. A. On 01/6/24 at 10:30 AM, Resident #83 ' s nails were observed to be long and jagged with dark brown substance underneath the nails. B. 01/08/25 at 3:52 PM, Resident #83 ' s nails observed to be long and jagged with dark brown substance underneath the nails. 4. A. On 01/06/25 at 9:45 AM, Surveyor observed Resident #87 walking down the hallway. Resident ' s fingernails were observed to have a dark brown substance underneath the nails. B. On 01/06/24 at 10:28 AM, Surveyor observed resident #87 fingernails had a dark brown substance underneath the nails and a brown substance was on top of the nails. 5. A. On 01/09/25 at 9:20 AM, CNA #12 said the brown substance under fingernails could be food or fecal matter. CNA #12 stated if it were fecal matter, it could have something like clostridium difficile or hepatitis in it, or any illness the resident might have in it. It could be transferred to staff or other residents. CNA #12 stated The resident could get it from digging, but we don ' t really have any diggers, or from toileting. Fecal matter carries a lot of things. B. On 01/09/25 at 9:30 AM, CNA #10 said the brown substance under fingernails could be fecal matter from digging because we have a lot that dig. It could have germs in it like clostridium difficile. 6. On 1/9/25 at 10:20 AM, the Nurse Consultant stated the facility does not have a policy for nail care.

Based on observations, interviews, record review, it was determined that the facility failed to ensure 1 (Resident #11) of 1 sampled resident ' s wheelchair was in good working condition. The findings are: A review of an Order Summary Report indicated that Resident #11 had diagnoses of type 2 diabetes and restless legs syndrome, and a physician ' s order for Apixaban, an anticoagulant medication used to treat and prevent blood clots, with common side effects that include bleeding. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #11 used a wheelchair for mobility. Review of Resident #11's Care Plan, revised 11/10/2024, revealed the resident had potential for skin tear and bruising related to fragile skin, and long-term use of anticoagulants. On 1/06/25 at 11:05 AM, Resident #11 indicated that the wheelchair was digging into her legs. She indicated that when she moves around in her chair the wheelchair scrapes her leg. She indicated that she has informed the staff about the wheelchair, and they indicated that they don't know why she hasn't received a wheelchair. Resident #11 indicated that she sits up in her wheelchair most of the day. Resident #11 raised up her left leg and the cap was missing from the frame of the wheelchair below the seat. The frame was pressing into Resident #11's leg. On 1/08/25 at 1:54 PM, the Administrator indicated that wheelchairs are inspected very shift. The Administrator indicated that Resident #1 ' s wheelchair should be in good repair. He indicated that that he wasn't for sure why a new wheelchair hadn't been ordered already. On 1/08/25 at 1:58 PM, the MDS Coordinator indicated that the lead CNA (Certified Nurse Aide) informed her that Resident #11 said her wheelchair was too small, and it was rubbing the back of her legs. On 1/09/25 at 9:44 AM, the Lead CNA indicated that wheelchairs are inspected nightly, and on shower days which are on Mondays, Wednesdays, and Fridays. The lead CNA indicated that the Administrator informed him about Resident #11's wheelchair yesterday. On 1/09/25 at 9:50 AM, the MDS Coordinator indicated that a skin assessment was completed on Resident #11 after she received her new wheelchair yesterday. She indicated that Resident #11 did not observe any damage to Resident #11 ' s skin. On 1/09/2025 at 10:30 AM, the Administrator indicated that the facility did not have a policy for wheelchairs or equipment.

Based on observation, record review, interview, and facility policy review the facility failed to ensure a resident on 2 liters of oxygen had a physician ' s order for oxygen therapy to ensure resident received the appropriate and safe dosage of oxygen therapy affecting 1 (Resident #37) of 1 resident sampled for oxygen therapy. Findings include: 1.Review of Medical Diagnosis revealed Resident #37 had diagnoses of atrial flutter, opioid dependency, and diabetes. a. The significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15(13-15 suggest cognitively intact). MDS section C0110, C1 indicated Resident #37 was receiving supplemental oxygen. b. Review of a policy titled Oxygen Safety, with a revision date 11/22/2016, revealed that oxygen therapy is administered only upon a written order of a licensed physician. c. On 01/06/2025 at 3:06 PM, Resident #37 was observed on 2 liters of oxygen via nasal cannula (LNC). d. On 01/07/2025 at 2:22 PM, Resident #37 ' s oxygen concentrator was set on 2 LNC, and tubing was dated 01/06/2025. e. On 01/07/2025 at 2:23 PM, during an interview with Licensed Practical Nurse (LPN) #5 at Resident #37's bedside, LPN #5 was asked to check the oxygen concentrator, and LPN #5 verified it was set on 2 liters. When asked why the resident was on oxygen, LPN #5 replied Resident #37 gets short of breath. f. On 01/07/2025 at 2:53 PM, LPN #5 was asked for assistance findings an oxygen order for Resident #37. LPN #5 checked for orders and revealed that she could not find oxygen orders. LPN #5 looked at the order summary and stated, We did a chest Xray on 06/03/2024, and put Resident #5 on oxygen at that time, but I am not findings an order. When asked why Resident #37 should have an order for oxygen, LPN #5 revealed that residents on oxygen require a physician ' s order directing staff on the appropriate dosage. g. On 01/08/2025 10:50 AM, the Administrator was asked if residents receiving oxygen therapy are expected to have an order for oxygen, and who was responsible for checking for orders. The Administrator revealed that residents with oxygen require an order because it is considered a medication, and confirmed nursing staff are responsible, but because there was not an order it did not appear on the Medication Administration Record (MAR) for documentation.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands before they handled clean equipment or food, and manufacture specification was followed for 2 of 2 meals observed. The findings are: 1. On 01/07/25 at 1:59 PM, Dietary Aide (DA) #1 picked up the water hose with his bare hand, used it to spray leftover food from inside of the dishes, contaminating his hands. DA #1 placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up a clean blade and placed it inside the blender to be used in pureeing food items to be served to residents who required pureed diet and or mechanical soft diets without performing hand hygiene. DA #1 was interviewed and asked what he should have done after touching dirty objects or before handling clean equipment. He stated he should have washed his hands. 2. On 01/07/25 at 4:02 PM, Dietary [NAME] (DC) #2 removed a pan of cooked turkey from the oven and placed it on the counter, contaminating her hands. Without washing her hands, she picked up pans to be used in transferring pureed food items to be served to residents who required pureed diet for the supper meal and placed them on the counter with her fingers inside the pans. DC #2 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment; she stated she should have washed her hands. 3. On 010/7/25 at 4:12 PM, DC #2 untied the bread bag, and placed it on the counter without washing her hands. DC #2 removed a glove from the glove box, contaminating the glove, then used the contaminated gloved hand 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 residents who required a pureed diet. 4. On 01/07/25 at 4:36 PM, DA #1 walked into the clean area of the dish washing machine from the dining room, contaminating his hands after touching the knob to open the door. Without washing his hands, Dietary aide #1 picked up napkins and placed them on the cart. He also picked up utensils from the area that would go into the resident's mouth and placed them on individual napkins, wrapping them for residents to use during their meals. When asked what the residents use the napkins for, he stated that they use them to wipe their mouths while eating. DA #1 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment; he stated he should have washed his hands. 5. On 01/08/25 at 8:31 AM, Dietary aide (DA) #3 removed his hands from his pocket, contaminating his hands. Without washing his hands, DA #3 picked up clean bowls and plates and stacked them up on the rack to be used in positioning food items to be served to the residents at the lunch meal. DA #3 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment; he stated he should have washed his hands. 6. On 01/08/25 at 8:35 AM, Dietary [NAME] (DC) #4 opened bags of shredded cabbage, shredded carrots, and shredded red cabbage and emptied them into a bowl, opened a container of mayonnaise poured some on top of the shredded green cabbage, shredded red cabbage and shredded carrots, then placed gloves on his hands, contaminating the gloves. Without changing gloves and washing his hands, DC #4 then used his contaminated gloved hands to mix cabbages and carrots to be served to the residents for lunch meal. DC #4 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment; he stated he should have washed his hands. 7. On 01/08/25 8:50 AM, an opened bottle of lemon juice was on a shelf above the food preparation counter. The manufacturer specifications on the bottle indicated to refrigerate after opening. DC #4 was interviewed and was asked what the lemon juice was used for; he stated kitchen staff use it to clean the grill and also use it when a recipe calls for it. At 11:40 AM, DC #2 was interviewed and was asked what the lemon juice was used for; she stated kitchen staff use it to clean the grill and also use it when a recipe calls for it. On 01/09/25 at 10:05 AM, Dietary Manager (DM) was interviewed and was asked what the lemon juice was used for; she stated kitchen staff use it to clean the grill and also use it when a recipe calls for it. 8. A review of facility policy titled, Handwashing and Glove Usage in Food service, initiated 2016, provided by the Dietary Manager on 01/08/2025, indicated, food handlers should wash their hands before starting work, after touching dirty dishes or clothing and after touching anything else such as dirty equipment.

Based on observations and interviews, the facility failed to ensure the residents resided in a safe, functional, and comfortable environment as evidenced by two (rooms [ROOM NUMBERS]) exhibiting stained, soiled privacy curtains and damaged chairs. The findings are: 1. During facility rounds on 1/6/25 at 10:18 AM, the Surveyor observed the privacy curtains in Rooms 104 (Resident #38 was a resident in this room) and room [ROOM NUMBER] (Resident #82 resided in this room) had dark brown stains in several areas. The substance on the curtain in room [ROOM NUMBER] had dark brown lumps in it. The white bedside chair in room [ROOM NUMBER] had the vinyl peeled off the top corner of the chair, exposing the foam and fabric underneath. The white chair in room [ROOM NUMBER] had a large hole, approximately 2 in diameter, on the right arm of the chair. The vinyl edges of the hole were sharp and rough to the touch. 2. During facility rounds on 1/9/25 at 10:10 AM, the Surveyor observed the dark brown stains on privacy curtains in rooms [ROOM NUMBERS] remained as found in previous observation. The privacy curtain in room [ROOM NUMBER] continued to have a dark brown lump of substance on it. The white bedside chair in room [ROOM NUMBER] had the vinyl finish peeled off the top corner of the chair, exposing the foam fabric underneath. The vinyl edges of the hole were rough to touch. The white chair in room [ROOM NUMBER] had a large hole, approximately 2 in diameter, on the right arm of the chair. The vinyl edges of the hole were sharp and rough to the touch. 3. During an interview on 1/9/25 at 9:20 AM, Certified Nursing Aide (CNA) #12 said the dark stains on the curtain in room [ROOM NUMBER] were from a milkshake the resident had thrown about a week previous, stating, But if it is not that and is fecal matter it can be dangerous to staff and resident because fecal matter has germs like C-Diff (clostridium difficile) or hepatitis and these make you sick. CNA #12 said the missing vinyl on the chair has the potential to be harmful to the resident because it is sharp, and it can have germs in it. 4. On 1/9/25 at 9:30 AM, CNA #10 said the substance and stains on the curtain in room [ROOM NUMBER] could be feces, and it could be harmful to a resident or staff because feces can have any sickness the resident might have and it can transfer to anyone who touches it, like C-diff. CNA #10 said the tear on the chair has the potential to be harmful to the resident because it is sharp, and the resident could sustain a skin tear and get the germs in it. 5. On 01/09/25 at 10:30 AM, the Nurse Consultant said they do not have a policy on furniture replacement.

Based on interview and record review, the facility failed to encode and transmit a Minimum Data Set (MDS) assessment following a resident ' s discharge in a timely manner for one (Resident #36) of one resident sampled for MDS encoding and transmission. The findings are: Per review of a Nsg-Discharge Summary Progress Note dated 9/13/2024 at 1:45 PM, Resident #36 was discharged from the facility on 9/13/2024. Review of Resident #36 ' s medical record on 1/9/2025 at 11:10 AM revealed the resident ' s MDS discharge assessment had not been completed or transmitted to the Centers for Medicare & Medicaid Services (CMS) as required. This observation took place 118 days following the resident ' s discharge from the facility. On 1/9/25 at 11:20 AM, the MDS Coordinator confirmed the MDS discharge assessment for Resident #36 was overdue, stating she is allowed seven days to enter the discharge information. She verified that Resident 36 ' s discharge was not entered in a timely manner.

Based on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected section A1500, the preadmission screening and assessment resident record (PASRR), reflecting a serious mental illness and/or intellectual disability affecting 1 of 1 sampled (Resident #2) resident with a level II PASRR. Findings include: 1. Review of Medical Diagnosis revealed Resident #2 had diagnoses of paranoid schizophrenia, bipolar, and diabetes. a. The annual MDS with an Assessment Reference Date (ARD) of 02/23/2024, revealed a Brief Interview for Mental Status (BIMS) score of 14 (13-15 indicate cognitively intact). Section A1500 indicated 0 resident 2 does not have a level II PASRR. b. Review of Resident #2 ' s Care Plan, with a revision date of 06/19/2024, revealed Resident #2 had a level II PASRR. c. On 01/08/2025 at 10:54 AM, the Social Director (SD) provided Resident #2 ' s form 703 and 787 from 02/08/2022 and stated Resident #2 had a level II PASRR. d. On 01/08/2025 3:24 PM, the MDS Coordinator was asked Resident #2 ' s results on section A1500 of the MDS, and what guidance was used to code to the MDS. MDS Coordinator reviewed the Annual MDS with an ARD of 02/23/2024. The MDS Coordinator stated section 1500 was coded wrong with 0 indicating Resident #2 did not have a level II PASRR, and confirmed the RAI manual was used for guidance. When asked why it was important to code correctly to the MDS, the MDS Coordinator stated the MDS drives the residents care plan and can affect reimbursement. e. On 01/08/2025 at 3:30 PM, the MDS Coordinator was asked for a copy of the section of the RAI manual that was used to code section A1500. f. On 01/08/2025 at 3:35 PM, the MDS Coordinator provided section A1500, from the RAI manual showing code 1 for yes if resident has a PASRR level II.

Based on record review and interview, the facility failed to care plan oxygen to ensure 1of 1 sampled (Resident #37) resident received individualized, resident-centered care addressing interventions, treatment, and health care goals. Findings include: 1. Review of Medical Diagnosis revealed Resident #37 had diagnoses of atrial flutter, opioid dependency, and diabetes. a. The significant Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 (13-15 suggest cognitively intact). Section C0110, C1 indicated the resident was receiving supplemental oxygen. b. On 01/06/2025 at 3:06 PM, Resident #37 was observed receiving two liters of oxygen. c. On 01/07/2025 at 2:53 PM, Licensed Practical Nurse (LPN) #5 was asked for assistance finding where oxygen was addressed on Resident #37 ' s care plan. LPN #5 stated, I cannot find a care plan for oxygen. When asked if Resident #37 should have a care plan addressing oxygen, LPN #5 stated care plans are important because if someone checked they would know how much oxygen Resident #37 was supposed to be on, why Resident #37 was on oxygen, and what interventions to look for. LPN #5 stated Resident #37 was placed on oxygen in the summer, then confirmed 06/03/2024, after a chest x-ray for shortness of breath was verified from the order summary. d. During an interview on 01/08/25 at 10:50 AM, the Administrator was asked if a resident was on oxygen that has been documented on the MDS, should it also be care planned. The Administrator revealed that oxygen should be care planned because the care plan directs staff on resident care. Administrator was asked to provide a care plan policy. e. The Consultant provided a letter indicating the facility does not have a care plan policy, but they do follow the Resident Assessment Instrument (RAI) manual. f. On 01/09/2025 at 9:16 AM, MDS Coordinator provided Chapter 4: Care Area Assessment (CAA) Process and Care Planning, from the RAI manual revealing assessment results must accurately reflect a residents need to develop a comprehensive care plan. The RAI process considers the efforts of the health care team to trigger areas of concern that may warrant interventions to prevent further decline. The MDS Coordinator noted that since there was not an order for oxygen, the trigger for care planning was overlooked. She confirmed that oxygen was documented on the MDS and should have been care planned.

Based on observation, interview and facility policy review, the facility failed to ensure showers were maintained in a clean and sanitary condition for resident use, as evidence by, black residue in the grout lines of the shower tiles on the floor and walls in two of four shower rooms. This failed practice had the potential to affect 90 residents (Census: 92) who received showers in the shower rooms. The findings are: The Surveyor observed a Proper Procedures for Disinfecting the Shower Rooms form on the wall in one of four shower rooms on 06/19/2024, which indicated, .Housekeeping is to disinfect the shower room in the morning before daily showers begin and at the end of the day when showers have been completed. Showers are disinfected as followed: 1) Spray disinfectant on shower chair, shower walls, and shower floor 2) Wait 10 minutes 3) Rinse off the shower chair, shower walls, and shower floor . Review of the Housekeeping policy, provided by the Administrator on 06/20/2024 indicated, .Procedure . Housekeeping staff will strive to keep the facility free from offensive odors, accumulations of dirt, rubbish, dust, and safety hazards . Review of the Order Summary Report revealed Resident #3 had a diagnosis of Osteoarthritis of Left Hip. Review of the Quarterly Minimum Data Set with an Assessment Reference Date of 05/31/2024 indicated Resident #3 had a Brief Interview for Mental Status score of 15 (13-15 indicates cognitively intact) and required partial to moderate assistance with shower/bathing activity. On 06/19/2024 at 9:38 AM, during an interview, Resident #3 was asked about the (black substance) in the showers, and when the resident was asked if a particular shower was used, Resident #3 confirmed that Resident #3 used all the showers in the halls that everyone used. Resident #3 confirmed that in those different showers Resident #3 saw dark, black areas in the grout on the floor tiles and on the base of the shower. Resident #3 added that Resident #3 required help with showering, and was not able to stand, but used a shower chair. On 06/19/2024 at 12:57 PM, the SPA room (shower room) between the 200 and 300 Halls, on the right of the 200 Hall had two shower stalls was observed. There was a black residue in between the tiles in the grout lines. There was also black residue observed in the grout lines on the lower part of the shower wall. On 06/19/2024 at 1:04 PM, the SPA room by the 500 Hall, in the corner, to the right of the nursing station, was observed. The first shower stall had a black residue observed in the grout lines of the tiles on the floor and on the wall. The second shower stall had black residue in the grout lines between the tiles on the floor and lower wall of the shower stall. The third shower stall had black residue on the grout lines between the tiles of the floor and in the corner going up the shower wall. A fourth shower stall had a small amount of black residue in the grout lines between the tiles of the floor. On 06/19/2024 at 2:00 PM, during an interview, Certified Nursing Assistant (CNA) #1 confirmed she sanitized the shower after use with soap first and then a purple spray solution kept in the supply closet by the 100 Hall. She confirmed she sanitized the showers sometimes before use and after every use. On 06/19/2024 at 2:36 PM, during an interview, Housekeeper #2 confirmed housekeeping staff were responsible for cleaning the showers. She confirmed they were cleansed in the morning and after lunch. She confirmed she used bathroom disinfectant, that was pink in color, to cleanse the showers. She confirmed she used a floor cleaner for the shower floor that had a dark blue label on it. On 6/19/2024 at 2:53 PM, during an interview and concurrent observation, Housekeeper #2 and this Surveyor entered the shower room between the 200 and 300 Halls, across from the nursing station and on the left side of the 200 Hallway. She was asked to look at the shower stalls and describe what she saw. She confirmed it looked like soap scum that had been there for a while. She described the color of it as black. There was a sheet on the wall titled, Proper Procedures for Disinfecting the Shower Rooms and it described the process of how housekeeping and CNAs should disinfect the shower room. On 06/19/2024 at 2:55 PM, during an interview and concurrent observation, Housekeeper #2 and this Surveyor entered the janitor's closet and there was a [brand name] dispenser on the wall to the right of the room and there were tubes coming from it and different colored labels on the front that indicated: Spray Bottle Fill: .Pink [brand name] cleaner; Mop Bucket Fill: [brand name] cleaner with two bottles. In the lower part of the dispenser, were the following containers: [brand name] cleaner (Pink); [brand name cleaner] (Light Blue); [brand name cleaner] times 2 containers (Dark [NAME] label). Housekeeper #2 stated, The green one is used on the floor in the shower rooms and in the residents' rooms. On 06/20/2024 at 9:13 AM, during an interview, the Housekeeping Supervisor confirmed the showers were cleansed twice a day with a disinfectant that was allowed to sit 5 to 10 minutes before being washed off. She confirmed an acid bathroom cleaner was used daily in the shower stalls. She was asked what housekeeping did if they noticed a black residue in the showers and she confirmed the showers were cleansed daily. On 06/20/2024 at 2:27 PM, the Housekeeping Supervisor confirmed during an interview by telephone that the housekeeping staff retrieved the solution from the dispenser, and it was already diluted and ready to be used. She confirmed that she gave the housekeeping staff cards that tell them the kill time for each disinfectant. Review of the [brand name] Reference Sheet, copyrighted 2021, provided by the Housekeeping Supervisor on 06/20/2024 indicated it was recommended for daily use disinfecting and cleaning washable hard non-porous environmental surfaces including shower rooms and spas, shower stalls and tiles. It indicated visibly soiled areas should be pre-cleaned and the surfaces must remain visibly wet for five minutes. It indicated the product should be diluted at a one to 16 (8 ounces) to one to 10.7 (12 ounces) per gallon of water.

Based on observation and interview, the facility failed to post the results of the most recent survey in a location where individuals wishing to examine survey results do not have to ask to see them. The findings are: On 11/08/2023 at 9:19 AM, the Director of Nursing (DON) was asked to provide the location of the survey results. The DON stated the results should be located on the entryway table, but the results could not be located. On 11/08/2023 at 11:19 AM, the DON provided the survey results binder and stated that the binder had been located in the kitchen. It had been found in the drawer used to store clothing protectors for the residents. The binder was coated in various dried substances that appeared to be food. On 11/08/2023 at 3:32 PM, five members of the Resident Council (Residents #10, #15, #29, #33, and #68) were asked if they were aware of the location of the survey results binder. All five residents stated they had not been informed of the location of the binder and had not seen it in the facility. On 11/09/2023 at 9:09 AM, the Administrator acknowledged that the results of the most recent state survey should have been placed in a location where individuals wishing to examine survey results do not have to ask staff in order to see them.

Based on observation, record review and interview, the facility failed to ensure foods stored in in the dry storage areas were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; floor was free of water standing and staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 85 residents who receive meals from the kitchen (Total census:85) as documented on a list provided by Dietary Supervisor on 11/09/2023 at 08:07 AM. The findings are: 1. On 11/06/23 at 9:13 AM, there were puddles of water on the floor leaking out from the steam table. Dietary Supervisor stated, We have had the maintenance man sealed it one time, but it started to leak again. 2. On 11/06/23 at09:15 AM, a container of sherbets on a shelf in the freezer had popsicles on it. The surveyor asked the Dietary Supervisor to describe the appearance of the sherbets. She stated, It had freezer burn. 3. On 11/06/23 at 9:23 AM, an opened gallon container of sherbet ice cream was on a shelf in the freezer. There were pieces of paper peels from the inside of the sherbet container and some black stains on the sherbet. The surveyor asked the Dietary Supervisor to describe the appearance of the sherbets. She stated, I think someone was scooping the sherbet so hard to cause the tears on the paper. There were some black stains on it. 4. On 11/06/23 at 9:29 AM, Dietary Employee (DE) #1 removed a container of sliced pineapple and placed it on the counter. Without washing her hands, she picked up bowls to be used in portioning foods and placed them on the counted with her fingers inside of them. On 11/08/23 at 2:38 PM, the surveyor asked the Dietary Employee what should you have done touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 5. On 11/06/23 at 9:30 AM, the following observations were made in the storage room. a. An opened box that contained a bag of rice crisps was on a shelf in the storage room. The box was not covered, and the bag was not sealed. b. Forty wooden shelves where canned goods were stored were chipped and exposed to the woods. 6. On 11/06/23 at 9:37 AM, an opened bag that contained an opened box of salt was on a shelf above the food preparation counter. The bag was sealed, and the box was not covered. 7. On 11/07/23 at 3:48 PM, the following observations were made in the kitchen area. a. There were sticky black stains smeared on the floor in front of the oven. b. There was grayish water standing on the floor by the food carts. c. An opened bag that contained an opened box of salt was on a shelf above the food preparation counter. The bag was not sealed, and the box was not covered. 8. On 11/07/23 at 5:02 PM, Dietary Employee (DE) # 2 removed a bag that contained dinner rolls from the refrigerator and placed it on the counter. He removed gloves from the glove bag and placed them on his hands. Without changing gloves and washing his hands, he removed dinner rolls from the bag, placed them on a pan to be baked and served to the residents with their supper meal. On 11/07/23 at 2:37 PM, the surveyor asked DE #2 what should you have after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. 9. A facility policy titled .Hand washing documented, Staff will wash hands and exposed portions of their arms to remove contamination after entering the kitchen and after engaging in other activities that contaminates the hands.

48483 49071 Based on observation, interview, and record review, the facility failed to ensure the residents living in the facility were provided a safe, clean, and comfortable homelike environment by maintaining walls in good condition for 3 (Rooms 101, 308, 407) rooms in the facility. The findings are: 1. On 11/06/23, during initial rounds the following was observed: a. On 11/06/23 at 10:07 AM in room [ROOM NUMBER] on secured unit surveyor observed 3 areas on the long wall with white spackled areas on wall and on the adjoining wall had area where wall had sheetrock exposed at the bottom of wall. Spackled areas measure 6.5x7, 4x9 and 5x3 inches. b. On 11/08/23 at 3:33 PM, room [ROOM NUMBER] B, surveyor observed wallpaper pulled away from the wall at the head of the bed in 3 areas. Areas measured 15x22, 9x12, and 14x17 inches. c. On 11/08/23 at 03:48 PM, the surveyor asked the Director of Nurses (DON), should a resident ' s room have wallpaper peeled off and hanging from the wall? Don stated, No, however, we are starting to do a remodel and will be fixing the walls. The Surveyor asked is this like a homelike environment? The DON stated, No, but we are fixing it. d. On 11/8/23 at 3:57 PM, a policy was provided by the Administrator titled, Resident Rights .15. Receive adequate and appropriate medical care, nursing care, protective and support services, and personal cleanliness in a safe and clean environment . 2. On 11/06/23 at 01:27 PM, the surveyor observed room [ROOM NUMBER] B with 2 long, dark marks on the left entrance wall. a. On 11/07/23 at 09:51 AM, the surveyor observed room [ROOM NUMBER] B with 2 long, dark marks on the left entrance wall. b. On 11/08/23 11:32 AM, The surveyor observed room [ROOM NUMBER]-B with 2 long, dark scratches on the left entrance wall. The surveyor requested for Maintenance to measure the marks on the wall. Maintenance stated, they measure 10 ft. 3 inches long and 2 ft. 3 inches high from the floor. c. On 11/08/23 at 11:36 AM, The surveyor asked Maintenance, were you aware of the marks on this wall? Maintenance stated, No, I've been out of town and just got back. 3. On 11/07/2023 at 9:39 AM, the surveyor observed a 36-inch section of wallpaper peeling away from the wall above the head of the occupied B bed in room [ROOM NUMBER]. Resident #38 was lying in the B bed and stated, Everything is falling apart in here. a. On 11/08/2023 at 2:11 PM, the 36-inch section of wallpaper peeling away from the wall above the head of the occupied B bed in room [ROOM NUMBER] was again observed. Resident #38 was lying in the B bed and stated, I'm surprised that it's still on the walls at all.

Based on interview and record review the facility failed to update a Minimum Data Set [MDS] for 2 [Residents #16 and #23] residents. This failed practice had the potential to affect all 75 residents. The findings are: 1. Resident #16 Physician's Order Summary dated 1/1/23 thru 11/30/23 showed, Seroquel (an antipsychotic medication) Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime related to other frontotemporal neurocognitive disorder Discontinued 01/23/2023. Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth at bedtime related to other frontotemporal neurocognitive disorder give 0.5 tab to = 12.5mg every night [QHS] Discontinued 07/17/2023. 1a. MDS with an Assessment Reference Date [ARD] of 10/4/23 showed, Resident is taking an antipsychotic and has taken it in the last 7 days. 1b. On 11/9/23 at 12:35 PM, the Surveyor asked the MDS Coordinator [MC], Can you pull up the orders for Resident #16 ' s antipsychotic? Is Resident #16 on an antipsychotic. No. The Surveyor asked, can you see where Resident #16 was taking an antipsychotic and when it ended? The MC said, one order of Seroquel ended on 7/17 and the other one ended on 1/23/23. The Surveyor asked, can you show the MDS reports from the 1st of the year for the medication section? Is it coded that Resident #16 is on an antipsychotic? It is coded for an antipsychotic for the 10/4/23 quarterly assessment. I missed it. 2. Resident #23 Physician's Order Summary dated 1/1/23 through 11/30/23 showed, Apixaban (an anticoagulation medication) Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to paroxysmal atrial fibrillation Discontinued 02/02/2023. 2a. The Surveyor reviewed the MDS with an Assessment Reference Date [ARD] of 3/2/23 it showed, Resident is taking an anticoagulant and has taken it in the last 7 days. 2b. The Surveyor reviewed the MDS with an [ARD] of 6/2/23 it showed, Resident is taking an anticoagulant and has taken it in the last 7 days. 2b. The Surveyor reviewed the MDS with an ARD of 9/2/23 it showed, Resident is taking an anticoagulant and has taken it in the last 7 days. 2c. On 11/9/23 at 12:35 PM, The Surveyor asked the MC, can you pull up the orders for Resident #23 anticoagulant? The Surveyor asked, is the resident on an anticoagulant? The MC said no. The Surveyor asked, when did the medication start and end? The MC said the medication ended on 2/2/23. The Surveyor asked, can you show the MDS reports from the 1st of the year for the Medication section? All 3 reports were coded that the resident received an anticoagulant. The Surveyor asked, what is the correct procedure to update an MDS? The MC said, I do it quarterly and if there is a significant change, any discharges or admission. The Surveyor asked, who signs off on the updated MDS? The MC said, the DON signs off on all MDS. The Surveyor asked, how do you know to update an MDS that is not annual or quarterly? The MC said, the nurses come to me if there is a significant change, admit, or discharge from hospice. On 11/9/23 at 1:00 PM, the Administrator said, we go by the most up-to-date State Resident Assessment Instruction [RAI] Manual as a policy for MDS.

Based on observation, record review, and interview, the facility failed to ensure office doors were secured to prevent the potential for residents gaining access to hazardous materials, and the potential for locking themselves in the office for 1 (Resident #2) of 3 (Residents #1, #2 and #3) sampled residents who were at risk for wandering. This failed practice resulted in an Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #2 who had been assessed for being at risk for wandering and was missing in the facility unnoticed by staff and found approximately 4 hours later, locked in the Treatment Room in a closet with treatment supplies. The failed practice had the potential to cause more than minimal harm to 62 residents who were at risk for wandering, according to the list provided by the Minimum Data Set (MDS) Coordinator on 10/10/2022. The Administrator was notified of the Immediate Jeopardy condition on 10/07/2022 at 11:48 a.m. The findings are: 1. Resident #2 was admitted on [DATE] with diagnoses of [CONDITION(S)] and Dementia. The Quarterly MDS with an Assessment Reference Date (ARD) of 09/13/2022 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision with locomotion on the unit and locomotion off the unit and wandering was present daily, was a significant risk of getting to a potentially dangerous place (e.g. [for instance], stairs, outside of the facility) and significantly intruded on the privacy or activities of others. a. The Office of Long-Term Care (OLTC) Incident and Accident Report (I&A), Division of Medial Services (DMS) form 7734 dated 09/26/2022 documented, .Date and Time Submitted (if known) 09/26/2022 12:58 am . Date and Time of Discovery: 09/26/2022 12:58 am . Name of Resident [Resident] . Type of Incident: Neglect . Summary of Incident . At approximately 10:00pm, staff notified [Administrator] Administrator they were not able to locate [Resident #2] in the facility. [Administrator] immediately gave direction to staff to complete a room to room search of building (100-500 hall), to ensure [Resident], resident did not fall asleep in another room or other locations in the facility. On 09/25/2022, police was immediately notified. On 09/25/2022, family was notified. On 09/25/2022, physician was notified. On 09/25/2022 facility began immediately reviewing video camera of allegation of abuse and neglect, at approximately 18:23pm [6:23 PM], resident is witnessed going inside the treatment office. Resident was alone upon entry to the treatment office, then [Resident #2], resident, enters closet inside office and close door. On 09/25/2022, staff in-service immediately began on abuse and neglect. On 09/25/2022, staff was in-serviced on completing every two-hour room checks on all residents. On 09/25/2022, staff was to review the elopement book, to ensure all elopement risk residents were in the facility. On 09/25/2022, began immediately gathering staff witness statements regarding abuse and neglect allegations. On 09/25/2022 at approximately 10:00pm, staff began completing a room to room, from 100 hall-500 hall, check for [Resident #2], resident. On 09/25/2022, at approximately 10:58 pm, [Resident #2], resident was found in Treatment office closet. On 09/25/2022, at approximately 10:58 pm, [Resident #2], resident was immediately accessed by nurse, and sent to [Hospital], in [City] for full assessment. Steps taken to Prevent Continued Abuse or Neglect During the Investigation: At approximately 10:00 pm, staff notified [Administrator], Administrator they were not able to locate [Resident #2], resident in the facility. [Administrator], Administrator immediately gave direction to staff to complete a room to room search of building (100-500 hall), to ensure [Resident #2], resident was in another room or other locations in the facility. On 09/25/2022, police was immediately notified. On 09/25/2022, family was notified. On 09/25/2022, physician was notified. On 09/25/2022 facility began immediately reviewing video camera of allegation of abuse and neglect, at approximately 18:23pm, resident is witnessed going inside the treatment office. Resident was alone upon entry to the treatment office, then [Resident #2], resident, enters closet inside office and close door. On 09/25/2022, staff in-service immediately began on abuse and neglect. On 09/25/2022, staff was in-serviced on completing every two-hour room checks on all residents. On 09/25/2022, staff was to review the elopement book, to ensure all elopement risk residents were in the facility. On 09/25/2022, began immediately gathering staff witness statements regarding abuse and neglect allegations. On 09/25/2022, began gathering resident witness statements regarding abuse and neglect allegation. On 09/25/2022 at approximately 10:00pm, staff began completing a room to room, from 100 hall-500 hall, check for [Resident #2], resident. On 09/25/2022, at approximately 10:58 pm, [Resident #2], resident was found in Treatment office closet. On 09/25/2022, at approximately 10:58 pm, [Resident #2], resident was immediately accessed by nurse, and sent to [Hospital], in [City] for full assessment . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities, DMS form 762 dated 09/26/2022 documented, .Date Incident Reported to OLTC: 09/26/2022 Time: 10:58 PM, Date and Time of Incident (if known): 09/26/2022 Time: 10:58 PM, Date and Time of Discovery: 09/26/2022 Time 10:58 PM . Complete Description of Incident . At approximately 10:00pm, staff notified [Administrator] Administrator they were not able to locate [Resident] in the facility. [Administrator] immediately gave direction to staff to complete a room to room search of building (100-500 hall), to ensure [Resident #2], resident did not fall asleep in another room or other locations in the facility. On 09/25/2022, police was immediately notified. On 09/25/2022, family was notified. On 09/25/2022, physician was notified. On 09/25/2022 facility began immediately reviewing video camera of allegation of abuse and neglect, at approximately 18:23pm, resident is witnessed going inside the treatment office. Resident was alone upon entry to the treatment office, then [Resident #2], resident, enters closet inside office and close door. On 09/25/2022, staff in-service immediately began on abuse and neglect. On 09/25/2022, began immediately gathering staff witness statements regarding abuse and neglect allegations. On 09/25/2022, staff was in-serviced on completing every two-hour room checks on all residents, with no negative findings completed 09/30/2022. On 09/25/2022, began gathering resident witness statements regarding abuse and neglect allegation. On 09/25/2022 at approximately 10:00pm, staff began a room to room, from 100 hall-500 hall, check for [Resident #2], resident. On 09/25/2022, at approximately 10:58 pm, [Resident #2], resident was found in Treatment office closet. On 09/25/2022, at approximately 10:58 pm, [Resident #2], resident was immediately accessed by nurse, and sent to [Hospital], in [City] for full assessment. Section III- Findings and Actions Taken . Approximately 10:00pm, staff notified [Administrator], Administrator they were not able to locate [Resident #2], resident in the facility. [Administrator], Administrator immediately gave direction to staff to complete a room to room search of building (100 hall- 500 hall), to ensure [Resident #2], resident did not fall asleep in another room or other locations in the facility. On 09/25/2022, resident was located in treatment office, behind a locked door, after her entry to a closet, within the treatment room. [Resident #2], resident was inside the closet, inside a box sleep, uninjured. After watching the video surveillance, it was noted that staff member walked by and closed the open door at approximately 21:40 closing the main door to office at the end of her shift. On 09/25/2022, police was immediately notified, with no negative findings, completed 09/30/2022. On 09/25/2022, family was immediately notified, with no negative findings, completed 09/30/2022. On 09/25/2022, physician was immediately notified, with no negative findings, completed 09/30/2022. On 09/25/2022, facility began immediately reviewing video camera of allegation of abuse and neglect, at approximately 18:23pm, resident is witnessed going inside the treatment office. [Resident #2], resident was alone upon entry to the treatment office, then [Resident #2], resident enters closet inside office and close door, with no negative findings, completed 09/30/2022. On 09/25/2022, staff in-service immediately began on abuse and neglect, completed with no negative findings 09/30/2022. On 09/25/2022, staff was immediately in-serviced on completing every two-hour room checks on all residents, with no negative findings completed 09/30/2022. On 09/25/2022, staff immediately reviewed the elopement book, to ensure all elopement risk residents were in the facility, completed with no negative findings on 09/30/2022. On 09/25/2022, began immediately gathering staff witness statements regarding abuse and neglect allegation, completed on 09/30/2022, with no negative findings. On 09/25/2022, began gathering resident witness statements regarding abuse and neglect allegation, completed on 09/30/2022, with no negative findings. On 09/25/2022 at approximately 10:00pm, staff began a room-to-room search from 100 hall- 500 hall, to check for [Resident], resident, on 09/30/2022, completed with no negative findings. On 09/25/2022, at approximately 10:58pm, [Resident #2], resident was found in treatment office closet. On 09/25/2022, at approximately 10:58pm, all employees working on 09/25/2022, 3/11 shift received a disciplinary action for failure to complete rounds every two hours of shift, with final warning, completed on 09/30/2022. On 09/25/2022, at approximately 10:58 am, [Resident], resident was immediately access by [Staff], DON, and sent to [hospital], in [city], for full assessment. On 09/25/2022, after completing investigation, no negative findings, complaint is unsubstated . c. The Witness Statement dated 09/25/2022 at 10:00 PM by the Director of Nursing (DON) documented, .received a call from [Administrator] that our resident [Resident #2] may have been missing for some time and everyone had done room searches. 10:40 PM, I arrived at facility and began room-room-bathroom-all doors locked & unlocked search. At 11PM [staff] and myself found [Resident #2] in the treatment nurse office in a closet lying in a box. The door to treatment room was locked and we unlocked it to get in. Resident is alert to self (baseline) has small know to back of head and some diaphoresis noted. 911 notified & [and] will send out for assessment. [Resident #2] was kept 1:1 [one on one] until ambulance arrived . d. The Nursing Progress Note dated 09/25/2022 at 22:30 [10:30 PM] documented, .Send resident to ER [emergency room ] for Eval [evaluation] and Tx related to unwitnessed fall per APN [Advanced Practice Nurse] . e. The Care Plan documented, . The resident is a wanderer and elopement risk. Resident will wander to the doors and try to exit them. Resident will wander until she gets sleepy and then will sleep anywhere. 09/29/22 resident was found in the tx [treatment] office. Date Initiated: 10/06/2022 .Wanderguard Bracelet Date Initiated: 10/06/2022 . wears wander guard bracelet Date Initiated: 06/20/2022 . f. On 10/05/2022 at 8:16 PM, there was a Treatment Supply Closet on the 400 hallway. The Treatment Supply Closet was unlocked, and the Surveyor was able to open it. The Treatment Nurses' Office, located next to the Treatment Supply Closet, door was open and unlocked, with the light on. Two doors in the Treatment Nurses' Office were unlocked and the Surveyor was able to open the doors. One closet contained wound supplies. The other door had what appeared to be heating and cooling equipment. g. On 10/07/2022 at 9:37 AM, the Surveyor asked the Administrator, What interventions are in place to prevent residents from wandering into unsecured offices and rooms that contain hazards? She stated, We put signs on the doors to ensure they are locked behind staff. Monitoring it with daily checks, and at the end of the day maintenance will go check the doors. We started that the week the resident was found in the room. The Surveyor asked, When does the maintenance shift end? She stated, It ends at 4:30 p.m. If someone is in the office after that they are to make sure it is locked at the end of the day. The Surveyor asked, How are residents accounted for during rounds? She stated, They have to be physically seen and be able to lay hands on every patient during rounds. The Surveyor asked, What happened with [Resident #2] on 09/25/2022? She stated, I got a call they were unable to locate her at about 9:30 PM. I told them to do room to room search. I arrived at 10:00 started the process of another search. I did a round of the complete building, then paired off staff 2 by 2 to check each patient room and hall. That's when we found her on 400 Hall in the Treatment Office. I even did an outside search too. The Surveyor asked, What time did you view the surveillance video? She stated, At about 10:30 p.m. I went as far back as 2:00 p.m. which was when we see her on 400 couch asleep. The door was open at 18:23 and the resident walked in. A nurse dropped her cart off at 18:20 [6:20 p.m.] and opened the door, went in the office, came out left the cart and turned right up the hall. The resident comes back looks out the door and walks in the office and we see her standing in the closet and the door closes. The Surveyor asked, Does the closet door lock? She stated, No. The Surveyor asked, What time did staff start their search for the resident? She stated, At 9:30 p.m. The Surveyor asked, What time were the family, physician and police notified? She stated, At 10 [10:00 p.m.] Police officer watched the video with us for a while. The Surveyor asked, What time was the resident found? She stated, At about 11 [11:00 p.m.]. The Surveyor asked, What time was the resident sent to the ER? She stated, 11:30 [p.m.] the ambulance came to pick her up they took her from my office. The Surveyor asked, Was the resident administered her 8:00 p.m. medication on 09/25/2022? She stated, I can't answer that. From the information received from the DON he documented giving meds at 8:00 pm, so he was terminated. (The Medication Administration Record (MAR) did not document the resident received her 8:00 PM medication). The Surveyor asked, Is the wander guard bracelet an appropriate intervention for the resident locking herself in a closet? She stated, No. h. The facility policy titled, Elopement and Wandering, provided by the Administrator on 10/07/2022 at 11:45 AM documented, .Appropriate measures will be implemented to identify and respond promptly to elopement and wandering . Procedure: Assessment . 2. Interventions will be developed according to the resident's specific needs . Prevention and Response . 3. It is the responsibility of all employees to immediately report to the charge nurse or Director of Nursing any attempt by a resident to leave the premises, or suspicion that a resident is missing from the facility . Return. Upon return of the resident to the facility, the nursing staff will examine the resident for injuries, contact the attending physician and report findings, notify the resident's responsible party and the state regulatory agency, complete and file an incident and accident report, and make appropriate entries into the resident's medical record . Training 1. Upon hire and annually, each employee shall be informed and trained of the Elopement and Wandering Policy and Procedure . 2. Each employee shall be informed of their responsibility in regards to: a. Door alarms; b. Reporting of elopement; c. Reporting behavior of residents, which may indicate they are at risk for elopement or wandering . i. The Safety Data Sheets for the products that were in the Treatment Office closet Resident #2 was locked were provided by the Administrator on 10/07/2022 at 1:20 PM documented, . [Brand] Moisturizing Body Cream . 2. Hazards Identification . Emergency Overview: .A white to off-white cream. May mildly irritate the eyes . Ingestion: Of low toxicity but ingestion of large quantities can be irritating or harmful . Super [Brand]-clothes Germicidal Wipes . Precautionary Statements-Prevention . Obtain special instructions before use, do not handle until all safety precautions have been read and understood, use personal protective equipment as required, wash face, hands and any exposed skin thoroughly after handling, avoid breathing dust/fume/gas/mist/vapors/spray, use outdoors or in a well-ventilated area . keep container tightly closed . Precautionary Statements-Response . If exposed or concerned: Get medical advice/attention . Eyes: IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing if eye irritation persists: Get medical advice/ attention . Skin: IF ON SKIN (or hair): Remove/Take off immediately all contaminated clothing. Rinse skin with water/shower . Inhalation: IF INHALED: Remove victim to fresh air and keep at rest in a position comfortable for breathing . Precautionary Statements- closed . Other information: May be harmful if swallowed. May be harmful if inhaled . U.S, EPA [United States Environmental Protection Agency] Label Information: Keep Out Of Reach of Children. Warning. Precautionary statements. Hazards to humans and domestic animals . Aloe [MEDICATION(S)] Protective Ointment . 2. Hazards Identification . Emergency Overview: An off-white ointment. May irritate the eyes . Product Classification under OSHA [Occupational Safety and Health Administration] Hazard Communication rule. Hazardous . Potential Health Hazards: .Eyes: May cause irritation . Ingestion: Of low toxicity but ingestion of large quantities can be irritating or harmful . Dakins Full-sodium hypochlorite solution . For external use only . Keep out of reach of children. If swallowed, get medical help, or contact a Poison Control Center right away . [MEDICATION(S)] - [MEDICATION(S)] ointment . Warnings: For External Use Only . When using this product: Do not get in eyes . Keep out of reach of children. If swallowed, get medical help, or contact a Poison Control Center right away . [MEDICATION(S)] Wound Cleansers . Section 4. First-Aid Measures . Eye Contact: Flush eyes with large amounts of water for at least 15 minutes. Remove contact lenses, if worn. If irritation persists, seek medical attention . Skin Contact: If irritation develops wash area with water. Get medical attention if irritation persists . Inhalation: Remove victim to fresh air and keep at rest in position comfortable for breathing. Seek medical attention if discomfort continues or if you feel unwell . Ingestion: Never give anything by mouth to an unconscious person. Consult a physician if necessary . 2. The Immediate Jeopardy was removed on 10/07/2022 at 1:43 PM, and the scope/severity remains at a level K when the facility implemented the following Plan of Removal provided by the Administrator on 10/07/2022 at 1:36 PM: a.On 10/07/2022, notified by the State Surveyor that facility failed to ensure office door to the supply room should be locked at tall times when staff are not present per Administrator interview. Nursing staff on the weekend have keys to the treatment room and left the door open. Supply room closet contained Dakin's solution, Sani-wipes, [MEDICATION(S)] Ointment, [MEDICATION(S)] ointment, moisture cream, aloe [MEDICATION(S)] cream, and wound dressing supplies, and shut the door behind her. On 10/06/2022, at 08:16 pm, surveyor discovered treatment office door open with light on and no staff present. They already addressed the issues, but the interventions failed. Surveyors came in and found the same treatment room unlocked. b. On 10/07/2022, the Administrator/ Designee immediately completed a walkthrough of the facility to ensure all residents were safe of harm and ensure office door to the supply room closet that contained Dakin's solution, Sani-wipes, [MEDICATION(S)] ointment, moisture cream, aloe [MEDICATION(S)] cream, and wound dressing supplies, was closed and secured, with no negative findings. Administrator/ Designee ensured treatment office door was closed and secure with no negative findings. c. On 10/07/2022, the Administrator/ Designee immediately initiated in-service to all staff to ensure were safe of harm and ensure office door to the supply room and offices should be locked at all times when staff are not present, with no negative findings. Administrator. Designee ensured the supply room closet that contained Dakin's solution, Sani-wipes, [MEDICATION(S)] Ointment, [MEDICATION(S)] ointment, moisture cream, aloe [MEDICATION(S)] cream, and wound dressing supplies, was closed and secured, with no negative findings. Administrator/ Designee ensured treatment office door was closed and secure with no negative findings. d. On 10/07/2022, the Administrator/ Designee immediately began monitoring to ensure office door to the supply room and offices should be locked at all times when staff is not present. Administrator/ Designee immediately began monitoring the supply room closet that contained Dakin's solution, Sani-wipes, [MEDICATION(S)] Ointment, [MEDICATION(S)] ointment, moisture cream, aloe [MEDICATION(S)] cream, and wound dressing supplies, are closed and secured. Administrator/ Designee immediately began checking and documenting on check-off for three times per week for four weeks, then two times per week for four weeks, then weekly thereafter or until compliance verified by Office of Long Term Care. Any negative findings will be corrected immediately when identified and an in-service and training of staff responsible for the identified failed practice. The Administrator/ Designee will notify Interdisciplinary Team at the daily Morning QA meeting Monday-Friday of any failed practice and correct the failed practice immediately. The Administrator will notify the Medical Director at the time of the occurrence of any failed practice and the Quarterly QA Meeting to ensure on-going compliance. e. On 10/07/2022, the Administrator/ Designee will immediately monitor the wandering residents every hour daily for four weeks, or until compliance verified by Office of Long Term Care. Administrator/ Designee will immediately monitor all other residents daily every two hours daily for four weeks, or until compliance verified by Office of Long Term Care. Administrator/ Designee will immediately changed door lock/ self-closing to the treatment office and treatment closet, and monitor, for four weeks, or until compliance verified by Office of Long Term Care.

[NAME] Based on observation, record review, and interview, the facility failed to ensure portable oxygen tanks were stored properly to prevent the potential of combustion and potential resident injury for 1 (Resident #23) of 3 (Residents #19, #23, and #81) sampled residents who received oxygen via portable oxygen cylinders. This failed practice resulted in Immediate Jeopardy, which caused, or could have caused serious harm, injury or death to Resident #23 who had a portable oxygen cylinder that was not properly secured in the resident's room, and had the potential to cause more than minimal harm to 80 residents who resided in the building according to the Resident Census and Conditions of Residents form dated 1/19/20. The Administrator was informed of the Immediate Jeopardy condition on 1/19/2020 at 1:34 p.m. 1. Resident #23 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/6/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required limited physical assistance of 1 person for bed mobility, required extensive physical assistance of 1 person for transfers, dressing, toilet use and personal hygiene, was occasionally incontinent of bowel and bladder, required oxygen therapy, and received Hospice services. a. On 1/19/2020 at 12:08 p.m., a plastic crate approximately 6 to 7 feet in the air on top of the armoire in Resident #23's room contained 3 oxygen cylinders with a white seal around the oxygen post valve gauge port. The oxygen cylinders were not secured with chains and 1 oxygen cylinder with a white seal around the oxygen post valve gauge port was standing on the floor, unsecured, and not a rack with chains. The oxygen cylinder was approximately 5 feet from the foot of Resident #23's bed. b. On 1/19/2020 at 12:27 p.m., the Assistant Director of Nursing (ADON) was asked, Should oxygen tanks be on top of the armoire and in the floor of a resident's room? The ADON stated, No. They should not be. The ADON was asked, How many are on top of the armoire? The ADON stated, 3. The ADON was asked, Are they full? The ADON stated, Yes. c. On 1/19/2020 at 12:48 p.m., Licensed Practical Nurse (LPN) #8 was asked, What kind of oxygen tanks are these? LPN #8 stated, C-237. LPN #8 was asked, How do you know it's full? LPN #8 stated, The white seals are not broken. LPN #8 was asked, How are oxygen tanks supposed to be stored? LPN #8 stated, They are stored in a crate, locked up, and never in a resident's room. d. On 1/19/2020 at 12:50 p.m., the Oxygen Storage Rooms on 400 Hall and 500 Hall had oxygen tanks stored in metal crates and behind a locked door. e. On 1/19/2020 at 12:58 p.m., Licensed Practical Nurse (LPN) #9 was asked, How should oxygen tanks be stored? LPN #9 stated, Locked up and never on the ground, and in the crates. LPN #9 was asked, Should oxygen tanks be stored in residents' rooms? LPN #9 stated, No. No tanks in the resident's rooms. f. On 1/19/2020 at 1:00 p.m., the Oxygen Storage Room on the 500 Hall had oxygen tanks stored in metal crates and behind a locked door. g. On 1/19/2020 at 1:34 p.m., the Administrator was notified of the Substandard Quality of Care (SQC) / Immediate Jeopardy. The Administrator stated, We didn't know the family was bringing the oxygen tanks in. h. On 1/21/2020 at 1:38 a.m., Maintenance Employee #1 was asked, Can you tell me the measurement of the armoire height from the floor to the top of the armoire? Maintenance Employee #1 stated, 6 feet. Maintenance Employee #1 was asked, Can you tell me the measurement of the top of the armoire to the ceiling? Maintenance Employee #1 stated, 1 foot and 11 inches from the ceiling. i. On 1/22/2020 at 8:47 a.m., the Director of Nursing (DON) was asked, Should small portable oxygen tanks be stored in a resident's room [ROOM NUMBER] to 6.5 feet above the floor? The DON stated, If they are in the crate, I honestly don't know any regulations on height. I personally wouldn't store them there. The DON was asked, What could happen if the portable oxygen tanks were to fall from the armoire 6 to 6.5 feet and hit the floor? The DON stated, I'm not sure. Most likely they would combust if they hit on the valve. The DON was asked, Would this be considered a hazard? The DON stated, Absolutely. j. A facility policy titled Oxygen, Portable, Oxygen Safety provided by the Administrator on 1/22/20 documented, .Oxygen cylinders must be stored in racks with chains, sturdy portable carts and / or approved stands . k. The Immediate Jeopardy was removed, and the scope and severity reduced to [NAME] on 1/19/2020 when the facility implemented the following Plan of Removal: 1.) .The 02 (oxygen) cylinders were immediately removed from resident (Resident #23's) room and placed in a secure setting until 02 tanks were picked up from the issuing oxygen company. 02 bottles were picked up at approximately 4:00 p.m. 2.) Notified resident (Resident #23's) MD (Medical Doctor) of the deficient practice. 3.) DON (Director of Nursing) / designee immediately upon notification of the deficient practice, using a current Resident Census, went room-to-room to ensure no loose or unsecure portable 02 tanks, with no negative findings noted. All portable 02 tanks were secured, with no unsecured portable 02 found. 4.) Shift-to shift in-servicing began by DON / designee prior to any licensed employee until all current and prn (as needed / part time) staff in-serviced on proper 02 use and storage. 5.) (Name) Hospice notified immediately, and all other hospices to be notified as well, to ensure all licensed staff prior to return to (facility) must be in-serviced on portable O2 storage and proper handling when administering 02 to a resident. 6.) Hospice staff must notify DON / designee prior to bringing portable O2 canisters and they must be stored in designated 02 supply room and not left in any resident room. 7.) All designated 02 storage rooms were checked by DON / designee to ensure that all 02 bottles are stored and secured, as required, with no negative findings noted. DON / designee will monitor every residents' room every shift daily times 14 days to ensure all portable 02 cylinders are not left unattended or unsecured, then monitor times 4 days once daily, then monitor 3 times a week for 8 weeks or until compliance is achieved. Any negative findings will be corrected immediately B. Based on observation, record review, and interview, the facility also failed to ensure an extension cord only had one elctrical item plugged into it for 1 (Resident #23) of 1 sampled resident who had an extension cord in their room. The facility failed to ensure topical ointments / medications were not left at the bedside for 5 (Residents #4, and #59, #26, #80, and #11) of 5 sampled residents who had medications left unattended at the resident's bedside. These failed practices had the potential to affect 45 residents who ambulated and were mobile in wheelchairs, according to a list provided by the Nurse Consultant on 1/23/2020. The findings are: 1. On 1/19/2020 at 12:07 p.m., an extension cord, approximately 3 feet long, was in Resident #23's room. There was a fan and a telephone charger plugged into the extension cord and into an electrical outlet in the wall. A tube of partially used tube of [MEDICATION NAME] Skin Protectant Paste with 16.5% Zinc Oxide was on Resident #23's bedside table, out in the open. a. On 1/21/2020 at 10:36 a.m., Licensed Practical Nurse (LPN) #6 was asked, Are residents supposed to have extension cords in their room? LPN #6 stated, No. LPN #6 was asked, What could happen? LPN #6 stated, It could catch on fire. LPN #6 was asked, How should [MEDICATION NAME] Skin Protectant Paste with 16.5% Zinc Oxide be stored? LPN #6 stated, Not in a room, not in the open. LPN #6 was asked, What could happen if a cognitively impaired resident obtained this item? LPN #6 stated, If they drank it, or put it in their mouth, I'd have to call the CDC (Centers for Disease Control and Prevention). LPN #6 was asked, Would this be considered a hazard? LPN #6 stated, Yes, if left out, for sure. b. On 1/22/2020 at 8:47 a.m., the Director of Nursing (DON) was asked, How should [MEDICATION NAME] Skin Protectant Paste with 16.5% Zinc Oxide be stored? The DON stated, Should be stored in a cart. It should not be left out in the open. The DON was asked, What could happen if a cognitively impaired resident obtained the [MEDICATION NAME] Skin Protectant Paste with 16.5% Zinc Oxide? The DON stated, They could eat it, misuse it. The DON was asked, Would this be considered a hazard? The DON stated, Absolutely. 2. Resident #26 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), was independent for bed mobility, transfers, toileting, and required set up for meals and personal hygiene. a. The Care Plan with revised date of 11/11/19 documented, .The resident has a dx (diagnosis) of [MEDICAL CONDITION] (CAD) . Give meds (medications) to control cholesterol level as ordered by the physician . b. A physician's orders [REDACTED].Atorvastatin Calcium Tablet 40 MG (milligrams) . Give 1 tablet by mouth at bedtime related to Pure [MEDICAL CONDITION] . c. On 1/20/20 at 8:08 a.m., a bottle labeled Atorvastatin Calcium 40 mg which contained pills was on Resident #26's armoire. d. On 1/20/20 at 10:51 a.m., Resident #26 stated, They gave it to me when I went to the (Hospital Name) about 10 days ago, and they gave it to me, and I forgot to give it to them. Resident #26 stated, I haven't been taking them. They came in here and got my bottle and took it to the Nurse's Station. e. On 1/21/2020 at 10:36 a.m., Licensed Practical Nurse (LPN) #6 was asked, How are medications stored? LPN #6 stated, Locked up in the medication room and cart, behind a 2-key system. LPN #6 was asked, Should medications be left in residents' rooms and pills on the floor? LPN #6 stated, No. LPN #6 was asked, What could happen if a cognitively impaired resident obtained the pills? LPN #6 stated, I'd have to call the CDC and do a medication error report. LPN #6 was asked, Would this be considered a hazard? LPN #6 stated, Yes. f. On 1/22/2020 at 8:47 a.m., the Director of Nursing (DON) was asked, How are medications stored? The DON stated, On the locked medication cart. The DON was asked, Should medications be left in the residents' rooms and pills on the floor? The DON stated, No. The DON was asked, What could happen if a cognitively impaired resident obtained the pills? The DON stated, It could cause serious side effects and possible death. The DON was asked, Would this be considered a hazard? The DON stated, Yes. 3. Resident #59 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/19 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on 2 person physical assistance for bed mobility, transfer, dressing and toilet use, was totally dependent on one person physical assistance for personal hygiene, and was always incontinent of bowel and bladder. a. A physician's orders [REDACTED].Apply zinc ointment to buttocks / inner thighs four times a day for 5 days related to MASD (Moisture Associated Skin Disorder) four times a day for MASD for 5 Days . b. On 1/19/20 at 11:01 a.m., an opened tube of protective barrier cream with 15% zinc oxide was on Resident #59's nightstand. c. On 1/21/2020 at 10:36 a.m., Licensed Practical Nurse (LPN) #6 was asked, How should barrier ointment with Zinc Oxide be stored? LPN #6 stated, Not in a room, not in the open. LPN #6 was asked, What could happen if a cognitively impaired resident obtained the barrier cream? LPN #6 stated, If they drank it, or put in their mouth, I'd have to call the CDC. LPN #6 was asked, Would this be considered a hazard? LPN #6 stated, Yes, if left out, for sure. d. On 1/22/2020 at 8:47 a.m., the Director of Nursing (DON) was asked, How should barrier ointment with Zinc Oxide be stored? The DON stated, It should be stored in a cart. It should not be left out in the open. The DON was asked, What could happen if a cognitively impaired resident obtained the ointment? The DON stated, They could eat it, misuse it. The DON was asked, Would this be considered a hazard? The DON stated, Absolutely. 4. Resident #80 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/7/2020 documented the resident scored 12 (8-13 indicates moderate impairment) on a Brief Interview for Mental Status, required limited one-person assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. a. On 1/19/20 at 11:30 a.m., Resident #80 was sitting in a wheelchair in her room. There was a bottle of 70% alcohol, green in color, sitting on the floor between her nightstand and the bed. The resident was asked what was in the bottle and she stated, alcohol. She was asked what it was used for. She stated she rubs it on her legs and shoulders when she's in pain. The bottle with the green colored liquid was labeled 70% [MEDICATION NAME] Alcohol First Aid Antiseptic For Rubbing and Massaging and Drug Facts on the back of the bottle stated .Warnings: Flammable: Keep away from fire or flame, heat, spark, electrical . When using this product: . do not use longer than one week . b. On 1/20/20 at 10:43 a.m., the resident was in her room, sitting in her wheelchair. She was asked about the color of the alcohol that was in the bottle still located on the floor between her bed and the night stand. She stated, Sometimes it's green, sometimes it's clear. I mix some bottles together sometimes. It's not the drinking kind. c. As of 1/22/20 at 2:40 p.m., the resident's medical record contained no documentation related to the self-administration of rubbing alcohol in the physician's orders [REDACTED]. d. On 1/22/20 at 2:46 p.m., LPN #5 was asked if she was aware of the rubbing alcohol in the resident's room. She stated, No. She doesn't have an order for [REDACTED].#5 went into the resident's room and located the bottle. At 2:54 p.m., LPN #5 took the bottle to the Director of Nursing's (DON) office and showed her the bottle. The DON was asked if the rubbing alcohol was allowed in a resident's room. She stated, Not particularly, no. She could ingest it or drink it. 5. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/2020, documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on one-person physical assistance for dressing and personal hygiene, was always incontinent of bowel, and had an indwelling urinary catheter. a. The Care Plan with a revised date of 1/14/2020 documented, .The resident is at risk for impaired cognitive function as evidenced by BIMS score and Dementia diagnosis . Cue, reorient and supervise as needed . The resident needs a safe environment . b. On 1/19/20 at 11:35 a.m., there was a tube of [MEDICATION NAME] on the resident's night stand with a pair of toenail clippers. c. On 1/21/2020 at 10:36 a.m., Licensed Practical Nurse (LPN) #6 was asked, How should [MEDICATION NAME] Ointment be stored? LPN #6 stated, Not in a room, not in the open. LPN #6 was asked, What could happen if a cognitively impaired resident obtained this item? LPN #6 stated, If they drank it, or put it in their mouth, I'd have to call the CDC. LPN #6 was asked, Would this be considered a hazard? LPN #6 stated, Yes, if left out, for sure. d. On 1/22/2020 at 8:47 a.m., the Director of Nursing (DON) was asked, How should [MEDICATION NAME] Ointment be stored? The DON stated, It should be stored in a cart. It should not be left out in the open. The DON was asked, What could happen if a cognitively impaired resident obtained the [MEDICATION NAME] Ointment. The DON stated, They could eat it, misuse it. The DON was asked, Would this be considered a hazard? The DON stated, Absolutely. 6. Resident #80 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/7/2020 documented the resident scored 12 (8-13 indicates moderate impairment) on a Brief Interview for Mental Status, required limited one person assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. a. On 1/19/20 at 11:30 a.m., Resident #80 was sitting in a wheelchair in her room. There was a bottle of 70% alcohol, green in color, sitting on the floor between her nightstand and the bed. The resident was asked what was in the bottle and she stated, alcohol. She was asked what it was used for. She stated she rubs it on her legs and shoulders when she's in pain. The bottle with the green colored liquid was labeled 70% [MEDICATION NAME] Alcohol First Aid Antiseptic For Rubbing and Massaging and Drug Facts on the back of the bottle stated .Warnings: Flammable: Keep away from fire or flame, heat, spark, electrical . When using this product: . do not use longer than one week . b. On 1/20/20 at 10:43 a.m., the resident was in her room, sitting in her wheelchair. She was asked about the color of the alcohol that was in the bottle still located on the floor between her bed and the night stand. She stated, Sometimes it's green, sometimes it's clear. I mix some bottles together sometimes. It's not the drinking kind. c. As of 1/22/20 at 2:40 p.m., the resident's medical record contained no documentation related to the self-administration of rubbing alcohol in the physician's orders [REDACTED]. d. On 1/22/20 at 2:46 p.m., LPN #5 was asked if she was aware of the rubbing alcohol in the resident's room. She stated, No. She doesn't have an order for [REDACTED].#5 went into the resident's room and located the bottle. At 2:54 p.m., LPN #5 took the bottle to the Director of Nursing's (DON) office and showed her the bottle. The DON was asked if the rubbing alcohol was allowed in a resident's room. She stated, Not particularly, no. She could ingest it or drink it.

Based on observation, record review and interview, the facility failed to ensure interventions were promptly developed and implemented after a significant weight loss occurred, to prevent further weight loss for 1 (Resident #7) of 2 (Residents #7 and #20) case mix residents who had experienced weight loss. The failed practice resulted in actual harm to Resident #7, who experienced a severe weight loss that was not addressed for 3 weeks, resulting in additional weight loss. The failed practice also had the potential to cause more than minimal harm to 12 other residents who experienced weight loss during November and / or December 2015, as documented on a list provided by the Administrator on 12/31/15. The findings are: Resident #7 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 10/2/15 documented, the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, had wandering behaviors that occurred daily, required supervision for eating after set-up, weighed 161 pounds (lbs.) and had no known weight losses. a. A Dietary assessment dated [DATE] and signed by the facility's Dietary Manager (DM) documented the resident weighed 161 lbs., had her own teeth, had no swallowing problems and, .appetite . Fair 50-75%. b. The Care Plan dated 10/2/15 documented a problem, Gastric Discomfort, with an approach, Provide diet as ordered . c. The facility's Weight History sheet dated January through December, 2015, documented the resident's weights were as follows: October 2015: 158.12 lbs. November 2015: 159.12 lbs. December 2015: 148.12 lbs. Between the months of November and December 2015, the resident experienced a severe weight loss of 6.91% in a one-month period. On 12/30/15 at 11:15 a.m., the Director of Nursing (DON) was asked the specific date the resident was weighed to obtain the December 2015 monthly weight. The DON stated, (Resident #7) is not weighed weekly, but monthly, so she would be weighed on the first week of December or the last day of November (2015). d. The current Physician order [REDACTED]. e. On 12/28/15 at 10:49 a.m., 2:20 p.m. and 4:30 p.m., and 12/29/15 at 8:25 a.m., 9:00 a.m., 9:50 a.m., 10:50 a.m. and 3:30 p.m., the resident was pacing throughout the hallway on the secure unit. The resident had no finger foods or snacks present during any of the above observations. f. On 12/28/15 at 5:10 p.m., the resident was served a regular meal of a cold turkey sandwich, with a relish plate, mayonnaise, a Mandarin orange salad, 10 ounces of water and 8 ounces of coffee. The resident fed herself and consumed approximately 100% of the meal. No supplements were provided. g. On 12/29/15 at 12:15 p.m., the resident was served a tossed salad with dressing, garlic bread, 1 pat of margarine, 4 ounces of ice cream, 2 ten-ounce beverages (water and an orange drink) and a packet of sugar. The resident fed herself and consumed approximately 75% of the meal. No supplements were provided. h. As of 12/29/15 at 12:45 p.m., there was no documentation in the clinical record of a physician order [REDACTED]. i. The Dietary Progress Notes dated 12/29/15 were copied on 12/30/15 and documented the RD's initial assessment of the resident. A period of 3 months and 6 days had passed since the resident's admission to the facility, with no RD assessment. The RD's initial assessment was also not documented until a period of 3 to 4 weeks had lapsed since the severe weight loss was documented from November to December 2015. The RD's note documented, Current weight is 148.12 pounds, down 11 pounds (-6.91%) X (times) 30 days . intake is fair . Would recommend adding supercal / green napkin program (weight loss prevention program) at all meals and snacks tid (three times per day) between meals. Will follow. j. On 12/30/15 at 11:15 a.m., the DON was asked why the resident's weight loss was not addressed until 12/29/15. She stated, The Registered Dietitian came in yesterday and made new orders. The DON was asked for evidence of any interventions that were implemented by the facility after the resident's weight loss was documented. On 12/30/15 at 1:00 p.m., the DON and the facility's Nurse Consultant looked through the Dietary Communication cards. The DON stated, I don't see any (interventions) but the Dietary Manager (DM) is at (the) doctor. Can we wait until she gets back and let her look? k. On 12/30/15 at 1:00 p.m., Certified Nursing Assistant (CNA) #4 weighed the resident on a stand-up scale. The resident weighed 144.0 lbs., which was an additional weight loss of 2.78% in 3-4 weeks. l. On 12/30/15 at 1:20 p.m., the DM was asked if she was aware of the resident's weight loss between November and December 2015. She stated, (I) haven't got December weights yet . I wasn't aware of the weight loss. The DM was asked if interventions were in place to address the resident's weight loss. She stated, No ma'am, but (RD) came last night, and I have not read her notes, because I just got to work. m. The facility's policy and procedure titled, Weight loss, prevention of, provided by the Administrator on 12/31/15, documented, .Procedure .DON will be notified .Dietary manager / department will be notified .Risk factors will be assessed by the DON and interdisciplinary team and interventions determined .Weight loss will be care-planned .All patients with significant weight loss will be weighed weekly for one month and then reevaluated by the interdisciplinary team .

Complaint # was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure assessments pertaining to elopement risk were accurate and were updated as conditions changed; interventions were developed and communicated to staff; and that interventions were monitored to ensure consistent implementation and effectiveness to ensure the safety for 2 (Resident # 1 and 5) of 5 (Resident # 1 through 5) case mix residents who were assessed as being at risk for elopement. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who eloped from the facility and had the potential to affect 7 residents in the facility who were at risk for elopement as documented on a list provided by the Administrator on 8/10/12. The facility was notified of the Immediate Jeopardy condition on 8/10/12 at 3:10 p.m. The findings are: 1. Resident # 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. a. The "Elopement and Wandering Assessment" form dated 7/20/12, completed by Licensed Practical Nurse (LPN) # 4, documented, "Instructions: Complete upon admission, quarterly and at significant change for residents who ambulate independently with or without the use of an assistive device or wheelchair. If answer is "Yes" in any of the assessment columns complete summary on side 2. If "Yes" to any questions with an asterisk*, resident is automatically at risk for elopement. ...Does the resident have a history of elopement or attempts of elopement prior to admission to this facility? *Yes. ... Elopement and Wandering Assessment Summary: Resident is at risk for elopement, as evidenced by family stated that (resident) left home prior to admission ... Appropriate interventions have been initiated ... POC (Plan of Care) updated. Additional comments: (Resident) to be monitored for attempts to escape. 100 hall observation full (at) this time." On 8/10/12 at 11:12 a.m., LPN #4 was asked, "On admission do you do elopement assessments?" LPN #4 stated, "Yes." LPN #4 was asked, "If a resident is at risk what do you do?" LPN #4 stated, "Put interventions in place, the whole team decides what to do?" LPN #4 was asked, "Did you do the elopement assessment for (Resident # 1) dated 7/20/12 (the date of admission)?" LPN #4 stated, "Yes." LPN #4 was asked, "Was (Resident # 1) at risk?" LPN #4 stated, "Well he wasn't then but the family stated he had wandered off from the house. He'd left the house looking for a bridge or something. So I put it on the assessment." LPN #4 was asked, "What was his intervention?" LPN #4 stated, "Staff was to monitor him and we planned to put (Resident # 1) on the 100 hall when a room became available." LPN #4 was asked, "How do I know, as a nurse, if a resident is at risk of elopement?" LPN #4 stated, "They have an elopement risk book. I do the assessment; someone else takes pictures and puts it in the book. I put the form in the book and it's on the care plan." LPN #4 was asked, "Did you put the form in the book on the 20th to let staff know he was at risk?" LPN #4 stated, "Yes." LPN #4 was asked, "When did you put the care plan in the chart?" LPN #4 stated, "Probably two or three days later." LPN #4 was asked, "Any other way you identify (Resident # 1) was at risk for elopement for staff?" LPN #4 stated, "In elopement book and I know (Administrator) told that nurse personally." LPN #4 was asked, "Any inservices for staff on admit that (Resident #1) was at risk for elopement?" LPN # 4 stated, "I know I didn't. This (pointed to elopement assessment) was the only thing I filled out." b. The Care Plan dated 7/20/12 documented, "... 15. Elopement risk (related to) family stating that resident wandered off from home and was headed toward the bridge prior to admission ... 1. Staff to monitor and watch resident for possible signs of elopement. 2. Resident to be evaluated and moved to 100 hall, if need be, when vacancy becomes available." c. The Daily Skilled Nurse's Notes dated 7/23/12 for the evening shift and signed by LPN #3 documented, "(Resident) eloped (at) around 6:05 p.m., notified ... (resident) returned to facility (at) 12:30 a.m. by Administrator, transferred to 100 hall." 1) The DMS-7734, OLTC (Office of Long Term Care) Incident and Accident Report form dated 7/24/12 at 11:00 a.m. documented, "... At approximately 8:40 p.m. the Administrator was notified by charge nurse, (LPN #3), of the elopement of (Resident # 1). (Resident #1) was found on Allen Street by police and taken to (hospital). ... Resident did not have any injuries related to incident. Upon investigation and review of cameras discovered that (Resident # 1) was sitting in his wheel chair at the end of 200 hall at 6:20 p.m. He stood up and walked to the outside door, right at the same time two other family members entered through this door. At 6:21 p.m. (Resident #1) went out the door as they came inside. ..." 2) The "Arkansas Incident Report" form completed by (City) Police Department documented, "... On 7/23/12, at approximately 7:47 p.m.(hours), officers responded to (address) Allen (street) in reference to an elderly ... male who was wandering around in the back yard of this residence. The caller believed the male was possibly in a confused state. Upon arrival, the male was located in the front yard of the residence. The man, who eventually identified himself as (Resident # 1) believed he was in (another city) and did not know how he had arrived at his current location. (Resident # 1) was very confused and kept referring to the area by roads he believed to be in (another city). ... (Family member) advised that (Resident # 1) was supposed to be (nursing facility). (Resident # 1) was transported ... to (hospital) ER for treatment. Contact was made with (LPN # 3), on-duty LPN at (nursing facility). (LPN # 3) stated she observed (Resident # 1's) wheel chair at the end of his hallway at approximately 7:45 p.m. An active search for (Resident # 1) began at this point (1 hour and 24 minutes after resident eloped see item c. 1)) and concluded upon the arrival of officers to advise that he had been located." The driving distance per Google map is 1.1 miles from the facility to the address the resident had been located. 3) On 8/9/12 at 3:00 p.m., LPN #3 was asked, "If a resident is at risk of elopement what do you do?" LPN #3 stated, "Check every 2 hours if at risk." LPN #3 was asked, "If new admit and family say they have been leaving home, what would you do?" LPN #3 stated, "Check more often, every hour." LPN # 3 was asked, "Do you know of any resident who eloped?" LPN #3 stated, "(Resident #1) ... It was close to 8:00 p.m. when I rounded corner to start med pass on 500 (hall). I noticed there was a wheel chair at end of hallway, by 200 hall. When I noticed it, I walked down there and asked a 200 hall aide whose it was. She said it didn't look like a wheelchair for any of residents on 200 hall and I thought it looked like (Resident #1's). I immediately went in his room and he wasn't in there. When we realized he wasn't in here somebody said they noticed a man walking out the side door. He was dressed in regular clothes." LPN #3 was asked, "Somebody?" LPN #3 stated, "I think it was a visitor. I got worried and we immediately done room to room search, everybody. Then we went outside and checked the premises." LPN #3 was asked, "Side door?" LPN #3 stated, "On 200 hall there is a door with a awning, right there." LPN #3 was asked, "Had he ever tried to elope before?" LPN #3 stated, "Not that I know of - I wasn't aware when he came back the second time that he was an elopement risk." LPN #3 was asked, "You weren't aware of his attempts of elopement at home before he came?" LPN #3 stated, "No." d. On 8/8/12 at 4:45 p.m., the exit doors on the 200 hall were observed. There were 2 exit doors. One door next to room 212 which exited to an enclosed courtyard area and one door next to room 211 which exited to a sidewalk and patio area, then led into the parking lot. Both doors had key pads that required a code to exit. Two family members were observed entering from the parking lot door. There were approximately 5 residents in the vicinity of the exit doors during this time. e. On 8/10/12 staff was interviewed regarding the elopement risk assessment completed for Resident #1 on 7/20/12: 1) At 8:35 a.m., CNA #2 was asked, "Did you work with (Resident # 1)?" CNA # 2 stated, "Yes." CNA #2 was asked, "When (Resident # 1) was readmitted in July did you know he was an elopement risk?" CNA #2 stated, "No, but his behavior was different, more confused." CNA #2 was asked, "How often do you review the elopement book?" CNA #2 stated, "I didn't know we had one." 2) At 8:55 a.m., CNA #3 was asked, "Did you work with (Resident #1)?" CNA #3 stated, "Yes, he was on 500 when he came back but I didn't have him much." CNA #3 was asked, "Did you know he was an elopement risk when he came back?" CNA #3 stated, "Yes." CNA #3 was asked, "How did you know that?" CNA #3 stated, "He was always talking about wanting to go home, wanting to leave." 3) At 9:05 a.m., CNA #4 was asked, "Do you know of any resident who eloped?" CNA #4 stated, "(Resident #1), not sure of the date. I was here that night working on 400 hall." CNA #4 was asked, "Did you know (Resident #1) was an elopement risk before he eloped?" CNA # 4 stated, "No." 4) At 9:20 a.m., CNA #5, who works on the 100 hall observation/closed unit, was asked, "Do you know of any resident who eloped?" CNA #5 stated, "(Resident #1), he was on 500 hall. I was on 3:00 p.m. to 11:00 p.m. that night on 100 hall." CNA #5 was asked, "Did you know he was an elopement risk prior to him leaving?" CNA #5 stated, "No." CNA #5 was asked, "If a resident elopes what do you do?" CNA #5 stated, "Put on 100 hall, observation hall, best way to monitor (Resident # 1)." CNA #5 was asked. "Can residents go off the 100 hall?" CNA #5 stated, "Yes, they are free to come and go." 5) At 10:35 a.m., LPN #2 was asked, "Do you know of any residents who eloped?" LPN #2 stated, "(Resident # 1) and (Resident #4)." LPN #2 was asked "What was done different after (Resident # 1) eloped? " LPN # 2 stated, "On observation unit, he can come off any time he wants to ..." LPN #2 was asked, "When (Resident # 1) is off the unit how do you keep up with him?" LPN #2 stated, "Just keep eyes open and look for him." 6) At 10:55 a.m. LPN #5, the 7:00 a.m. to 3:00 p.m. charge nurse on the 500 hall, where Resident # 1 resided prior to eloping, was asked, "Did you know (Resident # 1) was an elopement risk on readmit in July?" LPN #5 stated, "No." LPN # 5 was asked, "When did you find out he was an elopement risk?" LPN #5 stated, "He was more confused on the second admit. He would get up out of his chair and say things like 'I'm ready to go home'. He did that over time. He didn't do that initially." LPN #5 was asked, "When did you find out he was an elopement risk?" LPN # 5 stated, "After he eloped ..." LPN #5 was asked, "What was done differently after he eloped?" LPN #5 stated, "Moved to observation unit on 100 hall for more observation and more monitoring." LPN #5 was asked, "Do they have to stay on 100 hall?" LPN #5 stated, "I don't think they have to stay there." LPN #5 was asked, "Does anyone from 100 hall stay with them?" LPN #5 stated, "No, we are aware they are elopement risk so we watch them." f. On 8/10/12 at 11:32 a.m., the Director of Nurses (DON) was asked, "Do you know of any residents who eloped?' The DON stated, " ... (Resident # 1) in July." The DON was asked, "What was done different after (Resident # 1) eloped?" The DON stated, "Changed the signs on the door, added picture of a stop sign to get visitors attention, send letter out to family members, moved (Resident # 1) to 100 hall, name badges for staff with list of residents at risk for elopement, and in-services." The DON was asked, "On the 100 hall (Observation unit/closed unit) are residents allowed to come off the hall?" The DON stated, "Yes, if they are on the hall they have an extra door to go through. When they are off the hall the staff knows who to watch out for." The DON was asked, "Do you have 100 hall staff members go with residents on the 100 hall who are at risk for elopement?" The DON stated, "No." The DON was asked, "How does the 100 hall prevent any risk of elopement?" The DON stated, "When you look at it that way, it really don't." The DON was asked, "What is the intervention for (Resident # 1) on the elopement risk assessment form dated 7/20/12?" The DON stated, "Move to 100 hall and monitor for attempts to elope?" The DON was asked, "If I'm a nurse how do I know the resident is at risk for elopement?" The DON stated, "When they are admitted , if they are a risk we add to the elopement book at every nurses station." The DON was asked, "Do nurses or CNAs look at that book every day?" The DON stated, "No, not every day." The DON was asked, "Were any in services done with staff on the 7/20/12 admit that (Resident # 1) was at risk for elopement?" The DON stated, "No." The DON was asked, "Should an in-service have been done?" The DON stated, "Yes, that was on me. I didn't do it and I should of." 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The Social History and Initial assessment dated [DATE], written by the Social Service Director, documented, "... Reason for Admission: Transfer from another facility. Need for Observation Hall. Describe the events that led up to admission: Resident presents (with) confusion, elopement risk. ... Social Narrative: ... Her (family member) states that her (resident) boyfriend notified her that he could no longer manage (Resident #5). (Family member) stated ...tried to manage ... (Resident #5) (at) home, yet due to elopement and constant need for supervision was unable. (Resident #5) was placed in a Nursing facility, they didn't have observation hall ..." b. The Social Services Progress Notes dated 6/13/12 documented, "Admission: ... Admit due to need for observation hall. She is an elopement risk, very confused..." c. The Nurse's Notes dated 6/14/12 at 10:35 a.m. documented, "(Resident) wandering up and down 100 hall (observation/closed unit) ..." d. The Nurse's Notes dated 6/14/12 at 7:00 p.m. documented, "(Resident) (up) wandering in hallways ...is constantly attempting to leave off the hall way, standing at exits. ..." e. The Social Services Progress Notes dated 6/15/12 (no time) documented, "Resident very anxious today, she came to front hall way (not on the 100 hall), looking for son and wanting to go home. Staff redirected behaviors after several minutes, agreed to return back to room. ...Resident then came to main dining room area (not on 100 hall) with a few possessions in hand ..." f. The Nurse's Notes dated 6/15/12 at 2:02 p.m. documented, "(Resident was able to get off unit (observation/100 hall) multiple times this shift. Became very agitated and aggressive (with) staff when they attempted to assist (resident) back to hall ...Shortly after (Administrator) was able to assist (resident) back to room. After (approximately) 10 (minutes) (resident) found way off of unit again went to main dining room ..." g. The Nurse's Notes dated 6/20/12 at 1:10 p.m. documented, "...agitation and anxiety, (Resident) has packed belongings twice this shift and made numerous attempts to get off unit ..." h. The "Elopement and Wandering Assessment" form dated 6/26/12, completed by LPN #6, documented, "Instructions: Complete upon admission, quarterly and at significant change for residents who ambulate independently with or without the use of an assistive device or wheelchair. If answer is "Yes" in any of the assessment columns complete summary on side 2. If "Yes" to any questions with an asterisk*, resident is automatically at risk for elopement. ...*Does the resident have a history of elopement or attempts of elopement prior to admission to this facility? No. *Does the resident have a history of attempts of leaving the facility without informing staff? No. *Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near exit doors? No. Does the resident wander? No. ... Elopement and Wandering Assessment Summary: Resident is not at risk for elopement at this time. ..." On 8/10/12 at 12:06 p.m., LPN #6 was asked, "When was (Resident #5) admitted ?" LPN #6 stated, "6/13/12." LPN #6 was asked, "When was the elopement assessment done?" LPN #6 stated, "6/26/12." LPN #6 was asked to review the Nurse's Notes from 6/14/12 through 6/20/12 and the social notes. After LPN #6 reviewed the documentation, LPN #6 was asked, "Is (Resident #5) at risk for elopement?" LPN #6 stated, "Yes." LPN #6 was asked, "Did you look at the nursing and social notes or just talk with staff?" LPN #6 stated, "Talked with staff." LPN #6 was asked, "Is her elopement assessment accurate?" LPN #6 stated, "No." i. The Care Plan dated 6/26/12 did not identify the resident was an elopement risk. j. The Nurse's Notes dated 7/4/12 at 3:00 p.m. documented, "(Resident) wanted to go outside (with) staff, and attempted to get out of gate. Took staff (times) 3 to assist (resident) back into building." k. On 8/8/12 at 3:32 p.m., during initial rounds on the observation/closed/100 hall, Licensed Practical Nurse (LPN) #1 stated, "Resident is alert and confused, has behaviors - wanders, is an elopement risk ... beating on doors, trying to get out ..." l. On 8/8/12 at 5:10 p.m., the "Elopement Book - Station 1" for the 100, 200 and 300 halls, was reviewed. Resident #5 was not included as a resident who was at risk of elopement. m. On 8/9/12 at 9:40 a.m., Resident #5 was off the observation unit and was in the beauty shop having her hair done. n. On 8/9/12 at 11:30 a.m., Resident #5 was self-propelling on the 300 hall. Resident #5 asked this surveyor, "Where is the library?" There was no staff member with Resident #5. LPN #2 was called by this surveyor to assist resident. LPN #2 asked Resident #5, "What are you looking for?" Resident #5 stated, "Lunch." LPN #2 returned Resident #5 to the observation unit. Resident #5 had no name tag on to indicate that she was an elopement risk. o. On 8/9/12 at 12:48 p.m., Beauty Shop Operator #1 was asked, "Which residents are at risk for elopement?" Beauty Shop Operator #1 stated, "Oh you mean like leave the building. All of the residents on the 100 hall, (Resident #4) ... (Resident #5). I get them in here and get them done right away, not waiting, and when I get done I take them back to 100 hall or have an aide take them back." Beauty Shop Operator #1 was asked, "What did you do with (Resident #5) this a.m. when you finished her hair?" Beauty Shop Operator #1 stated, "(Certified Nurse's Assistant #1) came and got her to work (with) her on walking." p. On 8/10/12 at 8:32 a.m., Resident #5 was observed self-propelling down the 300 hall after the Director of Nurses (DON) propelled Resident #5 off the observation unit. The DON stopped at the nursing station then went toward the main dining room toward the front of the building. q. On 8/10/12 at 8:35 p.m., CNA #2 was asked, "How do you know which resident is at risk for elopement?" CNA #2 stated, "We have it on our name tag." CNA #2 showed this surveyor the back of the name tag. Resident # 5 was not listed as at risk for elopement. CNA #2 was asked, "Which residents do you have concerns with wandering, possible elopement?" CNA #2 stated, "Same residents." Indicating the resident that were identified on the back of her name tag. r. On 8/10/12 at 10:35 a.m., LPN #2, the charge nurse for the 100 hall, was asked "Which residents do you have concerns with wandering, possible elopement?" LPN #2 named 6 residents but did not name Resident #5. LPN #2 was asked, "Does (Resident #5) have behavior problems?" LPN #2 stated, "She didn't want to be here, beats on the door and wants to go with her family." LPN #2 was asked, "Do you consider her an elopement risk?" LPN #2 stated, "At times yes." s. On 8/10/12 at 11:32 a.m., the DON was asked to review the elopement assessment. The DON was asked, "Was the elopement assessment done on 6/26/12?" The DON stated, "Yes." The DON was asked, "Was (Resident #5) at risk per the assessment?" The DON stated, "No." The DON was asked to review the nurse's notes from 6/14/12 through 6/20/12. After the DON reviewed them, the DON was asked, "Is (Resident #5) at risk of elopement?" The DON stated, "Yes." The DON was asked, "Is (Resident #5) in the elopement risk book?" The DON stated, "No." The DON was asked, "Did you know about these behaviors?" The DON stated, "I knew she had wandered but not that she had packed her stuff?" The DON was asked, "Could (Resident #5) leave the building?" The DON stated, "Yes." The DON was asked, "If a staff member identifies behaviors that indicate an elopement risk, what are they supposed to do?' The DON stated, "Let me know." 3. Resident #4 had a [DIAGNOSES REDACTED]. a. The Plan of Care dated 10/10/11 documented, "...29. Elopement Risk...1. Monitor for patterns of elopement attempts...2. Monitor frequently for whereabouts...5. Place in elopement risk book..." On the back of a Plan of Care dated 10/22/09, handwritten documentation dated 3/16/12 documented, "3/16/12 Two visitors let (resident) out door...Posted signs on all exits to not let any (resident) out (without) staff." b. An Incident/Accident Report dated 3/16/12 documented, "...(resident) was found outside of facility by another resident family member...Steps to prevent Reoccurence: Posted sign on doors for visitors to not allow residents out the door (with) out a staff member present..." c. An Elopement and Wandering Assessment form dated 7/5/12 documented, "...If "Yes" to any questions with an asterick, resident is automatically at risk for elopement...Does the resident have a history of attempts of leaving the facility without informing staff?..." *Yes is checked for this resident. The other side of the form documented, "...Resident is at risk for elopement, as evidenced by Hx (history)...Additional comments: Observation unit..." 4. On 8/10/12 staff were interviewed regarding resident elopement and the 100 hall observation unit: a. At 9:35 a.m., CNA #6 was asked, "If a resident elopes what do you do?" CNA #6 stated, "Put them on observation unit." CNA #6 was asked, "Observation unit, do they have to stay on the unit?" CNA #6 stated, "It's like with (Resident # 4). No, she's always out and she roams the halls. We just know to keep an eye on her." b. At 9:45 a.m. ,CNA #7 was asked, "Have you worked on the 100 hall/observation unit?" CNA #7 stated, "Yes." CNA #7 was asked, "Do residents have to stay on that hall?" CNA #7 stated, "No." c. At 10:07 a.m., CNA #8 was asked, "On the 100 hall, do residents have to stay on the unit?' CNA #8 stated, "No, they can come out and roam around." CNA #8 was asked, "How do you know if (Resident #4) is off the 100 hall?' CNA #8 stated, "We see her." CNA #8 was asked, "Any other way you know she's out so you can keep an eye on her?" CNA #8 stated, "No." CNA #8 was asked, "Why is she back there, on the 100 hall?' CNA #8 stated, "She's at risk for elopement." d. At 10:25 a.m., CNA #9 was asked, "Do residents have to stay on the 100 hall/Observation unit?" CNA #9 stated, "No." CNA #9 was asked, "Can (Resident #1) come off if he wants to?" CNA #9 stated, "Yes, as long as we know where he's at." CNA #9 was asked, "Can (Resident #4) leave the hall?" CNA # 9 stated, "Yes, she comes in and out all the time." CNA #9 was asked, "Does anyone stay with them when they are off the hall?" CNA # 9 stated, "No, everyone just watches them." e. At 10:35 a.m., LPN #2 was asked, "Do you know of any residents who eloped?" LPN #2 stated, "(Resident #1) and (Resident #4). (Resident # 4) she got out the door, front door, a family member let her out." LPN #2 was asked, "Does (Resident #4) have to stay on the observation unit?" LPN #2 stated, "No." LPN #2 was asked, "When she's off the unit what happens?" LPN #2 stated, "She just sits in the chair and rolls around. I keep up with her and they all know to keep an eye on her. We don't have anyone stay on the observation unit." 5. On 8/10/12 at 1:45 p.m., the Administrator was asked, "Which residents do you have concerns with wandering/possible elopement?" The Administrator stated, "(Resident #5) thanks to you all, (Resident #3), (Resident #4), ... (Resident #1) and (Resident #2)". The Administrator was asked, "If a resident is at risk of elopement what do you do?" The Administrator stated, "Put it in the elopement risk assessment book, in-service staff and add resident to staff name tags." The Administrator was asked, "Do you know of any residents who eloped?" The Administrator stated, "(Resident #4) on 3/16/12, a family member held the front door opened for her. She was in the wheelchair and only got to the driveway." The Administrator was asked, "What did the facility do?" The Administrator stated, "Posted signs on doors, all doors, asking them not to let residents out of the building. In-serviced staff about (Resident #4) and did every 15 minute checks for 72 hours." The Administrator was asked, "Anyone else?" The Administrator stated, "(Resident #1), on 7/23/12, eloped out the 200 hall door. A family member opened the door and (Resident #1) timed it perfect. He just went out and the door did not close." The Administrator was asked, "What did the facility do?" The Administrator stated, "Sent a letter out to all family members telling them to let the door close completely before walking away. Inserviced staff on elopement policy and procedure. Made name tags for staff with a list of residents at risk for elopement. Changed the door signs, asking family not to let residents out. We did this wrong too - put identifiers on all resident's MARs (Medication Administration Records), TARs (Treatment Administration Records), and ADLs (Activities of Daily Living) for residents at risk of elopement, not a listing of residents at risk. Moved (Resident #1) to 100 hall and did every 15 minute checks." The Administrator was asked, "How long did you do every 15 minute checks?" The Administrator stated, "Seventy two hours." The Administrator was asked, "Did you know (Resident # 1) was at risk for elopement on the 7/20/12 admit?" The Administrator stated, "His (Family Member #1) brought him in and he was mad at her. He signed himself in ... I walked him down to the nurses ' station and showed him to his room. The (Family Member #1) stated she had to pick him up because he got out of (Family Member # 2's) house. (Family Member #2) had her doors locked while she showered and he got out. The police and (Family Member #1) had to get (Resident #1) in the car. I took (Resident #1) to the back nurses' station and showed him his room." The Administrator was asked, "Did (Resident #1) have any trouble walking?" The Administrator stated, "No. I went to the nurses ' station and reported to (LPN #7) what had happened but I didn't do any inservices with staff. I told them, You all, we need to watch him, but I didn't do any in services with them." The Administrator was asked, "Is the 100 hall a closed unit?" The Administrator stated, "I don't want residents to be closed in, so if they want off they can come off." The Administrator was asked, "What do you do to monitor residents at risk of elopement when they leave the 100 hall, does staff go with them?" The Administrator stated, "No." The Administrator was asked, "How does the 100 hall observation unit prevent elopement?" The Administrator stated, "There's another door to go through. I don't know but I feel that staff would go with them if they were exit seeking." 6. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 8/10/12 at 5:10 p.m. when the facility implemented the following Plan of Removal: a. As of 8/10/12 at 3:15 p.m., 7 residents had been identified as at risk for elopement. Beginning on 8/10/12 at 3:20 p.m. MDS Coordinators will reassess every resident in the building for risk of elopement to be completed by end of day on 8/13/12. They will be reassessed by completing the Elopement Assessment form. If any residents other than those on the current list are identified, staff will be in serviced immediately. b. All nursing staff (will be) in serviced at beginning of shift, beginning on 8/10/12 at 3:20 p.m. and will be ongoing, to include new hires and staff returning from leave. Training will take place before staff work on the floor. Training will be done by DON/designee and in-service sign in sheets used. Training will include: 1) Staff monitoring residents at risk for elopement (every) hour for where abouts in facility and to document on monitoring form. The monitoring forms will be submitted to the DON/designee daily for review. All staff will redirect residents at risk for elopement away from exit door area as needed. 2) Staff to recognize the "eye ball symbol" that is placed on the door frame of residents at risk for elopement. 3) Staff to report to their charge nurse of any resident that packs their belonging and/or verbalizes that they are leaving, or if the family member reports history of elopement for a new admission. When and if a resident exhibits these behaviors staff will monitor the resident every 15 minutes for 72 hours. Then resume one hour monitoring. 4) Charge nurse to immediately report to DON and (Administrator), and for charge nurse to start an inservice to all staff letting them know of the resident at risk, fill out an elopement assessment form and the pertinent information sheet and place it in the Elopement Book at both nurses stations, and to place an "eye ball symbol" on the residents door. c. At each QA Monday - Friday morning meeting the IDT team will go over any reports of or suspicion of any resident that may have been identified as a new elopement risk or any previously identified resident that attempted elopement and the DON/designee will immediately follow up to be sure the above steps have been taken and the causative factors have been identified and that if new interventions are needed it has been implemented. d. Other steps to prevent another failed practice include: a. Put all employee name tags on white paper with list of residents at risk of elopement on the back, to be updated with any changes Monday - Friday by human resources. If new residents are identified on weekends an in-service will be done with all staff at the beginning of each shift. b. Placing the letter sent to families regarding safety measures to take when visiting the facility in the admission packet immediately. c. Placing names of all elopement risk residents in front of the MAR, TAR, and ADL books to be updated as needed daily by DON/designee. d. Posting a list of all elopement risk residents in both med rooms to be updated as needed daily by DON/designee. e. Adding elopement risk resident to a new program called the "Icare" team. This involves giving the resident additional exercise by the restorative team. f. Facility to look into the possibility of obtaining a "Wander guard" system for the building.