Every finding on record at Springdale Health and Rehabilitation Center

Based on observations, interviews, record reviews and facility policy review it was determined that the facility failed to store portable oxygen cylinders properly based on two out of two observations. The findings include: On 02/09/2026 at 12:30 PM, a portable oxygen tank in the off position was observed resting stored against the wall to the right of the smoking area doorway in the Dining Area. A regulator was attached to the tank, and indicated the tank was filled and under pressure. Tubing was attached to the regulator and looped around the tank. Residents were seated at tables in the surrounding area eating lunch. On 02/11/2026 at 1:08 AM, this surveyor observed a portable oxygen tank, with regulator and tubing attached, resting on a dining table near the snack machine. The gauge on the regulator indicated the tank was filled. No staff or residents were in the area. During an interview on 02/11/2026 at 9:14 AM, License Practical Nurse (LPN) #1 indicated, staff removed the portable oxygen tanks from resident wheelchairs and put them on a caddy before taking residents outside to the smoking area. LPN #1 stated, The person taking the residents outside to smoke is responsible for the oxygen. Oxygen in the smoking area is a fire hazard and could explode. Oxygen can be in the tubing. LPN #1 confirmed nursing was responsible for oxygen tank removal and storage. During an interview on 02/12/2026 at 1:20 PM, Certified Nurse Assistant (CNA) #2 indicated, she did not know why oxygen tanks were being left in the dining area. CNA #2 stated, Only the nurses are allowed to remove oxygen from a resident. They are to turn it off and place it in one of those things that roll. During an interview on 02/12/2026 at 1:23 PM, CNA #3 revealed if the residents are smoking nurses should remove resident oxygen tanks. CNA #3 pointed out one empty caddy near the dining door, leading to the smoking area for storage. CNA #3 revealed it was not appropriate for the oxygen to be left un-stored, but oxygen was often seen unattended in the dining area. CNA #3 stated, CNA #3 sometimes places unsorted tanks in one of the rolling caddies. During an interview on 02/12/2026 at 1:30 PM, LPN #7 indicated portable oxygen tanks needed to be on the back of a wheelchair or secured in a caddie. LPN #7 stated it was not appropriate for oxygen tanks to be propped up on a wall or table because it could fall and explode, and it should never be on the floor. LPN #7 also stated, if an oxygen tank was empty or unused, it needed to be stored in an oxygen storage rack. During an interview on 02/12/2026 at 1:33 PM, the Director of Nursing (DON) indicated, if oxygen was being removed from a wheelchair, it needed to go into a secured device, a rollie, or a storage rack. The DON indicated CNAs were not to remove the oxygen tanks. She stated, Staff have been in-serviced. The reason for oxygen to be stored in a secure manner is because it is a safety hazard. During an interview on 02/12/2026 at 2:54 PM, the Administrator indicated the expectation was that oxygen tanks were stored properly, and she expected staff to follow policy. Review of a facility in-service titled Portable oxygen tank, dated 02/11/2026, indicated at no time should a tank be unsecured and it must be in a rack or a 2-wheel caddy. The in-service also indicated oxygen was not to be set on the floor or table. Review of a facility policy titled, Oxygen Storage Safety, dated 03/01/2010, indicated oxygen cylinders should be stored only in designated storage areas. Cylinders are to be secured from falling or mechanical shock.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy review the facility failed to ensure medications were properly stored to ensure residents did not have access to medications without supervision from an unsecured medication care and a medical supply storage closet left unsecured, during two of two observations. The findings include: On 02/11/2026 at 1:10 AM, this Surveyor observed Registered Nurse (RN) #12 pushing a cart of water pitchers down D Hall towards the kitchen with RN #12's back to the nurses station. A medication cart was near D Hall pressed against the nurse's station, unlocked and unattended. On 02/11/2026 at 1:33 AM, RN #12 was observed in the nurse's station talking to Licensed Practical Nurse (LPN) #13 with her back to the unlocked medication cart, and one resident in a wheelchair was seen on D hall, in the proximity of and facing the cart. This Surveyor opened the top-drawer of the unattended medication cart revealing resident medication cards. RN #12 stated that she had been stocking the medication cart about the time surveyors arrived and she forgot to lock the medication cart. RN #12 stated the medication cart was supposed to be locked when unattended so residents cannot get into the cart, and revealed there were residents that ambulate or self-propel in the facility [who could have access to an opened cart]. On 02/11/2026 at 1:35 AM, this Surveyor observed the Medical Supply Storage Closet door ajar. Observed inside the Medical Supply Storage Closet were scissors resting on top of an open medication cart, two containers of antibiotic cream resting in an open medication cart drawer, wound cleanser, and a bottle of vitamins in open shelving. RN #12 stated, the closet was for the treatment nurse and anyone that needed supplies. RN #12 and LPN #13 denied using the closet that shift, both confirmed the door was supposed to be locked, and residents were not allowed access to the closet. RN #12 stated, There are wound cleansers and other potentially hazard things to the residents if they were to get into it. During an interview on 02/12/2026 at 10:18 AM, the Director or Nursing (DON) indicated, her expectation was for staff to lock the medication cart and storage closet when unattended The DON stated, It is for resident safety, and to ensure that medications are not being taken by other residents or employees, and HIPPA compliance. The DON indicated the medication supply closet was supposed to be kept locked to prevent resident access and that during orientation nursing staff were trained on the medication room, and storage of medications. The Administrator was present during the interview and stated staff were expected to follow policy. Review of a facility orientation documents titled RN/LPN Orientation/Training dated 12/24/2025, revealed RN #12 received orientation/training that covered medication storage on 12/24/2025, and LPN #13 received new hire orientation training including medication storage on 09/29/2025. Review of a facility policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, 2017 revealed staff should ensure that medications and biologicals are stored in an orderly manner in cabinets, carts, refrigerators and drawers and be securely locked.

Based on observations, interviews, and facility policy review, the facility failed to ensure a safe, functional, and sanitary environment by failing to implement the smoking policy. The facility failed to ensure residents extinguished cigarette butts in non-combustible, self-closing ashtrays and failed to ensure staff smoked only in authorized areas. Specifically, cigarette butts were found on the ground around the resident patio, in flowerpots, and in a rock bed near the dining room exit leading to the staff smoking area.Based on observations, interviews, and facility policy review, the facility failed to ensure a safe, functional, and sanitary environment by failing to implement the smoking policy. The facility failed to ensure residents extinguished cigarette butts in non-combustible, self-closing ashtrays and failed to ensure staff smoked only in authorized areas. Specifically, cigarette butts were found on the ground around the resident patio, in flowerpots, and in a rock bed near the dining room exit leading to the staff smoking area for one of one building observed The findings include: On 02/10/2026 at 9:37 AM, this surveyor observed cigarette butts scattered across rock beds along the north side of the building, and behind the west side of the dining room outside the building. On 02/10/2026 at 11:33 AM and 11:40 AM, this Surveyor observed cigarette butts in the resident smoking area on the ground, in the flowerpots, and the concrete patio was littered with cigarette butts. The surveyor also observed cigarette butts in the rock bed adjacent to the dining room exit door. During an interview on 02/11/2026 at 4:07 PM, the Maintenance Director (MD2) indicated Floor Technicians (FT) were responsible for ground maintenance. During a tour and concurrent interview on 02/12/2026 at 10:40 AM, the Housekeeping Supervisor (HS) indicated maintenance was responsible for ground maintenance. Upon physical inspection with the HS, cigarette butts were identified on the ground around the staff gazebo, in flowerpots, and in the rock bed by the exit door as well as in the resident smoking area on the ground, in the flowerpots, and the concrete patio were covered with cigarette butts, even though patio was equipped with proper lid closing ashtrays and red metal extinguishing can. During an interview on 02/12/2026 at 11:08 AM, the FT indicated housekeeping was responsible for ground maintenance. During an interview on 02/12/2026 at 11:01 AM, the Administrator initially indicated ground maintenance was the responsibility of housekeeping but acknowledged conflicting reports from staff. The Administrator was informed of the widespread presence of cigarette butts at the front of the facility, the north side rock beds, the staff smoking area, and the resident smoking area. During an interview on 02/12/2026 at 12:11 PM, Certified Nurse Assistant (CNA) #8 verified that residents throw cigarettes on the ground. CNA #8 reported attempting to assist residents with ashtrays while smoking but the residents continue to throw the cigarette butts on the ground. Review of a facility policy titled Smoking, dated 10/15/2022, read in part Ashtrays must be non-combustible and prevent butts from falling out. Containers must have self-closing lids, and Smoking is permitted only in authorized areas.

Based on observations, interviews, and facility document review, the facility failed to provide a safe and functional environment by failing to ensure corridors were equipped with firmly secured handrails and failing to maintain resident room walls in good repair. Specifically, handrails were loose on E Hall and C Hall, one of one bedroom observed (Resident #19) had scratches in the paint on the left side of the wall beside the bed.Based on observations, interviews, record review and facility policy review, the facility failed to ensure corridors were equipped with firmly secured handrails; specifically, handrails were loose on two (E and C Halls) of four Halls observed. The findings include: On 02/10/2026 at 2:40 PM, this Surveyor observed the handrail outside of room [ROOM NUMBER] on E Hall was not secured to the wall. During an interview on 02/11/2026 at 11:24 AM, the Maintenance Director (MD2) confirmed the handrail was loose on E Hall and stated a resident pulling or propping on the rail could result in injury. MD2 stated there was no routine for checking handrails. During an interview on 02/11/2026 at 11:29 AM, the Maintenance Aide (MA) stated handrails were checked and fixed, but not all had been reached. Review of Maintenance Logs on 02/11/2026 at 11:31 AM, revealed for the previous two months there were no entries regarding loose handrails and only one entry for a missing handrail in a common area. On 02/12/2026 at 3:01 PM, this Surveyor observed a loose handrail on the left side of the hallway on the C Hall. During an interview on 02/12/2026 at 3:29 PM, the Administrator denied being aware of any loose handrails in the facility and stated that staff had access to maintenance logs to report items in need of repair. Review of the facility policy titled Federal Rights of a Resident, effective 11/28/2016, revealed the facility must provide a safe and comfortable homelike environment. The policy specifies that the physical layout must maximize resident independence and not pose a safety risk.

Based on observations, interviews, and facility policy review, the facility failed to ensure open food items stored in the refrigerator were dated; spoiled fruit was promptly removed/discarded from the walk-in refrigerator; a beverage labeled with a staff member's name was not stored in the walk-in refrigerator; and expired food was promptly removed/discarded by the expiration date to prevent service to residents; to ensure sanitary procedures including hand hygiene were followed when handling raw and cooked food, to prevent a potential foodborne illness in 1 of 1 kitchen. This failed practice had the potential to affect 95 residents as documented on a list provided by the Director of Nursing (DON) on [DATE] at 12:39 PM. Findings include: 1. A review of a facility dietary service policy titled, Food Receipt and Storage, dated [DATE] indicated, .Foods should be .stored properly to prevent food borne illnesses . Standard: Foods should be checked for freshness . stored in accordance . Storage of Foods . k. Open food items should be covered, labeled, and dated . a. During an observation and interview on [DATE] at 11:17 AM, one open bag of shredded lettuce was on a metal shelf in the walk-in refrigerator. The Registered Dietician (RD) #4 stated the lettuce should be labeled with the open date. b. During a concurrent observation and interview on [DATE] at 11:18 AM, two flats of strawberries were stacked on a metal shelf in the walk-in refrigerator. The top flat held 6 containers of strawberries covered with a gray fuzzy material. Registered Dietician (RD) #4 stated there were 6 quarts of strawberries covered with a moldy substance, and the strawberries need to be tossed. c. During an observation and interview on [DATE] at 11:30 AM, a 16.9 ounce bottle of water, with [Employee Name] written on label, was located on a metal shelf to the left of the refrigerator door. Registered Dietician (RD) #4 stated she did not know who (Employee Name) was and stated she would have to ask. No (Employee Name) is on the census list provided by the facility. d. During a concurrent observation and interview on [DATE] at 06:26 AM, a box containing individual servings of relish, with an expiration date of [DATE], was located on a shelf in the dry storage room. Dietary Manager (DM) #5 stated the half full case of relish should not be on the shelf or served to residents because it is out of date and if served it had the possibility to cause illness to the residents. 2. A review of a dietary service facility policy titled, Hand-washing Guidelines, dated [DATE], indicated, .Purpose: To prevent the spread of bacteria that may cause food borne illness . Process: .Hands should be washed in the following situations: .After hands have touched anything unsanitary . After hands have touched the face, nose . While preparing food, especially when changing preparation procedures, and when working with different raw foods . a. A review of an infection prevention policy titled, Hand Hygiene, dated [DATE] indicated, .Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques and will aide in the prevention of the transmission of infections. Standard: Handwashing should be performed .Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene .before and after .handling food (hand washing with soap and water) . b. During an observation on [DATE] at 7:31 AM, Dietary [NAME] (DC) #6 cracked 2 raw eggs into a frying pan on the stovetop, returned to the serving line, prepared two trays with plates, then placed scrambled eggs and sausage on the plates. DC #6 returned to stove, cracked a raw egg into frying pan, a portion of the shell fell into pan. DC #6 removed the shell, with clear egg material attached, from the pan with a metal spatula/[NAME] and used her fingers to dispose of the shell. DC #6 cracked 4 additional eggs into the frying pan and returned to the serving line. She placed scrambled eggs and a sausage patty on a plate and pushed the tray down the line toward the serving window. DC #6 removed two cooked eggs from the fry pan and cracked 2 raw eggs into the fry pan. No hand washing was performed when changing from raw food prep to cooked food area. c. During an interview on [DATE] at 7:34 AM, Dietary Manager (DM) #5 was notified of Dietary [NAME] (DC) #6's moving between stations, handling raw eggs and placing cooked food on plates to be served to residents without hand washing. DM #5 removed three trays prepared by the cook from the serving line and stated this should not occur. d. During a follow up interview on [DATE] at 8:36 AM, Dietary Manager (DM) #5 stated Dietary [NAME] (DC) #6 should not have handled raw egg products then moved back to the serving line without hand washing. It is very dangerous for residents due to possibility of cross contamination, salmonella and other bacteria. e. During an interview on [DATE] at 8:39 AM, Dietary [NAME] (DC) #6 stated you should not change work areas due to cross contamination and you should wash your hands.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure a staff member did not remove food from the floor and place it on a dining table during meal service; failed to ensure hand hygiene was performed while assisting a resident with their meal intake for 1 (Resident #12) resident of 2 sampled residents observed during meal service and failed to ensure hand hygiene was performed while handling meal trays; failed to ensure hand hygiene and glove changes were performed during tracheostomy care for 1 (Resident #99) resident of 1 sampled resident reviewed for tracheostomy care; and failed to ensure proper personal protective equipment (PPE) was used and hand hygiene was performed with glove changes, during perineal care for 1 (Resident #21) resident of 1 sampled resident observed during perineal care. Findings include: 1. A review of a dietary service facility policy titled, Hand-washing Guidelines, dated 02/01/2002, indicated, .Purpose: To prevent the spread of bacteria that may cause food borne illness . Process: .Hands should be washed in the following situations: .After hands have touched anything unsanitary . After hands have touched the face, nose . A review of an infection prevention facility policy titled, Hand Hygiene, dated 06/11/2020 indicated, .Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques and will aide in the prevention of the transmission of infections. Standard: Handwashing should be performed between procedures with resident . based upon the principle that all . secretions . and mucus membranes may contain transmissible infections agents . Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . before and after . handling food (hand washing with soap and water) . wiping nose . after contact with a resident . mucus membranes . or excretions . A review of the Face Sheet indicated the facility admitted Resident #12 with diagnoses that included frontal neurocognitive disorder, dysphasia, oropharyngeal phase, muscle wasting and atrophy, and lack of coordination. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2024, revealed Resident #12 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #12 required partial to moderate assistance with eating. A review of Resident #12's Care Plan, dated 07/18/2019, revealed the resident had the potential for weight loss. Interventions included intermittent assistance with meals, use small bites, alternate food and liquids. During an observation on 07/29/2024 at 12:55 PM, Nursing Assistant (NA) #1 picked up food from the floor and placed it on the resident's napkin on the table. No hand hygiene was performed. NA #1 placed food on a spoon and placed it in Resident #12's mouth. During an observation on 07/29/2024 at 1:05 PM, Nursing Assistant (NA) #1 was touching his mouth, face, and tapping his fingers on the table. No hand hygiene was performed. NA #1 then assisted Resident #12 with a beverage. During an interview on 07/30/2024 at 8:38 AM, Nursing Assistant (NA) #1 stated his hands should have been sanitized after touching his cheek and lips and he should not have picked up the food from the floor and put it back on the table because cross contamination and infection could be caused to the resident. 2. A review of the Facility Assessment with a review and approved date of 07/22/2024 revealed, .(19) Tracheostomy Comments: Our facility hasn't provided care for any patients with this need. In the event of a referral for a resident with an established trach and otherwise clinically accepted, staff would require additional training . A review of the policy titled, Tracheostomy Care with an effective date of 11/30/2017, documented, .Purpose: .Care of the tracheostomy is important to maintain an open airway and to prevent infection of the site. Standard: .Aseptic technique is used: .during cleaning . Process: .i) Remove old dressing, pull soiled glove down over the hand, and the soiled dressing, and roll glove over dressing; discard both into appropriate receptacle j) Put on sterile gloves k) Squeeze out excess normal saline from 4x4 and cleanse under tracheostomy tube flanges and ties l) Use cotton tipped applicator saturated with normal saline or hydrogen peroxide to remove any encrusted material difficult to remove with gauze. m) Continue cleaning until skin surrounding site is clean) Dry area with sterile 4x4 gauze o) Remove old tracheostomy ties while assistant holds neck plate of tracheostomy in place, OR if old ties not excessively soiled . Use of [Brand Name] Disposable Cannula . b) Remove present inner cannula . d) Reinsert new cannula . the inner cannula should be moistened with sterile saline or water soluble lubricant . g) Follow steps (i) through (r), OR Reusable cannula for dressing and tracheostomy tie changes . A review of the Matrix for Providers presented by the facility on 07/29/2024 indicated Resident #99 was admitted to the facility on [DATE] with a tracheostomy. A review of a facility document titled, Face Sheet indicated the facility admitted Resident #99 on 07/02/2024 at 4:06 PM, with diagnoses that included quadriplegia, acute respiratory failure, chronic respiratory failure with hypoxia and tracheostomy status. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/2024 revealed, Resident #99 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact, had upper and lower body functional limitations, required a wheelchair for mobility, required staff assistance for meals, was dependent on staff for oral hygiene, toileting, personal hygiene, and was receiving tracheostomy care and suctioning. A review of Resident #99's Care Plan, with a start date of 07/08/2024, revealed the resident had altered respiratory function related to chronic respiratory failure and potential for complications related to tracheostomy. Interventions included suction trach as ordered. A review of the Physician Orders, revealed Resident #99 had an order to clean trach site with sterile trach kit apply split sponge gauze dressing and monitor for s/s (sign/symptoms) of infection; Use tracheostomy product #6 mm (millimeter) daily suction as needed and change tubing and suction canister every Wednesday, and a PRN (as needed) order for trach suctioning. During an observation on 07/30/2024 at 2:15 PM, Licensed Practical Nurse (LPN) #2 explained care to Resident #99, inspected and loosened trach collar neck ties, removed gloves washed hands, and donned sterile gloves, removed a soiled split gauze from under the neck plate of the device, placed the soiled gauze into a container with the clean supplies, picked up clean split gauze out of the same container and placed under the neck plate. Skin and neck plate were not cleaned, no hand hygiene or glove change was performed between the dirty and clean tasks. LPN #2 fastened clean neck ties to the neck plate and secured with the hook and loop fastener over the top of the soiled neck ties. Removed soiled neck ties, gloves and disposed of supplies. During an interview on 07/30/2024 at 2:46 PM, Licensed Practical Nurse (LPN) #2 stated a sterile kit was used with a clean technique. The neck plate needs to be cleaned and the skin below it should be cleaned. LPN #2 stated, I kept the sterile gloves in play and did not sanitize or change gloves. LPN #2 stated the dirty items should not be taken to the clean field due to contamination and the potential to cause infection. During a concurrent observation and interview on 07/31/2024 at 7:45 AM, Certified Nursing Assistant (CNA) #3 was at the kitchen serving window, preparing resident meal trays. CNA #3 scratched her cheek and placed a lid on a bowl containing hot cereal, and then placed a dome cover on a plate without performing hand hygiene. CNA #3 stated hand hygiene should have been performed after touching her face to prevent cross contamination that can cause illness to residents. 3. A review of a facility policy titled, Enhanced Barrier Precaution, dated 04/29/2024 indicated, .3. EBP [Enhanced Barrier Precautions] requires donning [putting on] of gown and gloves during high-contact resident/guest care activities . 5. EBP is employed while performing High - contact resident/guest care activities . Providing hygiene . Changing briefs or assisting with toileting . A review of the Physician ' s Orders, revealed Resident #21 had a diagnosis of an open area to left lower extremity placed on Enhanced Barrier Precautions 06/26/24. During an observation on 07/30/2024 at 4:07 PM, Certified Nursing Assistant (CNA) #14 and Nursing Assistant (NA) #15 enter Resident #21's room with gloves on only. Resident #21 was placed on the bed utilizing a mechanical lift. Perineal care was provided. Dirty gloves were still on when NA #15 placed the clean brief on Resident #21 and touched Resident #21's bed. CNA #14 still had dirty gloves on when the mechanical lift was removed from the room. No hand hygiene was performed before, during, or after perineal care. No gowns were put on at any time. During an interview on 07/31/2024 at 4:16 PM, Certified Nursing Assistant (CNA) #14 acknowledged enhanced barrier precautions were ordered for Resident #21 and that they did not utilized PPE. CNA #14 stated gloves should have been changed after dirty care and hand sanitizer should have been applied. During an interview on 08/01/2024 at 9:52 AM, the Unit Coordinator/Infection Control (UC/IC) #9 stated it is not acceptable to pick up anything from the floor and place it on the table during a meal or while assisting residents. People walk on the floor, there are germs that can cause infection and you don't want to introduce something from the floor into a resident's mouth, it is just nasty and can make them sick. Staff should be sanitizing their hands if they touch their face or anything else. Infection prevention is number one. You don't know what is on their hands that can potentially introduce something to a resident and make them ill. She continued to say that when providing tracheostomy care, staff should sanitize their hands, put on gloves, and a gown, remove the dressing, clean the trach area, and remove the gloves and sanitize. They should then put on sterile gloves and finish putting in the inner cannula, new gauze under the plate, and secure neck strap. Gloves should be changed, and hands sanitized when going from dirty to clean. If that is not done it can cause a possible infection and with trachs (tracheostomy). You should try everything you can to not introduce anything new that would cause infection to a resident and possibly lead to death. UC/IC #9 stated enhanced barrier precautions should be used during perineal care, using hand hygiene and gloves. Hand hygiene and glove changes should be done when going from dirty to clean, and more frequently if the gloves become soiled. If staff are unsure about what to put on, they should ask their nurse. Enhanced barrier precautions are in place to prevent infection and germs that cause urinary tract infections (UTI) such as C-Diff (clostridioides difficile) and ESBL (extended spectrum beta lactamase). There is no way to determine the type of infection that could be caused if you are not using proper procedures. 42016

Based on observations, interviews, and policy document review, the facility failed to maintain a clean and safe environment for 3 sampled residents (Resident #13, #26, and #51). The findings are: A review of the policy titled; Cleaning-Wet Mopping indicated cleaning will be done daily and more frequently if spillage or visible soiling occurs. 1. During a concurrent observation and interview on 07/29/2024 at 2:48 PM, Resident #13 and a family member voiced a concern of the cleanliness and operation of a toilet riser located in the bathroom for Resident #13's assistance. Observation showed both back corners of the frame had dark orange and brown areas. On 07/30/24 at 9:47 AM, the surveyor observed the bathroom grout/tile beside and behind toilet in Resident #13's bathroom. A dark brown substance was observed at the bottom of the wall, and a dark brown area to the inner bottom of the door frame. On 07/31/24 at 10:45 AM, the surveyor observed the bathroom grout had been cleaned. No dark brown substance was noted in the grout. But the dark brown area to the inner bottom of the door frame remained. The surveyor observed the metal transition strip, which was 2 feet by 3 feet, protruding up, not level with the floor and noted to have sharp edges at the ends of both sides of the strip. A review of the Face Sheet indicated the facility admitted Resident #13 with diagnoses that included arthritis, multiple sites, and a history of falling. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/2024 revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident moderately cognitively impairment and required partial to moderate assistance with standing from a sitting position, and toilet transfers. 2. During a concurrent observation, and interview, on 07/30/24 at 8:38 AM, the wall of Resident #26's room was observed to have two large, damaged areas with paint missing at both the head of bed and to the side. Resident #26 stated they were present when he moved to this room. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/2024 revealed Resident #26 had a brief Interview of Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. 3. During a concurrent observation and interview with Housekeeping Supervisor #12 on 07/31/2024 at 10:45 AM, Housekeeping Supervisor #12 accompanied the surveyor to Resident #51's room and observed the bathroom in which a dark brown substance in the grout behind and beside the toilet had been cleaned. Housekeeping Supervisor #12 reported that she had been on her hands and knees this morning cleaning that up. She was asked to describe the bottom of the inner door frame to the surveyor. She described the area as rust that cannot be cleaned off and that it was maintenance's responsibility. She was asked to describe the metal transition strip. She described it as protruding and with sharp edges. She also reported that the lip should be flat to the floor because they could get cut or hurt or even trip and fall from it. During an interview with Resident #51 on 07/30/2024 at 9:47 AM, Resident #51 revealed that the resident had told maintenance about the floor numerous times and stated that the resident had believed that it was black mold. She reported that the new metal piece was placed over a line of black substance and was not cleaned prior to and that you could kind of see it. During a concurrent observation and interview with the Maintenance Director on 07/31/2024 at 2:10 PM. The surveyor took the Maintenance Director to Resident #51's bathroom and showed the metal transition strip. The Maintenance Director stated that the strip should be flat to the ground to ease transition through the door and the edges are sharp and dangerous. The area around the bottom of the door entry is surface damage and his level of repair would be to replace the door frame, but probably will be sanded and fixed. A review of Resident #51's Face Sheet revealed the resident had diagnoses to include dementia and bipolar disorder. A review of a quarterly Minimum Data Set (MDS) Quarterly with an Assessment Reference Date (ARD) of 05/31/2024 revealed Resident #51 had severe cognitive impairment and independently ambulated with staff assist and required set up or clean up assistance with toileting. A review of a Care Plan with review date of 07/03/24 revealed that staff were to observe the room for safety concerns such as glass or sharp objects, dated 12/13/2021. 50924

Based on observations, interviews, and record reviews, the facility failed to ensure staff did not stand over residents who required assistance during meals for 2 (Resident #12 and Resident #60) of 2 sampled residents observed during meal service. Findings include: During an interview on 08/01/2024 at 8:51 AM, Nurse Consultant (NC) #8 stated the facility did not have a policy for dining assistance or serving meals to residents and referred to the resident right of dignity. A review of a facility booklet titled, Resident Handbook undated, indicated, (a) Resident Rights. The resident has the right to a dignified existence . A review of the Face Sheet indicated the facility admitted Resident #12 with diagnoses that included frontal neurocognitive disorder, dysphasia, oropharyngeal phase, muscle wasting and atrophy, and lack of coordination. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/14/2024, revealed Resident #12 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #12 required partial to moderate assistance with eating. A review of Resident #12's Care Plan, dated 07/18/2019, revealed the resident had the potential for weight loss. Interventions included intermittent assistance with meals, use small bites, alternate food and liquids. A review of the Face Sheet indicated the facility admitted Resident #60 with diagnoses that included non-ST elevation myocardial infarction, dementia, and sequalae of nontraumatic subarachnoid hemorrhage. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2024, revealed Resident #60 had a Staff Assessment for Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #60 required setup or clean-up assistance with meals. A review of Resident #60's Care Plan, dated 01/15/2024, revealed the resident was at risk for choking, dehydration, requires staff assistance with activities of daily living (ADL), potential for weight loss. Interventions included observing the resident for signs and symptoms of aspiration, reminding resident to tuck chin when swallowing, alternate food and fluids, offer and encourage fluids, give verbal cues, divided plate, and allow sufficient time to feed. During an observation on 07/29/2024 at 12:51 PM, Certified Nursing Assistant (CNA) #7 was in the main dining room, standing on the left side of Resident #60 while assisting with placing food and beverage in the resident's mouth. During an observation on 07/29/2024 at 12:53 PM, Nursing Assistant (NA) #1 was in the main dining room, standing on the left of Resident #12, assisting with placing food in the resident's mouth. During an interview on 07/29/2024 at 2:41 PM, Nursing Assistant (NA) #1 stated you should be level with the resident while assisting them and you should not stand and bend over a resident. Standing over the resident is disrespecting them. During an interview on 07/31/2024 at 2:28 PM, Certified Nursing Assistant (CNA) #7 stated you should not stand to help someone eat. You should be level, because standing over them makes them feel like we are bigger than them. During an interview on 08/01/2024 at 9:52 AM, Unit Coordinator/Infection Control (IC #9) stated when assisting a resident with meals, staff should sit with the resident, be on the same level as them, talk to them, wipe their face, treat them with dignity. Staff should not stand to assist residents. 42016

Based on observation, record review, and interview, the facility failed to ensure residents were showered/bathed as scheduled to promote good personal hygiene for 5 Residents (Resident R #1, #2, #3, #4, #5) sample mix residents who require assistance with showering/bathing. The findings are: 1. Review of Resident #1's shower log lookback provided by the Nurse Consultant dated 10/01/2023 through 12/31/2023 documented the Resident had a shower on 10/10/2023; 10/24/2023; and 11/20/2023. a. Review of the care plan dated 10/09/2023 showed requires assistance to completed daily activities of care safely . bath per schedule. b. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2024 noted the Resident #1 required supervision or touch assistance with tub/ shower transfer; required partial or moderate assistance with shower/ bathing. 2. Review of Resident #2's care plan dated 12/11/2023 did not document daily activities care. a. The Quarterly MDS with an ARD of 01/02/2024 documented the Resident requires partial/ moderate assistance with shower/ bathing. b. Review of the shower log lookback provided by the Nurse Consultant dated 01/11/2024 through 02/10/2023 documented the Resident #2 had a shower on 02/09/2024. 3. Review of Resident #3's care plan dated 04/10/2018 documented unable to perform self-care requires total assistance . bath per schedule. a. Review of physician orders dated 01/05/2024 documented the Resident shower days are Monday, Wednesday, and Fridays. b. Review of the Quarterly MDS with an ARD of 01/17/2024 documented Resident #3 is dependent for shower/ bathing. c. Review of the shower log lookback provided by the Nurse Consultant dated 12/13/2023 through 02/10/2024 documented Resident #3 had a shower on 01/19/2024. 4. Review of Resident #4's care plan dated 12/26/2023 noted Activities of Daily Living (ADL) function unable to perform self-care requires total assistance . bath per schedule. a. Review of the Admission MDS with an ARD of 12/28/2023 noted the Resident #4 is dependent for shower/ bathing. b. Review of the shower log lookback provided by the Nurse Consultant dated 01/16/2024 through 02/10/2024 documented Resident #4 had a shower on 01/16/2024; 01/192024; 01/23/2024 and refused a shower/ bath on 01/26/2023. 5. Review of Resident #5 care plan dated 09/11/2023 did not document ADL assistance needs. a. Review of the Quarterly MDS with an ARD of 01/08/2023 noted Resident #5 had impairment on one side for both upper and lower extremity and was dependent on staff shower/ bathing and tub/ shower transfer. b. Review of the shower log lookback provided by the Nurse Consultant dated 01/17/2024 through 02/10/2024 documented the Resident had no shower from 01/17/2024 thru 02/10/2024 and that the Resident refused her shower on 02/10/2024 per shower sheet that Resident signed. c. On 02/14/2024 at 10:44 AM, the Surveyor observed Resident #5 in her room with hair that appears unclean and greasy. d. On 02/14/2024 at 10:44 AM, the Surveyor interviewed Resident #5 and asked, Are you receiving your shower/ bath? She stated, Not always no. I didn't even get offered one on Saturday. e. On 02/14/2024 at 10:47 AM, the Surveyor observed Resident #2 with hair that appears unclean and greasy. f. On 02/14/2024 at 10:47 AM, the Surveyor interviewed Resident #2 and asked, Are you receiving your shower/ bath? She stated, If possible, yes. I've missed several lately. I missed my shower Monday because a [Certified Nursing Assistant] CNA called in. I'm due again tomorrow so we'll see. g. On 02/14/2024 at 10:49 AM, the Surveyor observed Resident #3 in his room with hair that appears unclean and greasy. h. On 02/14/2024 at 10:49 AM, the Surveyor interviewed Resident #3 and asked, Are you receiving your shower/ bath? He stated, Not like I'm supposed too lately. I get them at night, and I'm supposed to be Monday, Wednesday, and Friday but not lately. They did give me one I believe on a Saturday. i. 02/14/2024 at 10:57 AM, the Surveyor observed Resident #4 with hair that appears unclean and greasy. j. On 02/14/2024 at 10:57 AM, the Surveyor interviewed Resident #4 and asked, Are you receiving your shower/ bath? She stated, I get a bed bath when they give me one. k. On 02/14/2024 at 11:02 AM, CNA #1 confirmed Residents #2, #3, and #4 had not been showered/bathed according to the shower schedule and the Residents hair was not clean. l. On 02/14/2024 at 11:10 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #1 and she confirmed Residents are not receiving their shower as scheduled. m. On 02/14/2024 at 01:09 PM, the Director of Nursing (DON) confirmed Residents #2, #4 and #5 do not appear to have had a bath according to the two shower a week schedule, and that their hair appears greasy. n. Hygiene and Grooming Policy provided on 02/14/2024 by the Nurse Consultant documented, Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity . Standard: Guidelines for the provision of hygiene and grooming services are: shower, tub or complete bed bath, as needed . Services may be provided on a varying schedule when a physician's order or physician documentation of a medical contraindication exists or when the resident needs services more frequently . o. Documentation of Routine ADL Care Policy provided on 02/14/2024 by the Nurse Consultant documented, Standard: The State of Arkansas requires specific documentation of ADL care provided by the C.N.A., and documentation of restraint use, by the C.N.A. Arkansas facilities should utilize a computer-generated ADL sheet that includes the use of restraints. Routine ADL care may include bathing .

Based on record review and interview, the facility failed to ensure the comprehensive care plan was individualized to addressed appropriate care and services for activities of daily living (ADL) for 2 Residents (R #2, #5) of 5 sampled residents who required ADL assistance. The findings are: 1. Review of Resident #'2's care plan dated 12/11/2022 did not document activity of daily living assistance. a. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2024 noted the resident required supervision or touch assistance with tub/ shower transfer; required set-up or clean up assistance with upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene; required partial or moderate assistance with shower/ bathing. 2. Review of Resident #5's care plan dated 09/11/2023 did not document activity of daily living assistance. a. Review of the Quarterly MDS with an ARD of 01/08/2023 noted the resident had impairment on one side for both upper and lower extremity and was dependent on staff for toileting hygiene, shower/ bathing, chair/ bed to chair transfer, and tub/ shower transfer; required substantial/ maximal assistance with upper body dressing, lower body dressing, putting on/ taking off footwear, personal hygiene, roll left to right, sit to lying; requires supervision or touching assistance with oral hygiene; requires set up or clean up assistance with eating. b. During an interview with the Director of Nursing (DON) on 02/15/2024 at 08:22 AM, she confirmed resident #2 and #5 were not care planned for their activities of daily living (ADL) care in order for staff to know what type of care to provide for them.

Based on record review and interview, the facility failed to ensure residents individualize plan of care was revised to reflect the current needs of the resident and updated to include oxygen use for 1 Resident (R #2) of 3 sample mix residents who use oxygen as documented in physician orders. The findings are: 1. Resident #2 care plan dated 12/11/2022 was not revised on 08/28/2023 to include oxygen use ordered by the physician. a. Physician order dated 08/28/2023 documented oxygen at three (3) liters per minute per nasal cannula for shortness of breath. b. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2024 documented oxygen therapy while a resident. c. During an interview with the Director of Nursing (DON) on 02/15/2024 at 08:22 AM, she confirmed an oxygen order should be on the care plan and that resident #2 did not have it on her care plan.

Based on observation and interview the facility failed to ensure practices were utilized to prevent cross contamination during dining and food preparation. The practice had the ability to affect all 90 residents who received their meals from 1 of 1 facility kitchen according to a list provided by consultant #1 at 9:38 AM and 34 residents who eat their meals in the main dining room according to a list provided by RN consultant #2 on 7/28/23 on. The findings are: On 7/24/23 at 11:15 AM observed on the top shelf above the 3-compartment sink there were 2 large skillets, one with a smaller skillet nested inside stored right side up. On 7/24/23 at 11:50 AM observed Certified Nursing Assistant (CNA) #1 obtain multiple clothing protectors out of a chest of drawers located in the main dining room. Clothing protectors were held against her person as she moved to the table. Upon reaching the table clothing protectors were placed on the table in a pile. CNA #1 placed a clothing protector on a resident. As the clothing protector came to rest on his person the resident reached for the protector and removed it. CNA #1 took the contaminated clothing protector and placed it on the next resident. Observed CNA #1 place multiple clothing protectors on residents and each time the protector was held against her person prior to placing the protector around the neck of the resident. On 7/24/23 at 11:55 AM observed CNA #1 offer resident a cup of coffee. CNA #1 brought cup to the table and placed it in front of the resident with her fingers placed around the top of the cup prior to placing a lid on the top of the cup. On 7/26/23 at 10:55 AM observed the oil vat of the deep fryer uncovered exposing the liquid to contaminants. The area around the vat was littered with what appear to be food particles in varying shades of brown. On 7/26/23 at 11:05 AM observed Dietary Aide #1 as she prepared a cheese sandwich, with her gloved hand picked up the zip lock bag containing the sliced cheese. She obtained several pieces of cheese and placed this on the bread using the hand with the contaminated glove. Using the same gloved hand which was previously contaminated Dietary Aide #1 reached inside the bread bag and obtained additional bread. Continuing to use the gloved hands which were previously contaminated Dietary Aide #1 placed the sandwiches in bags for consumption by the residents. On 7/28/23 at 11:00 AM observed Dietary Aide #2 placing the insulated domes on the drying rack. As she placed each dome on the rack all four fingers went inside the dome. The insulated domes are used to cover the plate of food. On 7/28/23 at 11:05 AM the surveyor asked the Dietary Manager how pots and pans should be stored. She stated, we allow them to air dry and then place them on a rack. When asked if they should be stored upside down or right side up, she stated, upside down. When discussing clean to dirty tasks, specifically a sandwich, the Dietary Manager stated, you should have all of your items that you need assembled and then I use tongs, so I don't unnecessarily touch the food. When asked if gloved hands should touch the container and then the food item she stated, no. On 7/28/23 at 12:05 PM Certified Nursing Assistant (CNA) #6 was asked if a clothing protector should be taken from one resident and placed on another. She stated, No. She was then asked how clothing protectors should be carried. CNA stated, away from the body. On 7/28/23 at 12:11 PM the Surveyor asked the Director of Nursing if a clothing protector should ever be taken from one resident and placed on another. She stated, absolutely not. She was then asked how clothing protectors should be carried by a staff member and why. DON stated, they should be carried away from the body because you don't want to cause an infection, there could be germs on your clothing. On 7/28/23 at 10:53 AM Licensed Practical Nurse #3 provided the policy titled Hand-washing Guidelines, with an effective date of February 1, 2002, which noted, hands should be washed after hands have touched anything unsanitary, i.e., garbage, soiled utensils, or equipment, dirty dishes, etc.

Based on observation and interview the facility failed to ensure that resident's right to receive mail on the weekend was maintained. The failed practice had the potential to affect all 91 residents who reside in the facility according to the census and condition which was provided by the Director of Nursing (DON) on 7/24/23 at 12:30 P.M. The findings are: 1. On 7/27/23 at 10:03 AM the Surveyor asked the Business Office Manager (BOM) if the residents received their mail on Saturdays. The BOM stated, No, we have no one working on Saturdays, that picks up the mail. 2. On 7/27/23 at 10:07 AM the Surveyor asked the Financial Assistant if anyone picks up the mail on Saturdays. The Financial Assistant stated, sometimes the Activity Aide stops by and picks it up because she doesn't like it to get wet and she is coming by to water the plants anyway. The Surveyor asked the Financial Assistant if the Activity Aide works every weekend. She stated, no. 3. On 7/28/23 at 11:09 AM the Surveyor asked the Activity Aide how the mail is delivered on Saturday. The Activity Aide said, I pick up the mail on Saturdays and place it in the Financial Assistants box. The Surveyor asked the Activity Aide if she worked on Saturday. The Activity Aide said, No, I just don't want the mail to get wet. 4. On 7/28/23 at 9:50 AM reviewed the resident handbook which was provided on 7/27/23 at 3:30 PM by Nursing Consultant #1. On page 11 the handbook states . (g)(8) The resident has the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through a means other than postal service .

Based on observation, interview, and record review the facility failed to ensure that linen and clothing is processed in a manner to minimize the risk of cross contamination. The failed practice had the ability to affect 91 residents who utilized linen and/or clothing processed by 1 of 1 facility laundry according to the Census & Condition which was provided by the Director of Nursing on [DATE] at 12:30 PM. The findings are: 1. On [DATE] at 10:12 AM observed the table where linen and clothing are processed for use by the residents contained a personal cell phone. The phone was partially covered by an item of clothing which was being readied to return a resident. 2. During an interview with laundry staff #1 on [DATE] at 10:15 AM she stated, you have to keep laundry off the floor, that's why I have this basket here. Laundry staff #1 was asked if there was any other precaution that is necessary to minimize cross contamination. Laundry staff #1 had nothing to add. Observed Laundry staff #1 prepared a woman's knit top to be placed on the hanger the item was held against the employee's person. Observed the employee as she processed several pieces of clothing. Each item was held against her person, coming in contact with her clothing. The surveyor asked Laundry Staff #1 what could happen if the clean laundry was held against her clothing. The employee stated, it could be contaminated. 3. On [DATE] at 11:31 AM the surveyor asked the Laundry Supervisor what should be done to prevent cross contamination of laundry. She stated, you shouldn't take a clean item back into the dirty area, if a clean item hits the floor, it should be put back in the dirty clothes. She was then asked what should take place if a clean item of clothing was held up against the laundry worker's person/clothing. She stated, it should be put back and washed again.

Based on observation, interview, and record review, the facility failed to ensure the nebulizer mouthpiece and medicine cup was contained after use for 1 (Resident #41) of 1 sampled resident. The findings are: A review of Resident #41 physician's order with a start date of 6/5/2023 noted an order for a breathing nebulizer treatment with albuterol every four hours as needed for shortness of breath. A review of Resident #41 physician's order with a start date of 6/5/2023 noted an order for a nebulizer treatment of budesonide twice a day. A review of Resident #41 physician's order with a start date of 6/5/2023 noted an order for ipratropium bromide with albuterol nebulizer treatment every six hours. On 07/24/23 at 11:19 a.m. observed Resident # 41 lying in bed with a nebulizer mouthpiece lying on top of the bedside table not contained. On 07/24/23 at 1:42 p.m. Resident #41 was lying in bed eyes closed, a nebulizer mouthpiece was lying on the nebulizer and not contained. On 7/27/2023 at 10:06 a.m., the surveyor asked Licensed Practical Nurse (LPN) #4, how are nebulizer masks/mouthpiece/tubing supposed to be stored when not in use? LPN #4 replied, in a zip lock bag. The Surveyor asked LPN #4, who is responsible for ensuring nebulizer masks/mouthpiece/tubing is contained when not in use? LPN #4 replied, nurses. The Surveyor asked LPN #4, why should the nebulizer masks/mouthpiece/tubing be contained when not in use? LPN #4 replied, to prevent any bacteria from getting in it. On 7/27/2023 at 10:18 a.m., the surveyor asked LPN #5, how are nebulizer masks/mouthpiece/tubing supposed to be stored when not in use? LPN #5 replied, in a bag. The Surveyor asked LPN #5, who is responsible for ensuring nebulizer masks/mouthpiece/tubing is contained when not in use? LPN #45 replied, nurses. The Surveyor asked LPN #5, why should the nebulizer masks/mouthpiece/tubing be contained when not in use? LPN #5 replied, to make sure it's not contaminated. On 7/27/2023 at 2:59 p.m., the surveyor asked the Director of Nursing (DON), how are nebulizer masks/mouthpiece/tubing supposed to be stored when not in use? The DON replied, in a bag and dated. The surveyor asked the DON, who is responsible for ensuring nebulizer masks/mouthpiece/tubing is contained when not in use? The DON replied, the nurse that gives the last nebulizer treatment. The surveyor asked the DON, why should the nebulizer masks/mouthpiece/tubing be contained when not in use? The DON replied, infection control/sanitary reasons. A Policy provided by the Nurse Consultant documented .Advanced Care Procedures: Nebulizer .To administer medication through continuous aerosol nebulizer .should be administered under orders of the attending physician .assemble the nebulizer/aerosol equipment, making sure the connections are secure .administer therapy .after completion of therapy a.) Remove nebulizer container, b.) rinse container with fresh tap water c.) dry with clean paper towel or gauze sponge d.) wipe mouth piece or mask with damp paper towel or gauze sponge e.) store in plastic bag .documentation should include length of therapy .discard administration setup every seven (7) days .

Based on observation, record review and interview the facility failed to ensure personal care items and sharpened pencils were contained on the secure unit. This failed practice had the potential to effect 15 residents who reside on the secure unit according to the Census List provided the by Nurse Consultant on 7/24/2023 at 11:00 a.m. The findings are: Resident #56 resides on the secure unit with diagnosis of bipolar disorder and schizophrenia. The Quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/2023 noted cognitive skills for daily decision making are severely impaired and the resident never or rarely made decisions. On 07/24/23 at 12:11 p.m. observed a bottle of hair spray, and a tube of toothpaste in Resident #56 bathroom not contained or secured. A plastic trash bag was observed under the toothpaste. A cup with sharpened colored pencils and sharpened regular pencils was observed on Resident #56 bedside table in the room. Resident #80 resides on the secure unit with diagnosis of Alzheimer's disease, depression, and anxiety. The Quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/2023 documented the resident scored a 3 (0-7) indicates severe impairment on a Brief Interview for Mental Status (BIMS. On 07/24/2023 at 12:07 p.m. observed a cup with sharpened pencils and sharpened colored pencils on Resident #80 nightstand not contained or secure. A can of shaving cream, a bottle of body wash, and a bottle of conditioner was observed on Resident #80 sink in the bathroom not contained or secure. On 07/27/2023 at 9:28 a.m. observed a bottle of body wash, a can of shaving cream, and a bottle of conditioner in Resident #80 bathroom not contained and secure. A cup of sharpened pencils and sharpened colored pencils were observed on top of Resident #80 nightstand and not contained or secure. On 07/27/2023 at 09:29 a.m. the Surveyor asked Certified Nursing Assistant (CNA) #2, where are pencils/colored pencils stored when not in use on the secure unit? CNA #2 replied, stored in a locked room, but we leave Resident #80 in the room. The Surveyor asked CNA #2, where is body wash, conditioner, and toothpaste supposed to be stored when not in use on the secure unit? CNA #2 replied, in a room locked up. The Surveyor asked CNA #2, why should pencils/colored pencils, toothpaste, body wash, and conditioner be contained when not in use? CNA #2 replied, so nobody else gets a hold of it, we have residents that wander. On 07/27/2023 at 10:06 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #4, where are pencils/colored pencils stored when not in use on the secure unit? LPN #4 replied, in a locked room. The Surveyor asked LPN #4, where is body wash, conditioner, and toothpaste supposed to be stored when not in use on the secure unit? LPN #4 replied, in a locked room. The Surveyor asked LPN #4, why should pencils/colored pencils, toothpaste, body wash, and conditioner be contained when not in use? LPN #4 replied, because not everybody is cognitively in their right minds, they could eat it, they do have wanderers on the unit. On 07/27/2023 at 2:59 p.m., the Surveyor asked the Director of Nursing (DON), why are pencils/colored pencils left out on the secure unit? The DON replied, it could be used as a weapon, they probably never thought of it being a weapon. The Surveyor asked the DON, where is body wash, conditioner, and toothpaste supposed to be stored when not in use on the secure unit? The DON replied, in the locked room.

Based on observation, interview, and record review, the facility failed to ensure skin assessments were performed on a consistent basis for 1 (Resident #23) sampled residents. The findings are: On 07/25/23 at 10:19 a.m. observed Resident #23 with a 2-inch red area to the right temple. Resident # 23 Stated he did not know how that happened. On 7/27/2023 at 3:20 p.m., a review of Resident #23 Medication Administration Record (MAR) for July 2023 noted skin audit to be done weekly, with an order date of 7/21/23. A skin audit was documented on 7/21/2023. No other skin audits were documented as performed. On 7/27/2023 at 3:37 p.m., a review of Resident #23 June 2023 MAR did not reveal documentation of skin audits. On 7/27/2023 at 9:56 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #6, when are skin audits done? LPN #6 replied, the LPN's do them weekly and it will be on the MAR. On 7/27/2023 at 2:59 p.m., the Surveyor asked the Director of Nursing (DON), when are skin audits done? The DON replied, weekly. The Surveyor asked the DON, who is responsible for the weekly skin assessments? The DON replied, the nurses. The Surveyor asked the DON, where is this documented? The DON replied, on the MAR or TAR (Treatment Administration Record). The Surveyor asked the DON, why did Resident #23 only have one skin audit for the month of July 2023? The DON replied, I do not know, because they are supposed to be done weekly, and there are none documented for the month of June 2023 either.

Based on observation, interview, and record review the facility failed to ensure Activities of Daily Living (ADL) care was provided for 4 sampled residents (Resident #9, #14, #23, #45), for 2 sampled residents (R#23 and R#45) who required assistance with ADL's. The findings are: 1. On 07/24/23 at 11:52 AM, observed Resident #9 lying on the bed. Resident #9 fingernails were approximately 1.5 inches beyond the fingertip, jagged and with dried black substance under them. a. On 07/25/23 at 09:00 AM, observed Resident #9 being assisted in a wheelchair down the hall. Resident #9 fingernails were approximately 1.5 inches beyond the fingertip, jagged with dried black substance under them. b. Review of Resident #9 care plan revealed a care plan, initiated on 8/22/19 to maintain ability to perform self-care for 90 days. Interventions included to provide nail care by nursing and nursing assistants. c. Review of the bath report roster for 7/1/23 to 7/25/23 revealed Resident #9 was bathed per schedule on 7/24/2023 at 9:59 AM. 2. Review of Resident #23 care plan with a start date of 3/17/2023 noted a care plan for self-care with interventions to assist with shaving and nail care as needed, to be provided by nursing and nursing assistants. a. On 07/25/23 at 10:30 AM, Resident #23 stated, I get showers on Mondays and Fridays, but did not get a shower yesterday, as they did not even ask if I wanted a shower. Resident #23 nails had a black dried substance under them. Resident #23 had whiskers, approximately 1/2 long to the face. b. On 7/27/2023 at 9:29 AM, the surveyor asked Certified Nursing Assistant (CNA) #2, when is nail care provided to the residents? CNA #2 replied, during showers and as needed. The surveyor asked CNA #2, who is responsible for nail care? CNA #2 replied, all of us. The Surveyor asked CNA #2, why should residents nails have smooth edges and be free of dried substances under them? CNA #2 replied, so they don't cut themselves and they should always be clean. c. On 7/27/2023 at 10:06 AM, the surveyor asked Licensed Practical Nurse (LPN) #4, when is nail care provided to the residents? LPN #4 replied, shower days. The Surveyor asked LPN #4, who is responsible for nail care? LPN #4 replied, nurses and CNA's. The Surveyor asked LPN #4, why should residents nails have smooth edges and be free of dried substances under them? LPN #4 replied, to prevent injuries, to be free of bacteria and good hygiene. d. On 7/27/2023 at 2:59 PM, the Surveyor asked the Director of Nursing (DON), when is nail care provided to the residents? The DON replied, on shower days and as needed. The Surveyor asked the DON, who is responsible for nail care? The DON replied, whoever gives the showers, unless they are diabetic, then the nurse is. 3. Review of Resident #14's Physician Orders, with a start date of 6/15/23 revealed an order for Diabetic nail care every 14 days. a. Review of Resident #14's Care Plan for activities of daily living with interventions to include, assist with hair, bath per schedule, and provide nail care to be provided by nursing and nurses assistants. b. On 07/24/23 at 12:54 PM Resident # 14 was sitting on the side of her bed. Her gray shirt was soiled down the front with a light brown substance. Her fingernails were approximately 1/2 inch long and had a brown substance under them. Her right shoe was soiled with a brown substance. c. On 07/25/23 at 10:47 AM Resident #14 was standing in her room in front of her bed. She was wearing the same gray shirt soiled with a light brown substance down the front and the same pants. Her fingernails were approximately 1/2 inch long and had a brown substance under them. Her right shoe was soiled with a brown substance. The surveyor asked if she likes her fingernails long. She stated, No, they need trimmed. Resident #14 stated she gets showers on Wednesdays and Saturdays. d. On 07/27/23 at 08:32 AM Resident #14 was lying in her bed. She was wearing the same gray shirt that she had been wearing on 7/24/23 and 7/25/23. It was still soiled with a light brown substance down the front. She was wearing the same pair of white pajama pants with a red bird print. Her fingernails were approximately 1/2 inch long and had a brown substance under them. Her right shoe was soiled with a brown substance. The resident stated she needed her fingernails trimmed. e. On 07/27/23 at 08:47 AM the Surveyor asked Licensed Practical Nurse (LPN) #2 who does the diabetic nail care. She stated, All of us do. LPN #2 explained, When the CNA's do showers, if the resident needs nail care, they will come and get any one of the nurses and they will cut them. LPN #2 stated Resident # 14 likes her fingernails long. LPN #2 accompanied the surveyor into Resident #14 room. The surveyor asked Resident # 14 if she likes her fingernails long. Resident # 14 stated, You trim them now? The Surveyor asked LPN #2 to describe Resident #14's fingernails. She stated, Well, they need to be cleaned. She was asked how often residents clothing should be changed. She stated, every day. She was asked when shaving and nail care is provided. She stated, That is part of showers. They should be shaved, and nails trimmed if needed. f. Review of the document New Bath Report Roster for 6/30/23 through 7/27/23 noted Resident #14 had a bath given on 7/7/23, 7/12/23, and 7/13/23. No other baths were documented on the list. g. On 7/25/23 at 9:05 AM The Nurse Consultant provided a policy titled, Hygiene and Grooming, with an effective date of 10/1/20 which noted, Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity. The policy further states, guidelines for the provision of hygiene and grooming services are shower, tub or complete bath, as needed .Shaving daily or as needed .Resident preferences for time of day, type of bath and frequency of bath should be honored, to the extent possible. Family members or social service staff may be called upon to assist when the resident refuses appropriate hygiene/grooming measures by nursing staff .Nail care is a part of grooming .Clothing should fit properly: torn, soiled or worn clothing should be given to the family .Safe, comfortable shoes and socks are needed when the resident is out of bed .Clothing needs should be referred to the social service department . 4. Review of Resident # 45 care plan, with a start date of 1/9/19 which noted the resident requires staff assistance with all Activities of Daily Living (ADL) with interventions to include bath per schedule and nail care as needed. b. On 07/25/23 at 10:38 AM Resident #45 was lying in bed, his facial hair was approximately 3/4 inches long. The Surveyor asked Resident #45 if he likes facial hair. He stated, No, I like it shaved. Observed his fingernails were approximately 1/2 inch in length and his left hand was contracted. His fingernails had a brown substance under them. The Surveyor asked Resident # 45 if he likes his fingernails long. He stated, No, I don't, but I can't cut them they have to do it. c. On 07/27/23 at 08:37 AM observed Resident #45 in bed. His fingernails were approximately 1/2 inch in length and had a brown substance under them. His facial hair was approximately 3/4 inch in length. The surveyor asked who usually trims his fingernails. He stated, The aides. The surveyor asked, Do you ever refuse care? He stated, No, never. The surveyor asked if he has to ask to have his fingernails trimmed or shaved. He stated, I guess so because they haven't done it. d. Review of the New Bath Report Roster for 6/30/23 through 7/27/23 noted Resident #45 had a bath on 7/7/23, 7/12/23, and 7/13/23. There were no other baths documented.

Based on observation, interview and record review, the facility failed to ensure residents meals were removed from serving trays for 12 of 15 residents served in the dining room on the secured unit, and failed to ensure a resident's bed linens were clean, and sanitary to enhance quality of life for 1 (Resident #23) of 1 sampled resident. The findings are: On 07/24/23 at 12:29 PM observed the dining room on the secure unit during lunch meal service. Twelve resident's meals were left on the meal serving trays during lunch. On 07/24/23 at 12:41 PM, the Surveyor asked Certified Nursing Assistant (CNA) #7, why were some of the resident's meals left on the serving trays during lunch meal service on 7/24/2023? CNA #7 replied, It's something that the staff normally do. On 07/24/23 at 12:49 PM, The Surveyor asked CNA #8, why were residents meals left on the serving trays during lunch meal service? CNA #8 replied, Just to make it easier to get it on and off the table. The Surveyor asked CNA #8, easier for the staff? CNA #8 replied, yes. On 7/27/2023 at 9:29 AM, the Surveyor asked CNA #2, why are residents meals served on serving trays? CNA #2 replied, we always just set them up like that, we now have to take them off to make it feel like home. The Surveyor asked CNA #2, how are residents provided dignity, if the meals are left on serving trays during meals? CNA #2 replied, I guess we aren't or didn't. On 7/27/2023 at 10:06 AM, the Surveyor asked Licensed Practical Nurse (LPN) #4, why are residents meals served on serving trays during? LPN #4 replied, they should take the meal off the tray to make them feel like home. The Surveyor asked LPN #4, how are residents provided dignity, if the meals are left on serving trays during meals? LPN #4 replied, they're not if they are left on there. On 7/27/2023 at 2:59 PM, the Surveyor asked the Director of Nursing (DON), why are residents meals served on serving trays during? The DON replied, I don't know. The Surveyor asked the DON, how are residents provided dignity, if the meals are left on serving trays during meals? The DON replied, they should all be removed from the trays. On 07/25/23 at 10:30 AM Resident #23 bed sheets had a brown dried substance at the head of the bed. The Surveyor asked Resident #23, when do you receive showers? Resident #23 replied, on Mondays and Fridays, but I did not get a shower yesterday. The Surveyor asked Resident #23, when was the last time your sheets were changed. Resident #23 replied, last week. On 07/27/23 at 02:40 PM Resident #23 bed sheets had a brown dried substance at the head of the bed. On 7/27/2023 at 2:44 PM, the Surveyor asked CNA #3, when are resident's sheets changed? CNA #3 replied, when they are soiled. The Surveyor asked CNA #3, who is responsible for that? CNA #3 replied, the CNA's. On 7/27/2023 at 2:47 PM, the Surveyor asked CNA #5, when are resident's sheets changed? CNA #5 replied, on first rounds in the morning, soiled or wet. The Surveyor asked CNA #5, who is responsible for that? CNA #5 replied, us, the CNA's. The Surveyor asked CNA #5, are Resident #23 sheets soiled? CNA #5 replied, yes, they are soiled. On 7/27/2023 at 2:50 PM, Resident #23 stated, it's chocolate pudding on my sheets. On 7/27/2023 at 2:51 PM, the Surveyor asked CNA #4, when are resident's sheets changed? CNA #4 replied, if visibly soiled, at residents request, and on shower days. On 7/27/2023 at 2:59 PM, the Surveyor asked the DON, when are resident's sheets changed? The DON replied, on shower days. The Surveyor asked the DON, who is responsible for ensuring residents sheets are clean and changed? The DON replied, the CNA's and the nurses should over see that. The Surveyor asked the DON, what are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines related to these concerns? The DON replied, there is no exceptions, those are things that cannot be circumpassed. A policy, titled Bed-Making an Unoccupied, with an effective date of 10/1/10 noted, .changing linens on the bed provides the resident with a clean, comfortable place to rest and sleep .linens should be changed on each resident's bed weekly, or more frequently when soiling occurs . soiling includes urine, feces, perspiration, spills of fluids or foods, or excessive wrinkling .

Based on interview and record review, the facility failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends. This failed practice had the potential to affect 19 (Resident #30, #34, #9, #56, #365, #24, #23, #72, #14, #59, #60, #80, #5, #62, #25, #45, #33, #68, #11) sampled residents who have a trust account managed by the facility. The findings are: 1. On 7/24/23 at 11:07 AM the surveyor asked Resident #72 who handled his money. Resident #72 said, the facility. The surveyor asked if he was able to get his money on the weekends. Resident #72 said, No, I have to get it by Friday. 2. During an interview on 07/25/23 at 10:23 AM Resident #23 stated, I can't get money when I want it. Resident #23 further stated, he can't get money on the weekends, he must ask for the money on a weekday. 3. On 7/27/23 at 10:34 AM the Surveyor asked the Business Office Manager (BOM) if the residents have access to their money on weekends. The BOM said, yes, they do. The Surveyor asked the BOM if she was aware of the last time a resident had accessed their money on the weekend. She stated, it has probably been a year or more. The surveyor asked the BOM if she was certain the residents were aware they could get money on the weekends. The BOM said, they know, because I go to their rooms on Friday to make sure they have money, if they need it. The BOM responded, we have a box that we keep cash in an envelope, with the nurse, if the resident needs money. The BOM asked a nurse to open her narcotic box. There was no envelope, the BOM and Financial Assistant stated, they had already taken it out. 4. On 7/27/23 at 10:40 AM, the Surveyor asked the Financial Assistant if she was the one to set up the envelope. The Financial Assistant stated, yes, I put $40 dollars in the envelope. 5. On 7/27/23 at 3:30 P.M a review of the Residents Handbook, page 13, Personal Funds the sixth paragraph states .A small amount of cash will be retained in the business office and will be available to satisfy residents' personal account withdrawal request of $25 or less. If you request a withdrawal from your personal account in excess of $25, accommodating the request may require up to 7 days. No personal account withdrawals can be made after the close of business hours or on weekends. You should anticipate your cash needs for weekends and withdraw funds accordingly on Friday before the business office closes . 6. On 7/28/23 at 12:47 P.M the Surveyor asked the BOM if they followed the 'Resident Handbook' that's given to residents upon entrance. The BOM said, sometimes, and confirmed the residents received the handbook on admission. The surveyor asked, can the residents get their money on the weekend, if needed. The BOM said, I try to anticipate my cash need on the weekend. The surveyor asked, how much money do you leave in the cash box for the weekend. The BOM stated, whatever I have left. I order petty cash and after I have given the residents the money they requested; I will put the remainder in the box. Sometimes I don't have much after Friday. The surveyor asked, if you only had $5.00 left, is that what you would leave in the box for the weekend. The BOM said, yes. We can only get so much at a time from the office. The Surveyor asked, how long does it take to replenish the petty cash. The BOM said, usually, 48 hours.

Based on record review and interview, the facility failed to ensure 1 (Resident #1) of 1 sampled resident was not pushed on the floor by the staff. This failed practice resulted in an Immediate Jeopardy, which caused an injury to Resident #1 who sustained a hip fracture and had the potential to effect 99 residents according to the Census and Conditions of Residents provided by the Administrator on 11/08/22 at 10:49 AM. The Administrator was notified of the current Immediate Jeopardy on 11/09/22 at 12:30 PM. The Plan of Removal was accepted on 11/09/22 at 4:15 PM. The findings are: 1. The facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, provided by the Administrator on 11/09/22 at 10:32 AM documented, .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . 2. Resident #1 was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Paranoid Schizophrenia, Bipolar Disorder and Alzheimer's Disease. The 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/14/22 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), had long and short-term memory problem and required supervision with set up help from staff for locomotion on and off the unit. a. The Care Plan with a start date of 9/09/22 documented, .I will not injure myself or others if I have behaviors x [times] 90 days .Do not argue with resident .Alert staff to wandering behavior . If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk to designated area with them .Redirect when wondering into other resident's rooms . b. The Incident Report dated 10/06/22 documented, .Date and time of incident: 10/05/22 Time: 9:30 PM .Date incident reported to OLTC [Office of Long Term Care]: 10/06/22 at 10:00 AM . Per CNA [Certified Nursing Assistant #1 witness statement received 10/06/22 at 8:15 AM by administrator: Resident #1 kept trying to enter rooms. He tried entering the break room. I put my hands on the doorknob/pull handle. He then attacked me by grabbing my right arm and yanking on it, kicking and ramming his head into me. While he had ahold of my right arm, I shoved him away from me and he fell on his right side. We picked him up and put him in a chair .Facility #2 called facility at 8:00 AM on 10/06/22 to verify Resident #1 was our resident. We verified that he is. The nurse stated that he has a fractured right hip and is being sent to surgery to repair the fractured hip. There were no witness statements from residents in the report. c. The Hospital records dated 10/06/22 documented, .Preoperative diagnosis: Displaced right intertrochanteric hip fracture . d. The X-Ray report dated 10/06/22 at 12:18 AM documented, .Findings: There is a comminuted intertrochanteric fracture of the right proximal femur, with displacement of the lesser trochanteric fragment. e. On 11/08/22 at 3:13 PM, the Surveyor asked the Director of Nursing (DON), How did [Resident #1] fall? He stated, [Resident #1] had come back about 4:30 PM or 5:00 PM. It was 10ish and they said he had got agitated. [CNA #1] had been giving him his space and he put his hand on the door so he couldn't open it. The Surveyor asked, Should [CNA #1] have called for assistance when resident first became agitated? He stated, [CNA #1] was one on one, it's kind of like one big, long event. From 3:30 PM to 10:00 PM he was trying to go into rooms. f. On 11/08/22 at 3:15 PM, the Surveyor asked CNA #1, How did [Resident #1] fall on the floor? He stated, I let him do everything he wanted to do, except go into the room. He was really good until about 7:30 PM. He tried to go in every room, and I kept him from going in there by keeping the short. He became violent and he kept trying to grab my arm and legs. He tried to grab the nurse cart and he grabbed my arm, and I twisted away. He tried to enter the break room. I held the top and bottom lock. He's known for barricading himself in his room, so I couldn't let him in there. The surveyor asked, Once he became agitated and tried to attack you can you tell me why you didn't call for assistance? CNA #1 stated, He wasn't going crazy at the time, he would just reach out and grab. The Surveyor asked, How did he fall? He stated, I was holding on to the door handles with both hands. He grabbed my arms with both hands. When he couldn't move my hands, he started kicking me. After about 40 seconds, I pushed him back with my arm so I could be free, and that's when he fell . g. On 11/09/22 at 9:32 AM, the Surveyor asked the Administrator, How did [Resident #1] fall? The Administrator stated, He had returned from [Facility #1], and at 7:30 PM the nurse said a switch flipped and he became aggressive. They tied to re-direct him, but he wouldn't do anything. They had an order to send him to the ER [emergency room ] for behaviors. The [Ambulance] was already in route. The fall to the hip had happened when the [Ambulance] had just arrived. The Surveyor asked, Did the nurse complete an assessment on [Resident #1]? The Administrator stated, The nurse didn't get a chance to do an assessment because [Ambulance] had arrived. He complained of hip pain, and he got on the gurney and went to the ER. h. On 11/09/22 at 4:15 PM, the Surveyor asked CNA #2, Were you working on the locked unit the day [Resident #1] fell ? She stated, I was doing my vitals, and [CNA #1] was right outside the door. [CNA #1] said he's attacking me again, and the next thing I see was [Resident #1] on the floor. Someone was here to take him somewhere, and I notified the nurse. The Surveyor asked, What was [Resident #1's] behavior? She stated, He was calm until after dinner. His one on one kept telling him to get out of people's room. He just kept hitting [CNA #1]. i. On 11/09/22 at 4:25 PM, the Surveyor asked CNA #3, Were you working on the locked unit the day [Resident #1] fell ? She stated, Yes ma'am. The Surveyor asked, Can you tell me how he fell ? She stated, [CNA #1] pushed him, so he fell . The Surveyor asked, Did you see him fall? She stated, I heard [CNA #1] scream, I looked out the door. [CNA #1] pushed him with both hands, and he fell to the floor. I came out and I asked what happened. [CNA #1] said he's hurting me. After he hit the floor, the resident was screaming. He said his leg was hurt. [Resident #1] was telling them how hurt he was. j. On 11/10/22 at 11:40 AM, the Surveyor asked the DON, Should the staff at any time push a resident? He stated, No. The Surveyor asked, Why is it important that the staff don't push a resident? He stated, You don't won't any injuries to occur. It could be a fall risk and they are advanced age. 3. The Immediate Jeopardy was removed on 11/10/2022 at 9:15 AM, when the facility implemented the following Plan of Removal provided by the Administrator on 11/10/2022 at 8:40 AM: .Plan of Removal .Immediate Action taken: 1. Facility conducting interviews with cognitive Residents to ensure they haven't been abused by any staff. Any Negative findings will be addressed immediately. 2. 1:1 [one on one] In-service Education with Administrator on Abuse and Neglect Policy - ensure a complete investigation is conducted on all allegations timely, specifically for this plan of removal, interviews with residents and reporting within 2 hours from the time the facility is made aware of a suspected allegation. 3. 1:1 In-service Education with RN/Charge [Initials] Abuse Policy and reading witness statements for unusual events obtained after hours and notification made to the Abuse Coordinator immediately for any types of abuse according to the Abuse Policy. 4. In-Service all Licensed Nurses on the Abuse Policy and reading witness statements for unusual events obtained after hours and notification made to the Abuse Coordinator immediately for any types of abuse according to the Abuse Policy. 5. On 10/6/2022, all facility staff were in-serviced on Abuse and Neglect Policy, Distressed Behavior Management and Acutely Disturbed Resident, and falls and transfers. 6. DON or designee to review and document on check sheet incidents/accidents, nurses' notes, witness statements morning meeting/clinical meeting to ensure abuse policy followed beginning immediately, then 5 times daily x 8 weeks or until compliance achieved by OLTC. Any negative findings will be corrected immediately

Based on observation, record review, and interview, the facility failed to ensure when a door alarm sounded staff went outside the facility to check for possible elopement of a resident for 1 (Resident #2) of 2 (Residents #2 and #3) sampled residents who were at risk of elopement. This failed practice had the potential to affect 2 residents who were at risk of elopement and resulted in past immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #2. The Administrator, Director of Nursing (DON) and the Consultant were notified of the Past Immediate Jeopardy (IJ) on 9/28/22 at 2:15 PM. This failed practice had the potential to affect 2 residents who were at risk of elopement. The findings are: 1. Resident #2 had diagnoses of Unspecified Dementia with Behavioral Disturbance, Secondary Parkinsonism and [CONDITION(S)] Disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/22 documented the resident scored 4 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and exhibited no behaviors of wandering. a. The Physician Order dated 03/03/22 documented, .Monitor Wonder Guard to R [right] ankle q [every] shift . 2. The OLTC [Office of Long Term Care] Incident and Accident Report documented, .Date of I&A [Incident and Accident]: 09/24/2022 Time: 11:28 PM . Page 2 of 4 Summary of Incident-Continued for Page 1 Facility Administrator was notified at 11:28 PM on 9/24/22. Resident was located off the facility premises and returned to the facility at 12:11 AM Page 3 of 4 Steps Taken To Prevent Continued Abuse or Neglect During the Investigation-Continued From Page 1 Notified POA [Power of Attorney], Administrator, [City] Police Department, and Physician. Body Audit performed on [Resident #2] with no negative findings. Resident is at baseline for mental, psychosocial, and physical well-being. Resident was placed on 1:1 [One on One] supervision for safety. Resident has wander guard in place, was checked and found to be working correctly. Initiated In-Service with staff to close fire doors at lobby at 7PM [7:00 PM]. All residents immediately accounted for by current resident census. Facility initiated shift-to-shift in-servicing with staff on elopement policy and procedure. Maintenance Director conducted door and wander guard alarm system checks with no negative findings at 12:50 AM. Facility began collecting witness statements from staff. a. A form titled SafeCare Solutions documented, .Date Serviced: 9/27/22 . Problem: Check Front Door Mag [magnet] Lock Services: Adjusted the strike plate on the front door mag lock and removed rubber grammar to prevent strike plate locking back. Checked and tested mag lock. Checked all other doors. b. A Staff Inservice dated 9/25/22 documented, Elopement and Wandering Residents: * Any Staff member becoming aware of a missing resident, staff should notify charge nurse Immediately. Search should be conducted in building and around facility grounds. * If a door alarm is sounding and staff cannot identify what made door alarm to engage, staff must Immediately notify charge nurse and exit out that door and do a visual parameter search around building to ensure that a resident had not eloped while staff in the building do a resident count on each hall to make sure all residents are accounted for. * In case of an actual elopement of a resident charge nurse is to notify Administrator and DON immediately and follow company protocol. * Double doors on A hall to be closed after screener leaves at 7:00 PM. * Outside button to enter into facility placed back outside for staff and visitors to utilize. c. A Door Alarm Response Protocol documented, Secure Care Door Alarm Response Protocol 1. When a Secure Care alarm is activated on a door, staff members will respond immediately to the door where the alarm is sounding. 2. Staff will immediately investigate the source of the Secure Care alarm and Nursing Management will oversee and assign staff to begin a search in the immediate vicinity, working outward. 3. A room to room search should be conducted if the source of the alarm activation is not readily determined . 3. On 9/28/22 at 11:17 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, What can you tell me about the night you heard the alarm when [Resident #1] exited the facility? She stated, I never checked the time I heard the alarm. When we heard it, we all got up to go check it. It was me, [CNA #2, .and CNA #3]. We started walking to the front door and when we got to Room 1 on A Hall the alarm quit sounding. We kept going and once we got to the front door, the lobby was empty, and we looked out the window of the door and another window and didn't see anyone. We did not go outside. That was a fail on our part, we just figured the door maybe was just acting weird. When we were looking for him later [CNA #2] told me it was around 8:00 PM when the alarm sounded. I was going to clock out and [Licensed Practical Nurse (LPN) #2] came and asked where he was, and I said he was in bed sleeping. She said, 'No he's not.' I could have sworn I saw him in bed. I know at 7:00 PM he was saying he was tired and wanting to go to bed. I told him, 'Ok you can go to bed.' I was doing the door screening then. [LPN #2] took him back with her when she came in. The Surveyor asked, Is that the last time you remember seeing him? She stated, Yes ma'am. The Surveyor asked, Has he ever tried to exit before? She stated, I think, but it's like him saying, 'I've got to go.' Then I would just get his mind on something else. 4. On 9/28/22 at 12:02 PM, the Surveyor asked LPN #2, Can you tell me what happened the evening [Resident #2] exited the facility? She stated, I arrived to the facility at 7 [7:00 PM] for my shift. He was sitting at the front with [CNA #1]. She was doing the screening. She was getting up to take her lunch. I took him back with to the Nurses Station. I put him near his hall. I left him there. I counted and got report so the other nurse could go. After that I was putting my cart onto one of the halls and this was a little before 8 [8:00] PM and he was on the F Hallway towards the Nurses Station but on the hall. I know it had to be after 8 PM I heard the alarm. We all heard it and maybe 5 CNAs went down A Hall to the front door. Afterwards I heard the alarm had shut off itself. At the time, I assumed they had turned it off. It was just around 11 [11:00 PM] when I noticed he wasn't in his room. Police said they initially found him on [Street Name] in a residential area. They picked him up from [Street Name] and took him to [Convenience Store], this was around 8:30 PM and got him some pizza and a drink. The police officer told me he figured he was from a home but there were no missing persons. When I called 911, they called back in about 20 minutes and said they had him and would be bringing him to facility. He was back at facility in about 15 minutes. The Surveyor asked, Had he ever attempted to exit before? She stated, All I have ever seen is him by the door but never seen him trying to get out. The Surveyor asked, What interventions were placed then? She stated, He was placed one on one with a CNA at all times after that and continues on one on one. 5. On 9/28/22 at 12:19 PM, the Surveyor asked CNA #2 was asked, Were you working the evening [Resident #2] exited the facility? She stated, Yes, I was on D Hall. The Surveyor asked, What can you tell me? She stated, The last time I saw him was around 6:30 to 6:45 PM, he was wheeling up front. He goes up there a lot when [CNA #1] is the screener. He likes her a lot. About 7:45 to 8:00 PM the front door alarm was going off and me and [CNA #1, . CNA #2] were walking up there and after we got about halfway up the A Hall the alarm quit. We went to the door, opened the door and looked both ways and didn't see anybody. The Surveyor asked, Did you go out and walk around? She stated, No, I did not. The Surveyor asked, Did anyone else? She stated, No. I went back to my hall. When I was getting report from the other halls because I was working night shift [LPN #2] came and asked us if we had seen [Resident #2]. We all started looking at that time. All inside and outside. The was around 11 to 11:05 PM. I think it was around 11:30 PM that we found where he was. The Surveyor asked, Had you ever witnessed him trying to exit facility before? She stated, Yes, he has pushed on the doors before, and I would always take him to the Nurses Station and tell the nurse. Usually on night shift if he's up we keep him at the Nurses Station and keep an eye on him. 6. On 9/28/22 at 1:44 PM, the Surveyor asked the DON, What can you tell me about the elopement of [Resident #2]? He stated, At 11:24 PM on 9/24/22, I got call from a nurse. She said they had looked all over, in every room, kitchen and outside everywhere and couldn't find him. I told them to make sure all other residents were accounted for and make sure no doors were open. I called [Administrator] then I called the facility back and told them to call police and go to room to room and match every head to every bed and to make sure there were eyes on every door. I called the consultant at 11:59 PM and got a call back from nurse that police had called, and they were bringing him back to the facility. I found out then that police had found him at 8:30 PM and took him to gas station and was with him until they brought him back. He was placed one on one, had maintenance come and check all the doors. We have inserviced all staff on elopement and they are to go outside of the entire facility. He continues to be one on one and will be one on one until we can find other placement for him. 7. On 9/28/22 at 2:15 PM, the Surveyor notified the Administrator, Director of Nursing (DON) and the Consultant of the Past IJ.