Every finding on record at Tennova Newport Convalescent Center

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 2 residents (#1) and (#2) of 7 residents reviewed for abuse.The findings include: Review of the facility's policy titled, Abuse Prevention - Reporting and Investigation Policy, dated 7/2/2025, revealed .In response to allegations of abuse .the facility must .Ensure that all alleged violations involving abuse .are reported immediately according to state and federal requirements . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Pain and Osteoarthritis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 9 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia and Depression. Review of a quarterly MDS assessment dated [DATE] revealed Resident #2's scores a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the facility's investigation dated 1/29/2026 at 6:10 PM, revealed Resident #1 reported to License Practical Nurse (LPN) D Resident #2 had smacked him [Resident #1] in the face. No redness, bruising or injury was noted to Resident #1 or Resident #2. The allegation of abuse was reported to the State Survey Agency on 1/31/2026 at 2:43 PM (a total of 44 hours and 23 minutes). During an interview on 6/16/2026 at 12:20 PM, the Administrator confirmed the allegation of abuse for Resident #1 and Resident #2 had not been reported to the State Survey Agency within 24 hours as required by State law.

Based on medical record review, observation, and interview, the facility failed to obtain a physician's order to maintain and specify frequency of catheter care for an indwelling urinary catheter for 1 resident (Resident #15) of 3 residents reviewed for indwelling urinary catheters. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses including Benign Prostatic Hyperplasia (a condition where the prostate and the surrounding tissue expands) and Obstructive and Reflux Uropathy (a condition where there is a hindrance to normal urine flow). Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #15 had Obstructive and Reflux Uropathy, severe cognitive impairment, and an indwelling urinary catheter. Review of a Care Plan dated 12/27/2022 showed Resident #15 had a plan of care for an indwelling catheter related to obstructive uropathy with an intervention of check tubing for kinks each shift during rounds and as needed. An observation on 3/7/2023 at 8:38 AM, showed Resident #15 was seated in a wheelchair and had a covered urinary catheter bag hanging below the level of the bladder on his wheelchair. Review of Resident #15's Physician's orders revealed no orders related to the indwelling urinary catheter. During an interview on 3/7/2023 at 4:00 PM, the Director of Nursing (DON) confirmed there were no Physician's orders for Resident #15's indwelling urinary catheter and she did not have a policy on the care of an indwelling catheter. During an interview on 3/8/2023 at 7:20AM, Certified Nurse Aide (CNA) #1 revealed the CNA Kardex for Resident #15's catheter care instructions were .Check tubing for kinks each shift during rounds and PRN [as needed] . There were no instructions on cleaning the catheter. The CNA was able to verbalize correct catheter care. During an observation and interview on 03/8/2023 at 9:30 AM, CNA #2 stated he would check for kinks or sediment in tubing and a discharge and report any of those symptoms to the resident's nurse. The CNA sanitized his hands and donned gloves and provided appropriate catheter care. He stated Resident #15 had not, to his knowledge, had a Urinary Tract Infection (UTI) since admission. During an interview on 3/8/2023 at 9:49 AM, the Administrator stated her expectation would be for staff to document on the status of the catheter and any changes, and to clean the catheter and check it every shift. The Administrator expected a urinary catheter policy should be available, and orders should be transcribed. The Administrator confirmed there were no Physician's orders for the use of Resident #15's indwelling urinary catheter. Review of Resident #15's Physician's orders, nurses' notes and labs from 12/16/2022-3/8/2023 revealed the resident had no documentation to show urinary tract infections had occurred. During an interview on 3/8/2023 at 10:24 AM, Registered Nurse #1 stated Resident #15 had no urinary tract infections since admission to the facility.

Based on medical record review, review of facility investigations, and interviews, the facility failed to update the baseline care plan with interventions to address a resident's safety needs after an elopement from the facility for 1 resident (Resident #1) of 5 residents reviewed. The facility's failure resulted in a second elopement from the facility and placed the resident in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 5/12/2022 at 10:00 AM in the Nursing Team Leader office. Immediate Jeopardy was removed onsite and was effective 4/19/2022-5/12/2022. The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Nursing Admission assessment dated [DATE] revealed the resident was ambulatory, able to make his needs known, and independent for activities of daily living (ADLs). Medical record review of Resident #1's baseline care plan dated 4/15/2022 revealed the resident was independent with bed mobility, transfers, walking, toileting, and was expected to decline in condition related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Medical record review of a Brief Interview for Mental Status (BIMS) dated 4/16/2022 revealed a score of 14, indicating Resident #1 was cognitively intact. Review of Resident #1's Elopement Risk Assessment (a document with a series of questions that predicts elopement risk) dated 4/18/2022 revealed the resident had a score of 0, which indicated no risk for elopement. Review of a facility investigation dated 4/19/2022 at approximately 4:15 PM, showed Resident #1 exited the building through an unlocked door to the patio, stepped up onto a flower box on the patio, and then stepped over a fence into an unsecured yard outside the fenced-in area. The resident was assisted back to the facility by Registered Nurse (RN) #1 and was assessed for injury with none noted. Resident #1 reported that he just wanted to go for a walk. Facility interventions included staff reminded the resident if he wanted to go for a walk, for his safety he should let a staff member know and they would escort him, and the facility placed a wander guard (a device that automatically locks egress doors when the device comes in proximity) on his right ankle. The facility completed an Elopement Risk Assessment on 4/19/2022 and Resident #1 scored 27, which placed him at high risk for elopement. Review of Resident #1's Baseline Care Plan dated 4/15/2022 revealed it was not updated after the elopement on 4/19/2022 to reflect the intervention of assisting the resident to go outside to prevent future elopements or the addition of the wander guard. The facility completed a BIMS on 4/20/2022 which revealed a score of 11, indicating Resident #1 had a decrease in cognitive status and was moderately cognitively impaired. Review of a facility investigation dated 4/20/2022 at approximately 5:50 PM, showed Resident #1 eloped a second time from the facility. Resident #1 raised the window in his room, pushed the screen out, and stepped out of the window. A housekeeper noted the resident had exited the building, notified Certified Nurse Assistant (CNA) #2 and CNA #2 immediately exited the building and escorted the resident back inside. Resident #1 was assessed for injury with none noted. The resident stated it was such a beautiful day outside, he just wanted to go out. The facility reminded the resident if he wanted to go outside, he needed to ask someone to go with him. The facility initiated every 15-minute checks for Resident #1. Review of Resident #1's Baseline Care Plan dated 4/15/2022 showed the care plan was updated on 4/20/2022 .exited out room window Risk: injury Goal will be safe in environment Intervention: q [every] 15-min [minute] checks . The care plan was not updated to reflect any other interventions including assisting the resident to go outside. During an interview with RN #2 on 5/9/2022 at 10:30 AM, she stated Resident #1 seemed like he was bored at times. She had shown the resident the DVDs, puzzles, books, and snacks available to him, and had shown him the patio if he wanted to sit outside. Interview and review of the baseline care plan with the Administrator on 5/11/2022 at 1:45 PM confirmed the baseline care plan had not been updated to reflect interventions to prevent elopement for Resident #1. Facility Corrective Actions included: On 5/12/2022 the Administrator, DON, Activities Director met and determined all residents with a moderate/high risk of elopement would be assessed through activities to ensure activities addressed appropriate interventions that are resident-centered to meet the resident's needs. The surveyor confirmed by interview with the attendees. On 5/12/2022, the facility updated care plans of Resident #2 and Resident #3, residents at risk for elopement, to reflect resident-centered approaches. The care plan updates were observed by the surveyor. On 5/12/2022, the facility implemented the 24-hour report, which will be taken to the morning Interdisciplinary Department Team (IDT) meeting every morning 5 days a week, and the weekend supervisor will review to assist in identification of new resident needs for care planning timely. The MDS nurse/designee/weekend supervisor will update the care plan. The surveyor observed the 24-hour report at the nurse station and interviews with 2 nurses confirmed new admissions, change in condition, and concerns were recorded on the 24-hour report. On 5/12/2022, the facility implemented the process to review new admission Baseline Care Plans within 72 hours of admission. The process will be audited by the DON/designee weekly for 8 weeks, then monthly for 3 months and the findings will be reported to the Quality Assurance Performance Improvement (QAPI) team to ensure compliance and identify modifications if necessary. The process was confirmed by interview with the Administrator and DON. On 5/12/2022, the facility implemented the process to review 10% of resident care plans monthly for 3 months by the IDT team, with the findings reported to the QAPI team to ensure compliance. The DON/designee will audit the process. This process was confirmed by interview with the Administrator and DON. Noncompliance at F-655 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-689

Based on review of facility policy, medical record review, review of facility investigations, review of weather forecasts, interviews, and observations, the facility failed to ensure 1 resident (Resident #1) of 5 residents reviewed for accidents received adequate supervision to prevent elopement. The facility's failure to ensure adequate supervision to prevent elopement for Resident #1 placed the resident in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). Resident #1 left the facility patio and was found across the street from the facility on 4/19/2022, and on 4/20/2022, the resident went through his room window and was in an adjacent parking lot to the facility. The Administrator was notified of the Immediate Jeopardy on 5/12/2022 at 10:00 AM in the Nursing Team Leader Office. The facility was cited F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective 4/19/2022-5/12/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/13/2022 at 11:00 AM, and the corrective actions were verified onsite by the surveyor on 5/13/2022. The findings included: Review of the facility policy Elopements/Missing Resident dated 9/16/2021 revealed The facility will take all steps within its control, to prevent a resident from leaving the campus or a safe area without authorization .2. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to) experience heat or cold exposure, dehydration, and/or other medical complications, drowning, or being struck by a motor vehicle . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Pancreas, Malignant Neoplasm of the Right and Left Lung, and Anxiety. Medical record review of the Nursing Admission assessment dated [DATE] revealed the resident was independently ambulatory, able to make his needs known, and independent for activities of daily living (ADLs). Medical record review of a Brief Interview for Mental Status (BIMS) dated 4/16/2022 revealed a score of 14, indicating the resident was cognitively intact. Medical record review of Resident #1's Elopement Risk Assessment (a document with a series of questions that predicts elopement risk) dated 4/18/2022 revealed the resident had a score of 0, which indicated no risk for elopement. Review of a facility investigation dated 4/19/2022 at approximately 4:15 PM, showed Resident #1 left the facility through an unlocked door in the facility leading to the patio, stepped up onto a flower box in the patio area, and then stepped over a fence (to an unsecured open yard outside the fenced-in patio). The resident was dressed in pants, shirt, shoes, and a jacket. The resident was assisted back to the facility by Registered Nurse (RN) #1 and was assessed for injury with none noted. The resident reported that he just wanted to go for a walk. The facility interventions were staff reminded Resident #1 if he wanted to go for a walk, he should let a staff member know and they would escort him, and the facility placed a wander guard (a device that automatically locks egress doors when the device comes in proximity) on his right ankle. Review of the temperatures in [NAME], Tennessee on the Accuweather app showed a temperature of 55 degrees Fahrenheit (F) on 4/19/2022. Medical record review of an Elopement Risk assessment dated [DATE] revealed the facility reassessed Resident #1's elopement risk and the resident scored 27, which placed him at high risk for elopement. Review of a nurse note dated 4/19/2022 at 11:00 PM revealed Res [resident] had coat on and attempted to go out back patio door. It was explained to res that security locks doors at night. Res expressed understanding. Res continued to wander hallways attempting to open door to laundry room, break room, and dirty linen room. Res was also attempting to use portable charting computer. Res was redirected to room by CNA [Certified Nurse Assistant] without incident . Medical record review of a BIMS assessment completed 4/20/2022 revealed a score of 11, indicating Resident #1's cognition had decreased from the baseline assessment conducted on 4/16/2022 and the resident had moderate cognitive impairment. Review of a facility investigation dated 4/20/2022 at approximately 5:50 PM, showed Resident #1 raised the window in his room, pushed the screen out, and stepped out of the window. A housekeeper noticed the resident had exited the building, notified Certified Nurse Assistant (CNA) #2, and CNA #2 immediately exited the building and escorted Resident #1 back inside. The resident was assessed for injury with none noted. The resident stated it was such a beautiful day outside, he just wanted to go out. Interventions included the staff reminded the resident if he wanted to go outside, he just needed to ask someone to go with him, and the facility initiated every 15-minute checks. Review of the temperatures in [NAME] Tennessee on the Accuweather app showed on 4/20/2022 the temperature was 72 degrees F. Review of a progress note dated 4/21/2022 at 9:01 PM revealed, Resident exit seeking this shift. Walking to all exits and asking staff for code to be let out. This nurse told resident that he could go outside as long as a staff member accompanied him. He stated 'Well, never mind then .I will go back to my room' . Continued review of the note showed the resident was making several phone calls to family and friends. Interview with CNA #1 on 5/4/2022 at 10:45 AM, confirmed on 4/19/2022, she and CNA #2 exited the building through the front door and CNA #1 went up the hill and CNA #2 went down the hill to look for the resident. CNA #2 saw the resident across a two-lane road in the bend of a curve, down the hill in front of the facility (approximately 421 feet from where he exited the patio). Resident #1 stated he was going to the store. Observation and interview with CNA #2 on 5/4/2022 at 11:00 AM, confirmed on 4/19/2022, he witnessed Resident #1 walking away from the facility, down the sidewalk on the other side of the street. CNA #2 confirmed on 4/20/2022, the Housekeeper yelled down the hallway that Resident #1 had climbed out of his window and was outside of the building. Observation and interview showed Resident #1 had crossed the facility parking lot and was in an adjacent parking lot on 4/20/2022. Interview with Registered Nurse (RN) #1 on 5/4/2022 at 11:15 AM, confirmed on 4/19/2022, RN #1 observed Resident #1 go outside of the building to the patio and sit down in a chair. The nurse assisted another resident into her room and went back to check on Resident #1. RN #1 notified CNA #1 and CNA #2 to look for Resident #1 inside the facility when she noticed he was no longer on the patio. RN #1 exited the patio through a latched gate located at the back of the patio and continued around the back yard of the facility. RN #1 spotted Resident #1 across the street, ran to the resident, and escorted him back inside the facility. Observation with the Plant Operations Assistant on 5/4/2022 at 11:45 AM, showed on 4/19/2022, Resident #1 traveled approximately 421 feet and crossed a residential street, and on 4/20/2022, the resident traveled approximately 181 feet across the back parking lot to an adjacent parking lot. During an interview with RN #2 on 5/9/2022 at 10:30 AM, she stated Resident #1 seemed like he was bored at times. She had shown the resident the DVDs, puzzles, books, and snacks available to him, and had shown him the patio if he wanted to sit outside. Telephone interview with the Housekeeper on 5/9/2022 at 1:50 PM, confirmed he was aware Resident #1 had eloped on 4/19/2022. On 4/20/2022, the Housekeeper was working in the hallway outside of Resident #1's room when he heard the shade hit the window. The Housekeeper knew the resident had gone out of the window, he observed the resident outside, and encouraged him to come back inside the facility. Resident #1 ignored his request, so the Housekeeper ran back inside the facility and yelled down the hallway to CNA #2 for help. Observation with the Maintenance Engineer on 5/10/2022 at 9:45 AM, showed the window Resident #1 exited from on 4/20/2022 measured 38.5 inches in height and 44.25 inches in width. When raised, the window had an opening of 34.5 inches in height and 44.25 width. The distance from the windowsill to the ground was 35.5 inches. During observation and interview with the Administrator on 5/10/2022 at 12:30 PM, the Administrator confirmed the door leading from the building to the patio was not a safe area because the gate that opens into the back yard of the facility did not lock. Continued observation and interview confirmed all the windows in the facility opened freely and had not been modified to prevent someone from climbing through. Facility Corrective Actions included: On 4/20/2022, Resident #1 was placed on every 15-minute checks. Review of facility documentation revealed the checks were documented as completed from 4/20/2022-4/25/2022. Interviews conducted with 2 nurses, 2 CNAs and a housekeeper confirmed the monitoring had taken place. On 4/20/2022, an elopement drill was conducted by the Administrator and Director of Nursing (DON). Sign in sheets were observed and interviews with 2 CNAs and 2 Nurses confirmed participation in the drill. On 4/20/2022-4/22/2022, all staff were re-educated on facility policy Elopement/Missing Resident, Wandering, and Code White by either the Administrator or DON. Sign in sheets were observed and interviews with 2 CNAs and 2 Nurses confirmed participation in the re-education of policies. On 4/22/2022, the Administrator completed Elopement Risk Assessments for all residents. Review of all Elopement Risk Assessments completed on 4/22/2022 confirmed only 2 additional residents (#2, #3) had been identified as being at risk with appropriate interventions implemented. On 5/9/2022, the facility re-instated the keypad door lock on the door leading from the facility to the outside patio which requires a code to be entered before exiting the facility. On 5/11/2022, the Plant Engineer placed a latch on the outside of the patio gate which can only be opened from the outside. Signage was placed on the door inside the building that leads to the patio, and the gate door leading to the back yard of the facility, indicating the door and gate were not an exit. Observed by the surveyor as completed on 5/12/2022. On 5/12/2022, facility maintenance installed devices on all the facility windows to open to only 8 inches in height. Observations conducted on 5/13/2022 confirmed all windows were secured. On 5/13/2022, the Plant Engineer placed an alarm sensor on the door leading from the building to the patio. The nurse on the front hall will check the functionality of the sensor every shift. Observation of education on the process for monitoring the newly installed sensor and interviews confirmed the device was functional. The surveyor confirmed on 5/13/2022 the process was in place and the sensor functioned properly. Elopement Risk Assessments are completed on admission and quarterly. All admission Elopement Risk Assessments will be reviewed in the IDT meeting 5 days a week for 8 weeks and then monthly for 3 months with the findings taken to the Quality Assurance Performance Improvement (QAPI) team quarterly meeting to ensure compliance with modifications. 10% of the quarterly Elopement Risk Assessments will be reviewed by the IDT monthly for 3 months with the findings taken to the QAPI quarterly meeting. Elopement Drills will be conducted on each shift monthly for 3 months and taken to the QAPI team meeting for review. Noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on medical record review, review of facility investigations, and interviews, the facility initiated a discharge and failed to meet the discharge requirements for 1 resident (Resident #1) of 3 residents reviewed for discharge. The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE], after living at a group home, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the facility on hospice services. Resident #1 discharged back to the group home on 4/25/2022. Medical record review of the Nursing Admission assessment dated [DATE] revealed the resident was ambulatory, able to make his needs known, and independent for activities of daily living (ADLs). Medical record review of a Brief Interview for Mental Status (BIMS) dated 4/16/2022 revealed a score of 14, indicating the resident was cognitively intact. Medical record review of Resident #1's Elopement Risk Assessment (a document with a series of questions that predicts elopement risk) dated 4/18/2022 revealed Resident #1 had a score of 0, which indicated no risk for elopement. Review of a facility investigation dated 4/19/2022 showed at approximately 4:15 PM, Resident #1 exited the facility through an unlocked door to the patio, stepped up onto a flower box, and then stepped over a fence into an open and unsecured yard. The resident was located across the street from the facility, was assisted back to the facility by Registered Nurse (RN) #1 and had no injuries. Resident #1 reported that he just wanted to go for a walk. The facility staff reminded the resident if he wanted to go for a walk, to let a staff member know and they would escort him. The facility placed a wander guard (a device that automatically locks egress doors when the device comes in proximity) on his right ankle. The facility completed a second Elopement Risk Assessment on 4/19/2022 and the resident scored 27, which placed him at high risk for elopement. The facility completed a BIMS assessment on 4/20/2022 which revealed a score of 11, indicating Resident #1 had a decline in cognition and had moderate cognitive impairment. Review of a facility investigation dated 4/20/2022 showed at approximately 5:50 PM, Resident #1 eloped a second time through his bedroom window and was in a parking lot adjacent to the facility. Certified Nurse Assistant (CNA) #2 immediately escorted Resident #1 back inside and the resident had no injuries. The resident stated it was such a beautiful day outside, he just wanted to go out. The facility reminded the resident if he wanted to go outside, he needed to ask someone to go with him. In response to the incident, the facility implemented checking the resident every 15 minutes. Review of a progress note dated 4/21/2022 at 11:00 AM, revealed the facility initiated a care plan meeting with the resident's hospice agency .Care planning meeting with [hospice agency], resident [Resident #1] and resident RP [Responsible Party, who was the owner of the group home where the resident previously lived]. Resident verbalizes understand [understanding] regarding the inappropriate means of laving [leaving] the facility X [times] 2 . [hospice agency] is seeking alternate placement for resident both resident and RP aware and are in agreement to finding an alternate placement for the resident. Review of a progress note dated 4/21/2022 at 9:01 PM revealed Resident exit seeking this shift. Walking to all exits and asking staff for code to be let out. This nurse told resident that he could go outside as long as a staff member accompanied him. He stated 'Well, never mind then .I will go back to my room' . Continued review of the note showed the resident was making several phone calls to family and friends. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .S. [MEDICATION(S)] (narcotic pain medication) 60 mg 1 tablet every 8 hours, and [MEDICATION(S)] Sulfate concentrate 20 mg/ml (milliliter) give 1 ml by mouth every hour as needed. Continued review showed the following medications were ordered: [MEDICATION(S)] 150 microgram (mcg) patch every 72 hours and [MEDICATION(S)] 15 mg IR every 4 hours as needed for pain. Review of Resident #1's Discharge summary dated 4/25/2022 revealed .History of Present Illness: The patient was admitted to the Convalescent Center from [group home name] on hospice care. The patient was admitted due to [CONDITION(S)] and need for ADL [Activities of Daily Living] with the patient's eventual progression of his cancer. While at the Convalescent Center the patient was high risk for escaping with 2 instance [instances] of leaving the facility unsupervised. He was reevaluated and found to have a SLUMS score [screening test for Dementia] indicating moderate to severe dementia. His medications were also adjusted making his pain medication regimen more simpler [easier to manage] by changing his [MEDICATION(S)] to [MEDICATION(S)] [narcotic pain medication that is applied by a patch to the skin] with [MEDICATION(S)] breakthrough. The patient has requested to return to [group home] for the time being . Medical record review revealed the resident's physician did not document in the medical record any specific resident needs the facility was unable to meet, how the facility attempted to meet the needs of the resident to prevent the resident from eloping from the facility, and how the services at the receiving facility would be able to meet the resident's needs. Interview with Social Services/Admissions Coordinator on 5/4/2022 at 12:00 PM, revealed Resident #1 was admitted to the nursing facility from a group home due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator on 5/9/2022 at 9:00 AM, revealed after the first elopement on 4/19/2022, a wander guard was placed on Resident #1, and he was encouraged to let staff know if he wanted to go outside and a staff member would go with him. The Administrator stated after the elopement on 4/20/2022, they implemented every 15-minute checks for the resident. Telephone interview with the Director of Nursing (DON) on 5/9/2022 at 12:00 PM, confirmed he initiated contact with the hospice Administrator on 4/20/2022 to request a meeting to discuss alternate placement for Resident #1 due to his elopement on 4/19/2022 and prior to the 2nd elopement on the evening of 4/20/2022. Telephone interview with the Hospice Social Worker on 5/9/2022 at 12:50 PM, revealed she had met with the facility staff for a care plan meeting on 4/21/2022. The Hospice Social Worker attempted to find alternate placement for Resident #1, contacting homeless shelters, and no one would accept him. The Hospice Social Worker stated she had called the Responsible Party (RP) the next day, told her about the medication changes (changes to make medication administration easier), and the RP agreed to accept the resident back to the group home. Telephone interview with the hospice Administrator on 5/9/2022 at 1:00 PM, confirmed the facility contacted her by phone on 4/20/22. The DON had requested a meeting to discuss possible alternate placement for Resident #1 due to his desire to take a walk outside unassisted. The Hospice Administrator stated she spoke with Resident #1 by phone on the evening of 4/20/2022 and told him he could potentially be discharged from the facility if he continued to go out of the facility unassisted. The hospice agency and the facility met at the facility on 4/21/2022 to find alternate placement for Resident #1. Interview with the DON on 5/10/2022 at 11:10 AM confirmed on 4/21/2022, the DON, Administrator, and Minimum Data Set (MDS) Nurse met with hospice staff to discuss finding alternate placement for Resident #1, as requested by the facility. The facility staff and hospice staff met with Resident #1's RP and informed her of the need for alternate placement and the plan at the time was to contact other area homeless shelters. The RP did not want to take Resident #1 back to the group home because of the medications he was prescribed for pain control for his cancer diagnoses. Interview with the DON on 5/10/2022 at 11:15 AM, revealed the Social Worker for hospice called the DON on 4/22/2022 and reported Resident #1's RP had agreed to accept him back to the group home with the medication changes that had been implemented. Interview with the Administrator on 5/10/2022 at 12:30 PM, confirmed the facility had planned to issue a 30-day discharge, but did not because the resident and his representative had agreed to the discharge after the facility had initiated the care plan meeting and requested the hospice provider find alternate placement for Resident #1. Telephone interview with the Primary Care Physician (PCP) on 5/10/2022 at 2:00 PM, revealed the facility determined it could not meet Resident #1's needs due to his behavior of wandering to unsafe areas. The PCP had changed the resident's pain medications from oral medications to patches for Resident #1 to be discharged back to the group home he was admitted from. The PCP stated she performed a test with the resident to determine if he possibly had dementia and the resident's score showed moderate to severe dementia. The resident remained independent with ambulation and all ADLs while in the facility.

Based on medical record review, review of facility investigations, and interviews, the facility failed to issue a 30-day notice of discharge, failed to notify the state Long-Term Care Ombudsman of the transfer, and failed to notify the resident and resident's representative of appeal rights for 1 (Resident #1) resident of 3 residents reviewed for discharges. The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE], after living at a group home, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the facility on hospice services. Resident #1 discharged back to the group home on 4/25/2022. Medical record review of the Nursing Admission assessment dated [DATE] revealed the resident was ambulatory, able to make his needs known, and independent for activities of daily living (ADLs). Medical record review of a Brief Interview for Mental Status (BIMS) dated 4/16/2022 revealed a score of 14, indicating the resident was cognitively intact. Medical record review of Resident #1's Elopement Risk Assessment (a document with a series of questions that predicts elopement risk) dated 4/18/2022 revealed Resident #1 had a score of 0, which indicated no risk for elopement. Review of a facility investigation dated 4/19/2022 showed at approximately 4:15 PM, Resident #1 exited the facility through an unlocked door to the patio, stepped up onto a flower box, and then stepped over a fence into an open and unsecured yard. The resident was located across the street from the facility, was assisted back to the facility by Registered Nurse (RN) #1 and had no injuries. Resident #1 reported that he just wanted to go for a walk. The facility staff reminded the resident if he wanted to go for a walk, to let a staff member know and they would escort him. The facility placed a wander guard (a device that automatically locks egress doors when the device comes in proximity) on his right ankle. The facility completed a second Elopement Risk Assessment on 4/19/2022 and the resident scored 27, which placed him at high risk for elopement. The facility completed a BIMS assessment on 4/20/2022 which revealed a score of 11, indicating Resident #1 had a decline in cognition and had moderate cognitive impairment. Review of a facility investigation dated 4/20/2022 showed at approximately 5:50 PM, Resident #1 eloped a second time through his bedroom window and was in a parking lot adjacent to the facility. Certified Nurse Assistant (CNA) #2 immediately escorted Resident #1 back inside and the resident had no injuries. The resident stated it was such a beautiful day outside, he just wanted to go out. The facility reminded the resident if he wanted to go outside, he needed to ask someone to go with him. In response to the incident, the facility implemented checking the resident every 15 minutes. Review of a progress note dated 4/21/2022 at 11:00 AM, revealed the facility initiated a care plan meeting with the resident's hospice agency .Care planning meeting with [hospice agency], resident [Resident #1] and resident RP [Responsible Party, who was the owner of the group home where the resident previously lived]. Resident verbalizes understand [understanding] regarding the inappropriate means of laving [leaving] the facility X [times] 2 . [hospice agency] is seeking alternate placement for resident both resident and RP aware and are in agreement to finding an alternate placement for the resident. Review of the medical record revealed no evidence a 30-day discharge notice and appeal rights had been issued to the resident, and no evidence the State Long-term care Ombudsman had been notified of the facility-initiated discharge of Resident #1. Interview with the Admissions Director on 5/4/2022 at 12:05 PM, revealed Resident #1 requested admission to the facility based upon his expected decline due his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephone interview with the Director of Nursing (DON) on 5/9/2022 at 12:00 PM, confirmed he had contacted the hospice Administrator on 4/20/2022 to request a meeting for alternate placement for Resident #1 due to his elopement on 4/19/2022, but before the resident's elopement on 4/20/2022. Interview with the Administrator on 5/10/2022 at 12:30 PM, confirmed the facility had planned to issue a 30-day discharge, but did not because the resident and his representative had agreed to the discharge after the facility had initiated the care plan meeting and requested the hospice provider find alternate placement for Resident #1.

Based on review of facility policy, medical record review, review of facility investigation, and interviews, the facility failed to report an allegation of abuse timely to facility Administration and to the State Survey Agency for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention - Reporting and Investigating Policy dated 6/11/2021 revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately according to state and federal requirements . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the quarterly MDS dated [DATE] revealed the resident had both short and long-term memory problems. The resident required total assist for bed mobility, activities of daily living (ADLs), and eating with 1-2 person assist. The resident was always incontinent of bowel and bladder. Review of a facility investigation dated 3/23/2022 showed Certified Nurse Assistant (CNA) #1 was overheard by CNA #3 on 3/22/2022 tell Resident #1 she was too fat and she did not need to fight against her and should allow CNA #1 to provide incontinence care. Interview with the Administrator on 4/11/2022 at 12:15 PM confirmed CNA #3 failed to report the allegation of abuse timely to Administration and was not reported until the following day. Telephone interview with CNA #3 on 4/11/2022 at 3:25 PM confirmed she was providing care for Resident #2 (Resident #1's roommate) while CNA #1 provided care for Resident #1 and overheard CNA #1 tell Resident #1 she was too fat to fight against her. Continued interview revealed CNA #3 reported the comments to her mentor (CNA #7) and CNA #7 told CNA #3 she should tell someone the next day what had happened. Telephone interview with CNA #7 on 4/11/2022 at 3:45 PM confirmed CNA #7 told CNA #3 she should report what she had overheard the next day. During continued interview she stated .realize now should have taken [CNA #3] to the nurse on the floor .Didn't think about it being abuse .

Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to ensure 1 resident (Resident #1) was free from abuse of 5 residents reviewed for abuse. The findings include: Review of facility's policy titled Resident Abuse - Identification, Investigation and Reporting with a revision date of [DATE] showed .It is the Policy of this facility to protect residents from .abuse . 'Abuse' means the willful infliction of injury .with resulting physical harm, pain . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 7 indicating the resident had severe cognitive impairment. The resident required assistance of one person with activities of daily living (ADL's). Review of the medical record showed Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired on [DATE]. Medical record review of the quarterly MDS assessment dated [DATE] showed Resident #2's BIMS score was 7 indicating the resident had severe cognitive impairment. The resident required assistance of one person with ADL's. Medical record review of a current care plan for Resident #2, last reviewed on [DATE], showed .the resident has a behavior problem r/t [related to] being agitated and assertive to other residents .[DATE] Episode with another resident [Resident #1] . Review of a facility investigation dated [DATE] at 5:30 PM showed Resident #2 was witnessed striking Resident #1 with his cane across the back of his shoulders and neck leaving reddened areas to the back of Resident #1's neck. During an interview on [DATE] at 9:30 AM, Resident #1 stated .yes I remember .I said something to her [Resident #2] about her salvation and she didn't like it .she took my cane and hit me on my shoulder . During an interview on [DATE] at 3:00 PM, Registered Nurse (RN) #1 stated .I heard raised voices coming from the dining room I went in there immediately and she [Resident #2] was on one side of the table and he [Resident #1] was on the other side and she had his cane .he had a red spot on his right shoulder . During a telephone interview on [DATE] at 3:20 PM, the Administrator stated .from what I was told .[Resident #1] said something about her [Resident #2's] salvation .so she got up and wrestled his cane from him and smacked him with it . The Administrator confirmed the facility failed to ensure Resident #1 was free from abuse.

Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to report an allegation of abuse to the State Survey Agency within the federally required time frame of 2 hours for 1 resident (Resident #1) of 5 residents reviewed for abuse. The findings include: Review of the facility's abuse policy titled Resident Abuse - Identification, Investigation and Reporting with a revision date of [DATE] showed .Alleged Abuse must be reported to the Tennessee Depart of Health, Division of Licensure and Regulation, Office of Health Care Facilities .Immediately . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 7 indicating the resident had severe cognitive impairment. The resident required assistance of one person with activities of daily living (ADL's). Review of the medical record showed Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired on [DATE]. Medical record review of the quarterly MDS assessment dated [DATE] showed Resident #2's BIMS score was 7 indicating the resident had severe cognitive impairment. The resident required assistance of one person with ADL's. Review of a facility investigation dated [DATE] at 5:30 PM showed Resident #2 was witnessed striking Resident #1 with his cane across the back of his shoulders and neck leaving reddened areas to the back of Resident #1's neck. Review of a facility investigation dated [DATE] revealed .IRS [Incident Reporting System] .Date of Report: [DATE] .Date of occurrence: [DATE] . During an interview on [DATE] at 3:00 PM, Registered Nurse #1 stated .I heard raised voices coming from the dining room I went in there immediately and she [Resident #2] was on one side of the table and he [Resident #1] was on the other side and she had his cane .he said that she had hit him with the cane .he had a red spot on his right shoulder .I called our administrator immediately . During a telephone interview on [DATE] at 3:20 PM, the Administrator stated .I realized I failed to report it to the state . The Administrator confirmed the facility failed to follow their abuse policy and failed to report allegations of abuse to the state agency within 2 hours for Resident #1. Refer to F-600.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide assistance with Activities of Daily Living (ADL) for 1 resident (Resident #1) of 3 residents reviewed for nail care. The findings include: Review of Nail and Foot Care protocol revealed .Do not cut the nails of a patient who has diabetes, impaired peripheral circulation, or an increased risk of bleeding .Refer the patient to a podiatrist or other appropriate health care professional . Review of a Nurse Practitioner (NP) note dated 6/18/2020 revealed Resident #1 was seen by the NP on 6/18/2020 and the resident's nails were cut. Review of a Physician note dated 8/17/2020 showed Resident #1 was seen by the physician on 8/17/2020 and the resident's nails were not cut. Review a NP note dated 10/6/2020 showed Resident #1 was seen on 10/6/2020 by the NP and the resident's nails were cut. During an interview on 10/22/2020 at 11:00 AM Activities/CNA #1 stated nail care is done during showers and the physician cuts the toenails of diabetic residents. During an interview on 10/22/2020 at 11:35 AM the Social Services Director stated the physician/nurse practitioner cuts the nails of residents with Diabetes. The Social Services Director stated the NP cuts diabetic residents nails every 60 days. The Social Services Director stated the NP was sick on one of the visits and Resident #1 did not get her nails trimmed. During an interview on 10/22/2020 at 1:00 PM the Administrator stated the NP cuts the nails of diabetics on her 60 day visits. Continued interview revealed the NP was out sick on one of the scheduled visits and Resident #1's nails were not cut. During a telephone interview on 10/22/2020 at 1:25 PM the NP stated she did rounds every 60 days and cuts toenails of diabetics during her visit. The NP stated she was out sick during one of these scheduled visits, the physician did the visit and did not cut the nails of Resident #1. The NP stated she cut the resident's nails on her next visit.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow infection control practices for isolation precautions for 2 residents (#4 and #11) of 2 residents on isolation precautions of 14 sampled residents. The findings include: Review of the facility policy Isolation Precautions Policy last revised 4/21/16 revealed .To interrupt the spread of infection by controlling transmission of highly infectious pathogens .Contact Precautions .for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment .Wear gloves when entering the room if your hands will have contact with the patient or times (items) in the patients room .Wear a clean gown when entering room if your clothing will have contact with the patient or items in the patient's room, or if the patient is incontinent (have no control over urination or defecation) .Droplet Precautions .Patient Placement .Door should be kept closed .Private room is indicated .Masks should be worn when entering room and must be worn if working within 3 feet of the patient .Obtain Isolation cart (cart containing personal protective equipment (PPE)) from central supply or clean storage room .Place Isolation sign on door .All associates entering an isolation room must carry out appropriate techniques . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of laboratory result dated 10/21/19 revealed .Sputum .[MEDICAL CONDITION] Resistant Staph Aureus (MRSA) isolated .Called to and read back .This organism requires contact isolation. If isolation is not currently being used, place patient in isolation per infection control policy . Continued review revealed Licensed Practical Nurse (LPN) #1 initialed the laboratory result and wrote .MD .aware 10:20 AM .faxed . Medical record review of a telephone order dated 10/21/19 at 10:20 AM revealed .Respiratory Isolation . Medical record review of a nurse's note dated 10/21/19 at 3:18 PM revealed .Lab called a medic alert.[MEDICAL CONDITION] in sputum, MD (medical doctor) .called and made aware at 10:20 AM .Respiratory isolation, droplet precaution . Observation on 10/21/19 at 12:00 PM, of Resident #4's room, revealed no isolation sign indicating isolation or see the nurse before entering the resident's room to alert visitors or staff regarding isolation. Continued observation revealed Certified Nursing Assistant (CNA) #2 adjusting Resident #4's oxygen nasal cannula without the use of PPE. Interview with the Administrator in Training on 10/21/19 at 12:00 PM, at the nurse's station, confirmed the resident had not been placed in respiratory isolation as ordered by the physician. Interview with CNA #2 on 10/21/19 at 12:35 PM, in the dining room, confirmed she was unaware Resident #4 had a respiratory infection which required respiratory isolation when she adjusted the resident's oxygen nasal cannula. Interview with the Infection Control Preventionist on 10/22/19 at 12:45 PM, in the conference room confirmed .as soon as you find out (resident has infection requiring isolation) they should be put in isolation immediately . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Continued review revealed the resident was always incontinent of bowel and bladder. Medical record review of the care plan dated 7/17/19 and last revised 8/8/19 revealed .The resident has [DIAGNOSES REDACTED]icile ([MEDICAL CONDITION] infection) r/t (related to) infection, antibiotic use .CONTACT ISOLATION .Educate resident/family/staff regarding preventive measures to contain the infection . Observation on 10/21/19 at 9:40 AM, of Resident #11's room, revealed a Contact Isolation sign on the door of Resident #11's room with appropriate PPE hanging on the door available for staff use. Observation on 10/21/19 at 12:55 PM, in Resident #11's room, revealed CNA #1 opened up the resident's lunch tray without the use of a gown or gloves. Continued observation revealed CNA #1 touched Resident 11's over bed table with her bare hands. Further observation revealed CNA #1 then walked around the bed and leaned over the bedside to adjust items on the meal tray with her contaminated hands. Continued observation revealed the CNA #1's clothing came in contact with the side of Resident #11's bed. Interview with CNA #1 on 10/21/19 at 3:13 PM, in the hallway, confirmed she had entered Resident #11's room to deliver the lunch tray without wearing a gown or gloves. Further interview confirmed she touched the over bed table with her bare hands and leaned over the bed to adjust items on Resident #11's meal tray and her clothing came into contact with the resident's bed. Interview with the Infection Preventionist on 10/22/19 at 4:14 PM, in the conference room, confirmed staff were expected to wear gown and gloves when entering a contact isolation room for a resident with [MEDICAL CONDITION] infection.

Based on medical record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 1 resident (#12) of 14 residents reviewed for MDS accuracy. The findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Informed Consent For Use of Restraints documentation dated 9/17/18, revealed .Restraint: .Merriwalker (Merry Walker) (self-enclosed walker/chair combination device) .Purpose for recommended restraint: .assist c (with) ambulation . Medical record review of Resident #12's current comprehensive care plan, revised 8/20/18, revealed .Resident to use Merri-walker (Merry Walker) for increased safety while ambulating . Medical record review of Resident #12's Annual MDS dated [DATE], revealed the resident was severely cognitively impaired. Continued review revealed physical restraint use was not coded on the MDS. Medical record review of the physician's orders [REDACTED].Restraints .MerriWalker (Merry Walker) when out of bed to aid ambulation . Observation of Resident #12 on 10/22/19 at 1:24 PM, at the nurse's station, revealed the resident ambulating independently in her Merry Walker. Interview with MDS Coordinator #1 and the Administrator in Training on 10/22/19 at 10:33 AM, in the MDS office, confirmed Resident #12's Merry Walker was not coded as a restraint.

Based on medical record review and interview, the facility failed to refer 2 residents (#8 and #23) after the residents were identified with possible serious mental disorders, to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR) of 3 residents reviewed for PASARR. The findings include: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the [DIAGNOSES REDACTED]. Medical record review of the most recent PASRR (PASARR) Level I assessment dated [DATE] revealed Resident #8 had mental health [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 had [DIAGNOSES REDACTED]. Observation on 10/21/19 at 10:05 AM, in the resident's room, revealed Resident #8 in bed watching television and eating a snack. Continued observation on 10/24/19 at 10:25 AM, in the resident's room revealed Resident #8 watching television and eating a snack. Interview with the Director of Nursing (DON) on 10/23/19 at 9:46 AM, in the DON's office, confirmed a new PASRR was not submitted after the [DIAGNOSES REDACTED].#8. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the most recent PASRR Level 1 assessment dated [DATE] revealed Resident #23 had a mental health [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #23 has [DIAGNOSES REDACTED]. Observation on 10/21/19 at 9:42 AM, in the dining room, revealed Resident #23 sitting up in a reclining chair asleep. Interview with the DON on 10/23/19 at 8:17 AM, in the conference room, confirmed Resident #23's PASRR was completed by the hospital prior to admission and had not been reviewed for accuracy by the facility. Further interview confirmed a new PASRR was not submitted to include the [DIAGNOSES REDACTED].

Based on review of facility policy, medical record review, observation, and interview, the facility failed to develop a care plan for a restraint 1 resident (#12) of 14 sampled residents. The findings include: Review of the facility policy, Restraints, reviewed 8/2011, revealed .The residents care plan shall reflect the medical reason for the restraint, alternatives, declines in physical condition, potential complications, interventions .and any other pertinent interventions . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #12's Annual Minimum Data Set ((MDS) dated [DATE], revealed the resident was severely cognitively impaired. Continued review revealed physical restraint use was not coded on the MDS. Medical record review of the Physician's Orders dated 9/1/19, revealed .Restraints .MerriWalker (Merry Walker) (self-enclosed walker/chair combination device) when out of bed to aid ambulation . Medical record review of Resident #12's current comprehensive care plan revealed no documentation of the Merry Walker as a restraint. Observation of Resident #12 on 10/22/19 at 1:24 PM, at the nurse's station revealed the resident ambulating independently in the Merry Walker. Continued observation revealed the resident smiling. Interview with MDS Coordinator #1 and the Administrator in Training on 10/22/19 at 10:33 AM, in the MDS office, confirmed the facility failed to care plan Resident #12's Merry Walker as a restraint.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary pantry and kitchen with foods items not stored in a container with a tight-fitting lid, undated foods, unlabeled foods, and open to air food items, in 1 of 1 pantry and in 1 of 1 kitchen for the nursing home potentially affecting 54 residents. The findings include: Review of the facility policy Use and Storage of Food brought to Residents from the Outside, last revised 1/2018, revealed .Food brought in by family or other visitors is permitted, provided care is taken to ensure food is handled properly for safe and sanitary storage, and consumption .If the prepared food is not served immediately to the resident, the food must be stored in a container with a tight-fitting lid, clearly labeled with the resident's name and room number, the date the food was brought in to the resident . Review of the facility policy Food and Supply Storage, last revised 1/2017, revealed .All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Cover, label and date unused portions and open package .products are good through the close of business on the date noted on the label . Observation and interview with Dietary Manager (DM) #1 on 11/26/18 at 9:04-9:14 AM, in the pantry area, of the stand-alone refrigerator revealed: A) One 8 x 9 inch Styrofoam plate loosely covered with aluminum foil containing: ham, corn bread dressing, whole corn, and mashed potatoes with 50% consumed. Continued observation revealed the plate of food was undated, not in a container with a tight-fitting lid, and available for resident use. B) One 8 x 9 inch styrofoam plate loosely covered with aluminum foil containing 3 servings of pecan pie with 50% consumed. Continued observation revealed the plate of food was undated, not stored in a container with a tight-fitting lid, and available for resident use. C) One 8 x 9 inch styrofoam plate loosely covered with aluminum foil containing two servings of chocolate cake with 50% consumed, 1 slice of cherry pie partially consumed with a used plastic spoon and fork laying on the slice of cherry pie, 1/3 serving of apple pie with 50% consumed. Continued observation revealed the plate of food was undated, not stored in a container with a tight-fitting lid, and available for resident use. D) One 9 by 12 inch styrofoam plate containing cornbread dressing, whole corn kernels, mashed potatoes, green peas, ham with 50% consumed. Continued observation revealed the plate of food was undated, not stored in a container with a tight-fitting lid, and available for resident use. E) One 10 inch aluminum circle pie pan containing banana pudding, cherry soufflé, and marshmallow cream dessert, with approximately 50% of the food consumed. Continued observation revealed the food was undated, not stored in a container with a tight-fitting lid, and available for resident use. F) One 20 fluid ounce bottle of orange liquid appropriately 75% full, not labeled with a resident name, undated and available for resident use. G) One 10 fluid ounce bottle of water appropriately 50% full, not labeled with a resident's name, undated, and available for resident use. Interview with DM #1, at the same time as the observation, confirmed the food in the styrofoam plates was brought in by family or other visitors and stored in the pantry refrigerator. Continued interview confirmed DM #1 was unaware of how long the food had been in the pantry refrigerator. Further interview confirmed the food from the styrofoam plates had been placed back in the refrigerator after being partially consumed. Further interview confirmed the facility failed to maintain a sanitary pantry with foods stored in the refrigerator after being partially consumed, dirty used forks and spoons left in styrofoam plates, food items not stored in a container with a tight-fitting lid, and no date on the food items to inform staff when the food was stored in the refrigerator. Observation and interview with DM #1 on 11/26/18 at 9:21 AM of the countertop area in the pantry, revealed one 18 ounce box of cereal approximately 50% full in a plastic bag open to air, undated, and available for resident use. Interview with DM #1confirmed the facility failed to maintain a sanitary pantry with undated and unlabeled food. Observation and interview with DM #2 on 11/26/18 at 9:38 AM, in the kitchen, of the bread stand revealed: A) One 2 pound bag of bread containing 4 slices of bread open to air, and available for resident use. B) One 2 pound bag of bread containing 2 slices of bread open to air, and available for resident use. Interview with DM #2 confirmed the facility failed to maintain a sanitary kitchen with food items open to air, and available for resident use. Observation and interview with DM #2 on 11/26/18 at 9:43 AM, in the kitchen, of supplies over the prep table, revealed one 32 ounce bag of bread crumbs appropriately 50% full opened to air and available for resident use. Interview confirmed the facility failed to maintain a sanitary kitchen with food items open to air, and available for resident use. Observation with DM #2 on 11/26/18 at 9:46 AM, in the kitchen, of the walk-in freezer, revealed one brown bag of french fries approximately 1/3 full, open to air, undated, and available for resident use. Interview with DM #2 confirmed the facility failed to maintain a sanitary kitchen with food items open to air, undated, and available for resident use. Observation with DM #2 on 11/28/18 at 10:14 AM, in the kitchen, of the stand-alone cooler #1, revealed twelve pancakes in a clear plastic bag, on a shelf, undated with a use by date, and available for resident use. Interview with DM #2 confirmed the pancakes needed a use by date listed on the bag or a hand written date on the bag of pancakes. Continued interview confirmed the facility failed to maintain a sanitary kitchen with undated food items available for resident use.

Based on facility policy review, medical record review and interview, the facility failed to ensure a complete medical record for 1 resident (#49) of 27 residents sampled. The findings include: Review of the facility policy Advance Directives revised 2/23/17, revealed .Documentation of advance directives and decisions regarding health care choices will be maintained in the resident's medical record . Further review revealed .Physician order for [REDACTED]. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #49's current comprehensive care plan, last revised 11/6/18, revealed .Advanced Directives Full Code Status . Medical record Review of the POS [REDACTED].Guardian/Health Care Representative was incomplete; and the Health Care Professional Preparing Form was blank and incomplete. Interview with the Assistant Director of Nursing on 11/26/18 at 4:23 PM, at the nurse's station confirmed .it is missing a whole lot . Continued interview confirmed the facility failed to ensure the POST form was complete.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to maintain infection control precautions for 1 resident (#62) of 1 resident in isolation precautions of 25 sampled residents. The findings included: Review of facility policy Isolation Precautions Policy last revised 4/21/16 revealed, .Purpose .To interrupt the spread of infection by controlling transmission of highly infectious pathogens .Section II: Isolation Categories .2. Contact Precautions .a. In addition to Standard Universal Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment .b. Patient placement- private room or in room with patient with same infection with same microorganism but with no other infection . Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].Education provided for contact isolation for [DIAGNOSES REDACTED] (Clostridium Difficile) (an intestinal bacterial infection which is highly contagious) to (Resident #62) and his (family member) .verbalized understanding . Medical record review of a Physician's telephone order dated 1/16/17 revealed, .Contact Isolation . Observation on 1/16/17 at 10:11 AM, during initial tour, revealed a sign outside of Resident #62's room .Contact Isolation . Continued observation revealed two other residents cohabiting in the room with Resident #62 Observations conducted throughout the survey on 1/17/17 and 1/18/17 revealed Resident #62 remained in contact isolation and remained housed in the room with two other residents. Interview with the Director of Nursing (DON) on 1/17/17 at 2:17 PM, in the conference room, confirmed Resident #62 was diagnosed with [REDACTED]. Continued interview confirmed Resident #62 was not moved to a private room and remained in the same room with two residents who did not have[DIAGNOSES REDACTED]. Continued interview confirmed the facility failed to follow the facility policy.

Based on medical record review, observation, and interview, the facility failed to provide medically related social services for 3 residents (#8, #22, and #34) of 6 residents reviewed for dental services of 25 sampled residents. The findings included: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's documentation dated 11/23/16 revealed .N/O (new order) ask dentist to check on replacing partial plate . Observation and interview with Resident #8 on 1/18/17 at 9:53 AM, in the resident's room, revealed the resident's dental bridge in a plastic bag on resident's over bed table. Interview revealed .They tell me someone is coming (to fix bridge) but I have not seen anyone yet .been going on a few months now . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's documentation dated 10/2/16 revealed .res (resident) lower dentures were out this morning .resident stated .'opened my plastic case with them (dentures) inside and they fell out in the floor and broke' .Dentures placed back in the cup .Will have Dr . (dentist) look at them tomorrow while (he/she) is here . Interview with Resident #22 on 1/18/17 at 9:25 AM, in the dining room, revealed They keep saying they are getting someone in here to fix my bottom dentures, but have not. Continued interview revealed dentures had been broken for 2 months. Interview with the Registered Dietician (RD) on 1/19/17 at 9:39 AM, in the Dietician's office, revealed Resident #22's dentures had been broken for some time. Interview with the Social Worker and the Administrator on 1/19/17 at 2:34 PM, in the Social Services office, revealed the Social Worker was aware Resident #8's bridge was broken and was aware Resident #22's dentures were broken. Continued interview confirmed a local dental provider would see residents if the facility would provide transportation to dental office and the facility failed to arrange transportation. Further interview confirmed the facility failed to provide medically related social services for Resident #8 and #22. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nurse's documentation dated 6/26/16 revealed Resident #34 was seen by a dentist and the resident requested to have remaining teeth pulled and he wanted a full set of dentures. Continued review revealed .Referred to Social Services to explore the options for having teeth extracted and purchase of dentures . Medical record review of a Social Service note dated 7/20/16 revealed dental services for teeth extractions was scheduled for 8/18/16. Medical record review of a Report Of Consultation (dental) dated 9/18/16 revealed .Pt. (patient) wants teeth removed and dentures placed . Observation with Resident #34 on 1/18/17 at 10:00 AM, in the resident's room, revealed the resident was missing multiple upper and lower teeth. Interview with Resident #34 and the Director of Nursing (DON) on 1/19/17 at 10:26 AM, in the resident's room, revealed Resident #34 wanted his teeth pulled and dentures made. Continued interview revealed Resident #34 had been seen by a dentist but .have never come back . Interview with the DON and the Social Worker on 1/19/17 at 10:49 AM, in the DON's office, confirmed Resident #34 was seen by a dentist on 6/26/16 and had requested to have the remaining teeth pulled and dentures made. Continued interview confirmed the resident was seen again by a dentist on 9/18/16 and again requested to have the remaining teeth pulled and dentures made. Further interview confirmed the facility failed to provide transportation to a dental office for requested dental services and failed to provide medically-related social services for Resident #34.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide dental services for 3 residents (#8, #22, and #34) of 6 residents reviewed for dental services of 25 sampled residents. The findings included: Review of facility policy, Oral Health Program last revised 3/2003 revealed .residents will be provided with comprehensive diagnostic dental treatment embracing .a system that assures that each resident is reexamined as needed, but at least once a year . Medical Record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's documentation dated 11/23/16 revealed .N/O (new order) ask dentist to check on replacing partial plate . Observation and interview with Resident #8 on 1/18/17 at 9:53 AM, in the resident's room, revealed the resident's dental bridge in a plastic bag on the resident's over bed table. Interview revealed .they tell me someone is coming (to fix bridge) but I have not seen anyone yet .been going on a few months now . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's documentation dated 10/2/16 AM revealed .res (resident) lower dentures were out this morning .resident stated .'I opened my plastic case with them (dentures) inside and they fell out in the floor and broke' .Dentures placed back in the cup .Will have Dr . (dentist) look at them tomorrow while (he/she) is here . Interview with Resident #22 on 1/18/17 at 9:25 AM, in the dining room, revealed .They keep saying they are getting someone in here to fix my bottom dentures, but have not . Continued interview revealed dentures had been broken for 2 months. Interview with the Registered Dietician (RD) on 1/19/17 at 9:39 AM, in the Dietician's office, revealed Resident #22's dentures had been broken for some time. Interview with the Social Worker and the Administrator on 1/19/17 at 2:34 PM, in the Social Services office, revealed the Social Worker was aware Resident #8's bridge was broken and was aware Resident #22's dentures were broken. Continued interview confirmed a local dentist would see residents if the facility would provide transportation to dental office and the facility failed to arrange transportation for Resident #8 and #22. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's documentation dated 6/26/16 revealed Resident #34 was seen by a dentist and the resident requested to have remaining teeth pulled and he wanted a full set of dentures. Continued review revealed .Referred to Social Services to explore the options for having teeth extracted and purchase of dentures . Medical record review of a Social Service note dated 7/20/16 revealed dental services for teeth extractions was scheduled for 8/18/16. Medical record review of a Report Of Consultation (dental) dated 9/18/16 revealed .Pt. (patient) wants teeth removed and dentures placed . Observation with Resident #34 on 1/18/17 at 10:00 AM, in the resident's room, revealed the resident was missing multiple upper and lower teeth. Interview with Resident #34 and the Director of Nursing (DON) on 1/19/17 at 10:26 AM, in the resident's room, revealed Resident #34 wanted his teeth pulled and dentures made. Continued interview revealed Resident #34 had been seen by a dentist but .have never come back . Interview with the DON and the Social Worker on 1/19/17 at 10:49 AM, in the DON's office, confirmed Resident #34 was seen by a dentist on 6/26/16 and had requested to have the remaining teeth pulled and dentures made. Continued interview confirmed the resident was seen again by a dentist on 9/18/16 and again requested to have the remaining teeth pulled and dentures made. Further interview confirmed the facility failed to provide transportation for requested dental services for Resident #34.

Based on facility policy review, medical record review, observation, and interview, the facility failed to complete a urinary assessment for 1 resident (#55) of 1 resident reviewed for urinary incontinence of 25 residents reviewed. The findings included: Review of facility policy, Bladder Retraining, last revised 5/2012, revealed .Each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible .A comprehensive assessment is to be completed within fourteen (14) days of admission and whenever there is a change in .urinary tract function . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS) (moderately impaired cognitive skills) and was frequently incontinent of urine. Medical record review of the quarterly MDS dated [DATE] revealed the resident was always incontinent of bladder. Medical record review revealed no documentation a bladder assessment was completed to determine if the resident was a candidate for a bladder retraining program. Interview with the Director of Nursing (DON) on 1/19/17 at 1:50 PM, in the DON's office, confirmed the facility failed to complete a bladder assessment for Resident #55.