Every finding on record at Southridge Village Nursing and Rehab

Number of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to ensure the provider documented a rationale for the continuation of psychotropic medications on the Medication Regimen Review (MRR) form for three (Residents #2, Resident #7, and Resident #52) of five residents reviewed for unnecessary medications. The findings include: Resident #2 Review of an Order Summary Report revealed Resident #2 had diagnoses which included depression and anxiety and had an order for psychotropic medication which indicated to give the medication by mouth every six hours as needed for anxiety. Review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/2025 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) Score of 9, which indicated the resident had moderate cognitive impairment. The MDS also revealed Resident #2 required partial to moderate assistance with toileting and personal hygiene, and to shower/bathe self. The MDS also indicated Resident #2 had an active diagnosis of anxiety disorder. Review of a Care Plan, with a review date of 02/13/2026, revealed Resident #2 used an anti-anxiety medication with interventions to administer the medication as ordered by the physician and monitor the resident for adverse reactions such as drowsiness, slurred speech, impaired thinking and judgement. Review of the Progress Notes from 11/16/2025 to 12/20/2025, has no rationales documented for the continued use of the prescribed antidepressant medication. Review of a Pharmacy MRR-Antidepressant form, with an effective date of 12/05/2025, revealed the Consultant Pharmacist notes indicated the resident has recent documented falls. The provider chose to continue the dose of the medication, and the rationale was blank. The provider electronically signed (e-signed) the document on 12/11/2025. The Director of Nursing (DON)/Designated RN (Registered Nurse) section indicated continue POC (plan of care). Given as needed for seizure. The DON e-signed the form on 12/11/2025. Resident #7 Review of an admission Record indicated the facility admitted Resident #7 on 01/28/2024 with diagnoses which included dementia, Alzheimer's disease (disorder affecting memory, thinking, language and behavior) and anxiety. Review of an Order Summary Report revealed Resident #7 had an order for an antipsychotic medication to be administered in the morning and in the evening. Review of a quarterly MDS with an ARD of 01/26/2026, revealed Resident #7 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #7 required supervision or touching assistance with personal hygiene, and tub/shower transfer; partial to moderate assistance with shower/bathing self and that Resident #7 was taking a high-risk drug classed as an antipsychotic. Review of a Care Plan, with a review date of 02/13/2026, revealed Resident #7 used a psychotropic medication and had an intervention to monitor/document/report as needed for adverse reactions such as unsteady gait, frequent falls and behavior symptoms not usual to the person, and there was a black box warning for the psychotropic medication and to see MAR [Medication Administration Record]. Review of Resident #7's Progress Notes for 01/20/2026 to 02/18/2026 did not include any rationales from the provider for the continuation of the antipsychotic medication. Review of a Pharmacy MRR-Antipsychotic form, with an effective date of 02/06/2026 for Resident #7, revealed the antipsychotic recommendation was for a gradual dose reduction (GDR) of the medication. The consultant pharmacist notes were blank. The provider chose to continue the medication with no changes and did not document a rationale. The DON chose the response provider response received and accepted. The DON e-signed the form on 02/06/2026. Resident #52 Review of an admission Record indicated the facility admitted Resident #52 on 07/02/2024 with diagnoses which included dementia (disorder affecting memory, thinking, language and behavior), anxiety and depression. Review of an Order Summary Report revealed Resident #52 had an order for psychotropic medication to be given at bedtime related to depression. Review of a quarterly MDS with an ARD of 01/13/2026 revealed Resident #52 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated Resident #52 had severe cognitive impairment, never/rarely made decisions of daily living, was dependent on staff for eating, toileting personal hygiene and to shower/bathe self. The MDS also indicated Resident #52 was taking a high-risk drug classed as an antidepressant. Review of a Care Plan, with a review date of 01/14/2026, revealed Resident #52 used an antidepressant medication with interventions that included to monitor, document and report as needed for adverse reactions such as a change in behavior, mood, cognition or gait changes. Review of a Pharmacy MRR- Antidepressant form for Resident #52, with an effective date of 06/05/2025, revealed the antidepressant recommendation was for a taper/GDR of the psychotropic medication. The Consultant Pharmacist notes were blank. The provider chose to continue the medication with no changes and documented the resident was stable on the current dose but did not document any evidence or specific behaviors. The DON chose the option of 'MD response received and accepted' and e-signed the form on 06/08/2025. Review of Progress Notes for 05/01/2025 to 07/01/2025 for Resident #52 did not reveal any provider documentation to indicate a rationale for continuing the psychotropic medication. During an interview with the DON on 02/20/2026 at 5:03 PM, she stated she was typically on the receiving end of the MRR or the Assistant Director of Nursing (ADON) when asked who follows up with the provider if there was no rationale on the MRR. She stated she reviewed the MRR after the provider completed his/her sections on the form. She stated she was fairly new and still learning the gradual dose information but was familiar with the Centers for Medicare and Medicaid Services (CMS) guidelines for GDR. In an earlier conversation in the conference room on 02/20/2026, the DON stated she had just spoken with the provider on the telephone about the concern of not documenting a rationale for continuing psychotropic medications, and the provider was new and did not know he was supposed to document a rationale for continuing psychotropic medications. The DON stated during this interview at 5:03 PM, the provider had started January of this year (2026). Review of a facility policy titled Medication Regimen Review revised date of April 2007, indicated the purpose of the MRR is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. This policy also revealed the consultant pharmacist will provide a written, signed and dated copy of the report with the irregularities found and recommendations for their solution to the DON and medical doctor for each resident.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, facility policy review, it was determined that the facility failed to ensure personal items were not stored in Personal Protective Equipment (PPE) container to prevent contamination of clean PPE for one of four PPE storage cabinets; failed to ensure the door to a biohazard room was secured to prevent access by residents or visitors; failed to ensure staff performed hand hygiene when entering and exiting resident rooms during clean laundry delivery to prevent cross contamination from resident to resident on one of one hall observed during laundry delivery; and failed to ensure staff performed hand hygiene and glove changes during medication administration via a central line to prevent the potential introduction of infection for one (Resident #37) of one resident reviewed for central line medication administration. The findings include: Incident #1 During an observation on 02/17/2026 at 11:35 AM, on 200-Hall, enhanced barrier precautions (EBP) signage was located outside rooms [ROOM NUMBER]. A plastic 3-drawer cabinet, on wheels, containing PPE was located to the right of room [ROOM NUMBER]. The top drawer of the cabinet contained a hairbrush, personal care wipes, an empty glove box, masks, and mask/face shield combo. During a concurrent observation and interview on 02/17/2026 at 11:40 AM, Medical Records (Med Rec) #2, opened the top drawer of the EBP cabinet, removed the empty glove box. Med Rec #2 identified the open container of wipes as partially used pack of personal care wipes, not disinfectant wipes, and stated the wipes and hairbrush should not be in drawer, because the drawers were clean areas and the brush and wipes were not clean due to use. Med Rec #2 removed the wipes and brush from the drawer. Med Rec #2 stated, PPE cabinets were not at each door as PPE was located so it was accessible for anyone that may need it. Review of a facility policy titled, Enhanced Barrier Precautions, dated August 2022, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. The policy further indicated, Signs are posted in the door or wall outside the resident room indicting the type of precautions and PPE required. PPE is available close to or inside of the resident room. Incident #2 During an observation on 02/17/2026 at 11:44 AM, a sign indicated Dirty Utility was hanging next to a door, with a push button keypad lock, labeled Biohazard. The Door was not secured and opened when pulled. The Dirty Utility Room contained two gray barrels on wheels, labeled as soiled linens: one yellow barrel on wheels, and one red barrel on wheels. During an interview on 02/17/2026 at 11:49 AM, Certified Nursing Assistant (CNA) #3 was asked if the door marked BIOHAZARD was secured. CNA #3 pushed the door and heard a click and stated, No it must not have shut all the way. CNA #3 stated the door was secured, to keep residents out, due to trash, chemicals and dirty bedding. CNA #3 indicated the yellow barrel was used for trash and confirmed a bag of trash was in the barrel. The gray barrel was used for soiled bedding and had recently been picked up. The red barrel was a biohazard barrel and was currently empty. During an interview on 02/17/2026 at 11:52 AM, Environmental Supervisor stated, the biohazard room should not be open due to the chemicals and other hazards, and residents could get hurt [if they entered]. Incident #3 During an observation on 02/17/2026 at 2:03 PM, Environmental (Enviro) #4 was delivering clean laundry on 400-hall. Clothing was not covered to prevent contamination. The cart contained clothes hanging on hangers and folded laundry in an attached open metal basket below the hanging clothing. Enviro #4 entered and exited Rooms 407, 408, 409, 410, 411, 413, 415, 416, 417 and 418 without performing hand hygiene. Enviro #4 did not perform hand hygiene when entering or exiting room [ROOM NUMBER]which had an EBP sign on the name plate This surveyor also observed Enviro #4 hang dirty hangers on the metal basket with clean laundry upon exiting each room and draped clean blankets over their arm to deliver into rooms without a barrier. During an interview on 02/17/2026 at 2:11 PM, Enviro #4 stated, the cover for the clean laundry cart should have been utilized to prevent contamination of clean laundry and I should have performed hand hygiene when going from room to room to prevent cross contamination. Enviro #4 stated they did not know why the resident in room [ROOM NUMBER] was on EBP. Enviro #4 stated training was provided on how to deliver laundry. During an interview on 02/18/2026 at 12:14 PM, the Assistant Director of Nursing (ADON) stated Environmental Services was responsible for training their employees on infection control. During an interview on 02/20/2026 at 9:05 AM, Enviro #9 stated the process for delivering clean was as follows: clean laundry cart was loaded, the cover was put over the clean laundry, (Enviro #9 used an empty clean laundry cart to demonstrate placing the cover over clean laundry) and the cart would be taken to the hall for delivery. Upon arrival at the hall, cover pulled back, hands sanitized, clean laundry removed, cover pulled back over clothes, laundry taken into residents' room and put away (in drawer or closet), dirty hangers picked up and hung on outside of basket at the bottom of the cart. Hands would be sanitized, cover lifted, clean laundry removed and delivered to the next resident. Enviro #9 stated placing dirty hangers on the outside of the basket was not a concern if the hangers did not touch clean laundry but that it may be possible for hangers to touch laundry in basket. During an interview on 02/20/2026 at 9:19 AM, Environmental Supervisor stated Enviro #4 had worked in three positions at the facility and when moved to laundry Enviro #4 received three days of training on how to handle clean laundry during orientation. Staff were trained on the shift they were hired for. Environmental Supervisor stated she did infection control training by verbal, demonstration and had Enviro #4 do return demonstration to allow for concerns to be corrected. Environmental Supervisor could not remember if correction of Enviro #4 was required. Environmental Supervisor stated cart covers were used to prevent cross contamination and could cause residents to become sick if laundry became contaminated. Due to concern with dirty hangers being hung on cart with clean laundry, Environmental Supervisor stated, late night shift was going to pick up all hangers and sanitize them. Review of a personnel file indicated Enviro #4 was employed in Housekeeping, Environmental, and Dietary departments. Review of a facility document titled, Code of Conduct, dated as signed by Enviro #4 on 05/09/2025, advised All personnel shall follow safe work practices and comply with all applicable safety standards and health regulations. Review of a facility document titled, General Orientation Checklist, 05/09/2025, revealed Enviro #4 received education in Housekeeping/Laundry, on linen cleaning, and disposal cart care, safety, and cart storage by Environmental Supervisor. Education overview of the nursing department included Infection control procedures/protocol (handwashing etc.) was done by the ADON. Review of a facility document titled, Hand Hygiene Competency, dated 05/09/2025, indicated Enviro #4 was competent in handwashing with soap and water and hand hygiene with alcohol-based gel. Review of a facility document titled, Job Description Housekeeper/Floor Technician, dated as signed by Enviro #4 on 05/09/2025, outlined duties and responsibilities, Safety and Sanitation Functions as following facility policies and procedures that included infection control and hand sanitation. No other job descriptions were contained in the employee file. Review of a facility policy titled, Handwashing/Hand Hygiene, revised on October 2023, indicated This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to promote hand hygiene included training of personnel on the importance of hand hygiene to prevent spread of infections and All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for hand hygiene included after touching a resident's environment. A policy and procedure for clean laundry handling were requested, the facility provided policies and procedures titled Laundry and Bedding, Soiled and Departmental (Environmental Services) – Laundry and Linen, and stated no other policy was available. The policies provided did not directly address transport of clean clothing, handling of clean laundered clothing, or dirty hangers. Review of a facility policy titled, Departmental (Environmental Services) – Laundry and Linen, revised January 2014, indicated to cover linen carts to keep linen hygienically clean and free of pathogens, to protect it from environmental contamination. Review of a facility policy titled, Laundry and Bedding, Soiled, revised September 2022, indicated, Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. Incident #4 Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2026, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact, and received antibiotics by Intravenous (IV) access. Review of an admission Record indicated the facility admitted Resident #37 with diagnoses that included osteomyelitis (bone infection); chronic osteomyelitis with draining sinus right humerus (arm); muscle wasting and atrophy; difficulty walking; infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts; chronic atrial fibrillation (irregular heartbeat); difficulty swallowing; and diabetes mellitus type 2. Review of an Order Summary Report revealed active orders dated 02/20/2026, which included Peripherally Inserted Central Catheter (PICC) line tubing changes; PICC line dressing changes; flush orders; and [name brand antibiotic] orders. Review of a Medication Administration Record (MAR) dated 02/01/2026-02/28/2026, revealed IV tubing was scheduled to be changed every four days, and documented as changed on 02/18/2026; dressing was scheduled to be changed weekly on Thursdays, and last documented change prior to 02/18/2026 was 02/12/2026; and [name brand antibiotic] was scheduled to be received three times daily, and last administration was documented as 09:00 AM on 02/18/2026. Review of a Care Plan Report, revised on 01/16/2026, indicated Resident #37 had an Activities of Daily Living self-care performance deficit related to a left femur (leg) fracture and limited mobility; altered cardiovascular status related to chronic atrial fibrillation; and potential nutritional problem related to osteomyelitis. Review of a Nsg [Nursing] Admit/Readmit Assessment and Care Plan, with an effective date of 01/15/2026, indicated Resident #37 had a PICC line in the left antecubital (inner elbow area.) Review of a Nsg Every Shift Skilled Charting, with an effective date of 02/17/2026, indicated Resident #37 had a PICC line and was receiving antibiotic medications. During an observation on 02/18/2026 at 1:33 PM, Resident #37 was observed self-propelling their wheel chair and exiting the restroom. Licensed Practical Nurse (LPN) #1 entered Resident #37's room spoke with resident about medication to be administered. Medicare Manager (MC Manager) came to the doorway of resident's room with a yellow gown and gloves, LPN #1 placed a 100 ml Normal Saline (NS) fluid bag and a vial of un-constituted powdered [name brand antibiotic] with attached adapter on the overbed table, did not clean of the table prior to setting down supplies, and stepped out of the room. Resident #37 was sitting in wheelchair on the right side of the lower end of the bed. LPN #1 re-entered Resident #37's room, with the yellow gown and gloves provided by MC Manager and did not perform hand hygiene. LPN #1 donned the yellow gown and right-hand glove, dropped second glove on floor, donned a clean glove on left hand and with right gloved hand picked up dirty glove from floor and placed the dirty glove on overbed table next to the NS bag. LPN #1 then walked to the left side of the bed, placed gloved left hand on IV pole and moved pole supporting IV pump to end of bed near resident. No hand hygiene or glove change was performed. LPN #1 removed the cover of connected vial adapter attached to antibiotic vial and cap from the 100 ml NS bag and spiked the bag, squeezed fluid bag injecting NS into powdered [name brand antibiotic] vial and vigorously shook vial until fluid and powder were incorporated. LPN #1 removed the empty IV bag setup, used in previous medication administration, hanging on IV pole, from the IV tubing dated 02/18/2026. LPN #1 stated the IV tubing was hung with morning dose of medication. LPN #1 removed spike access port protective cover, from the medication bag, and inserted spike end of IV tubing, squeezed the drip chamber to fill with fluid, and hung the bag on the IV pole. LPN #1 reached into their scrub pocket with right gloved hand, removed alcohol prep pad, removed the disinfection cap from single lumen PICC line, located in left arm, opened alcohol pad package, scrubbed PICC needleless connector for 30 seconds, attached 10 milliliter (ml) syringe of normal saline, released clamp, received blood return, and flushed with 10 ml of normal saline. LPN #1 then removed the end cap from IV tubing, attached the tubing to the PICC line , and started the IV pump - set at 200 milliliters per hour (ml/hr), volume to be infused set at 100 ml to run over 30 minutes. IV Pump did not immediately start, LPN #1 pressed prime line, PRIME appeared on pump and infusion started. No air was visible in the IV line. LPN #1 gathered used supplies, removed gown and gloves, disposed of items and performed hand hygiene. During an interview on 02/18/2026 at 1:48 PM, LPN #1 stated IV tubing was changed every four days and new tubing was hung when LPN #1 administered morning dose of medication. LPN #1 stated gown and gloves were used when accessing a single lumen PICC to prevent outside pathogens from entering the system and causing infection that could affect the resident's heart. LPN #1 stated she performed hand hygiene prior to entering the resident's room using hand sanitizer on the wall. LPN #1 stated the table should have been cleaned prior to the medications and supplies being placed on the table, the glove dropped on the floor should not have been picked up and placed on the overbed table near the medication, gloves should have been changed and hands sanitized after picking up the glove from the floor, and touching the IV pole, before cleaning the lumen and accessing the PICC. LPN #1 stated the break in infection control procedures could have caused cross contamination and the resident to develop an infection. During an observation and concurrent interview on 02/18/2026 at 2:15 PM, LPN #1 sanitized hands, stopped the IV pump, clamped the PICC line, disconnected the IV tubing and cleaned the lumen with alcohol prep pad for 30 sec, attached 10 ml syringe of NS flush, opened clamp, flushed with 9.5 ml NS, removed NS syringe, removed [anticoagulant] syringe from package, expressed air, attached syringe and flushed PICC with [anticoagulant] and engaged clamp. LPN #1 stated 10 ml of NS was used to flush the PICC line followed by 5 ml of [anticoagulant]. LPN #1 removed an orange cap from a sealed package and placed it on the PICC access port, disposed of supplies, removed gown, gloves, and performed hand hygiene. Review of a facility document titled, Job Description, unsigned by LPN #1, with a date of hire 09/16/2025, outlined the purpose of the job position, The primary purpose of your job position is to provide direct nursing care to the patient and to ensure that the highest degree of quality care is maintained at all times. Drug administration functions indicated Prepare and administer medications as ordered. Personnel functions indicated to ensure all departmental policies and procedures are followed at all times. Safety and sanitation functions indicated to monitor for adherence to all safety and infection control policies and procedures. Specific requirements indicated must not pose a direct threat to the health or safety of other individuals in the workplace. Review of a document titled, Code of Conduct 2025, signed by LPN #1 on 09/16/2025, instructed All personnel shall follow safe work practices and comply with all applicable safety standards and health regulations. Review of a facility document titled, Arkansas Patient Rights, signed by LPN #1 and dated 09/16/2025, indicated The right to receive adequate and appropriate health care. with established and recognized practice standards. Review of a facility document titled, General Orientation Checklist, dated 09/16/2025, indicated LPN #1 received overview of responsibilities and duties related to blood borne pathogens and infection control procedures/protocol (handwashing). Review of a facility document titled, Infection Prevention and Control Program, signed by LPN #1 on 09/16/2025, indicated Prevention – use standard precautions for every resident, sanitize hands often, use gloves, and hand hygiene was to be completed anytime hands become soiled, upon entering or exiting any patient room or care area, anytime a resident is touched. Review of a facility document titled, Hand Hygiene Competency, dated 09/16/2025 indicated LPN#1 was competent with handwashing and use of alcohol-based hand rub. Review of a policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections, with a revised date of August 2014, stated the purpose of the procedure was to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. The general guidelines included Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including appropriate infection control measures to prevent IV catheter-related infections. When working with IV equipment aseptic techniques shall be observed. Nursing Practice Guidelines to Prevent Catheter-Related Infections included observing proper hand hygiene procedures of handwashing or alcohol-based hand rubs, before and after accessing the site. Review of the policy and procedure titled, Central Venous and Midline Catheter Flushing, with a revised date of April 2016, indicated the purpose of the procedure included to maintain patency of midline and central venous catheters and ensure entire dose of medication was administered. General guidelines indicated no physician order was needed for the procedure. The Saline, Administer, Saline (SAS) method included flushing with 10 ml syringe of normal saline (NS) amount as ordered or per facility protocol. During an interview on 02/20/2026 at 2:25 PM, the Director of Nursing (DON) stated all employees are expected to follow infection prevention protocols. Education was provided upon hire and included handwash check offs and donning/doffing PPE. PPE bins (storage containers) should contain only basic PPE, gloves, face protectors, masks, gowns, and not hairbrushes, or personal wipes due to the infection risk to residents. Staff are expected to perform hand hygiene during laundry delivery when going in and out of resident rooms, entering EPB room with clean laundry and exiting with empty dirty hangers, picking up clean laundry and entering another resident room should not be done for safety of residents and the risk of bringing infection to the secondary resident. Staff should not drape clean laundry over their arms. During an interview on 02/20/2026 at 6:20 PM, the Administrator stated staff were expected to abide by infection prevention practices, use sanitizer, wash hands, and abide by all isolation guidelines if on EBP, contact, droplet, or other type of isolation. The Administrator also stated they expected nurses to change gloves and wash hands during resident care abide by all policies to prevent spreading infections and to keep residents safe.

Based on interviews, record review and facility policy review, it was determined that the facility failed to ensure education was provided when a pneumococcal vaccine was offered for one (Resident #41) of one resident. The findings include: Review of an admission Record indicated the facility admitted Resident #41 with diagnoses that included hemiplegia (loss of movement on one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (stroke) affecting the right dominate side, cognitive communication deficit, aphasia (language disorder), and malignant neoplasm (cancer) of colon. Resident #41's family member was listed as the responsible party. Review of an Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/09/2025, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #41's pneumococcal vaccine was not up to date; vaccine was offered and declined. Review of Resident #41's Care Plan Report, revised on 12/23/2025, did not address vaccinations. Review of an Order Summary Report, for February 2026, revealed Resident #41 had no orders for vaccines. Review of a form titled, Participation in Immunization Programs, revealed Resident #41 agreed to participate in the immunization program, Consent to Vaccination/Permission to Administer Vaccines, had no last known vaccination for pneumonia. The document further indicated, I authorize the facility to administer a one-time pneumococcal vaccine to me. The document further outlined an understanding that Resident #41 had the legal right to refuse administration of these vaccines at the time of administration and was E-signed by Resident #41's responsible party. Review of Clinical Immunizations report dated 02/20/2026, revealed Resident #41 refused the Pneumococcal conjugate vaccine (PCV) and the Pneumococcal polysaccharide vaccine(PPSV) vaccines. Review of Clinical Immunizations View Immunization PPSV, dated 02/17/2023, indicated Resident #41 refused the PPSV vaccine and education was provided. Review of Clinical Immunizations View Immunization, dated 06/29/2023, indicated Resident #41 refused the PCV vaccine and education was not provided. During an interview on 02/18/2026 at 12:14 PM, the Assistant Director of Nursing (ADON) stated immunizations were offered on admission and annually. Pneumonia was reoffered yearly if the resident had not previously received the vaccine, and verbal education included risks and benefits of receiving the vaccine. Vaccines received or refused, were documented in the resident's electronic health record. To ensure flu and pneumonia vaccines were offered annually, the ADON ran an audit annually for residents who admitted to the facility outside the flu season and those who previously refused. Residents, responsible parties, or Power of Attorney's (POA) would be contacted for residents who could not consent or decline. The ADON confirmed Resident #41's responsible party had refused the influenza and COVID vaccines when offered upon admission, in 2023. The ADON confirmed Resident #41 was offered and refused the PPSV23 pneumonia vaccine, with education, on 02/17/2023, upon admission, and the PCV20 vaccine on 06/29/2023, without education. The ADON could not provide the information Resident #41 was offered or declined regarding the pneumonia vaccine with education since 2023. During an interview on 02/20/2026 at 9:45 AM, the ADON provided a document titled Participation in Immunization Programs, signed by Resident #41's responsible party on 02/06/2023, and stated the pneumonia vaccine had not been reoffered to the resident since 2023. During an interview on 02/20/2026 at 2:25 PM, the Director of Nursing (DON) stated their expectation was all nurses would follow infection prevention protocols. During an interview on 02/20/2026 at 6:20 PM, the Administrator stated, we don't want to spread infections, and expected staff to abide by all policies to keep residents safe. Infection Prevention staff were expected to follow CMS guidance on offering resident's vaccinations. Flu vaccines were offered yearly, and residents were offered pneumonia vaccines as long as no contraindications, to control the spread of pneumonia and flu. Review of a facility policy titled, Pneumococcal Vaccine, revised August 2016, indicated, All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy also states Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) and resident/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicting the date of the refusal of the pneumococcal vaccination. The policy adopts and incorporates by reference, OBRA (Omnibus Budget Reconciliation Act) Regulatory Reference numbers included 483.80(d). Other references included Centers for Disease Control and Prevention (CDC) 2014, Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults ≥65 years: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report 63(37) Related documents included the vaccine information statements for Pneumococcal Conjugate Vaccine (PVC-13) and Pneumococcal Polysaccharide Vaccine (PPSV). Review of the adopted and incorporated by reference OBRA Regulatory Reference 483.80 document titled, Title 72-Public Health Chapter IV – Centers for Medicare & Medicaid, Department of Human Services, Subchapter G-Standards and Certification, Part 483-Reqirements for State and Long Term Care Facilities, Subpart B-Requirements for Long Term Care Facilities up to date as of 02/23/2026, indicated .(d)(2) Pneumococcal disease . (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or resident's representative has the opportunity to refuse immunization; and (iv) the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding benefits and potential side effects of pneumococcal immunization, and (B) That the resident either received the pneumococcal immunization, or did not receive the pneumococcal immunization due to medical contraindication or refusal. Review of the adopted and incorporated by reference document titled, CDC 2014 Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults ≥65 years: Recommendations of the Advisory Committee on Immunization Practices (ACIP), dated 11/22/2019, indicated New Pneumococcal Vaccine Recommendations for Adults Ages ≥[AGE] years old, PCV13 [13 refers to the protection from the number of bacterium types that cause pneumococcal disease] vaccination recommended based on risk for pneumococcal disease as a result of underlying medical conditions. ACIP recommends one dose of PPSV23 [23 refers to the protection from the number of bacterium types that cause pneumococcal disease] for all adults ≥65 years, unless the dose was received before age [AGE], should receive additional dose, 5 years after previous dose. Review of the adopted and incorporated by reference document titled, Morbidity and Mortality Weekly Report, dated 01/09/2025, summarized what was known on the pneumococcal vaccine topic before October 2024, included single dose of 15-valent, 20-valent or 21-valent PVC was recommended for all adults aged ≥65 years. Additions to the report made by the committee 10/23/2024 included a single dose of PCV for all adults aged ≥[AGE] years old who are PCV naïve [have never had the vaccine] or who have an unknown vaccination history. Review of the adopted and incorporated by reference document titled, Vaccine Information Statement, Pneumococcal Conjugate Vaccine, dated 05/29/2025, recommendation included, 2. Pneumococcal conjugate vaccine .Adults 50 years or older who have not previously received PCV should receive a PCV vaccine. Review of the adopted and incorporated by reference document titled, Vaccine Information Statement, Pneumococcal Polysaccharide Vaccine (PPSV23), dated 05/29/2025, indicated PPSV23 was recommended for adults following a dose of PCV15 pneumococcal conjugate vaccine. Review of a document titled, Arkansas Code of 1987 (2024), Chapter 10, Subchapter 13 Nursing Home Resident and Employee Immunization, Section 20-10-1301, indicated It is recognized that: .(3) The CDC recommends that individuals over the age of sixty-five (65) years have .a pneumococcal vaccine one (1) time; .(6) The elderly living in an institutional setting, where disease may be more readily transmitted, are less protected than those living in the community. As used in this subchapter: .(4)(b) Each nursing home facility in this state shall: (3) Document and report annually immunizations against; .(B) Pneumococcal disease for residents.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive assessment was completed quarterly for a smoking safety screen for one sampled resident (Resident #21). The findings are: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #21 scored 13 (cognitively intact) on the Brief Interview for Mental Status (BIMS). A review of the Care Plan revealed Resident #21 uses smokeless tobacco products and may keep smokeless tobacco products at the bedside. A review of the Smoking Safety Screen and Care Plan revealed Resident #21 was safe to use chewing tobacco. The assessment was signed on 11/22/2022. On 07/22/2024 at 12:11 PM, the Surveyor observed Resident #21 with five cans of chewing tobacco in the resident's room, Resident #21 had chewing tobacco in the resident's cheek and was asleep in a recliner. On 07/24/2024 at 2:55 PM, the MDS Coordinator confirmed the last smoking safety screening assessment was completed in 2022. The MDS Coordinator stated that the assessment should be done quarterly. She then stated that it could be important to assess alertness and cognition for the resident to be able to self-administer chewing tobacco, that way we can make sure the plan of care is administered correctly for the residents. On 07/24/2024 at 3:05 PM, the Director of Nursing (DON) stated that the assessment should be done annually and once a month to make sure they are safe to smoke, things can change quickly. The DON stated that with smokeless tobacco they can choke on it. A review of the policy titled, Smoking Policy-Residents stated, that .9. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff .

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to update and revise the care plan to include restorative services for 1 (Resident #81) resident reviewed for care planning and revision. Findings include: A review of a facility policy titled, Care Planning- Interdisciplinary Team, revised on 09/01/2013, indicated, .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of comprehensive care plan for each resident . A review of the Medical Diagnosis portion of the electronic health record indicated the facility admitted Resident #81 with diagnoses that included lower urinary tract calculus and muscle wasting and atrophy. The signification change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2024 revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #81's Care Plan, initiated on 09/07/2023, revealed the resident had an Activities of Daily Living (ADL) self-performance deficit related to weakness. Interventions included physical and occupational therapy evaluation and treatment as per medical doctor order. Restorative nursing services were not included in the interventions. A review of the Order Summary Report revealed Resident #81 had no orders for restorative nursing services. A Restorative Nursing Program document, dated 07/11/2024, included two pages which included instructions for the Restorative Nursing Assistant (RNA) to follow when providing restorative nursing services to Resident #81. Instructions were provided by physical therapy (PT) and occupational therapy (OT). During an interview on 07/24/2024 at 3:00 PM, the Occupational Therapist (OT) confirmed that Resident #81 had been discharged from therapy services due to the resident not progressing towards the goals. When asked what happens once someone is discharged from therapy services, she stated that usually restorative starts working with the resident. She confirmed that Resident #81 had a plan for restorative nursing services and, the Occupational Therapist found two pages of instructions given to the Restorative Nursing Assistant (RNA) by OT and physical therapy (PT) staff, which were signed by the RNA. During an interview on 07/24/2024 at 3:15 PM, Restorative Nursing Assistant (RNA) #2 confirmed Resident #81 was not currently on the case mix for restorative nursing services. When asked how long it had been since Resident #81 had received restorative services, RNA #2 stated, It has been a while. During an interview on 07/24/2024 at 3:17 PM, the surveyor requested a copy of the restorative documentation for Resident #81. The Nurse Consultant confirmed at 3:20 PM, there was no documentation, and that the Restorative Nursing Assistant (RNA) was currently adding Resident #81 to restorative services. During an interview on 07/25/2024 at 8:45 AM, the Medicare Manager confirmed she was the overseer of the restorative program. She stated the procedure for getting notified when a resident is added to the restorative program involves therapy, who at that time discusses and educates the Restorative Nursing Assistant (RNA) and has them sign the instructions, then therapy gives the instructions to the Medicare Manager, who then puts it into the electronic medical record, by adding orders and placing it on the resident's care plan. The Medicare Manager stated that meetings are held weekly to discuss the residents on restorative services. The Medicare Manager stated, At first therapy was not going to put her on restorative, but I went to them and asked for them to put her on a restorative plan. I think it was a lack of therapy giving me the paperwork. During an interview on 07/25/2024 at 9:06 AM, the Director of Nursing (DON) confirmed the Medicare Manager oversees the restorative program. She stated the information is passed on from therapy after evaluation, then the Medicare Manager is given the paperwork and then enters the information into the electronic medical record. We do orders and tasks for the restorative program. When asked when the information should be added to the care plan, the DON responded, Should be added to the care plan within twenty four hours.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to provide restorative services to improve or maintain Activities of Daily Living (ADL) functions for 1 (Resident #81) of 1 resident reviewed for restorative services. Findings include: A review of a facility policy titled, Restorative Nursing Services revised on, July 2017 indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care . A review of the Medical Diagnosis portion of the electronic health record indicated the facility admitted Resident #81 with diagnoses that included lower urinary tract calculus and muscle wasting and atrophy. The signification change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2024, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #81's Care Plan, initiated on 09/07/2023, revealed the resident had a care plan for an Activities of Daily Living (ADL) self-care performance deficit related to weakness. Interventions included physical and occupational therapy evaluation and treatment as per medical doctor order. A review of Order Summary Report, revealed Resident #81 had no orders for restorative nursing services. A review of Restorative Tracking Log, dated July 2024, did not include Resident #81. A review of Restorative Nursing Program dated 07/11/2024, included two pages which included instructions for Restorative Nursing Assistant (RNA) to follow when providing restorative nursing services to Resident #81. Instructions were provided by physical therapy (PT) and occupational therapy (OT). During a concurrent observation and interview on 07/22/2024 at 11:00 AM, Resident #81 was lying in bed, and confirmed there were no issues with staff and that the food is good. During a concurrent observation and interview on 07/23/2024 at 3:00 PM, Resident #81 was lying in bed. Resident #81 confirmed therapy had been recently received and now was no longer receiving those services. During an interview on 07/24/2024 at 3:00 PM, the Occupational Therapist (OT) confirmed that Resident #81 had been discharged from therapy services due to the resident not progressing towards the goals. When asked what happens once someone is discharged from therapy services, she stated that usually restorative starts working with the resident. She confirmed that Resident #81 had a plan for restorative nursing services and, the Occupational Therapist found two pages of instructions given to the Restorative Nursing Assistant (RNA) by OT and PT (Physical Therapy) staff, which were signed by the RNA. During an interview on 07/24/2024 at 3:15 PM, Restorative Nursing Assistant (RNA) #2 confirmed that Resident #81 was not currently on the case mix for restorative nursing services. When asked how long it had been since Resident #81 had received restorative services, RNA #2 stated, It has been a while. During an interview on 07/24/2024 at 3:17 PM, the surveyor requested a copy of the restorative documentation for Resident #81. The Nurse Consultant confirmed at 3:20 PM, there was no documentation, and that the Restorative Nursing Assistant (RNA) was currently adding Resident #81 to restorative services. During an interview on 07/25/2024 at 8:45 AM, the Medicare Manager confirmed she was the overseer of the restorative program. She stated the procedure for getting notified when a resident is added to the restorative program involves therapy, who at that time discusses and educates the Restorative Nursing Assistant (RNA) and has them sign the instructions. Then therapy gives the instructions to the Medicare Manager, who then puts it into the electronic medical record, by adding orders and placing it on the resident's care plan. The Medicare Manager stated that meetings are held weekly to discuss the residents on restorative services. The Medicare Manager stated, At first therapy was not going to put her on restorative, but I went to them and asked for them to put her on a restorative plan. I think it was a lack of therapy giving me the paperwork. During an interview on 07/25/2024 at 9:06 AM, the Director of Nursing (DON) confirmed the Medicare Manager oversees the restorative program. She stated the information is passed on from therapy after evaluation, then the Medicare Manager is given the paperwork and then enters the information into the electronic medical record. We do orders and tasks for the restorative program. When asked when the information should be added to the care plan, the DON responded, Should be added to the care plan within twenty four hours.

Based on observation, and interview, the facility failed to ensure staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 94 residents who received meals from the kitchen (total 94) as documented on the list provided by the Dietary Supervisor on 5/2/2023. The findings are: 1. On 05/01/23 at 10:53 AM, Dietary Employee #1 opened the oven to check on food items. She picked up a container of beef base from the shelf above the food preparation table and placed it on the counter. She picked a measuring cup, turned on the sink faucet and obtained water. After she turned off the faucet, she picked up pans from the shelf below the steam table and placed them on the counter. She did not wash her hands, she removed pan liners from a box under the food preparation counter and placed them into the pans. Her fingers touched the interior surfaces of the plastic pan liners that contained ground meat and pureed meat to be served to the residents during lunch. At 10:57 AM, she picked up a clean blade and attached it to the base of the blender and pureed food to be served to the residents for lunch. 2. On 5/01/23 at 11:10 AM, Dietary Employee #1 used a rag to wipe spilled foods off the counter. She did not wash her hands, she picked up a clean blender blade and attached it to the base of the blender to be puree food for residents on pureed diets. 3. On 5/01/23 at 11:15 AM, Dietary Employee #1 used a rag to wipe spilled foods off the counter. She removed two boxes of okra from the walk-in freezer and placed them on the food cart. She removed two boxes of grits from a shelf in the storage room and placed them on the counter. She obtained water from the sink, turned off the faucet. She picked up pans from under the steam table and placed them on the counter, contaminating her hands. She did not wash her hands, she picked up pan liners and spread them inside a pan, her fingers touched the interior surfaces of the pan liners of the pan that contained food to be served to the residents. 4. On 5/01/23 at 11:23 AM, Dietary Employee #1 removed bags of shredded cheese and placed them on the counter, touched the deep fryer handle, and turned off the stove, contaminated her hands. She did not wash her hands; she removed a pan liner from a box below the food preparation counter. She spread the pan liner inside a pan and poured grits into the pan to be served to the residents for lunch. 5. On 5/01/23 at 12:05 PM Dietary Employee #1 picked up a box of glove, removed gloves from the box and placed them on her hands. She up a rack that contained snack bags and placed it on the counter. She did not wash her hands, she picked up rolls and put them in bags to be served to the residents for lunch meal. 6. The facility policy titled, Employee Cleanliness and Handwashing Technique, provided by the Dietary Supervisor on 05/02/23 at 2:30 PM documented, Dietary department employees are required to wash hands . a. before beginning shift . j. any other time deemed necessary .

Based on observation, interview, and record review, the facility failed to ensure toenails were cut to maintain good hygiene and prevent complications for 1 (Resident #93) of 15 (Residents #1, #15, #19, #20, #28, #39, #49, #78, #80, #88, #93, #149, #150, #449 and #450) sampled residents who require assistance with Activities of Daily Living (ADL's). The findings are: 1. Resident #93 had a diagnosis of Displaced Intertrochanteric Fracture of Left Femur and Subsequent Encounter for Closed Fracture with Routine Healing. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive assistance with personal hygiene. a. The Care Plan with an initiated date of 02/17/23 documented, .Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 05/01/23 at 1:44 PM, Resident #93's toenails were approximately 1/2 inch long, beyond the tip of the toe. c. On 05/02/23 at 2:14 PM, Resident #93 was lying in bed, his toenails were still approximately 1/2 inch long, beyond the tip of the toe. d. On 05/03/23 at 9:45 AM, the Surveyor asked Certified Nursing Assistant (CNA) #2 if she knew anything about Resident #93's toenails. CNA #2 stated, No. The Surveyor asked CNA #2 to accompany her to the room to look at Resident #93's toenails. The Surveyor asked CNA #2, When do the residents get their toenails cut? CNA #2 stated, The Wound Care Nurse is asked to cut them, or the Social Worker will make an appointment with the Podiatrist. e. On 05/03/23 at 9:51 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1 if Resident #93 had an appointment to have his toenails cut. LPN #1 said, The Wound Care Nurse will trim them during his shower. f. On 05/03/23 at 10:10 AM, the Surveyor asked Registered Nurse (RN) #1 if she was aware she was to cut Resident #93's toenails today during his shower. RN #1 said, In the past, during bath I have tried to cut his toenails and he refused care. When the Podiatrist was last here, he [Resident #93] refused to let him [the Podiatrist] touch his toenails. I will try to cut them and see if he will let me. RN #1 asked Resident #93, Can I cut your toenails? Resident #93 stated, They need it. The Surveyor asked RN #1 if there were documented refusals in the chart. RN #1 reviewed the record and was not able to find any documentation of refusals. g. A facility policy titled, Foot Care, provided by the Administrator on 05/04/23 at 1:00 PM documented, .Residents will receive appropriate care and treatment in accordance with professional standards of practice .Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes .

Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the Physician, to minimize the potential for hypoxia, (low levels of oxygen in the body tissues), or other respiratory complications for 1 (Resident #451) of 10 (Residents #32, #39, #75, #79, #80, #88, #149, #299, #450 and #451) sampled residents who had Physician's Orders for oxygen therapy according to a list provided by the Administrator on 05/03/23 at 2:26 PM. The findings are: 1. Resident #451 had a diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen. a. A Care Plan with an initiated date of 04/27/23 documented, The resident has altered respiratory status/difficulty breathing . Oxygen Settings: O2 [Oxygen] via nasal prongs @ [at] 2-4L [Liters] as needed. Humidified as necessary . b. The May 2023 Medication Administration Record (MAR) documented, Oxygen as needed for Shortness of Breath 2-4 Liters/MIN [minute] per nasal cannula PRN [as needed] -Order Date- 04/26/2023 . c. On 05/01/23 at 1:33 PM, Resident #451 was sitting up on the side of his bed eating lunch, Resident #451's oxygen was set at 1.5 Liters per minute via nasal cannula. d. On 05/02/23 at 8:55 AM, Resident #451 was in bed watching tv [television]. Resident #451's oxygen was set at 1.5 Liters per minute via nasal cannula. e. On 05/03/23 at 10:29 AM, Resident #451 was sitting up in a wheelchair eating a snack at his bedside table. Resident #451's oxygen was set at 1.5 Liters per minute via nasal cannula. f. On 05/03/23 at 1:38 PM, Licensed Practical Nurse (LPN) #2 accompanied the Surveyor to Resident #451's room. The resident was lying in bed watching tv. The Surveyor asked the LPN #2 to look at the resident's oxygen flow rate setting and asked, What is the flow rate set on? LPN #2 looked at the oxygen concentrator flow meter and stated, 1.5 liters per minute. You read it right in the middle of the ball. Anything else I can help with? g. On 05/03/23 at 1:46 PM, the Surveyor accompanied the Director of Nursing (DON) to Resident #451's room and asked what Resident #451's oxygen flow rate was. The DON answered, 1.5 liters. Well, it's between 1.5 and 2. The Surveyor asked what the exact setting of the flow rate was. The DON answered, It's supposed to be between 2 and 4. Let me fix it. The DON adjusted the oxygen flow rate to 2 liters per minute. h. On 05/03/23 at 2:00 PM, the Surveyor asked the DON who was responsible for making sure the resident's oxygen was set at the appropriate rate. The DON answered, The nurses. They are supposed to check them and set them at the right rates. The Surveyor asked what could happen if flow rates are not set at the right rate. She answered, They could either become hypoxic and not get enough oxygen or get too much and it could be harmful. i. The facility policy titled, Oxygen Administration, provided by the Administrator on 05/03/23 at 2:26 PM documented, .Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets, as documented on a Diet List provided by the Food Service Supervisor on 05/02/23. The findings are: 1. On 05/01/23 at 11:01 AM, Dietary Employee #1 placed 6 servings of baked chicken into a blender, added chicken broth and pureed. At 11:04 AM, she poured the pureed chicken into a pan. The consistency of the pureed chicken was not smooth. It was lumpy. There were pieces of meat visible in the mixture. 2. On 5/01/23 at 11:37 AM, Dietary Employee #1 used a 4-ounce spoon to place seven servings of grits into a blender, added cheese and pureed. 05/01/23 at 11:40 AM, she poured the pureed grits into a pan. The consistency of the pureed grits was lumpy. 3. On 5/01/23 at 11:47 AM, Dietary Employee #1 placed six servings of dinner rolls into a blender, added warm milk and pureed. She poured the pureed bread into a pan on the steam table. The pureed bread was thick. 4. On 5/01/23 at 11:54 AM, Dietary Employee #1 used a 4-ounce spoon to place six servings of fried okra into blender, added warm milk and pureed. At11:59 AM, she poured the pureed fried okra into a pan on the steam table. The texture of the pureed fried okra was runny. 5. On 5/1/2023 at 1:08 PM, as Certified Nursing Assistant #1 assisted residents with their lunch, she was asked to describe the consistency of the pureed chicken served to the residents on pureed diets. She stated, Pureed meat was chunky.

Based on observation, record review and interview, the facility failed to ensure nebulizer masks/tubing/mouthpieces were properly contained when not in use; and the facility failed to ensure Yankauer suction tips were properly contained when not in use to prevent the potential for the spread of infection and/or other diseases for 2 Residents (#4 and #6) of 6 (#1, #2, #3, #4, #5, #6) sample mix residents. The findings are: 1.Resident (R) #4 had a diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/22 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview Mental Status (BIMS), required limited assist of one staff for bed mobility, transfer dressing, and personal hygiene; required supervision for toilet use; and was occasionally incontinent of bowel and bladder and used oxygen therapy. a. The Care Plan with a revision date of 11/08/22 documented, .the resident has oxygen therapy r/t [related to] dx [diagnosis] of COPD .updrafts per Medical Doctor (MD) orders .may self-administer after nurse sets up . b. The Physician Order with a start date of 02/01/23 documented, .Ipratropium-Albuterol Solution 0.5-2.5 (3mg (milligram)/3 ml (milliliter) 1 dose inhale orally four times a day .may self-administer after nurse sets up . c. On 03/06/23 at 9:59 a.m., R #4 was lying in bed. A nebulizer machine was on R #4's over the bed table. The nebulizer mouthpiece/tubing was not contained. The Surveyor asked, Do you use the nebulizer. R #4 replied, Yes. The Surveyor asked, How often do you get updraft treatments? R #4 replied, 4 or 5 times a day. The Surveyor asked R #4, Do you give the updraft treatments to yourself? R #4 replied, Yes, after the nurse sets it up. d. On 03/07/23 at 11:20 a.m., R #4 was lying in bed. R #4 stated, I just gave myself an updraft treatment. A nebulizer was on R #4's the bed table. The nebulizer mouthpiece/tubing was sitting in the holder. The nebulizer mouthpiece/tubing was not contained. e. On 03/07/23 at 11:25 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, How are nebulizer masks/tubing/mouthpieces supposed to be stored when not in use? LPN #1 replied, In a plastic bag. The Surveyor asked, How are Yankauers supposed to be stored when not in use? LPN #1 replied, In a plastic bag. The Surveyor asked, Why should Yankauers and nebulizer masks/tubing/mouthpieces be contained when not in use? LPN #1 replied, To keep dust and germs from landing on them. The Surveyor asked, Who is responsible for ensuring Yankauers and nebulizer masks/tubing/mouthpieces are contained when not in use? LPN #1 replied, Everybody. The Surveyor asked, Who cleans the nebulizer masks/tubing/mouthpieces after R #4 self-administers an updraft treatment. LPN #1 replied, Usually the nurse. The Surveyor asked, LPN #1, Tell me about R #4 self-administration of the updraft treatment. LPN #1 replied, I set it up, turn on the machine and hand it to R #4. R #4 will turn it off. I go back in and dump it and rinse it. The Surveyor asked LPN #1, How is the nebulizer mouthpiece supposed to be stored after use? LPN #1 replied, It's supposed to go in the bag. 2.Resident (R) #6 had diagnoses of Malignant Neoplasm of upper lobe right bronchus or lung and neoplasm of unspecified behavior of brain. The 5-day MDS with an ARD of 1/11/2023 documented the resident scored 15 (13-15 cognitively intact) on the BIMS, required limited assist of one staff for bed mobility and personal hygiene; required extensive assist of one staff for transfer and dressing; and was totally dependent on one staff for toilet use; was occasionally incontinent of bladder and always incontinent of bowel and used oxygen therapy. a.The Physician Order with a start date of 02/20/23 documented, .suction as needed for increased secretions . b. On 03/06/23 at 10:46 a.m., R #6 was lying in bed. A suction machine was on the nightstand next to R #6 bed. The Yankauer was observed lying on the nightstand and not contained. c. On 03/07/23 at 1:16 p.m., the Surveyor asked the Director of Nursing (DON), How are nebulizer masks/tubing/mouthpieces supposed to be stored when not in use? The DON replied, In a bag. The Surveyor asked, How are Yankauers supposed to be stored when not in use? The DON replied, In a bag. The Surveyor asked, Why should Yankauers and nebulizer masks/tubing/mouthpieces be contained when not in use. The DON replied, So they don't get any bacteria on them. The Surveyor asked, Who is responsible for ensuring Yankauers and nebulizer masks/tubing/mouthpieces are contained when not in use? The DON replied, Nursing. The Surveyor asked, Who cleans the nebulizer masks/tubing/mouthpieces after R #6 self-administers an updraft treatment. The DON replied, The nurses. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and following the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, I want them to strictly to adhere to the policy and procedures from our facility and state, so it ensures patient safety, good patient outcomes, and good quality of care. d. On 03/07/23 at 1:45 p.m., the Surveyor asked the Administrator, How are nebulizer masks/tubing/mouthpieces supposed to be stored when not in use? The Administrator replied, In a bag. The Surveyor, How are Yankauers supposed to be stored when not in use? The Administrator replied, In a bag. The Surveyor asked, Why should Yankauers and nebulizer masks/tubing/mouthpieces be contained when not in use? The Administrator replied, Sanitation issues. The Surveyor asked, Who is responsible for ensuring Yankauers and nebulizer masks/tubing/mouthpieces are contained when not in use? The Administrator replied, The staff, nurses. The Surveyor asked, Who cleans the nebulizer masks/tubing/mouthpieces after R #6 self-administers updraft treatment. The Administrator replied, The nurse. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and following the CMS guidelines. The Administrator replied, I expect them to follow them. 3. The facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer provided the Administrator on 03/07/23 at 10:15 a.m. documented, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .administer therapy until medication is gone .when treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece, and medication cup .rinse the nebulizer equipment with hot water and allow to dry .when equipment is completely dry, store in a plastic bag with the resident's name and the date on it .

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secure location and according to state laws and accepted standards of pharmacy practice for 2 Residents (#3 and #4) of 6 (#1, #2, #3, #4, #5, #6) sample mix residents. This failed practice had the potential to affect 7 residents who were cognitively impaired and ambulated by any means on the 100, 200, and 400 Hall according to a list provided by the Administrator on 03/07/23 at 2:16 p.m. The findings are: 1.Resident (R) #3 had diagnoses of Respiratory Failure and Diabetes. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/23 documented the resident scored 14 (13-15 indicated cognitively intact) on the Brief Interview for Mental Status (BIMS), was totally dependent on two staff for bed mobility, transfer, toilet use, and personal hygiene; required extensive assist of two staff for dressing; was always incontinent of bowel and bladder. a. The Physician Order with a start date of 01/08/23 documented, .Nystatin Powder apply to affected areas topically as needed for yeast/redness . b. On 03/06/23 at 11:11 a.m., R #3 was lying in bed in her room. A plastic bottle labeled Medicated Body Powder was in a basket on the top shelf of the built-in chest of drawers. An unlabeled medicine cup containing 0.5 ml to (milliliters) 1 ml of a whiteish/greyish powder. c. On 03/06/23 at 11:14 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #2, What is in the medicine cup? LPN #2 replied, Nothing I brought R #3. The Surveyor asked, Can you tell me what is (ingredients) in the medicated powder. LPN #2 looked at the back of the medicated powder bottle and replied, Zinc and Menthol Powder. d. On 03/06/23 at 11:35 a.m., the Surveyor asked LPN #2, Why should residents not have medicated powder and unlabeled medicine cups containing powder left in their rooms and not contained? LPN #2 replied, Because it's medication. The Surveyor asked LPN #2, Who is responsible for ensuring bottles of medicated powder and unlabeled medicine cups of powder are not left in the resident's rooms. LPN #2 replied, I am. e. The Material Safety Data Sheet (MSDS) provided by the Administrator via email on 03/06/23 at 3:33 p.m. documented, . Medicated Body Powder .active ingredients: Menthol 0.75% [percent], Zinc Oxide 1.0 % .harmful if swallowed .if respiration is compromised, endotracheal intubation and intermittent positive pressure breathing should be considered .material and/or its emissions may aggravate preexisting eye disease .keep out of reach of children .avoid creating excess dust . 2. Resident (R) #4 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Chronic Kidney Disease. The MDS with an ARD of 12/22/22 documented the resident scored 15 (13-15 indicated cognitively intact) on the BIMS, required limited assist of one staff for bed mobility, transfer dressing, and personal hygiene; required supervision for toilet use; and was occasionally incontinent of bowel and bladder. a. The Care Plan with a revision date of 11/08/22 documented, .the resident has oxygen therapy r/t [related to] dx [diagnosis]of COPD .updrafts per MD orders .may self-administer after nurse sets up . b. The Physician Order with a start date of 02/01/23 documented, .Ipratropium-Albuterol Solution 0.5-2.5 (3 mg (milligram)/3 ml 1 dose inhale orally four times a day .may self-administer after nurse sets up . c. On 03/06/23 at 9:59 a.m., R #4 was lying in bed. A nebulizer machine was on R #4's over the bed table. There was 3-5 ml of clear liquid in the nebulizer medicine cup. The nebulizer mouthpiece/tubing was not contained. The Surveyor asked R #4, Do you use the nebulizer? R #4 replied, yes. The Surveyor asked, How often do you get updraft treatments? R #4 replied, 4 or 5 times a day. The Surveyor asked, Do you give the updraft treatments to yourself. R #4 replied, Yes, after the nurse sets it up. d. On 03/07/23 at 11:20 a.m., R #4 was lying in bed. R #4 stated, I just gave myself an updraft treatment. A nebulizer was on R #4's over the bed table. The nebulizer medicine cup was sitting in the holder of the nebulizer. The nebulizer medicine cup contained 1 to 2 ml of clear liquid. e. On 03/07/23 at 11:25 a.m., the Surveyor asked LPN #1, Where is medicated powder supposed to be stored when not in use? LPN #1 replied, On the treatment cart nurse's cart or medication room. The Surveyor asked, Why should medicated powder be contained and not left out in resident's rooms or facility? LPN #1 replied, Another resident could eat it or swallow it. The Surveyor asked, Where should unlabeled medicine cups of powder be stored? LPN #1 replied, The medication cart, treatment cart, or the medication room. The Surveyor asked, Why should unlabeled medicine cups with powder be contained and not left out in the resident's rooms or facility? LPN #1 replied, If it doesn't have a label, it shouldn't be left out and a resident could eat it. The Surveyor asked, Who is responsible for ensuring unlabeled medicine cups with powder are not left out in the residents' rooms and facility? LPN #1 replied, The nurse. The Surveyor asked, Why would there be 3-5 mls of clear liquid in a nebulizer medicine cup sitting on R #4's nebulizer in R#4's room? LPN #1 replied, Because it wasn't dumped. The Surveyor asked, Tell me about R #4's self-administration of the updraft treatment. LPN #1 replied, I set it up, turn on the machine and hand it to R #4. R#4 will turn it off. I go back in and dump it and rinse it. The Surveyor asked, Who is responsible for ensuring the resident administers all the medication after self-administration of an updraft treatment? LPN #1 replied, The nurse. f. On 03/07/23 at 1:16 p.m., the Surveyor asked the Director of Nursing (DON), Where is medicated powder supposed to be stored when not in use? The DON replied, In the medication cart or treatment cart. The Surveyor asked, Why should medicated powder be contained and not left out in resident's rooms or facility? The DON replied, It's a medication and could be ingested. The Surveyor asked, Where should unlabeled medicine cups of powder be stored? The DON replied, There shouldn't be unlabeled medicine cups of powder out. The Surveyor asked, Why should unlabeled medicine cups with powder be contained and not left out in the resident's rooms or facility? The DON replied, It should never be left out. The Surveyor asked, Who is responsible for ensuring unlabeled medicine cups with powder are not left out in the resident's rooms and facility. The DON replied, Nursing. The Surveyor asked, Why would there be 3-5 mls of clear liquid in a nebulizer medicine cup sitting on R #4's nebulizer in R #4's room. The DON replied, There shouldn't be anything in there. The Surveyor asked, Who is responsible for ensuring the resident administers all the medication after self-administration of an updraft treatment? The DON replied, The nurse. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and following the Centers for Medicare and Medicaid Services (CMS) guidelines. The DON replied, I want them to strictly to adhere to the policy and procedures from our facility and state, so it ensures patient safety, good patient outcomes, and good quality of care. e. On 03/07/23 at 1:45 p.m., the Surveyor asked the Administrator, Where is medicated powder supposed to be stored when not in use? The Administrator replied, The treatment cart or medication room. The Surveyor asked, Why should medicated powder be contained and not left out in a resident's rooms or facility? The Administrator replied, To prevent anyone who's cognitively impaired from getting a hold of it. The Surveyor asked, Where should unlabeled medicine cups of powder be stored? The Administrator replied, It should be disposed of. The Surveyor asked, Why should unlabeled medicine cups with powder be contained and not left out in the resident's rooms or facility? The Administrator replied, So someone cognitively impaired doesn't get a hold of it. The Surveyor asked, Who is responsible for ensuring unlabeled medicine cups with powder are not left out in the resident's rooms and facility. The Administrator replied, Anybody that sees it. The Surveyor asked, Why would there be 3-5 mls of clear liquid in a nebulizer medicine cup sitting on R #4's nebulizer in R #4's room. The Administrator replied, There shouldn't be any in there. The Surveyor asked, Who is responsible for ensuring the resident administers all the medication after self-administration of an updraft treatment? The Administrator replied, The nurses. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and following the CMS guidelines. The Administrator replied, I expect them to follow them. The facility policy titled, Storage of Medications provided by the Administrator via email on 03/06/23 at 3:33 p.m. documented, .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner .drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .the nursing staff shall be responsible for maintaining medication storage .drugs for external use, as well as poisons, shall be clearly marked as such .drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems .

Based on observation, record review, and interview, the facility to ensure the environment was as free of potential accident hazards as possible, as evidenced by the failure to ensure medications were stored and contained to prevent potential accidental ingestion and/or other injuries to cognitively impaired residents who were able to ambulate by any means. This failed practice had the potential to affect 14 (R #1, R #3, R #8, R #15, R #17, R #18, R #21, R #31, R #32, R #33, R #46, R #52, R #55, R #56) Cognitively Impaired Residents who could ambulate, according to a list provided by Licensed Practical Nurse (LPN) #1 on 11/8/2022 at 3:51 p.m. The findings are: 1. On 11/7/2022 at 9:31 a.m., a pair of black handled, sharp and pointed pair of scissors was on the bathroom sink in [named] room. 2. On 11/7/2022 at 9:56 a.m., a biohazard sharps container with no lid, containing 6 uncovered razors, was in a wire rack on the wall in the bathroom of [named] room and was not contained. A tube of [named] Paste was on top of the paper towel dispenser in room [named] and was not contained. 3. On 11/7/2022 at 12:34 p.m., a pair of black handled, sharp, and pointed pair of scissors was on the bathroom sink in [named] room. 4. On 11/7/2022 at 12:36 p.m., an open bottle of [MEDICATION(S)] was in a pink basin on top of the built-in dresser in [named]room and not contained. An opened bottle of Normal Saline 0.9% [percent] and a bottle of Sterile Water was on the nightstand in [named] room and not contained. 5. On 11/7/2022 at 2:42 p.m., an opened bottle of [MEDICATION(S)] was in a pink basin on top of the built-in dresser in [named] room and not contained. An opened bottle of Normal Saline 0.9% [percent] and a bottle of Sterile Water was on the nightstand in [named] room and not contained. 6. On 11/8/2022 at 12:30 p.m. a biohazard sharps container with no lid, containing 6 uncovered razors, was in a wire rack on the wall in the bathroom of [named] room and was not contained. A tube of [named] Paste was on top of the paper towel dispenser in [named] room and was not contained. 7. On 11/8/2022 at 12:33 p.m., The Surveyor asked licensed Practical Nurse (LPN) #1, Why is the sharps container with razors not covered and the tube of [named] Paste left out? LPN #1 replied, I don't know, I'm not sure how he got the paste. The Surveyor asked LPN #1, Should it be left out? LPN #1 replied, no. The Surveyor asked LPN #1, Who is responsible for ensuring those items are not left out. LPN #1 replied, all the staff. The Surveyor asked LPN #1, What is the ingredient in the paste? LPN #1 replied, [MEDICATION(S)] 16%. 8. On 11/8/2022 at 12:56 p.m., an opened bottle of Normal Saline 0.9% and a bottle of Sterile Water was on the nightstand in [named] room and not contained. 9. On 11/8/2022 at 3:10 p.m., The Surveyor asked Certified Nursing Assistant (CNA) #1, Why should items like [named] Paste, Normal Saline, Sterile Water, and [MEDICATION(S)], not be left out in the resident's rooms? CNA #1 replied, anything that says keep out of reach of children, shouldn't be in resident's rooms. The Surveyor asked CNA #1, who is responsible for ensuring these items are not left out? CNA #1 replied, we are. The Surveyor asked CNA #1, Why should sharps containers containing used razors be contained in a resident room? CNA #1 replied, safety issues. The Surveyor asked CNA #1, Who is responsible for ensuring these items are contained? CNA #1 replied, all of us. 10. On 11/8/2022 at 3:24 p.m., the Surveyor asked LPN #2, Why should items like [named] Paste, Normal Saline, Sterile Water, and [MEDICATION(S)], not be left out in the resident's rooms? LPN #2 replied, It's a risk for accidental ingestion. The Surveyor asked LPN #2, Who is responsible for ensuring these items are not left out? LPN #2 replied, everybody. The Surveyor asked LPN #2, Why should sharps containers containing used razors be contained in a resident room? LPN #2 replied, to prevent accidents. The Surveyor asked LPN #2, Who is responsible for ensuring these items are contained? LPN #2 replied, nurses. 11. On 11/8/2022 at 3:36 p.m., The Surveyor asked the Director of Nursing (DON), Why should items like [named] Paste, Normal Saline, Sterile Water, and [MEDICATION(S)], not be left out in the resident's rooms? The DON replied, hazardous to the residents if they drink it, overdose. The Surveyor asked the DON, Who is responsible for ensuring these items are not left out? The DON replied, everybody. The Surveyor asked the DON, Why should sharps containers containing used razors be contained in a resident room? The DON replied, they should not be in any room. The Surveyor asked the DON, Who is responsible for ensuring these items are contained? The DON replied, everybody. The Surveyor asked the DON, What are your expectations from your staff regarding following the facilities policy and procedure and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, I expect them to do it. 12. On 11/8/2022 at 4:04 p.m., The Surveyor asked the Administrator, Why should items like [named] Paste, Normal Saline, Sterile Water, and [MEDICATION(S)], not be left out in the resident's rooms? The Administrator replied, resident safety. The Surveyor asked the Administrator, Who is responsible for ensuring these items are not left out? The Administrator replied, everyone. The Surveyor asked the Administrator, Why should sharps containers containing used razors be contained in a resident room? The Administrator replied, resident safety. The Surveyor asked the Administrator, Who is responsible for ensuring these items are contained? The Administrator replied, Whoever puts them out. The Surveyor asked the Administrator, What are your expectations from your staff regarding following the facilities policy and procedure and the CMS guidelines? The Administrator replied, that we follow them. 13. A policy provided by the Administrator on 11/8/2022 at 9:40 a.m. documented .Storage of Medications .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner .the nursing staff shall be responsible for maintaining medication storage . 14. A Material Safety Data Sheet provided by the Administrator on 11/8/2022 at 2:59 p.m. documented . [named] Paste .inhalation .remove to fresh air .if not breathing .give artificial respiration .if breathing is difficult .give oxygen .call a Physician .exposed persons should be kept under medical observation for 48 hours because delayed effects may occur .ingestion .treat symptomatically .skin contact .wash skin with soap and water .obtain medical attention if irritation persist .eye contact .immediately flush eyes with plenty of water for at least 15 minutes .lifting lower and upper eyelids occasionally .get medical attention if discomfort persists .

Based on observation, record review and interview, the facility failed to ensure housekeeping services were consistently provided to maintain a sanitary, orderly and comfortable living environment and improve the quality of life for residents that were dependent on staff for cleaning, as evidenced by failure to ensure the floors were free of substances, the residents bathrooms remained free of brown substance in and around the toilet, the residents trash cans were free of used briefs, and the resident's bedside commodes were free of liquid substances. This failed practice had the potential to affect all 94 residents that were dependent on staff for cleaning according to the Census and Condition provided by the Administrator on 11/7/2022 at 1:23 p.m. The findings are: 1. On 11/7/2022 at 9:00 a.m., in [named] room, a used medicine cup was in the floor between the residents' beds. The bathroom trash can was full of used briefs. There was a brown substance on the floor in front of the commode and in the commode and on the toilet riser. A bedside commode had 1000 cc's (cubic centimeters) of dark brown liquid. A trash can near the bed was full of used briefs. 2. On 11/7/2022 at 9:13 a.m., there was brown substances on the floor in front of the toilet and on the inside and outside of the toilet in [named] room. 3. On 11/7/2022 at 9:31 a.m., there was a brown substance inside the toilet in [named] room. 4. On 11/7/2022 at 9:33 a.m., there was a piece of chip in the floor and brown substances in the toilet in [named] room. 5. On 11/7/2022 at 9:46 a.m., paper and cookies/cake were on the floor in [named] room. 6. On 11/7/2022 at 9:50 a.m., there were brown substances on the toilet riser seat and a brown/white paper between the toilet and toilet riser seat in [named] room. 7. On 11/7/2022 at 10:17 a.m., there was paper, and debris in the hallway floor on [named] Hall. 8. On 11/7/2022 at 10:19 a.m., there was paper in the floor at the end of bed in [named] room. 9. On 11/7/2022 at 10:28 a.m., there were brown substances in and on the outside of the toilet in [named] room. 10. On 11/7/2022 at 12:38 p.m., there was paper, and debris in the hallway floor and residents' rooms on [named] Hall. 11. On 11/7/2022 at 2:41 p.m., there was paper, and debris in the hallway floor and residents' rooms on [named] Hall. 12. On 11/8/2022 at 10:45 a.m., a used medicine cup was on the floor between resident's beds in [named] room. The toilet riser in the bathroom had brown substances on it. The bathroom trash can had used briefs in it. A bedside commode had 1000 cc's [cubic centimeters] of dark liquid. The trash can next to bed was full of used briefs. A visitor in [named] room stated, that is the same trash that I put in the bathroom on Sunday, they do not empty the trash every day or sweep the floors every day. 13. On 11/8/2022 at 12:52 p.m., there were brown substances in the toilet in [named] room. 14. On 11/8/2022 at 1:08 p.m., there was plastic/paper debris in front of bed in [named] room. 15. On 11/8/2022 at 1:11p.m., The Surveyor asked the Housekeeping Supervisor (HKS), How often are the resident's rooms cleaned? HKS replied, daily. The Surveyor asked the HKS, What do the housekeepers clean? The HKS replied, they wipe down tables, dust the furniture, sweep and mop, spray the bathroom with disinfectant spray, clean the room, then do the bathroom. The Surveyor asked the HKS, Who is responsible for cleaning the bedside commodes? The HKS replied, the Certified Nursing Assistants (CNAs). The Surveyor asked the HKS, Who is responsible for cleaning toilet risers in the resident's bathrooms? The HKS replied, We clean those if they are in the bathroom. The Surveyor asked the HKS, Who is responsible for taking out the trash? The HKS replied, Housekeeping do it when cleaning the room, but on their last rounds after lunch, CNA's pull their own trash if there's briefs in it. The Surveyor asked the HKS, are the briefs supposed to be left in resident's rooms? The HKS replied, no, as the CNA's change them, it should be taken out after each change. 16. On 11/8/2022 at 2:39 p.m., the toilet riser had a brown substance on the inside and there was brown/white paper between the toilet and the toilet riser seat in [named] Room. The Surveyor asked the HKS, Why should residents' rooms be clean and free of brown substances on or in the toilet seats/risers and free of debris? The HKS replied, The housekeeper didn't take the riser out and for infection control. 17. On 11/8/2022 at 3:10 p.m., The Surveyor asked Certified Nursing Assistant (CNA) #1, Who is responsible for ensuring residents trash containing briefs is taken out? CNA #1 replied, the CNA's. The Surveyor asked CNA #1, Who is responsible for ensuring residents bedside commodes are emptied and clean? CNA #1 replied, we are. The Surveyor asked CNA #1, How often are residents rooms cleaned? CNA #1 replied, I work second, they are gone when I get here. 18. On 11/8/2022 at 3:11 p.m., The Surveyor asked CNA #2, Who is responsible for ensuring residents trash containing briefs is taken out? CNA #2 replied, CNA's, briefs should be left in rooms. The Surveyor asked CNA #2, Who is responsible for ensuring residents bedside commodes are emptied and clean? CNA #2 replied, we are. The Surveyor asked CNA #2, how often are residents rooms cleaned? CNA #2 replied, I see them down here. 19. On 11/8/2022 at 3:24 p.m., The Surveyor asked Licensed Practical Nurse (LPN) #2, Who is responsible for ensuring residents trash containing briefs is taken out? LPN #2 replied, everybody responsibility. The Surveyor asked LPN #2, who is responsible for ensuring residents bedside commodes are emptied and clean? LPN #2 replied, the CNA's. The Surveyor asked LPN #2, How often are residents rooms cleaned? LPN #2 replied, I'm not sure, it appears daily. 20. On 11/8/2022 at 3:36 p.m., The Surveyor asked the Director of Nursing (DON), who is responsible for ensuring residents trash containing briefs is taken out. The DON replied, the CNA's that does peri-care, CNA's change the trash throughout the day. The Surveyor asked the DON, Who is responsible for ensuring residents bedside commodes are emptied and clean? The DON replied, CNA's and nurses. The Surveyor asked the DON, How often are residents rooms cleaned? The DON replied, daily. The Surveyor asked the DON, What are your expectations from your staff regarding following the facilities policy and procedure and the Centers for Medicare and Medicaid Services (CMS) guidelines. The DON replied, I expect them to do it. 21. On 11/8/2022 at 4:04 p.m., The Surveyor asked the Administrator, who is responsible for ensuring residents trash containing briefs is taken out? The Administrator replied, the CNA's. The Surveyor asked the Administrator, who is responsible for ensuring residents bedside commodes are emptied and clean? The Administrator replied, CNA's. The Surveyor asked the Administrator, how often the residents' rooms are cleaned? The Administrator replied, daily. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policy and procedure and the CMS guidelines? The Administrator replied, that we follow them.

Based on observation, interview and record review the facility failed to ensure staff applied proper Personal Protective Equipment prior to entering Isolation/Quarantine rooms, appropriate signage was on resident's door, and isolation doors were closed, when possible, to prevent the possible spread of infection for 3 (Residents 1, 2, 3) sample mix residents. The findings are: a. On 8/24/22 at 1:10 pm, rounds were done on 100 halls, the COVID-19 hall. room [ROOM NUMBER], 105 and 106 with PPE (Personal Protective Equipment) bin outside of door and signage on door stating Droplet Precautions Please wear Gown, Gloves, and mask. Visitors: See nurse before entering room. There are also signs showing donning and doffing of PPE. room [ROOM NUMBER] with door open and resident in recliner dressed, with eyes closed. room [ROOM NUMBER], door open. COVID-19 rooms per Assistant Director of Nursing (ADON) are 112, 114, 115, 116 and 117 all with doors open with Droplet Precaution and Contact Precaution signs on the doors of those rooms. b. On 8/24/22 at 1:15 pm, Certified Nursing Assistant (CNA) #1 was asked, Why are all the doors open to the isolation rooms? She stated, Well, they are giving them their lunch trays. Noted most residents already eating and only half of food left on plates. No lunch cart on hall. c. On 8/24/22 at 1:20 pm, the ADON was asked, Are the doors to isolation/quarantine rooms to be open? She stated, No, but one resident opens his own door, we try to tell him, but he says he wants to go home which is back to his own room. d. On 8/24/22 at 1:41 pm, CNA #1 was observed going into room [ROOM NUMBER] without any PPE on. When she came out of room the ADON corrected her and told her she needed to put all the PPE on. She stated, Even just to see what she needs really quick? The ADON stated, Yes. e. On 8/24/22 at 1:54 pm, all isolation doors on 100 halls were closed. NA #2 entered room [ROOM NUMBER] which is COVID-19 positive with gown and gloves, but no eye protection. He then came out with the old PPE on, doffed it, rolled it up and opened all the drawers in the PPE bin to find a bag to put his PPE in. He was asked, Did you forget to put on something? He stated, Ah, I don't know. Surveyor stated, You forgot your eye protection. He stated, Oh dang. Staff across the hall in full PPE stepped into doorway and stated, I'll take that and put in here, (room [ROOM NUMBER] which is also isolation). She stated, At least you put it in a bag, but you are supposed to take it off in the room. f. On 8/25/22 at 8:47 am, a Hospice nurse came down hall and asked Licensed Practical Nurse (LPN) #1 how resident in 417 was. She gave her a report, let her know she was in isolation due to outbreak and told her that the PPE was down the hall in the dresser. The Hospice nurse went down the hall got gloves and then went to room, did hand hygiene, put on gloves and knocked and went into room. LPN #1 went to door, knocked, and opened it and told her she needed to put a gown on when going into room. Hospice nurse came out, went to the bin down the hall and got a gown and put it on. She then came to surveyor and stated, Educate me. I thought contact isolation was just gloves. LPN #1 stated, It's whatever is on the door sign, you have to follow that. Contact precaution signs only are on the doors to rooms [ROOM NUMBERS] which are unvaccinated rooms. g. On 8/25/22 at 10:13 am, the Infection Control Nurse/Director of Nurses was asked, What PPE should be worn when someone is COVID-19 positive or in quarantine? She stated, Cover hair, shoe covers, goggles or face shield, N95, gown and gloves. She was asked, How do you let visitors or contract staff know about precautions? She stated, There is a sign at the front door letting everyone know that an N95 is required to enter, there is a person at the desk too. She was asked, So they are to let them know about precautions? She stated, Yes. And there is a sign on every door that has instructions on what to wear. She was asked, During outbreak what isolation should unvaccinated residents be in? She stated, Droplet and contact isolation. h. A facility policy received from the administrator on 8/24/22 at 1:40 pm titled Coronavirus Disease (COVID-19)-Identification and Management of Ill Residents documents, .Residents with Suspected COVID-19 Infection .2. The door to room remains closed to reduce the transmission of [CONDITION(S)]-CoV-1. If keeping the door closed poses resident safety risks, and the door needs to remain open, facility will work to implement strategies that minimize airflow into the hallway . i. A facility policy received from the administrator on 8/24/22 at 1:40 pm titled Isolation-Initiating Transmission-Based Precautions documents .3. When Transmission-Based Precautions are implemented, the Infection Preventionist .d. Determines the appropriate notification on the room entrance door or other prominent location so that personnel and visitors are aware of the need for and the type of precautions, instructions for the use of PPE, and/or instructions to see a nurse before entering the room. j. A facility policy received from the administrator on 8/24/22 at 1:40 pm titled Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures documents, .2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including .c. Appropriate use of PPE; d. Transmission-based precautions, where indicated .

Based on observation and interview, the facility failed to ensure food items stored in the freezer and dry storage area were covered or sealed; hot food items were heated to a temperature of at least 135 degrees Fahrenheit (F.) before being placed on the steam table to await service; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 70 residents who received meals from the kitchen (total census: 71), as documented on a list provided by the Dietary Supervisor on 12/16/21 at 2:51 P.M. The findings are: 1. On 12/15/2021 at 11:33 a.m., the following observations were made in the walk-in freezer: a. An open box of hamburger patties was stored on a shelf in the walk-in freezer. The box was not covered, and the inner bag was not sealed. b. An open box of catfish was stored on a shelf in the walk-in freezer. The box was not covered, and the inner bag was not sealed. 2. On 12/15/21 at 11:50 AM, Dietary Employee #1 got a can of ham base and a measuring cup and placed them on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets. 3. On 12/15/21 at 11:51 AM, an open bag of hotdog buns was on top of the microwave in the kitchen. The bag was not sealed. 4. On 12/15/21 at 12:40 PM Dietary Employee #1 turned on the handwashing sink faucet and washed the blender with soap and hot water. She sanitized the blender and turned off the faucet, contaminating her hand. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 5. On 12/15/21 at 12:46 PM, Dietary Employee #2 dropped a lid to a sippy bottle inside the steam table where pans of food items were placed while awaiting meal service. The water in the pan was not clean and Dietary Employee #2 did not sanitize the lid before using it to cover a bottle that contained pureed vegetables to be served to a resident for the lunch meal. 6. On 12/15/21 at 12:53 PM, the Dietary Supervisor was wearing a glove on his hand when he used the water hose to spray off leftover foods from the blender. Without, changing gloves and washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 7. On 12/15/21 at 12:54 PM, the Dietary Supervisor placed 9 servings of dinner rolls in a blender, added warm milk and pureed. He transferred the pureed bread into a pan and placed it on the steam table. The temperature of the pureed bread was 130 degrees Fahrenheit. 8. On 12/16/21 at 10:20 AM, Dietary Employee #2 was asked, What should you have done when you picked up a lid to a bottle that fell in hot water on the steam table? She stated, I should have washed it. 9. On 12/16/21 at 10:25 AM, the Dietary Supervisor was asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, Remove the glove and wash my hands.

Based on record review and interview, the facility failed to ensure the Admission Minimum Data Set (MDS) was completed within 14 days after admission, to ensure all necessary information was collected, triggered on the Care Area Assessments (CAAs), and made available for the Interdisciplinary Team's (IDT's) review prior to making care planning decisions for 1 (Resident #319) of 2 (Residents #318 and #319) sampled residents who were new admissions. The findings are: Resident #319 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS entry tracking record dated as completed 12/2/21 documented the resident was admitted to the facility on [DATE] from another nursing home or swing bed. a. As of 12/15/21 at 10:00 a.m., there was no admission MDS available for review in the electronic health record. As of 12/16/21 at 9:38 a.m., there was an Admission MDS with an Assessment Reference Date of 12/14/21 set for completion in the facility software; however, none of the assessment items had been completed. b. On 12/16/21 at 10:27 a.m., Registered Nurse (RN) #1 was asked how long a facility had to complete an admission MDS and stated, Fourteen days. RN #1 was asked, Can you identify what [Resident #319's] 14th day was? RN #1 stated, He was admitted on [DATE] so that would make it 12/14/21. RN #1 was asked, Was the admission MDS completed timely? RN #1 stated, No it wasn't.

Based on observation, record review and interview, the facility failed to ensure a mechanical lift was utilized in accordance with the manufacturer's instructions to minimize the potential for transfer-related injuries for 1 (Resident #56) of 1 sampled resident who required the use of a mechanical lift for transfers. The findings are: Resident #56 had diagnoses of Muscle Wasting / Atrophy and [CONDITION(S)] / [CONDITION(S)] following Cerebral Infarction. The Quarterly Minimum Data Set with an Assessment Reference Date of 09/22/21 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status and was totally dependent on two-plus persons for bed mobility and transfers. a. The Care Plan with a revision date of 12/09/20 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] activity intolerance, fatigue, [CONDITION(S)] . The resident requires Mechanical Lift, Red lift pad, with 2 staff assistance for transfers . b. On 12/15/21 at 10:31 a.m., Certified Nursing Assistant (CNA) #1 and CNA #2 transferred Resident #56 from the bed to a reclining Geri-chair. The CNAs placed the Geri-chair at the foot of the bed and positioned a red sling under the resident. CNA #1 positioned the legs of the lift under the bed, in the fully open position, and locked the casters of the lift. After lifting the resident, the CNA unlocked the casters and positioned the resident in the sling over the Geri-chair. The CNA then locked the casters before lowering the resident into the Geri-chair. c. On 12/15/21 at 2:01 p.m., CNA#1 was asked, When were you last trained on using the mechanical lift? CNA #1 stated, Not long ago. CNA #1 was asked, Did you lock the casters of the lift? CNA #1 stated, Yes, I did. CNA #1 was asked, Are you aware the mechanical lift guidelines document to leave the casters unlocked? CNA #1 stated, If I did, I forgot. I thought about should I or shouldn't I lock the wheels. I second guessed myself. d. On 12/15/21 at 2:15 p.m., the Director of Nursing and the Administrator were asked, Should CNAs follow the manufacturer's instructions for the mechanical lift? Both stated, Yes. e. The Mechanical Lift user's manual, provided by the Administrator on 12/15/21 at 1:35 p.m., documented, .Leaving the [NAME] brakes unlocked will allow the lift to 'walk forward' to center itself over the patient's center of gravity as it raises. This increases the stability of the lift .

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator or freezer were sealed/covered; expired food items were promptly removed /discarded on or before the expiration or use by dates to minimize the potential for food borne illness or bacteria growth for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 78 residents who received meals from the kitchen (total census:79), as documented on a list provided by the Dietary Employee #3 on [DATE]. The findings are: 1. On [DATE] at 11:59 AM, the storage room contained a box of approximately 20 bananas with brown and black wet substances, and a bag of Japanese Style Breadcrumbs open and not sealed properly. At 12:01 PM, the walk-in cooler contained a cart with approximately 60 beverages in styrofoam cups not covered. The DM stated, I'll put a tray on it. At 12:04 PM, the walk-in cooler contained a bag of celery with a best by date of [DATE] that was watery, a bag of lettuce with no date, a box of approximately 10 whole cantaloupes that had a white fuzzy substance on them. At 12:06 PM, the walk-in freezer contained a box of chunk fry beef fritters that were opened and not sealed properly. At 12:10 PM, the reach in refrigerator contained a 5-pound container of Low-fat Cottage Cheese with a best by date of [DATE]. At 12:14 PM, Dietary Employee #1 was scooping ice from the ice machine into cups and picked up an ice cube with his bare fingers and put it back in a cup. 2. On [DATE] at 2:11 PM, a bag that contained 12 hot dog buns was on a bread rack in the storage room. One of 12 buns had a mold-like substance on it.

Based on observation, record review and interview the facility failed to ensure the call lights were within reach to assure residents could call for assistance when needed for 2 (Residents #17 and #3) of 11 (Residents #3, 17, 19, 41, 53, 80, 60, 33, 32, 18 and 233) who were dependent on staff for Activities of Daily Living (ADL)'s. This failed practice had the potential to affect 41 residents who were dependent on staff for assistance and able to use the Call Light, as documented on a list provided by the Director of Nursing (DON) on 10/1/2020 at 3:00 p.m. The findings are: 1. Resident #17 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/20 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required supervision to limited assistance for bed mobility, transfer and toileting and required physical help with the bathing activity. a. The Care Plan with review date of 2/3/20 documented, . The resident has an alteration in musculoskeletal status . Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. b. On 09/28/20 at 12:11 PM and 3:37 PM, the call light was clipped to the sheet under the bedspread and was not within reach of the resident who was sitting in a recliner next to the bed. c. On 09/29/20 at 09:35 AM, the resident was sitting in a recliner and the call light was clipped to bed, hanging close to floor, not within reach of the resident. The resident was asked, Can you reach your call light if you needed help? He looked around on his bed and could not find the call light. He stated No. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/20 documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), required limited assistance to extensive assistance for bed mobility, transfer and toileting and required physical help with the bathing activity. a. On 9/28/20 at 12:11 PM, the resident was lying in bed. His call light was hanging off the back of the bedside table. At 3:37 PM, the call light remained out of reach of the resident. b. On 9/29/20 at 9:35 AM, the resident was sitting in the bed. His call light was tied to the bedrail and lying on the floor. The resident was asked, Can you reach your call light if you needed help? He looked around and did not see the call light. He stated No call light. c. On 9/29/20 at 9:45 AM, Licensed Practical Nurse (LPN) #3, was asked, Should the call light be within the Resident's reach? She stated, Yes. At 9:50 AM, Certified Nursing Assistant (CNA) #2 was asked, Should the call light be within the Resident's reach? She stated, Yes. At 10:00 AM, the DON was asked, Should call lights be within resident's reach? She stated, Yes, always and staff should be checking while monitoring residents that the call light is within reach.

Complaint # was substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to ensure supervision was provided to prevent elopement from the facility as evidenced by failure to ensure interventions were immediately developed and consistently implemented to prevent the risk of further elopement for 1 (Resident #4) of 3 (Residents #4, #6 and #9) case mix residents who were at risk for elopement. The failed practice resulted in Past Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #4, who displayed exit seeking behaviors beginning 11/24/13 and eloped from the facility 11/26/14, and had the potential to affect 12 residents at risk for elopement, according to a list received from the DON on 2/6/14 at 12:06 p.m. The facility was informed of the Past Immediate Jeopardy on 2/6/14 at 2:58 p.m. The findings are: Resident #4 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set with an Assessment Reference Date of 1/15/14 documented the resident scored 8 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status, exhibited no wandering behaviors, required extensive assistance of two-plus people for transfers, did not walk in the room, required extensive physical assistant of one person for walking in the corridor, required limited physical assistance of one person for locomotion on and off the unit and used walker and a wheelchair for mobility. a. An Elopement Assessment form documented, "...Patient is at risk for Elopement: (Yes) 10/4/13" 1) On 2/6/24 at 11:18 a.m., Licensed Practical Nurse (LPN) #2 was asked, "Do you fill out the Elopement Assessment forms?" The LPN stated, "I do." The LPN was asked to explain what the check in the yes box for 10/4/13 on the Elopement Assessment form meant for (Resident #4). The LPN stated, "She (Resident #4) had increased behaviors that I had seen or been made aware of, so we changed it to yes as an elopement risk." The LPN was asked, "When you assess a resident as an elopement risk what do you do?" The LPN stated, "I notify the Social Services department and they put them in the elopement book. As far as I know they are put on the I-MAR (Electronic-Medication Administration Record) as an elopement risk, that's part of what we do." The LPN was asked who puts them on the I-MAR. The LPN stated, "Nursing puts them in the I-MAR, someone from the Social Services department puts them in the Elopement Book." 2) On 2/6/14 at 11:30 a.m., the DON was asked if she was aware Resident #4 had been assessed as an elopement risk. The DON stated, "I don't know, like I said I get a list. I could go back and look at that list." At 12:06 p.m., the DON presented Elopement Risk lists dated 10/10/13, 10/19/13 and 10/22/13. Resident #4 was listed on all three. b. A Nurse's Notes dated 11/22/13 at 2 a.m. documented, "Resident up wandering, looking for people and wanted to leave. Given juice and sandwich and redirected." 11/22/13 10-6 (10:00 p.m. - 6:00 a.m. shift) Resident up wandering and packing. Resident voices she is going home. No c/o (complaint of) pain. No c/o s/s (signs/symptoms) hypo/hyperglycemia. All needs met. Will monitor. 98.1 (temperature), 66 (pulse), 18 (respirations), 142/78 (blood pressure)." On 2/6/14 at 10:40 a.m., the DON was shown the above Nurses Notes above and asked if at this time the resident was considered an elopement risk. The DON stated, "I would think so because I think we had people checking on her, looking to see where she was." The DON was asked if there was anywhere that would be documented. The DON stated, "I think we just told the aides on the hall." c. A Nurse's Notes dated 11/24/13 LE (late entry) at 11:00 and signed by Licensed Practical Nurse (LPN) #1 documented, "Res. (Resident) exit seeking today. Res. redirected easily." 11/24/13 at 4:07 p.m., "Resident agitated and exit seeking-Klonopin 1/4 given Not easily redirected." 1) On 2/5/14 at 10:00 a.m., LPN #1 was asked about the above entries in the Nurse's Note that identified Resident #4 as displaying exit seeking and if anything was put into place to ensure the resident did not elope. The LPN stated, "I don't really remember. I know we were watching her, but other than that I don't know if anything else was put into place." The LPN stated, "I know at one point she was exit seeking so much that we activated the alarm here up by the desk by the fire panel. Anytime anyone goes in or out of a door an alarm sounds." The LPN was asked if the alarm was activated before or after the resident eloped? The LPN stated, "I know for sure it was after she had gotten out. We set the alarm system up front so when anyone goes in or out the alarm sounds." 2) On 2/6/14 at 10:40 a.m., the DON was asked about Nurses Note dated 11/24/13 at 11:00 that documented, "Resident exit seeking today. At 4:07 p.m. the Nurse's Notes documented, Resident agitated and exit seeking-Klonopin given, not easily directed." The DON was asked if interventions to prevent elopement were put in place at that time. The DON stated, "I'm not sure about that." e. Nurse's Notes entries dated 11/26/13 and signed by LPN #1 documented, "1320 (1:20 p.m.) Res had been exit seeking before lunch. Res. unable to be located in the building (at) this time. Res. being search for (at) this time by all staff. ...1340 (1:40 p.m.) Res. located outside facility. No coat or shoes on. Res. being returned to facility via staff ...1343 (1:43 p.m.) Spoke (with) (name)-notified of Res. escaping building. Awaiting return call... 1400 (2:00 p.m.) N.O. (New Order) 1. Ship to Geripsych (geriatric psychiatric) R/T (related to) Elopement from facility. ...1400 Left msg (message) for (name), son to please call facility back... 1600 (4:00 p.m.) Full body audit done-No notable injuries. Res. does have notable cough (at) this time. No Red areas, bruises, or scratches noted." A Nurse's Notes entry dated 11/26/13 at 10:00 p.m. documented, 98 (temperature) - 65 (pulse) - 20 (respirations) - 178 / 74 (blood pressure) Res has been calmer this pm. Remains confused voices wants (and) needs. Remains (with) CNA (Certified Nursing Assistant) 1 on 1. (No) exit seeking. Cog (Cognitive) skills severely impaired. Safety awareness impaired. Assisted (with) ADLS (Activities of Daily Living). FSBS (Finger Stick Blood Sugar) WNL (Within Normal Limits). Resp (Respirations) even, non-labored. (No) return call from son this shift. Cont. (Continue) to monitor." 1) On 2/5/14 at 10:00 a.m., LPN #1 was asked about the Nurse's Note dated 11/26/13 at 1:30 p.m. that documented, "Res had been exit seeking before lunch..." The LPN stated, "(Resident #4) walked out the door leading to the smoking area behind someone and was immediately brought back in." The LPN was asked what was put in place to monitor the resident to ensure she did not get out again. The LPN stated, "That is what somebody told me. I was unaware of that until we went looking for her. But I had been told that later." The LPN was asked, if any interventions were put into place after she was brought back in at lunch to keep her from walking out another door? The LPN stated, "Not that I'm aware of, but I don't know who brought her back in. Normally if I have one who is exit seeking I will keep them where I can keep an eye on them." The LPN was asked if anybody told her that the resident was brought back in at lunch. The LPN stated, "I believe I was told after lunch that she had gotten out before lunch and had been brought back in." The LPN was asked, "How did you realize she was gone?" The LPN stated, "Of course I didn't put it in there (Nurse's Notes) and I don't remember. I think they went to check on her and she wasn't in her room, but I wouldn't stake my life on that." The LPN was asked where the resident was found. The LPN stated, "She had cut across a field and was diagonal from here. They had called, a gentleman had seen her and he had her." The LPN was asked who went to get the resident. The LPN stated, "There were several who went to look for her, I don't know who picked her up." The LPN was asked, "How was she dressed?" The LPN stated, "She had a pair of pants on, short sleeved shirt, no shoes, she didn't have a coat on." The LPN was asked, "Was it cold outside?" The LPN stated, "It was cold enough you would have wanted to have a jacket if you went outside, because that was one of my concerns it was cold outside." The LPN was asked, "Do you know how long she was gone?" The LPN stated, "I couldn't tell you exactly how long, because before they said she was exit seeking before lunch. So lunch is at 12 (12:00 p.m.) and this was at 1:30 (p.m.) so I'm not sure, but she had gotten out after she ate lunch." The LPN was asked, if she knew the resident ate lunch. The LPN stated, "No, I really don't know because that was back in November." The LPN was asked what she did after the resident was back in the building. The LPN stated, "I know we put her on very close monitoring, we were attempting to get her out to Geri-psych. I don't know if we put anyone 1 on 1 with her." 2) On 2/5/14 at 1:40 p.m., CNA #1 was asked, "Do you know of any residents who have eloped?" The CNA stated, "(Resident #4), she got out of the dining room door about lunch time (11/26/14), but we saw her go out and we went and got her right back in. I sat her down to eat lunch. I started serving lunch, she got up then. We called a code gray and several staff went looking for her. She got out the first time when someone opened the door, then she got out again." The CNA was asked if this was all the same day. The CNA stated, "Yes." 3) On 2/6/14 at 10:40 a.m., the DON was asked about the documentation on the Nurses Noted dated 11/26/13 at 1:20 p.m. The DON stated, "They couldn't locate her. I remember them saying she didn't have any shoes on. They said she was looking for her house or something. There were several staff members that went and brought her back." The DON was asked if she knew where the resident was found. The DON stated, "I believe it was the Industrial Park area." The DON was asked, "Once she started exit seeking why did you not put her on one hour monitoring?" The DON stated, "I can't really tell you that, I really don't remember. I think the one hourly checks was put in after she had gotten out of the building, and the aide checks were increased to 15 minutes." The DON was asked were the 15 minute CNA checks for Resident #4 or for everyone. The DON stated, "For everyone who is an elopement risk." At 12:30 p.m., the DON was asked were any different interventions put into place after Resident #4's exit seeking behaviors on (11/24/13) and the elopement on (11/26/13) The DON stated, "We put in place one hour monitoring for all residents at risk for elopement, in-serviced all the staff about elopement, residents at risk, Elopement Book and where to find it and what all is in the book. We talked about red stars to identify them or red marks on the outside of the doors by their names." f. Social Service Notes dated 11/26/13 at 1:00 p.m. documented, "R (resident) was found to be walking around in the Industrial Park area less than quarter mile from facility. R is on Elopement Risk and managed to leave facility undetected. R does not know door code and it is my belief R may have went out the door behind a visitor. R was found to be safe and w/o (with out) any physical/emotional trauma/injury. R stated she was running away from home and asked staff not to tell her mother. R stated she was 'following the dogs.' R was changed and dressed in warm clothes and lay down to take a nap. Staff to stay one on one with R." Summary of Incident Report dated 11/26/13 at 1:30 p.m. documented, "At approximately 1:30 p.m., 11/26/13, Administrator received a call from a neighboring building stating that they had (Resident #4) with them and they were wondering if the facility could come pick her up. Resident (name) who is noted as having increasing behaviors was at the neighboring building and picked up by staff immediately. Upon investigation by Administrator Resident exited the building by following a visitor out." g. An In-service Sign In sheet titled "What is Elopement, Who is at risk, Where is the Elopement Book, and What is exit seeking" dated 11/26/13 was provided by the DON on 2/6/14. All staff had signed the In-service Sign In sheet. The Medication and Treatment Administration Record Report for Elopement Risk were copied on 1/31/14 at 9:30 a.m. and documented hourly checks were being done from 11/26/13 through 1/30/13, for Resident #4 and 2 other case-mix residents who were identified as elopement risks. h. On 2/6/14, 10 CNA staff members (CNAs #3 through #12) and 3 LPN staff members (LPNs #3, #4 and #5) were asked to state interventions related to the in-service on elopement. All members were able to verbalize interventions to put in place for residents at risk for elopement outlined on the in-service provided on 11/26/13. i. On 2/6/14 at 8:00 a.m., rounds were conducted with the Maintenance Supervisor. All exit doors sounded an alarm when pushed on. j. On 1/30/14 at 5:00 a.m. and on 2/5/14 at 7:45 a.m., the front door alarm sounded signaling an attempt by Resident #6 to exit the facility. On both attempts staff responded immediately. k. As of 2/6/14 at 1:40 p.m., the facility had no other reported elopements from the facility from 11/26/13 through 2/6/14.