Every finding on record at The Blossoms at the Village Rehab & Nursing Center

Based on record review, observation, and interview, it was determined that the facility failed to serve three (Resident #56, #30, and #68) of three residents ordered fortified foods, reviewed for diet orders. The findings include: Resident #56 A review of Resident #56's admission Record indicated the facility admitted the resident on 06/28/2024, with diagnoses which included dementia. A review of Resident #56's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/2025, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A review of Resident #56's Care Plan revised on 07/14/2025, revealed the resident had a nutritional problem or potential nutritional problem related to a history of dysphagia and poor by mouth intake. Resident #56's Care Plan also included interventions, which directed staff to provide and serve diet as ordered. A review of Resident #56's Diet Type Report revealed the resident had a diet order for fortified food with lunch. A review of Resident #56's Order Summary revealed the resident had an order for regular texture, thin liquids consistency, fortified food with lunch, two tablespoon butter with breakfast, eight ounces of whole milk with breakfast, give ice cream two times a day with lunch and supper, for weight loss. Resident #30 A review of Resident #30's admission Record indicated the facility admitted the resident on 06/30/2021, with diagnoses which included Alzheimer's and anemia. A review of Resident #30's quarterly MDS with an ARD of 09/26/2025, revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. A review of Resident #30's Care Plan, revised on 07/14/2025, revealed the resident had a nutritional problem or potential nutritional problem due to Alzheimer's. Resident #30's Care Plan also included interventions which directed staff to provide fortified foods at breakfast, large portions with breakfast. A review of Resident #30's Order Summary revealed regular fortified food diet, regular texture, thin liquids consistency, large portions at breakfast, and ice cream at lunch. A review of Resident #30's Diet Type Report revealed the resident had a diet order for regular fortified foods. Resident #68 A review of Resident #68's admission Record indicated the facility admitted the resident on 10/29/2020, with diagnoses which included late onset Alzheimer's disease. A review of Resident #68's annual MDS with an ARD of 10/23/2025, revealed a BIMS score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #68's Care Plan, revised on 04/28/2025, revealed the resident had a nutritional problem or potential nutritional problem due to Alzheimer's disease. Resident #68's Care Plan also included interventions, which directed staff to add fortified foods, weekly weights until stable. A review of Resident #68's Order Summary revealed regular fortified foods, regular texture, thin liquid consistency. A review of Resident #68's Diet Type Report indicated the resident had an order for regular fortified foods. During a concurrent observation and interview on 12/17/2025 at 12:00 PM, this surveyor observed [NAME] #2 with melted butter in a glass container and poured an unmeasured amount on top of the mashed potatoes for the residents that was ordered fortified foods. [NAME] #2 indicated, that is my fortified mashed potatoes. During an observation on 12/17/2025 at 12:27 PM, Resident #56's tray card indicated the resident liked mashed potatoes and required fortified foods. There were no mashed potatoes served to the resident. Resident #30 and Resident #68's tray cards indicated both residents required fortified foods. During an observation on 12/17/2025 at 1:39 PM, Resident #56 was served lunch, from the regular menu, in their room. Resident #56's lunch tray revealed only a biscuit with a soup-like substance on top of it, a bowl of salad, a cookie, and a drink. There were no fortified foods observed. During an observation on 12/17/2025 at 1:42 PM, Resident #30 was served from the alternate menu, which was an open-faced turkey sandwich, chips, and a cookie. The resident was only served the turkey sandwich and a drink. There were no chips, cookie, or fortified foods observed. This surveyor also observed that Resident #68 was served from the regular menu which was a biscuit with a soup-like substance on top of the biscuit, side salad and a cookie. The resident was served the regular menu with no fortified food observed. During an interview on 12/18/2025 at 10:38 AM, [NAME] #2 revealed, We had a fortified log before the last dietary manager. I don't know where it is. I just found it. I find something to put in the food like cream, butter, cheese, or whatever to make it high in calories. If the residents had pudding, I would probably put cream in it because it's fattening. I don't know if we have an updated one. This one is from 2019. I have not been making fortified foods by the menu. It is important to make sure the residents are getting their calories they need. Not getting the fortified dish, it could cause weight loss which could cause health issues. During an interview on 12/18/2025 at 1:43 PM, with [NAME] #3 revealed, Residents that are required to receive fortified foods have it documented on their tray card. If there is a fortified menu, I don't know where it is. I still make fortified foods for the residents. I add milk, chicken stock, sour cream, and butter. I don't really measure it; I just add it in. It's important for the residents to get more protein to help with weight loss. During an interview on 12/18/2025 at 2:00 PM, the Regional Dietary Manager (RDM) indicated, The staff are supposed to be trained to know the fortified menus are in the back of the production book. [Cook #3] told me that the binder was pulled out earlier for you but couldn't find it at first. The importance of fortified foods is to make sure the residents are getting the extra calories they need for weight loss. The fortified menu ensures the appropriate amount of extra calories the residents need. The meal card indicates whether the resident is on fortified foods.

Number of residents sampled: Number of residents cited: Based on observations and interviews it was determined that the facility failed to post the required nurse staffing information for resident and visitor access. Specifically, the facility failed to post nurse staffing information on 12/17/2025 until 2:00 PM. The findings include: During an observation on 12/17/2025 at 2:00 PM, this surveyor observed the facility's common areas and discovered there was no nurse staffing information posted anywhere in the building for residents and visitors. Effort to locate the nurse staffing information was made at the front entrance area, at the entrance to every hall, in the common area, and the nurse's station. Upon request, the Human Resource Director went into his office and wrote the information on a sheet of paper and posted it on a glass window facing the common area close to the entrance of the facility. During an interview on 12/17/2025 at 2:12 PM, the Human Resources Director stated the daily posted staffing was not out and posted at the beginning of the shift as mandated, because he had been, working on updating it. The Human Resources Director stated today's information was not on there and he had been busy and not gotten to it today. During an interview on 12/19/2025 at 12:22 PM, the Director of Nursing (DON) stated the information was there for the facility's visitors and residents to know how many nurses and Certified Nursing Assistants (CNAs) were in the building. During an interview on 12/19/2025 at 12:28 PM, the Administrator stated she was aware that the daily nursing staff information was supposed to be posted, however she was not aware of the importance or purpose for the information. During a follow-up interview on 12/19/2025 at 12:35 PM, the Administrator stated the information regarding additional staffing information like names and assignments were on the facility's staffing sheets in a different area of the same room and all people had to do was ask for it and the staff would show it to them.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to assess for, obtain physician's order for, and care plan for self-administration of medications for 2 (Resident #41 and Resident #73) of 2 residents reviewed for self-administration of medications. Findings include: 1. A review of a facility policy titled, Medication, Self-Administration of Policy and Procedure, provided 08/15/2024 indicated, the purpose is to provide patient with right to self-administer medication when deemed safe and In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. 2. Review of the Admission Record indicated the facility admitted Resident #73 on 08/31/2023 with diagnoses that included dementia, age-related physical debility, and glaucoma. a. The signification change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. b. A review of Resident #73's Care Plan, initiated on 05/20/2024, revealed the resident has a terminal prognosis related to Alzheimer's disease and has was admitted to hospice. Interventions included: observe patient closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain and work with nursing staff to provide maximum comfort for the resident. No care plan was located to indicate self-administration of medication. c. An Order Summary Report that listed orders active as of 08/15/2024 revealed Resident #73 did not have an order for any type of eye medication/drops and had no order to self-administer medications. d. A review of the Assessments portion of Resident #73's electronic health records revealed that no self-administration of medications assessment was completed. e. During an observation on 08/12/2024 at 10:05 AM, a bottle of artificial tears was noted on the nightstand beside Resident #73's bed. f. During an observation on 08/13/2024 at 8:04 AM, a bottle of artificial tears was noted on top of the nightstand beside Resident #73's bed. g. During an interview on 08/13/24 at 8:26 AM, Medication Assistant Certified (MA-C) #4 confirmed there was a bottle of artificial tears that was on the nightstand of Resident #73. MA-C #4 picked up the bottle of artificial tears and reported that the resident's family member brought the medication into the facility and leaves the medication at bedside. MA-C #4 then confirmed that the back of the bottle stated, Keep out of reach of children. 2. A review of the Admission Record indicated the facility admitted Resident #41 on 07/29/2024 with diagnoses that included vascular dementia with agitation, chronic obstructive pulmonary disease and allergic rhinitis. a. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/01/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact. b. A review of Resident #41's Care Plan, initiated 08/05/2024, revealed the resident has a behavior problem: refuses medication. Intervention included explaining all procedures to the resident before starting and allowing the resident to adjust to changes. No care plan was located to indicate self-administration of medication. c. An Order Summary Report that listed orders active as of 08/14/2024 revealed Resident #41 had orders for ipratropium/albuterol inhaler 20-100 microgram/actuation (mcg/ACT) one puff orally two times a day and fluticasone propionate nasal suspension 50 mcg/ACT two sprays in both nostrils two times a day. d. A review of the Assessments portion of Resident #41's electronic health records revealed that no self-administration of medications assessment was completed. e. During an observation on 08/14/2024 at 7:31 AM, Medication Assistant-Certified #4 (MA-C), went into Resident #41's room to administer medications. The ipratropium/albuterol inhaler and fluticasone propionate nasal suspension were sitting on the bedside table in front of the resident. Once pill form medications were administered, Resident #41 picked up the fluticasone propionate nasal suspension and inserted into right nostril and squirted spray two times without waiting between sprays, then moved to left nostril and squirted spray two times without waiting between sprays. Resident #41 placed the cap on the fluticasone and then picked up the ipratropium/albuterol inhaler. One puff was administered by the resident with no issues. Resident #41 then put the inhaler back in her mouth and took a second puff. f. During an interview on 08/14/2024 at 7:35 AM, MA-C #4 confirmed that Resident #41 did administer inhaler and spray and that no instructions were given to the resident prior to resident self-administering the medication. g. During an interview on 08/14/2024 at 12:00 PM, the Assistant Director of Nursing (ADON) confirmed before a resident self-administers medications, the physician must evaluate and give orders, an assessment must be completed, and the resident is care planned for self-administration of medications.

Based on observations and interviews, the facility failed to ensure an unattended medication cart was not left unlocked and keys unattended. The findings include: On 08/15/24 at 9:35 AM, the Surveyor observed an unattended medication cart in the hallway on the secured unit unlocked with the keys in the lock. On 08/15/24 at 9:41 AM, Licensed Practical Nurse (LPN) #9 confirmed the unattended medication cart was unlocked with keys inside lock. LPN #9 stated anyone could have gotten anything, any of the drugs or narcotics, and a resident could get a medication that could harm or kill them. On 08/15/24 at 10:54 AM, the Administrator confirmed an unattended medication cart should not be unlocked with the keys in the lock. The Administrator stated there was access to the medications, the residents can take the medications, and/or harm themselves. On 08/15/24 at 12:22 PM, the Surveyor was informed there was not a policy on accidents and hazards.

Through observation, interview, and policy review, the facility failed to ensure food brought in for residents was properly labeled, food items received had both open and expiration dates, and food serving items were properly stored. The findings are as follows: 1. On [DATE] at 5:46 AM, three drink pitchers were laying on their side with the opening not properly covered to prevent foreign substances from entering the pitchers used for resident's drinks. 2. On [DATE] at 5:47 AM, four cups were laying on their side with the opening not properly stored to prevent foreign substances from entering the cups used for resident's drinks. 3.On [DATE] at 5:51 AM, four food dome covers were sitting on the counter, by the serving window, with the inside facing the ceiling, not covered. 4. On [DATE] at 5:57 AM, a container with pureed breadcrumbs was not completely sealed. 5. On [DATE] at 7:29 AM, the nourishment room refrigerator contained the following items: a. one plastic bag that contained one open bottle of thousand island dressing, one open bag of yellow cheese squares, one open bag of ham circles, one unopened bag of imitation crab meat, and one bag of [brand] string cheese sticks without residents' name, date of purchase, or and open date b. One 2-quart 100% vegetable juice did not have a resident's name or open date on the container. c. One 8-ounce medium cheddar shredded cheese without a resident's name or a received date. d. The Dietetic Technician inferred the refrigerator was for resident use only, and the residents name should have been on the items. 6. On [DATE] at 7:44 AM, one brownie mix package had an expiration date of [DATE]. The Dietetic Technician confirmed the product had expired and needed to be thrown away. 7. On [DATE] at 7:50 AM five 14.75 ounce cans of classic pink salmon did not have a received date. The Dietetic Technician confirmed the product was missed when the other cans had been dated. 8. On [DATE], Dietetic Technician confirmed the pureed breadcrumbs were not completely sealed. Dietetic Technician then properly sealed the container without stating why the container should have been properly covered. 9. On [DATE], a document titled Storage of Resident Food: Policy and Procedure (undated) showed, Family and resident will be encouraged to date items 10. On [DATE] at 3:10 PM, a Food Storage Areas Policy and Procedure (undated) showed, Refrigerated and frozen foods are dated upon delivery. Canned goods should be dated. 11. On [DATE] at 9:40 AM, the Dietetic Technician stated that something could get in the opened pureed bread container. 12. On [DATE] at 11:00 AM, a Handling Clean Equipment and Utensils Policy and Procedure (undated) showed, Clean equipment will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination. Glasses and cups will be stored on a clean sanitary surface.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure hand hygiene was performed during medication administration, failed to ensure drinking cups did not become contaminated while preparing for medication administration, and failed to follow procedures for Enhanced Barrier Precautions for a resident with a feeding tube for 2 (Resident #92 and Resident #67) of 2 residents reviewed for infection prevention and control and hand hygiene; and failed to provide proper storage for oxygen tubing and updraft tubing and apparatus at bedside for 1 (Resident #7) of 1 reviewed for infection prevention and control measures. Findings include: A review of an undated facility policy titled, Hand Hygiene Policy and Procedure, supplied 08/14/2024, indicated the process and purpose was to cleanse the hands between resident direct contact and to prevent spread of infection. 1(e) before and after entering isolation precaution settings. 1(j) before and after handling peripheral vascular catheters and other invasive devices. A review of an undated facility policy titled, Isolation Policy and Procedure supplied 08/15/2024 indicated that the purpose was to prevent the spread of infection. To be utilized on all residents in isolation: a) isolation and precaution categories include a) Isolation and Precaution Categories include: (i)Enhanced Barrier Precautions (EBP). Enhanced Barrier Precautions (EBP): 1. EBP precautions are utilized for residents that have wounds and/or indwelling medical devices (central line, catheter, feeding tube, tracheostomy) and has a multi-drug resistant organism. An undated facility policy titled, Oxygen Administration Policy and Procedure supplied 08/15/2024 offered no relevant information in regard to how oxygen tubing and updraft tubing and apparatus should be stored at bedside. A review of the Admission Record, indicated the facility admitted Resident #7 with diagnoses of chronic obstructive pulmonary disease and atherosclerotic heart disease of native coronary artery without chest pain. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/01/2024 revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident has moderate cognitive impairment. Resident was not marked as having oxygen in special treatments, procedures, and programs. A review of Resident #7's Care Plan, initiated on 09/28/2022, revealed that Resident#7 has 1) altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease with shortness of breath. Interventions include oxygen per medical doctor's orders and administer medication/puffers as ordered. Monitor for effectiveness and side effects. 2) Resident #7 has oxygen therapy related to chronic obstructive pulmonary disease. Interventions include: monitor/document side effects and effectiveness and give medications as ordered by physician. 3) Resident #7 has a behavior problem-at times resident takes her oxygen bag and puts trash in it and throws it away. Intervention includes: if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. A review of Order Summary Report, revealed Resident #7 has the following orders: 1) change oxygen tubing, humidifier water (if applicable), bag and date every Wednesday night shift for oxygen use. 2) Change updraft mask and tubing weekly, bag and date every Wednesday night shift for updraft use. 3) Oxygen at two liters per minute via nasal cannula as needed for shortness of breath. During an observation on 08/12/24 at 10:19 AM, Resident # 7 was lying in bed. Oxygen was being administered via nasal cannula at 2 liters per minute. No date seen on tubing. No humidifier bottle. The updraft machine at bedside had the tubing and apparatus (mask) lying on the nightstand without proper storage. During an observation on 08/13/24 at 8:39 AM, Resident # 7's oxygen concentrator was not in use and the oxygen tubing was draped across the nightstand and concentrator without proper storage. The updraft mask was lying on top of the nightstand without proper storage. During an interview on 08/13/24 at 8:45 AM, Certified Nursing Assistant #7 confirmed the tubing for the updraft machine and the oxygen tubing was not properly stored. During an interview on 08/13/24 at 8:50 AM Licensed Practical Nurse (LPN) #8 confirmed the oxygen tubing was lying across the nightstand and not being properly stored. LPN #8 confirmed the updraft tubing was not properly stored. When LPN #8 was asked what the importance was of keeping them properly stored, she stated, To keep from giving them more germs. During an interview on 08/15/24 at 12:00 PM, the Assistant Director of Nursing stated, Oxygen and updraft tubing should be in plastic bags with their names and date on them. They should not be left out lying around. A review of the Admission Record, indicated the facility admitted Resident #67 with diagnoses of schizophrenia and dysphagia (difficulty swallowing). The quarterly MDS, with an ARD of 06/04/2024 revealed Resident #67 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. During an observation on 08/14/2024 at 8:00 AM, LPN #3 was at a medication cart. LPN#3 removed gloves from prior medication administration and without sanitizing hands picked up two plastic drinking cups which were stuck together. LPN #3, with fingers inside the cup, separated the two plastic cups and placed the one the fingers had been inside of on top of the medication cart and filled the cup with water. Medications were then prepared for Resident #67. Medications were then delivered to the resident, and Resident #67 consumed the water inside the drinking cup. LPN #3 confirmed that cups were pulled apart with fingers being placed inside of the cups. Confirmation was given by LPN #3 that gloves were removed and hands were not sanitized before medication administration. A review of the Admission Record, indicated the facility admitted Resident #92 with diagnoses that included: encounter for attention to gastrostomy, dysphagia, pharyngeal phase, and moderate protein-calorie malnutrition. The quarterly Minimum Data Set (MDS), with an ARD of 07/18/2024, revealed Resident #92 had BIMS score of 13 which indicated the resident is cognitively intact and Nutritional Approaches marked as feeding tube while a resident. A review of Resident #92's Care Plan, initiated on 04/15/2024, revealed the resident requires tube feeding related to dysphagia due to osteophyte protrusion and moderate protein-calorie malnutrition. Interventions included all medications may be given simultaneously through feeding tube, flush feeding tube per facility protocol before and after medication administration. A review of Order Summary Report revealed Resident #92 had an order for nothing by mouth and tube feeding formula 1.5 at 70 cubic centimeter (cc)/hour via pump continuously with water flushes of 35 milliliters (ml)/hour. May disconnect as needed for activities of daily living, medications, and flushes. May mix medication with up to 60 ml of water prior to medication administration. Flush feeding tube with 60 ml of water before and after medication administration. During an observation on 08/14/2024 at 3:30 PM, LPN #3 did not sanitize hands prior to medications being set up for administration to Resident #92. After medications were placed in plastic medication cup, without sanitizing hands, placed medications in a pill crushing pouch and crushed the medications. The medications were then placed in a plastic drinking cup. After placing stethoscope and a pair of gloves in scrub pocket, LPN #3 entered Resident #92's room. LPN #3 did not put on a gown or gloves prior to entering the resident's room. After entering, LPN #3 went into the bathroom to obtain tap water from the sink, returned to the bedside of Resident #92 and placed the water and medication glass on the bedside table. LPN #3 left the bedside and went back to the medication cart, outside of the resident's room door and picked up a plastic spoon, applied gloves, added water to the medication glass and stirred with the plastic spoon. LPN #3 went over to the resident, explained medications were going to be administered and lifted the covers from the abdominal area to access the feeding tube. LPN #3 adjusted the feeding tube, disconnected the feeding tube and draped the tubing over the feeding pump pole. Using the same gloves without sanitizing hands, removed the stethoscope from scrub pocket, placed a piston syringe in the feeding tube port and auscultated and aspirated feeding tube to verify placement. Once placement was confirmed, the piston syringe was removed from the port, the plunger was removed and then piston syringe was placed back into the port. The feeding tube was flushed with 60 milliliters (ml) of water, medication mixture was added, after medications passed through the feeding tube, tube was flushed with 60 ml of water. LPN #3 reconnected the feeding to the feeding tube, straightened Resident 92's gown, placed trash in trash can, adjusted the covers over the resident, moved the bedside table and wheelchair closer to the bed, removed the gloves, left the room, went to the medication cart and sanitized hands. LPN #3 confirmed hand hygiene and glove changes had not occurred during the process of administering medications through the feeding tube.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, These failed practices had the potential to affect 103 residents who received meals from the kitchen, (total census: 104 ) as documented on a list provided by the Dietary Supervisor #1 on 11/02/23 at The findings are: 1. On 11/01/23 10:26 AM Dietary Employee (DE) #1 opened the refrigerator door, removed a bag of shredded cheese, and placed it on the food preparation counter. At 10:27 AM DE #1 removed gloves from the glove box and held it while he picked up the empty glove box and threw it into the trash. Without washing his hands, he placed gloves on his hands, contaminated the gloves, he then used the same contaminated gloved hand to remove shredded cheese from the bag and sprinkled them on top of macaroni with kidney beans and meat sauce. He placed the pan in the oven to be baked and served it to the residents for lunch meal. 2. On 11/01/23 at 10:39 AM DE #1 picked up a pot that contained beef broth from the stove and placed it on top of the food preparation counter, he plugged the code attached to the blender on the wall socket. Without washing his hands. He removed a glove from the glove, contaminating the glove. Then used the same contaminated gloved hand to pick up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. 3. On 11/01/23 at 10:45 AM DE #2 pushed a cart that contained 4 bags of orange mix and 4 pitchers towards the food preparation sink. She turned on the sink faucet and obtained water in each pitcher. Then, she turned off the faucet with her bare hands. She opened bags of orange mix, emptied, in a pitcher each mixed. Without washing her hands, she picked up a lid to each pitcher with her fingers inserted inside the lid and covered the pitchers. She placed the pitchers of orange mix in the refrigerator to be served to the residents for lunch meal. 4. On 11/01/23 10:56 AM DE #1 picked up a pot that contained milk from the stove and placed it on the counter. Without washing his hands, he removed a glove from the glove box, contaminating the glove. He then used the contaminated glove to pick up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. 5. On 11/01/23 at 11:16 AM DE #3 pushed a cart that contained pans of dessert toward the food preparation area. She transferred the pans to the counter. She placed gloves on her hands, contaminating the gloves. She picked up a knife and used it to slice Iced oatmeal cake. Then, she used her contaminating gloved hands to pick up sliced Iced oatmeal cake and placed it in individual bowls to be served to the residents for lunch. 6. On 11/01/23 at 11:23 AM DE #3 placed a pan that contained Iced oatmeal cake on the counter. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender. At 11:27 AM When DE #3 was ready to place dessert into a blender to puree. The surveyor immediately asked DE #3 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 7. On 11/01/23 at 11:34 AM DE #2 opened the refrigerator door. She took out a pitcher that contained orange juice and placed it on the counter. Without washing her hands, she picked up glasses by their rims and poured orange juice in them to be served to the residents for lunch meal. The surveyor asked DE #3 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 8. A facility policy titled . Proper hand washing, and gloves use provided by the Dietary Surveyor on 11/02/2023 at 01:11 PM documented, Gloves are changed any time hand washing would be required or if the gloves become contaminated by touching other non-food contact surface such as door handles and equipment. Staff should be reminded that gloves become contaminated just as hands do, and should be changed often. When in doubt, remove gloves and wash hands again. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove.

.Based on observation and interview the facility failed to ensure residents who reside on the secure unit were fed in a manner that provided dignity to each resident. This included standing over residents while feeding and calling residents honey, sweetie, mama, baby and granny. This failed practice had the ability to affect 24 residents residing on the secured unit as documented on the resident list by hall that was provided by the Administrator on 10/30/23. a. On 10/31/23 at 12:27 PM Certified Nursing Assistant (CNA) #1 was observed standing over residents feeding them. CNA #1 walked to the opposite end of the table and stood over the resident assisting them with feeding. CNA#1 was calling resident's honey, swettie, mama, and sugar. b. On 10/31/23 12:31 PM CNA #1 was observed leaving that end of the table and went to another resident to assist her with feeding standing over her the entire time. c. On 11/01/23 at 12:26 PM CNA#1 was observed in dining room at the end of the table standing in between two residents assisting them both with feeding. d. On 11/01/18 at 12:34 PM CNA #1 was observed moving to the side of the dining table and standing over a resident to assist her with eating. e. On 11/02/23 at 8:17 AM CNA #1 was asked, should staff stand over a resident while assisting them to eat? CNA # replied, No. f. On 11/2/23 at 8:17 AM CNA#1 was asked, how should you address a resident. CNA#1 replied, by their name we shouldn't call them honey, and sweetie. g. On 11/02/23 at 8:19 AM Licensed Practical Nurse (LPN) #1 was asked, should staff stand over a resident while assisting them with meals? LPN #1 replied, No. h. On 11/2/23 at 8:19 AM LPN#1 was asked, How should a resident be addressed. LPN#1 stated, by their name. i. On 11/02/23 at 8:30 AM Director of Nurses (DON) was asked, should a staff stand over a resident while assisting them with meals? DON replied, No j. On 11/2/23 at 8:30 am DON was asked, how should a resident be addressed. DON stated, by their name Don was asked, is calling them honey, sweetie, mama, appropriate. DON replied, No it isn't. k. On 11/2/23 at 9:15 am DON informed surveyor that facility did not have a policy and procedure on Dignity.

Based on interview and record review, the facility failed to ensure residents received an individual financial record statement quarterly for 1 (Resident #18) of 82 residents. This failed practice had the potential to affect 82 residents that had resident trusts managed by the facility. The findings are: 1. On 10/31/23 at 3:47 PM, the Surveyor asked the Business Office Manager (BOM) how often statements are provided. The BOM stated, Quarterly. The Surveyor asked how they were issued. The BOM stated, Through the mail. We do have some that we hand out here. 2. On 10/31/23 at 3:47 PM, the Surveyor asked the BOM for documentation that a statement was provided to R#18. The BOM stated, I do not have documentation. I mailed [R#18's] out to [the resident's] daughter per daughter's request. The Surveyor asked BOM to look in the computer to see if daughter was Resident #18 financial POA. BOM stated, no [the daughter] is not, [the daughter] is only POA for [R#18's] care not for finances. The Surveyor asked so should you have sent his quarterly statement to [the resident's] daughter. BOM replied, no I should not have. 3. On 11/02/23 at, 12:18 PM the Surveyor asked the Administrator who should receive quarterly resident trust statements. The Administrator stated, Whoever is listed as the responsible party or to the resident if they are listed as their own person. The Surveyor asked when POA's were active. The Administrator stated, When the resident is incapacitated. The Surveyor asked if a resident was their own person should they be receiving their statements and not the responsible party. The Administrator stated, Yes. 4. On 11/02/23 at 12:20 PM, the Surveyor asked the Administrator if the facility had a Trust Account Policy, Administrator stated, we do not.

F569 Based on interview and record review, the facility failed to ensure Medicaid recipient residents and/or their responsible parties were notified when their resident trust balance was within $200 of the maximum Medicaid recipient cash assets for 1 (Resident #18,) of 82 residents who were dependent on Medicaid for services and had trust funds managed by the facility. The findings are: 1. On 10/31/23 at 11:48 AM, The surveyor asked for October Trust account balances, and Business Office Manager (BOM) told surveyor they had not closed out the month of October yet. Surveyor then asked for the most recent month of statements she had closed out. BOM then provided surveyor with the month of September account balances. 2. On 10/31/23 at 12:25 PM, the Surveyor asked BOM manager to provide a letter for R #18 who had a balance of $3267.42. BOM provided copy of the letter that she stated she had given to Resident #18. The Surveyor went to resident #18 room to discuss the letter and the amount he had in his trust fund. Resident #18 informed the surveyor that he had never received a letter notifying him that he had that much money in his account. Surveyor then asked Resident #18 do you receive a quarterly statement? Resident replied, I have never received anything regarding my money, I wasn't aware of how much money I had. 3. On 10/31/23 at 3:47 PM surveyor interviewed Business Office Manager (BOM). The Surveyor asked, do you provide letters monthly when a resident is within $200 of his Medicaid allowable Balance. (BOM) replied, Every month I put them in envelopes and put them in the Activity Directors Box for her to pass out to the residents. The Surveyor asked, so you never personally give the notification monthly letter to the resident, (BOM) replied No I don't the surveyor asked did you give Resident #18 a quarterly statement. (BOM) stated, No I sent it to his daughter per her request. The Surveyor asked (BOM) to confirm that she was his POA. (BOM) looked on the computer then stated, She is only POA for his care, not his finanances the surveyor asked, should you have given the quarterly and monthly statement to resident #18 yourself. (BOM) replied, yes I should have. 4. On 11/2/23 at 11:58 AM Business Office Manager (BOM) was asked if the facility had a policy addressing a residents Personal Funds.( Bom) stated ,we do not have a Policy.

Based on observation, interview, and record review the facility failed to ensure state survey results, and contact information for the ombudsman, and the Office of Long-Term Care [OLTC] was readily available for residents, family members, and staff in the locked unit. This failed practice affected 1 resident (R#2) of 4 sampled residents (R#2, R#74, R#90, R#100) and had the potential to affect 24 residents residing in the locked unit. The findings are: a. Resident #2 with a diagnosis of EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS, BRIEF PSYCHOTIC DISORDER, and ANXIETY DISORDER, UNSPECIFIED. The Minimum Data Set [MDS] with an assessment reference date [ARD]s of 09/11/2023, and a Brief Interview for Mental Status [BIM]s of 7 (0-7 means severely impaired cognition). b. On 11/01/2023 at 10:40 AM, Resident #2 asked Surveyors for the contact information of the OLTC. The Surveyors looked around the locked unit and were unable to find contact information for the OLTC, and ombudsman. c. On 11/01/2023 at 10:50 AM, the surveyors left the unit and asked the Director of Nursing [DON] where contact information for the ombudsman, and the OLTC were kept readily assessable to residents, family members and staff in the unlocked and locked areas of the facility. The DON walked down 100 hall and located the ombudsman poster, but not the contact information for the OLTC. The surveyor asked the DON what her process is when residents, and family members ask for the OLTC and ombudsman contact information. The DON told the surveyor nobody has ever asked for this contact information before. The surveyor told the DON and RN #1 that a resident in the locked unit asked for it today. The DON said, We do not have the contact information for the ombudsman and the OLTC in the closed unit. d. On 11/01/2023 at 10:54 AM, RN #1 was observed looking in the main lobby for the contact information for the OLTC and said, I know we do not have the OLTC's number posted. e. On 11/01/2023 at 11:20 AM, The administrator told the surveyor that the contact information for the ombudsman, and the OLTC was found in the main lobby near the DON office, but not in the locked unit, on 300 hall. f. On 11/01/2023 at 02:00 PM, The DON provided the Resident Rights and Quality of Life Policy and Procedure and it states: Policy: All residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. Residents' rights will be explained to the responsible party or legal guardian as appropriate. 8. To be informed of his or her legal rights, including the manner of protecting personal funds, a description of the requirements and procedures for qualifying for Medicaid, a posting of the names, addresses, and telephone numbers of all pertinent state client advocacy groups, and a statement that the resident may file complaints with the state survey and certification agency . 26. To seek immediate access to any of the following: . b. Any representative of the State . d. The State's long-term care ombudsman .

Based on observation, interview and record review, the facility failed to ensure that resident chairs were free of tears, exposing the foam cushion in the smoking area to ensure an environment free of accident hazards. This failed practice had the potential to affect 4 sampled residents (R#26, R#69, R#92, R#95) of 18 residents residing on 100 hall, 200 hall, and 400 hall that smoke in the main smoking area. The findings are: a. 11/01/23 10: 08 AM, The Surveyor observed the 10:00 AM smoke break with Certified Nursing Assistant [CNA] #3 and CNA #4. The surveyor observed two chairs that have torn seats with the foam stuffing exposed. One chair has what appears to be a 12 x 3 rip down the middle of the seat with the foam cushion exposed. The second chair is ripped across the front of the seat exposing the foam cushion in an area that appears to measure 12 x 3 1/2. CNA #4 pointed out the fire extinguisher and fire blanket. CNA #4 told the Surveyor to her knowledge there has not been any smoke related accidents. b. 11/01/23 3:14 PM, The Surveyor asked the Director of Nursing [DON] to accompany the Surveyor to the smoking area off the dining room. The Surveyor observed the DON looking at the ripped chairs with exposed cushion foam. The Surveyor asked the DON if the torn chairs with exposed cushion seat foam were appropriate to use in an area where residents smoke. The DON told the Surveyor said she was concerned the foam stuffing from the ripped chairs could be a fire hazard and needed to be thrown away. c. On 11/02/2023 at 12:43, The MDS nurse provided a Smoking/Tobacco/Electronic Smoking Device Policy and Procedure Purpose: To provide a safe environment for those residents who choose to smoke .

Based on observation, interview, and record review the facility failed to ensure water was accessible and provided for 1 (Resident #46) of 5 sampled residents ( R#40, #44, #46,#61,#65), who required assistance with getting fluids. The failed practice had the potential to affect 9 residents who drink water according to the documentation of resident's who take fluid by mouth who are dependent on staff that was provided on 11/2/23 at 10:38 am by the (DON) Director of Nursing. The findings are: 1. Resident #46 had a diagnosis of unspecified Dementia, severe with Agitation. The quarterly (MDS) Minimum Data Set with an (ARD) Assessment Reference Date of 10-20-2023 documented the resident scored a 00 (0-7 indicates severe cognitive impairment) on the (Brief Interview for Mental Status) BIMS and Section G documented extensive +1-person assistance with eating, extensive +2-person assistance with bed mobility and total dependence 2-person assistance with toileting. a. On 10-30-23 at 09:38 AM, the Surveyor observed resident #46 out in the lobby and remained out in the lobby until resident was taken to dining area for lunch. Resident had no access to water while in the common area. No water was on resident #46 tray for lunch. b. On 10/31/23 at 08:10 AM, observed Resident #46 up in common area in geri chair until lunch time when they took resident to room to change her and then took resident#46 to dining room. Resident #46 had no access to water while out in the common area that morning. At 01:48 PM resident was lying in her bed with eyes closed. Water pitcher was across the room on the dresser with small amount of water in it, no ice or straw. Not close to where resident could reach it. c. On 11/01/23 at 08:09 AM, observed resident #46 up in geri chair in dining room being fed breakfast. No water or juice was on tray. After breakfast resident was taken to common area. At 08:42 AM Administrator came out and asked staff to take residents to their rooms. Resident #46 was taken to her room and left up in her geri chair in her room with no access to water. At 1:31 PM resident #46 was being fed lunch by staff, no water was on tray and resident did not like the pink liquid that was offered she wouldn't drink it. At 02:42 PM resident was lying in bed on her right side with eyes closed. Water pitcher was on bedside table at the end of her bed with small amount of water and no ice in it. Out of reach of resident. d. On 11/02/23 at 10:42 am The Surveyor interviewed Certified Nursing Assistant (CNA) # 2, surveyor asked, while resident is up in common area who is responsible for making sure water is offered? CNA #2 replied, there should be someone assigned to give them fluids. Should water be available and in reach for a resident when they are in their rooms. ( CNA)#2 replied, yes who is responsible for making sure there is water and it is placed in reach of the resident.(CNA)#2 , any staff who comes in the room. Should water be offered when staff is in the room if a resident is unable to get the water themselves. (CNA)#2 replied, yes we all should. e. On 11/2/23 at 10:47 am surveyor interviewed Licensed Practical Nurse (LPN)#3, When a resident is up in the dining area who is responsible for making sure they receive hydration. (LPN)#3 replied, the CNA who is assigned to the resident should make sure they are getting fluid. When resident is brought back to their room who is responsible for making sure the resident is offered fluids. (LPN)#3 replied, the nurse and the cna who is taking care of the resident. Should the water pitcher be in reach of the resident. (LPN)#3 replied, yes it should be on their bedside table, or if they are up in a chair it should be in reach of them. f. On 11/2 23 at 10:54 am the DON was asked, When a resident is sitting up in the common area for several hours who is responsible for making sure they receive fluids. DON replied, all the staff should. When the resident is taken back to their rooms should there be fluids in their room. DON replied, yes Where should the fluids be located in the room. DON replied, Where the resident can reach them. When staff enter the room should residents who cannot get their water themselves be offered a drink of water. DON replied, yes, most definitely. 2. Policy provided on 11-01-23 at 2:00 PM from the Director of Nurses titled Hydration Policy and Procedure. Purpose To assure that the resident receives the sufficient amount of fluid based on individual needs to prevent dehydration. Policy the facility will provide oral fluid with each meal and during med pass. Also, refreshments will be offered mid-morning, mid-afternoon, and at bedtime. Procedure 1. Nurses will provide water, juice, and/or house supplement with each med pass. 2. C.N.A. will offer fluid to the resident at mid-morning, mid- afternoon, and at bedtime. 3. C.N.A. will document hydration program in effect for each shift on the resident's ADL's .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold and hot food products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. This failed practice had the potential to affect 24 residents who receive meal trays in their rooms on the 300 Hall (Unit), as documented on a list provided by the Dietary Supervisor on 11/02/23/13/2023 at :AM. The findings are: 1. On 11/01/23 at 11:50 AM An unheated food cart that contained 23 trays for lunch was delivered to 300 hall (Unit) by the Certified Nursing Assistant#1. 2. 11/01/23 12:58 PM, the surveyor was rounding on secure unit when she got to room [ROOM NUMBER] and noticed R#67 was lying in her bed with hands in the air talking jibberish to the ceiling. There was no evidence of a lunch tray anywhere in the resident room. I went back down the hall and looked in the tray cart and found the resident tray untouched. At 1:01 asked the Licensed Practical Nurse #1 if the resident in room [ROOM NUMBER] R#67 had eaten and she stated she did not know, I showed her the tray in the cart. The nurse immediately asked the Certified Nursing Assistant #1 to go down and bring the resident to the dining room. The other surveyor asked her how long the trays had been in the cart, Certified Nursing Assistant #1 stated we got the trays at about 11:50 am At 01:07 PM The Licensed Practical Nurse #1 (LPN) started pulling the tray from the cart and the other surveyor #2 asked LPN #1 to wait so she could temp the tray. The LPN #1 checked the food temperatures on the tray and stated, a. milk was 55.4V. b. The shake was 63.8 degrees Fahrenheit. The manufacturer specification on the carton documented keep refrigerated. c. Macaroni and cheese with meat sauce was 102.3. degrees Fahrenheit. The LPN asked the surveyors if the temperature was ok and surveyor #2 asked her, What do you think. LPN #1 replied, the tray has been there a while and we need to get her a new tray. LPN #1 stated, we need to get her a new tray. 3. On 11/02/23 at 07:17 AM An unheated food cart that contained trays for breakfast was delivered to 300 hall by the Certified Nursing Assistant #5. At 07:59 AM immediately after the last resident was served in their room on 300 hall (Unit), temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with the following results: a. Milk 50.9 degrees Fahrenheit. b. Shake 53.6 degrees Fahrenheit. c. Scrambled eggs 83.6 degrees Fahrenheit. d. Ground sausage 84.3 degrees Fahrenheit. e. Hush brown 81.9. f. Regular sausage 80 degrees Fahrenheit. g. Oatmeal 109. degrees Fahrenheit. h. Pureed eggs 82 degrees Fahrenheit. i. Pureed oatmeal 106 degrees Fahrenheit. j. Pureed sausage 84,5 degrees Fahrenheit. K. Pureed bread 83.1 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to ensure staff washed and/or sanitized their hands during meal service on the facility's 'special secured unit to prevent cross-contamination which had the potential to affect 24 residents residing on the 'special secured unit as documented on the resident list by hall provided by the Administrator on 10/30/23. The findings are: 1. On 10/31/23 at 12:24 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 feeding a resident then she moved to the resident next to her and started mixing ice cream and milk to make her a milkshake without sanitizing hands. CNA#1 goes over to another resident at the table pats her arm and then begins feeding her without sanitizing hands after last resident, and after touching her arm. 2. On 11/01/2023 at 12:26PM CNA #1 is standing between two residents and is feeding one, then another without sanitizing her hands. CNA #1 stops feeding both residents and moves around to other residents at table and starts assisting them with feeding never sanitizing her hands in between any of the resident she was assisting. a. On 11/02/23 at 8:17 AM, the CNA#1 was asked what should occur after touching a resident's spoon and glass before assisting another resident with feeding? CNA#1 replied, we should sanitize our hands. CNA #1 was asked, what should happen between assisting a resident with eating and then lifting up another residents legs, then going over to another resident to assist them with their meal. The CNA#1 stated, Oh no. I should have washed and sanitized. I know better. CNA#1 was asked what could happen when hands are not washed or sanitized before touching a resident's plate, silverware, lids, and straw. The CNA#1 stated, Cross contamination. b. On 11/02/23 at 8:20 AM, the Licensed Practical Nurse (LPN) #1 was asked when should hand washing, or sanitization be performed during meal service. The LPN stated, Before and after, and sanitize between trays, and between feeding residents. The LPN was asked if hands needed to be washed or sanitized after touching a resident's legs what could the outcome be if this is not done. LPN replied, cross contamination. c. On 11/2/23 at 08:30 am, surveyor asked DON, what should happen when feeding a resident and then going to another resident to assist them with feeding. DON replied, they should sanitize their hands. What could happen if someone doesn't sanitize/wash hands in between feeding residents. DON replied, they can transfer infection. d. On 11/2/23 at 09:47 am the DON provided the facility policy titled Hand Hygiene Policy and Procedure Purpose To cleanse the hands between resident direct contact, to prevent spread of infection. Policy Hand hygiene will be performed by all staff consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination . Procedure1. H. Before and after assisting a resident with meals .

Based on observation, interview, and record review the facility failed to ensure resident without self-administration approved by the Interdisciplinary Team [IDT]. This failed practice affected 1 resident (R#92) of 4 sampled residents (R#69, R#74, R#90, R#92) and had the potential to affect 11 residents with nebulizer orders. The findings are: a. Resident #92 with diagnoses of chronic obstructive pulmonary disease, unspecified, anorexia and muscle wasting and atrophy, not elsewhere classified, multiple sites. b. On 10/30/23 at 10:16 AM, the Surveyor observed Resident #92 sitting on the bedside holding a nebulizer over the resident's nose and mouth. Resident #92 was observed holding the mask with the resident's left hand, removed the head strap and placed the nebulizer mask back over the nose and mouth. c. On 10/30/23 at 10:19 AM, the Surveyor observed Resident #92 turning nebulizer off and placed it back in the storage bag. The surveyor looked in the nebulizer bag and observed clear fluid in the chamber. Resident #92 said, I am finished. c. On 10/30/23 at 10:24 AM, the Surveyor asked Licensed Practical Nurse [LPN] #2 to explain the process for administering nebulizer treatments and updrafts. LPN #2 said, We set them up and let them do their own treatment. They can do that on my hall. The Surveyor asked if the Interdisciplinary Team [IDT] team has assessed resident #92 and the other residents using a nebulizer for administration rights. LPN #2 said, I do not know. The Surveyor asked LPN #2 if resident #92 got the complete dose. LPN #2 walked to the bedside and removed the nebulizer mask and chamber from the storage bag. LPN #2 told resident #92 that the resident had missed some of the medication and LPN #2 wanted to make sure the resident got it all. LPN #2 was observed placing the nebulizer mask on resident and turning the updraft machine on. d. On 11/01/23 at 12:15 PM, the Surveyor asked the Director of nursing [DON] what was their process for administering nebulizers, and do they have any residents that have self-administration rights. The DON said, Nobody, has self-administration rights. The nurse must go in with the resident and stay while they are getting nebulizers or updrafts. The Surveyor asked why is this important and the DON told the Surveyor to make sure they get the full dose of medication and do not pull off their mask or dump their medication out. The DON told the Surveyor if they refuse to complete the treatment it should be dumped out, the chamber cleaned and placed to dry. e. On 11/01/2023 at 12:37 PM, The DON provided the Medication, Self-Administration of Policy and Procedure.Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer . 2. If the resident indicates no desire to self-administer medications, this is documented in the appropriate place in the resident's medical record, and the resident is deemed to have deferred this right to the facility. f. On 11/02/2023 at 10:30 AM The DON told the Surveyor they have not documented resident #92 has deferred the right to self-administrate medication.

Based on interview and record review, the facility failed to promptly notify the state mental health authority after a significant change in resident's mental condition for 1 (Resident #55) of 5 (Residents #2, 16, 65, 69, 258 ) sampled residents requiring a Preadmission Screening and Resident Review (PASSAR) Level II screening. The findings are: Resident (R) #55 was admitted to the facility on [DATE]. R#55 received the following diagnoses post admission: 1. Major depressive disorder, recurrent with psychotic symptoms 11/20/2020 2. Delusional disorders 08/25/2021 3. Unspecified psychosis not due to a substance or known physiological condition 08/25/2021 4. Major depressive disorder, recurrent 02/23/2022 5. Altered mental status, unspecified 7/27/2023 6. Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety 7/27/2023 The Surveyor was unable to locate documentation of PASSAR Level II screening being performed. On 11/01/2023 at 01:20 PM the Minimum Data Set (MDS) Coordinator was asked to provide documentation of PASSAR screenings for R#55. The MDS Coordinator stated, We don't have one for [R#55], I went and spent an hour in the shed looking. I haven't been here long and don't know what they did before that. On 11/02/2023 at 09:36 AM the Administrator was asked if R#55 should have had a PASSAR Level II performed following the diagnoses received. The Administrator stated, Yes, I don't think [R#55] required one when they came in, but it should have been submitted once the provider put those in.

Based on observation and interview, the facility failed to ensure the medication cart on the Secure Unit was locked and medications were not left out on top of the medication cart unsupervised. This failed practice had the potential to affect 17 residents who were ambulatory or moved independently in a wheelchair on the 300 Hall. The findings are: 1. On 07/16/23 at 6:34 PM, the medication cart was parked on the end of the 300 Hall by the exit door. The medication cart was unlocked, and there were 8 cups with medications in them, and a bottle of Tylenol on top of the cart. There were no staff on the hall. 2. On 07/16/23 at 6:35 PM, Licensed Practical Nurse (LPN) #1 was outside with a resident smoking. 3. On 07/16/23 at 6:41 PM, Certified Nursing Assistant (CNA) #1, and CNA #2 were coming out of a resident's room. 4. On 07/16/23 at 6:50 PM, LPN #1 walked in the building from the back door of the 300 Hall. The Surveyor asked, What time are the medications due that you have pulled? She stated, 6:00 PM. The Surveyor asked, Can you tell me why you left the medications unattended? She stated, I shouldn't have. The Surveyor asked, Can you tell me why you pulled the medications before you were ready to administer them? She stated, I have no good answer for you. The Surveyor asked, Is the medication cart locked? She stated, No, it's not locked. I'm on a Dementia unit and everything I've done is completely wrong. I'm very sorry it won't happen again. The Surveyor asked, Should you leave medications unattended? She stated, No. The Surveyor asked, What could happen if you leave medications unattended? She stated, Anybody can take them and have a reaction. 5. On 07/17/23 at 2:45 PM, the Surveyor asked the DON, Should the nurses leave medications out on their medication cart unattended? She stated, Not at any time. The Surveyor asked, Should the medication cart be locked if it is left unattended? She stated, Yes. The Surveyor asked, Why is it important that medications are not left unattended? She stated, It could harm someone. A resident could walk by and pick up the medication. 6. A facility policy titled, titled, Medication Administration General Guidelines Policy and Procedure, provided by the Director of nursing (DON) on 07/17/23 at 2:09 PM documented, .2. Administration .c.medications are administered at the time they are prepared. Medications are not pre-poured .l. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .

Based on observation, interview, and record review, the facility failed to ensure orders for twice daily wound care for a resident unstageable pressure ulcer to the left ischium was implemented when ordered to promote healing of the pressure ulcer for 1 (Resident #1) of 2 (#1 and #2) sampled Residents. The failed practice had the potential to affect 3 residents that had pressure ulcers according to the list provided by the Administrator on 06/06/23 at 2:30PM. The findings are: 1. Resident #1 Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/25 documented that the resident had one unstageable pressure ulcer present on admission. a. The Care Plan with a revision date of 05/08/23 documented, . Focus: Resident #1 has potential for pressure ulcer development .Goal: The residents' Pressure Ulcer will show signs of healing and remain free from infection .Intervention/Tasks: . Follow facility policies/protocols for the prevention/treatment of skin breakdown . b. The Physician's Order from the Hyperbaric Wound Clinic dated 05/08/23 at 13:45 [1:45] documented, .Lt (left) Ischial - pack with Dakin's moist 1/2 inch Nugauze, dry 4 x4, Opti lock [4x4], Medi pore tape. Change dressings at least twice daily . c. The Physician's Order with a start date of 05/10/23 documented, Left ischial Unstageable Pressure injury: Clean with Dakin's, apply Medi honey, then Hydrogel gauze and cover with dry dressing QD [each day] and PRN [as needed] everyday shift for wound as needed for soiled or dislodged . d. The Physician Order from the Hyperbaric Wound Clinic dated 05/22/23 documented, .Lt Ischial: pack with Dakin's moisten gauze, Opti lock [5x5.5], Medi pore tape - change BID (Twice Daily) e. On 06/06/23 at 11:25AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Did you provide care to (Resident #1)? LPN #1 stated, Yes. The Surveyor asked, Did (Resident #1) have wounds? LPN #1 stated, Yes. She was admitted with 14 wounds. The Surveyor asked, Where were Resident #1's wounds located? LPN #1 stated, She had the most wounds on her feet. She had a surgical wound on her abdomen, a wound on her right long finger and a wound on her left ischium. The Surveyor asked, Was Resident #1 going to the wound clinic? LPN #1 stated, Yes. The Surveyor asked, When Resident #1 went to the wound clinic on 05/08/23 what were the orders she came back with for her wound on her left ischium? LPN #1 looked in the Electronic Record and stated, Pack with Dakin's moist 1/2 inch Nugauze, dry 4x4, Opti lock 4x4 and Medi pore tape. The Surveyor asked, How often did the order say to do wound care on the left ischial wound? LPN #1 stated, It is supposed to be done twice daily. The Surveyor asked, Was that order written? LPN #1 looked in the Electronic Record and stated, Yes. The Surveyor asked, Why was the order changed on 05/10/23? LPN #1 stated, I am not sure. The Surveyor asked, Do you know who changed the orders? LPN #1 looked in the Electronic Record and stated, My DON [Director of Nursing] put the order into the record. The Surveyor asked, When Resident #1 went to the wound clinic on 05/22/23 what were the orders that she came back with for her wound on her left ischium? LPN #1 looked in the Electronic Record and stated, Pack with Dakin's moistened gauze, Opti lock, Medi pore tape. Change BID. The Surveyor asked, Did that order get written? LPN #1 stated, Not that I see. The Surveyor asked, Why were the new orders not carried out? LPN #1 stated, I am not sure. The Surveyor asked, Why did Resident #1 continue to go to the wound clinic if the facility was not following their recommended orders for the wound to her ischium? LPN #1 stated, I am not sure. f. On 06/06/23 at 11:45AM, the Surveyor asked the DON, Did you provide care to Resident #1? The DON stated, Yes. The Surveyor asked, Did Resident #1 have wounds? The DON stated, Yes. The Surveyor asked, Where were her wounds? The DON stated, She had a wound on her left ischium, one of her middle fingers, a surgical wound on her abdomen and multiple wounds on her feet. The Surveyor asked, Did Resident #1 go to the wound clinic? The DON stated, Yes. The Surveyor asked, When Resident #1 went to the wound clinic on 05/08/23 what were the orders she came back with for her wound on her left ischium? The DON looked in the Electronic Record and stated, Pack with Dakin's moist 1/2 inch Nugauze, dry 4x4, Opti lock 4x4 and Medi pore tape. The Surveyor asked, How often does it say the dressing is to be changed? The DON stated, Change the dressing at least twice daily. The Surveyor asked, Was this order written? The DON stated, Yes. The Surveyor asked, Why was the order changed on 05/10/23? The DON stated, I talked with (Primary Care Physician) and informed him that packing the wound with Nugauze and the resident then having to sit on it was causing pressure on the surrounding tissues. This was causing the skin to turn purple resulting in more trauma to the area. I asked if we could change the treatment to Meta honey and hydrogel daily because Meta honey helps to debride, and he agreed with changing the order. The Surveyor asked, Did you contact the wound clinic when you changed the order? The DON stated, No. I did not. The Surveyor asked, When Resident #1 went to the wound clinic on 05/22/23 what were the order she came back with for her wound on her left ischium? The DON looked in the Electronic Record and stated, Pack with Dakin's moisten gauze, Opti lock 5 x5.5, Medi pore tape. Change BID. The Surveyor asked, Was that order carried out? The DON looked in the Electronic Record and stated, No the order was not changed. I did not see these orders. There is a note saying she returned with no new orders. I do not know why the order did not get carried out. The Surveyor asked, Should these orders have been carried out since they were the most current wound care orders for the wound on the resident left ischial wound? The DON stated, Yes they should. The Surveyor asked the DON for a copy of the facilities policy for wound care. g. On 06/06/23 at 1:05PM, the Surveyor asked the Administrator, Should facility staff implement the orders that are written by the wound clinic for care of a resident's wounds when the resident is being seen at the wound clinic? The Administrator stated, Yes. When they send orders back with them, we should follow those orders. The Surveyor asked, Were you aware that the wound clinic sent order back on Resident #1's wounds and those orders were not implemented? The Administrator stated, I was made aware in stand-up meeting that the wound clinic sent orders and her PCP [Primary Care Physician] came in and he changed that order. The Surveyor asked, Were you aware that there was an order written by the wound clinic on 05/22/23 that changed the order the PCP wrote that was not implemented? The Administrator stated, I was not aware of that. When she came back from the wound clinic, they should have carried out the order or contacted the PCP to clarify the order if they had questions about it. h. The facility policy untitled, provided by the DON on 06/06/23 at 12:15 PM, documented, .Policy: Any resident identified with a wound/skin concern will have a treatment in place to assist with healing of the wound/skin concern .Procedure: .Treatment Order will be entered in the physician orders for the identified wound/skin concern .Treatment Nurse or designee will perform wound care/skin care as order by the physician .

Based on record review and interview the facility failed to ensure a Baseline Care Plan was completed with the minimum necessary information to meet the resident's care needs within 48 hours after admission for 4 (Resident #1, #2, #3, #4) of 4 case mix residents who were admitted in the past 30 days. The failed practice had the potential to affect 31 residents who were admitted in the past 30 days, as documented on the list provided by the Administrator 2/7/23 at 2:30 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had diagnoses of Unspecified Fracture 4th [fourth] Thoracic Vertebra, Chronic Kidney Disease, and Essential Hypertension. a. Resident #1's Baseline Care Plan was completed on 1/16/23. 2. Resident #2 was admitted to the facility on [DATE] and had diagnoses of Essential Hypertension, Glaucoma, and other Cord Compression. a. Resident #2's Baseline Care Plan was completed on 1/30/23. 3. Resident #3 was admitted on [DATE] and had diagnoses of Essential Hypertension, Chronic Obstructive Pulmonary Disease, and Rheumatoid Arthritis. a. Resident #3's Baseline Care Plan was completed on 1/30/23. 4. Resident #4 was admitted on [DATE] and had diagnoses of Post Laminectomy, Acute Kidney Failure, and Metabolic Encephalopathy. a. Resident #4's Baseline Care Plan was completed on 2/7/23. 1. On 2/9/23 at 12:30 pm, the Surveyor asked Licensed Practical Nurse (LPN) #1, who is responsible for doing the Baseline Care Plan? He stated, the admitting nurse. The Surveyor asked, if the Baseline Care Plan is not done in a timely manner how would staff know how to take care of the resident? He stated, They wouldn't. The Surveyor asked, you admitted R #2 on 1/23/23 and didn't complete the Baseline Care Plan until 1/30/23, can you explain that? He stated, I have 2 halls and I'm very busy. The Surveyor asked, how long do you have to do a Baseline Care Plan? He stated, 24 hours. 2. On 2/9/23 at 12:40 pm, the Surveyor asked LPN #2, who is responsible for doing the Baseline Care Plan? she stated, usually the admitting nurse. The Surveyor asked, if the Baseline Care Plan is not done in a timely manner how would staff know how to take care of the resident? She stated, the nurse would have to look up the information and pass the information to the Certified Nursing Assistants (CNA)'s. The Surveyor asked, how long do you have to do a Baseline Care Plan? she stated, I just know they have to be done on admission or within 24 hours. 3. On 2/9/23 at 1:30 pm, the Surveyor asked the Assistant Director of Nursing (ADON), who is responsible for doing the Baseline Care Plan? she stated, on admit the nurse does them. The Surveyor asked, if the Baseline Care Plan is not done in a timely manner how would staff know how to take care of the resident? She stated, the nurses would have to refer to the hospital paperwork and the CNAs would check with the nurse. The Surveyor asked, how long do you have to do a Baseline Care Plan? she stated, within the 1st [first] 24 hours. 4. On 2/9/23 at 2:25 pm, the Surveyor asked the Nurse Consultant, who is responsible for doing the Baseline Care Plan? she stated, normally it is the nurse who is admitting the resident. The Surveyor asked, if the Baseline Care Plan is not done in a timely manner how would staff know how to take care of the resident? She stated, by asking or getting the information during report. The Surveyor asked, how long do you have to do a Baseline Care Plan? She stated, I think it's within the 1st 24 hours. 5. On 2/9/23 at 2:50 pm, the Surveyor asked the Administrator, who is responsible for doing the Baseline Care Plan? She stated, The floor nurses. The Surveyor asked, if the Baseline Care Plan is not done in a timely manner how would staff know how to take care of the resident? She stated, they would have to ask, and that's the thing, we check to see if they are done, if not the ADON would have them come back and do it. The Surveyor asked, how long do you have to do a Baseline Care Plan? She stated, in the 1st 24 hours.

Based on observation, record review and interview, the facility failed to ensure a resident in a wheelchair was properly secured on the transport van to prevent an accident with injury for 1 (Resident #1) of 1 sampled resident who was transported on the facility van in the past 30 days. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1, who tilted backward in the facility van during transport and hit her head, and had the potential to cause more than minimal harm to 15 residents who were transported via wheelchair on the facility van in the last 30 days, as per a list provided by the Administrator on 09/01/21. The findings are: 1. A typed letter dated 4/12/21 from the van company to the facility documented, .An in-service training and equipment inspection was conducted on April 12, 2021. These attendees were trained in the proper use and operation of the wheelchair lift and tie-down restraints on the facility's vehicle . [Certified Nursing Assistant (CNA) #1]. The following vehicle was inspected: 2019 Ford Transit T350 . 2. Resident #1 was admitted to the facility on [DATE] and had diagnoses of [CONDITION(S)], End Stage [CONDITION(S)] (ESRD), Dependence on Renal [CONDITION(S)], Type 2 Diabetes Mellitus and Hypertension. The Nursing Admit / Readmit Assessment and Care Plan dated 08/20/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required substantial / maximal assistance with transferring to and from a bed, chair or wheelchair; and had very limited mobility (ability to change and control body position). a. A Physician's Order dated 08/21/21 documented, .[MEDICATION(S)] Tablet 5 MG [milligram]. Give 1 tablet by mouth two times a day for blood thinner for 30 days . b. An Incident and Accident (I&A) Note dated 8/25/21 at 4:14 pm documented, .Incident Description: At approx. [approximately] 1145 [11:45 a.m.], transportation driver notified this nurse that resident had fallen while in the facility van. Driver stated that she had forgotten to hook the front wheels of the resident's w/c [wheelchair] prior to pulling out of the parking lot. As she was pulling through the stop sign by the nursing facility, she heard the resident yell out. Driver looked in the rearview mirror and stated she saw the resident falling backwards in the w/c. She immediately pulled over, assisted the resident back to a seated position in the w/c. She asked the resident if she was hurt and if she was okay, resident stated, 'Yes I am okay, please don't tell anyone about this. I am fine.' Driver transported resident to [CONDITION(S)] and returned to facility. Upon returning, driver came to this nurse and explained the situation. This nurse accompanied driver to notify the Administrator, DON [Director of Nursing], and APRN [Advanced Practice Registered Nurse]. Upon returning from [CONDITION(S)], this nurse assessed resident. Small raised area noted to right side of the back of the head, resident reports it is tender to touch but does not hurt when she is just sitting or lying down. Small abrasion with discoloration to L [left] forearm noted. VS [Vital Signs] WNL [Within Normal Limits], neurological checks also WNL. APRN, Admin, and DON notified of findings. Immediate Intervention: resident assessed, VS WNL, neuro [neurological] checks initiated and WNL at this time, Small raised area noted to right side of the back of the head, resident reports it is tender to touch but does not hurt when she is just sitting or lying down. Small abrasion with discoloration to L forearm noted . c. A Body Audit Form dated 8/25/21 documented, .Small raised area - arrow pointing to left back head . Discoloration left forearm . d. A Nursing (Nsg.) General Note dated 8/26/21 at 1:49 p.m. documented, .Continues neuro for recent fall in facility van. No abnormal VS noted. No changes in activity noted. No new injuries noted . e. A Nsg I&A Follow Up dated 8/26/21 at 1:08 p.m. documented, .Resident states 'She [CNA #1] pulled up the hill at the stop sign and I felt myself falling backwards. It really is not a big deal; I am ok and not hurting at all. She just forgot to put those little hooks on my front wheels, please don't tell anyone else, I am fine' . f. An Office of Long-Term Care (OLTC) Witness Statement Form dated 8/25/21 and signed by CNA #1 documented, .I was transporting resident to [CONDITION(S)] but as we came out the parking lot of our facility, I got to the stop sign. As I slowly went up the hill and I started to hear the resident yell. I looked into the rear-view mirror and the resident was slowly falling backwards. I immediately pulled over and checked on the resident. The resident stated that she was ok, and nothing was hurting her. When I returned to the facility, I immediately notified my ADON [Assistant Director of Nursing] which then we went to speak with the Administrator. I realized after checking on resident I didn't hook the front wheels. g. On 08/31/2021 at 10:36 a.m., the ADON was asked about the van incident involving Resident #1. She stated, I am familiar with [Resident #1]. [CNA #1] came to me between 11:30 - 11:45 a.m. on the day of the incident with the van and asked to speak to me privately. She told me that she was going up the incline by the Stop sign outside of the nursing home and she heard the resident yell. When she looked in the rear-view mirror, she saw the resident falling backwards in the wheelchair. She stated she pulled off to the side of the road immediately and asked the resident if she was okay and then sat the resident back up. She stated the resident asked her not to tell anyone and she then drove the resident to [CONDITION(S)]. The resident did not fall out of the wheelchair; the chair tilted backwards. The CNA stated that once she pulled over, she realized she had forgotten to hook and secure the front wheels of the wheelchair. The CNA, after transporting the resident to [CONDITION(S)], returned to the facility and notified me of the incident. The CNA stated that she panicked, and the resident was telling her not to tell anyone, and she made a bad judgement call. I immediately brought the CNA to the Administrator's office. The Administrator took over from there. The DON was also called to the Administrator's office. I think that the Maintenance Man brought the resident back from [CONDITION(S)]. I assessed the resident on return to the facility. The resident had a small bump to the back, right side of her head and discoloration to the left forearm. I notified the Nurse Practitioner, and we initiated 72-hour neuro assessments. The resident told me that nothing happened on the van. I told her that the CNA had already told me, and the resident then told me that the wheelchair had fallen back. The resident came back from [CONDITION(S)], I believe, between 3:00 and 3:30 p.m. I called [CONDITION(S)] after the CNA told me of the incident. I asked if I could come to [CONDITION(S)] and assess resident, and they told me I could not come to assess her; they were not allowing anyone in. I cannot remember who I spoke to; I did not tell her of the incident. I was told not to tell her of the incident. I was told to call [CONDITION(S)] for an assessment and tell them it was urgent, but not to tell them what happened. I did not tell them of the incident. No one at the [CONDITION(S)] unit was aware that the resident's wheelchair had tipped back, and that the resident had hit her head. h. On 08/31/21 at 11:43 a.m., the Administrator was asked about the van incident. He stated, .On a Wednesday, as we were finishing up our stand-up meeting, I looked out of the window and saw the van sitting on the side of the road. [CNA #1] would not answer our phone calls; she did answer the Maintenance Man's call. When she was asked if everything was okay, she told him yes, she did not need any help, she was straightening up something in the back and then she took off. When [CNA #1] returned to the facility, she went to speak with the ADON. The ADON and [CNA #1] came to my office. The CNA told me that she had not fastened the front two hooks on the front of the resident's wheelchair. When she drove up the incline by the Stop sign outside of the nursing home, she heard the resident yell, she looked through the rear-view mirror and the resident was tilted backwards in her wheelchair. She stated that she stopped the van and took care of the resident. [CNA #1] told me the resident did not have any injuries. I told her that she should have called the nurse immediately. She stated the resident made her promise not to tell anyone because she was fine. She stated the reason she came and told us was because she was feeling guilty for not doing the right thing. I sent the CNA home after she wrote a statement. [CNA #1] was subsequently terminated. The ADON assessed the resident. I am not sure at what time the resident returned from [CONDITION(S)]. [CNA #1] came to my office at approximately 12:30 p.m. to tell me of the incident. We did call and ask the [CONDITION(S)] unit if we could come to [CONDITION(S)] and do an assessment on the resident. I was afraid that if we told [CONDITION(S)] of the van incident, we would be breaking HIPAA [Health Insurance Portability and Accountability Act of 1996], because the resident told the CNA that she did not want anyone to know. The doctor was notified when the resident was assessed upon return from [CONDITION(S)]. The Maintenance Man picked up the resident from [CONDITION(S)] . i. On 08/31/21 at 12:01 p.m., the Maintenance Director was asked what he recalled about the van incident. He stated, The Administrator and I observed the van pulled over on the opposite side of the highway from the nursing home. This was on August 25th at 10:27 a.m., per my phone record. The van driver had pulled over on the side of the road. I called the van driver to make sure that everything was okay. She told me that she was straightening some things up in the back of van and everything was okay. She did not tell me that anything had happened to the resident. The van driver then shortly thereafter left the area. I later was informed by the Administrator that something did happen. She told me that I would have to come in and fill out a statement. This was the day after. I did pick up the resident that evening from [CONDITION(S)]. I checked all of the belts and floor anchors prior to picking up resident, and I did not find any problems; everything was working fine. The resident did not indicate that anything had happened. I was trained on the van by the previous Maintenance Director how to secure residents on the van . j. On 08/31/21 at 12:22 p.m., the DON was asked about the van incident. She described the incident as above, then stated, .The ADON and van driver went to the Administrator's office, and that is when I became involved . The van driver stated that she had forgotten to tie down the front of the wheelchair. The van driver had been here 7 years; she made a mistake. The ADON assessed the resident upon return to facility. The resident told the ADON to just let it go. The Maintenance Man picked up the resident from [CONDITION(S)]. The ADON did call [CONDITION(S)] to get permission to do an assessment. The [CONDITION(S)] unit did not allow this. Due to the resident's HIPAA, we did not tell [CONDITION(S)] of the incident . k. On 08/31/2021 at 12:35 p.m., Resident #1 was in her room, sitting on the side of bed. After getting the resident's permission to interview her, the Surveyor asked the resident if she had been involved in an incident on the van. She stated, Yes, the van driver did not hook the front wheels on the wheelchair. She drove up the incline after the driveway, and my wheelchair fell , tilted backwards. The resident stated she bumped her head and the van driver stopped the van and helped her back into a sitting position and then drove her to [CONDITION(S)]. She stated the Maintenance Man picked her up from [CONDITION(S)], and she had never had any other problems with the van. She stated, The CNA did come to see me when I got back from [CONDITION(S)] and apologized for what happened. l. On 9/01/21 at 7:55 a.m., the surveyor drove from the facility to the [CONDITION(S)] clinic to check the distance; the trip odometer indicated a distance of 10 miles (distance resident was transported after the van incident without being checked by a nurse). m. The manufacturer's instructions for the van's restraint system, provided by the Administrator on 9/01/21 at 11:06 a.m., documented, .Secure Wheelchair . Position wheelchair to face forward . Locate 4 tie downs (retractors). Attach and lock-in to floor anchorage . Attach 4 tie-downs to solid frame members of wheelchair . Make sure tie downs are locked and properly tensioned . n. The facility removed the immediate jeopardy and corrected the failed practices on 8/25/21, prior to the survey, as evidenced by the following: 1.) An In-service Education Report dated 8/25/21 documented, .Notify the facility with any incident on the van immediately. Resident must be assessed by Licensed Nurse, Paramedic, or EMT [Emergency Medical Technician] prior to being moved . This in-service was signed by the Maintenance Director . 2.) The facility self-reported the incident to the Office of Long Term Care on 8/25/21, as evidenced by the DMS form 762 dated 8/25/21, which documented, .Findings and Actions Taken . Investigation immediately begun including notifying the family, physician, and [County Sheriff's office]. The Social Director immediately started interviews with all cognitive residents that have been in the facility van to see if they had ever been hurt due to not being strapped down correctly with no new negative findings. Body audits immediately begun on all non-cognitive residents that travel on the facility van with no new negative findings. Facility van will not leave the premises until [van company] comes to assess van to ensure that all w/c hooks and straps are working properly. [Van company] called back and stated that we would need to bring the van to them on Friday the 27th [8/27/21]. Then at this time [van company] checked off the Maintenance Director so he can come back to check off anyone else that may need to drive the van. No one will drive this facility van unless they have been checked off on all Policies and Procedures. In-service on all types of abuse immediately begun. [CNA #1] was terminated on 8/26/21 due to not following Policy and Procedure. [Resident #1] is doing very well as of this date. No new incidents with the van at this time . An Offense Report from the County Sheriff's Office (CSO) documented the incident was reported to the CSO on 8/25/21. 3.) Resident #1's Care Plan included a revision dated 08/25/21 which documented a description of the 8/25/21 van incident and, .Van driver terminated, van out of service until inspected by [van company] and staff trained by [van company] . 4.) A Facility Employee Memorandum dated 8/26/21 documented, Employee Name: [CNA #1] . Date of Occurrence: 8/25/21 . Date of Memorandum: 8/26/21 . Did not follow facility P&P [Policy & Procedure] when having an incident on the van . Action Taken: Termination . Comment / Explanation: Due to not following the facility van P&P and you have been to training and still chose not to follow P&P . 5.) A Midnight Census Report dated as printed 8/26/21 documented the facility's efforts to interview other residents about their experiences on the van to determine if any other residents had been affected. The report documented, While riding facility van, have you ever experienced an incident where you were not properly strapped down or fell over in wheelchair? A total of 58 residents interviewed had a response of No documented next to their names; Resident #1 was the only resident whose response documented, Yes. 6.) An OLTC Witness Statement form dated 8/26/21 by the facility's Treatment Nurse documented, No negative findings on all non-cognitive residents. Body audit completed. 7.) The Nsg I&A Follow Up dated 8/26/21 at 1:08 p.m. documented, .Long Term Intervention: .Van Driver in-serviced by Administrator. Added to the Care Plan: 08/25/2021 . 8.) A typed letter dated 8/27/21 from the van company to the facility documented, .An in-service training and equipment inspection was conducted on August 27, 2021. Attendee - [Maintenance Director] was trained in the proper use and operation of the wheelchair lift and tie-down restraints on the facility's vehicle . The following vehicle was inspected: 2019 Ford Transit 350 . Concerns: N/A [not applicable]. Corrections: N/A . 9.) On 08/31/21 at 12:01 p.m., the Maintenance Director stated, .Once we found out that something had happened, the van was taken out of commission. That Sunday, I was told that I would have to go to [van company] to receive retraining on the van and securing residents. I went for the training on 08/27/21. When I went to [van company] for training, I took the van with me, and they did their annual inspection. Nothing was replaced, no concerns were found on inspection . 10.) On 08/31/21 at 12:58 p.m., the Administrator stated, .The Maintenance Man did check the van after the incident before picking up resident to make sure everything was working properly, there were no concerns at that time . The van got locked down after the incident. The van did not move again until the Maintenance Man took it with him to the [van company] for training; they also checked the van to make sure that everything was working properly . The Administrator also stated no one other than the Maintenance Director would be allowed to transport residents on the facility van until a new van driver was hired, trained and checked off. 11.) On 08/31/21 at 3:30 p.m., the Maintenance Director was asked to demonstrate the procedure for securing a wheelchair for transport on the facility van. The Surveyor sat in a wheelchair, and the Maintenance Director loaded and secured the Surveyor in the wheelchair, using the van's restraint system. All steps of the manufacturer's instructions were correctly followed.

Complaint # (AR 660) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure non-pressure related wounds were thoroughly assessed and measured weekly with the results documented, to enable accurate tracking of healing progress or prompt identification of deterioration of the wounds; and, failed to ensure severe deterioration in the condition of a wound and the absence of pedal pulses were immediately communicated to the physician to prevent potential delays in treatment for 1 (Resident #1) of 4 (Residents #1, #2, #3, and #4) case mix residents who had wounds. These failed practices resulted in a pattern of past noncompliance at the level of actual harm to Resident #1, whose wound deterioration was not immediately addressed, and had the potential to cause more than minimal harm to 5 residents who had wounds, according to a list provided by the Administrator on 7/10/18 at 4:40 p.m. The findings are: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 10/29/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive two plus person physical assistance for personal hygiene, was always incontinent of bladder and of bowel, was at risk of developing pressure ulcers, had no pressure ulcers, and had no venous or arterial ulcers. a. Nursing Weekly Licensed Nurse Skin Assessments dated 10/30/17 through 11/27/17 documented, .Pink area to the great toe, scabbed area to the 2nd toe . There was no documentation on any of the skin assessments sheets to indicate the wounds to the left great and second toes were measured from 10/30/17 to 12/11/17. b. A physician's orders [REDACTED].TAO (triple antibiotic ointment) to great toe . c. A physician's orders [REDACTED].Medi-honey to great toe . There was no documentation between 12/11/17 and 4/23/18 to indicate the wounds to the toes deteriorated, improved or that the treatment orders were changed during that timeframe. d. A Weekly Nursing Wound Observation note dated 4/23/18 documented, .Left great toe 9.5 cm (centimeters) X (by) 5 cm X 1 cm with slough. No change in treatment . A check box on the form indicated the information was reported to the physician; however, there was no documentation of any follow-up with the physician to determine if a change in treatment may have been necessary to address the significant decline in the condition of the wound to the great toe. On 7/10/18 at 3:08 p.m., the Treatment Nurse was asked if she had notified the physician of the decline in the resident's wound on 4/23/18. She stated, I notified them that week of the 23rd (4/23/18) of what was going on in the wound. I usually call them, or if they are in the building I will tell them. On 4/23/18, I notified the Medical Director (MD). I left him a message. He did not respond to the message. I left a voice message. There is a number that we call. The answering service answered, and I left a message with them to have the MD call me. I did not speak to him, nor did anyone tell me that he had called back. The next day I was able to speak to the APN (Advanced Practice Nurse). If I had not been able to talk to the APN, I would have called him back. I would have told him that the toe had opened up and was declining. Sometimes, he will call back and I won't be here. If he had called back and spoken to a Nurse, I would think that they would have charted it. The APN was more aware of it. The APN, I think she was on vacation at that time. At the time of completing the documentation (the check box for physician notification) on the wound observation sheet, I had not spoken to him. I had left a message. e. A Weekly Nursing Wound Observation note dated 4/30/18 written by the Wound Treatment Nurse documented, .Left great toe 9.5 cm X 3 cm X 1 cm, eschar with bloody drainage. Treatment changed to Dakin's, Santyl, and [MEDICATION NAME], same treatment to 3rd toe . This was a period of 7 days after the deterioration in the left great toe wound was initially identified. f. A Weekly Wound Observation Note dated 5/7/18 and written by the Treatment Nurse documented, .Left great toe 9.5 cm X 5 cm X 3 cm, slight improvement this week, no pedal pulse . The wound had increased in width by 2 cm and in depth by 2 cm. There was no further documentation related to the presence or absence of pedal pulses, or that this information was immediately communicated to the physician. g. A Nurses Progress Note dated 5/11/18 at 2028 (8:28 p.m.) documented, .Resident sent to ER (emergency room ) (local hospital) for eval (evaluation) and treatment of [REDACTED]. Transported via ambulance. Daughter and son-in-law arrived at facility prior to pick-up. Will follow to hospital . 1.) A hospital History and Physical dated 5/11/18 documented, .A 94 y.o. (year old) female presenting with left foot infection . past history of multiple medical problems including Dementia, [MEDICAL CONDITION], Diabetes Mellitus, and [MEDICAL CONDITION], presented in emergency room from the nursing home with left foot infection, gradual onset, severe in amount, persistent and progressively getting worse and associated gangrenous, with blackened eschar present, no distal pulse, great toe completely blackened, along with the 1st and 2nd toes, redness ascending to mid-foot. Pt. (patient) unable to communicate and provide history and collateral history taken from emergency room . Imaging with destructive changes involving 1st and 2nd phalanges and 1st metatarsal on view of imaging . admitting [DIAGNOSES REDACTED]. Hospital course dated 5/15/18 . She is a nursing home patient admitted with gangrenous toe which required a LBKA (left [MEDICAL CONDITION]) operation . 2.) A Nursing Admit and Reassessment and Care Plan dated 5/17/18 documented, .LLE (left lower extremity) AKA (above the knee amputation) 46 staples to surgical site, with scant amount of serosanguinous drainage noted . h. On 7/9/18 at 3:25 p.m., the Medical Director was asked if he recalled anything about Resident #1's wounds to her left great toe. He stated, No. I did not know. The only thing I knew was when the DON called me and reported the resident had a bad wound and she needed to send her to the hospital. I reviewed the chart from the hospital and the resident had very poor circulation. i. On 7/10/18 at 11:25 a.m., Certified Nursing Assistant (CNA) #1 stated she had worked for the facility for one and a half years, and had worked all shifts. She stated she worked on the 100 Hall. She stated, I am familiar with (Resident #1). Before they bandaged her foot, there was fluid on the toes; her toes were swollen. At night we would loosen the sheet over her feet. There were no sores on her feet. Later on, there were blisters on her feet and they busted open. She had one on the big toe to bust open, and one on the 2nd and 3rd toes. After that, there were bandages put on her feet, and I did not see the toes under the bandages. On the day that the resident went to the hospital, the 3 to 11 nurse changed the bandage. They wanted her to do a treatment. I helped the nurse, holding the resident while she did the treatment. The toes were black . The resident yelled all of the time when rolling her for pericare. I would always see the Treatment Nurse with supplies in her hands going into the resident's room, but I never saw her do the treatments . j. On 7/10/18 at 11:34 a.m., CNA #2 stated she had worked for the facility for 5 months, And had worked on the 100 Hall most of the time. She stated, I am familiar with (Resident #1). I saw her feet when I took care of her. It started out like a blister on her toe. It was red then, darker, and then sorer. I would watch it. I worked on the 300 Hall for a while, and then, when I returned to the 100 Hall, the resident was in the hospital. She had an amputation. I do not see the Treatment Nurse do the treatments. I do assist her at times. I do see her out and going into the residents' rooms, but I do not help her all of the time. On the weekend, the RN (Registered Nurse) Supervisor does the treatments. k. On 7/10/18 at 11:42 a.m., CNA #3 stated she had worked for the facility for 2 months and rotated halls. She stated, I am familiar with (Resident #1). I know that she had a sore. It had a bandage on it. I never saw the sore. I saw a bandage on her foot, and the next thing I knew the leg was cut off. The resident has a sore on her bottom, at this time. Sometimes, I help with treatments if the Treatment Nurse needs my help. On weekends, sometimes the nurses do their own treatments, or the RN supervisor. l. On 7/10/18 at 11:50 a.m., Licensed Practical Nurse (LPN) #1 stated she had worked at the facility for 3 ½ years. She stated, I am familiar with (Resident #1). I never saw her foot prior to the amputation. The Treatment Nurse always did the wound care on the resident. The RN Supervisor does the treatments on weekends. I am aware of blisters on top of the resident's toes. There was one small blister, a reddened area to the second toe. Then it went to having a dressing on it. The resident was then sent out for an amputation. I do see treatments being done. I also see treatments being done on the weekend. m. On 7/10/18 at 11:56 a.m., the Treatment Nurse stated she had worked for the facility for 5 years and had been the Treatment Nurse for approximately 2 years. She stated, I am familiar with (Resident #1). The areas to her toes started as an abrasion last (MONTH) / November. I monitored the areas. I observed the areas weekly. There was no treatment needed at that point. The skin was blanching. The resident has severe [MEDICAL CONDITIONS]. There were times I could palpate the pulse, and there were times when I could not palpate the pulses . In December, the areas to the resident's toes were not resolved. An order was written for TAO (Triple Antibiotic Ointment) with a dry dressing. A week or so later, the areas were still not changing. The treatment was changed to [MEDICATION NAME]. The areas on the resident's toes continued to show no change and there were no super concerns. In April, the area opened up on the resident's left great toe. Prior to (MONTH) 23rd (4/23/18), the resident's toe had the appearance of a scrape / scratch. In April, I started doing wound report documentation. On (MONTH) 23rd, the area on the resident's left great toe started to open up. The area appeared vascular in nature. At the end of April, the treatment was changed to Santyl. On 5/9/18 when I did the treatment, there were no further changes to the resident's toes. They had remained the same since the change of treatment to Santyl. On 5/11/18, the resident was sent to hospital. I was on vacation at that time. I do all of the wound treatments. I never asked anyone else to assess the wounds to the resident's toes. I discuss skin concerns in the daily stand-up meetings. I never had an RN (Registered Nurse) to assess the wounds with me. n. On 7/10/18 at 12:15 p.m., the Advanced Practice Registered Nurse (APRN) stated she had worked at the facility for 9 months. When asked if she was aware of the skin concerns for Resident #1, she stated, I recall the resident bumping her toe. There was an abrasion there. Sometimes, it was scabbed over, and sometimes it was pink in color. In April, it changed. It was an actual abrasion with no scab. The treatment was changed at that time. I did not see the resident again; I was notified of the deterioration (5/11/18), and the resident was sent out to the hospital. o. On 7/10/18 at 12:38 p.m., LPN #2 stated she had worked for the facility for 3 years on the evening shift, 3 to 11, and worked the 100 Hall more often than the other halls. She stated, I am familiar with (Resident #1). The first time observing the areas, there was a scabbed-over area behind the nail bed to the great toe, and a smaller area to the 2nd and 3rd toes. The areas were scabbed over, not open or draining. We kept the resident's heels floated. The dressings to the resident's foot were done by the day shift. On the evening shift, we monitored the dressings and changed them as needed. The resident was in no pain or acute stress. The resident was nonverbal for the most part. The resident had very fragile skin . I was moved around to other halls for a couple of weeks. Upon return to the 100 Hall, the resident's dressing had increased in size. There was a figure 8 dressing in place. On the evening that the resident was transferred to the hospital (5/11/18), a CNA told me that she had noted an odor to the resident's foot. When I went to look at the resident, there was no drainage visible through the dressing. No fever. The resident's extremities were always cooler. I removed the dressing. There was a lot of tissue damage to all of the resident's toes, reaching up into the dorsal part of the foot. The rest of the foot was intact. Drainage was limited. I was concerned with the amount of tissue damage. I called the DON (Director of Nursing). She was off duty. I was told that they were aware of the resident's foot. The report from the day shift was that the resident's foot was not improving. When I saw it myself, I thought something needed to be done. I called the Doctor and received an order to transfer the resident to the ER (emergency room ). I notified the resident's family, who stated that they were aware of concerns with the wounds on the resident's foot. The resident returned from the hospital with an amputation. Usually, the treatments are in place when I come on duty in the evening. The weekend supervisors do treatments on the weekend. p. On 7/10/18 at 1:18 p.m., the Director of Nursing (DON) was interviewed via telephone. She stated she was familiar with Resident #1. When asked about the wounds to the resident's toes, she stated, I assessed the wounds to the resident's left foot on the Friday (5/11/18) that the resident was sent out to the hospital. I reviewed the documentation for the wounds on that Wednesday (5/9/18) and noted a significant change from the documentation to the visualization on Friday. She stated, After the assessment on Friday, I asked the 3 to 11 nurse (LPN #2) to also look at the wound to see if she was in agreement that there was a change in the wound. (LPN #2) agreed that there was a change. We called the APN (Advanced Practice Nurse) and received orders to transfer the resident to the emergency room . She stated she was not in the building when the resident left to go to the hospital. She had worked late that day and was here when the APN was called. She stated typically, she does not look at the wounds unless there is a significant change. She stated, at this point, either she or RN #1 would assess the wound. She stated all wounds were discussed in the daily start-up meetings and that she reviewed the weekly wound reports from the Treatment Nurse. She stated she also speaks with the nurses on the hall regarding wounds. She stated she had last observed the resident's toes at the end of (MONTH) (YEAR) and that there was a significant change to the wounds between the end of (MONTH) and 5/11/18, prior to the resident's transfer to the hospital. She stated the abrasion to the toes was initially caused by the resident having foot drop, and the toes rubbing on the end of the bed. She stated a RN completed treatments on the weekends, but did not conduct wound assessments. She stated the Treatment Nurse accompanied the Wound Doctor on weekly rounds and assessed the residents' wounds. When asked who would assess the wound if the resident was not being seen by the Wound Doctor, she stated the Treatment Nurse does the wound assessments for those residents. q. The facility put corrective measures in place, beginning on 5/11/18, as evidenced by the following: 1.) A facility Quality Assessment and Assurance document dated 5/11/18, received from the Administrator on 7/10/18 at 3:50 p.m., documented, .Issue . Resident (identifier) had wound to left foot that upon assessment had change in condition and needed to be seen in the ER (emergency room ) . Incident . On 5/11/18 the DON (Director of Nursing) went to assess the wound on the resident's foot. The resident's foot with change from the last documented wound observation. APN (Advanced Nurse Practitioner) notified of the wound change and order received to send resident out to the ER for evaluation of wound. Upon admission to the hospital the resident had no blood flow to the leg. The resident had amputation above the knee on 5/13/18 . Investigation into cause . On 12/11/17 treatment noted areas of abrasion to the left great toe and the 2nd toe. The Treatment Nurse initiated treatment on the abrasion areas and noted them on the weekly skin assessment. The Treatment Nurse did not investigate the cause of the abrasions. The resident's feet have noted deformity and extensive foot drop. Treatment Nurse said the areas of abrasion are consistent with the low air loss mattress device at the end of the bed. The areas on the feet according to Treatment Nurse remained essentially the same until the week of (MONTH) 23rd. At this time the Treatment Nurse contacted the APN and family due to the worsening of the wound. They now showed opening and slough. The wound continued to initially deteriorate and the treatment was changed on 4/30/18. After the treatment change, the wound initially improved due to Santyl treatment, showing granulation. On 5/7/18 the Treatment Nurse noted a lack of pulse. The physician was notified about the wound, but failed to notify the physician of the lack of pedal pulses. The resident has had a long history of [MEDICAL CONDITION], cardiovascular disease and diabetes. The DON looked at the wound on 5/11/18 and noted the change from the previous wound documentation. APN was notified and family. New order received to send resident to ER for evaluation .Immediate interventions . Resident assessed and sent to the ER for evaluation . Vascular studies indicate lack of blood flow to left leg . Amputation of left leg above the knee on 5/13/18 . Identify others at potential risk . All residents have the potential to be at risk . Action to prevent similar incident . Complete facility body audit to evaluate skin within facility . In-Service nurses on reporting change in condition with return test to prove competency . In-Service nurses on completing documentation on any newly identified areas and investigating if not observed . In-Service CNAs (Certified Nursing Assistants) on reporting change in residents' skin. Or any new odor with wounds . 2.) An In-service Education Report dated 5/11/18 documented, .Any resident that is having a change in any wound such as color, odor, or any new areas you must report this to the nurse in charge . 3.) An In-service Education Report dated 5/11/18 documented, .Any resident that is having a change in condition, you must do the proper assessment for the change of condition. Also, you must complete the documentation of any newly identified areas . 4.) An In-service Education Report dated 5/14/18 documented, .Must report to physician and family any change in condition in wounds, and any change in treatment orders. Must change treatment to any wound that does not improve within 2 weeks . 5.) On 7/9/18 at 11:07 a.m., the Treatment Nurse provided wound care for Resident #1. The suture line to the left AKA was intact, no open areas were visible. 6.) A Quality Assessment and Assurance (QAA) document provided by the Administrator on 7/10/18 at 3:50 p.m. documented the facility initiated a monitoring plan on 5/14/18, which was continued through 7/6/18, that included observing and monitoring 3 residents weekly for wound measurements and treatments, 5 residents weekly for body audits, and monitoring of any treatment order changes 5 days per week. The outcomes documented on the form indicated no further negative findings were identified between 5/14/18 and 7/6/18. The surveyors also found no current failed practices related to wound assessments and care during the complaint investigation survey.

Complaint # (AR 780) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to prevent accidents for Resident #1. The facility failed to ensure direct care staff was able to identify and immediately report exit seeking behaviors to licensed nursing staff, which resulted in failure to promptly develop and implement interventions to prevent elopement for 1 (Residents #1) of 3 (Residents #1, 2 and 3) case mix residents who were at risk for elopement. The failed practice resulted in past immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who wandered out of the facility undetected in a wheelchair and fell down an embankment into a water-filled ditch, resulting in hypothermia and other complications. The failed practices also had the potential to cause more than minimal harm to 10 residents who were at risk for elopement, according to a list provided by the Administrator on 3/1/17. The facility removed the immediate jeopardy and corrected the underlying failed practices on 2/24/17, prior to the survey entrance date. The facility was informed of the past immediate jeopardy condition on 3/1/17 at 12:00 p.m. The findings are: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 12/10/16 documented the resident scored 3 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, wandering behavior not exhibited, was independent with bed mobility, required limited assistance with transfers and dressing, required supervision with eating, required limited assistance with toilet use and personal hygiene and required physical help in part of the bathing activity. a. A Nursing (Nsg) Admit/Readmit Assessment and Care Plan dated 12/12/16 documented the resident scored 9 (9-10 indicates at risk to wander) on the Elopement Risk section and that the resident was independent with walking in his room, independent with locomotion on and off the unit via a wheelchair, was steady at all times when moving from a sitting to a standing position, was not steady but able to stabilize without human assistance when walking, was steady at all times when moving on and off the toilet and was steady when transferring between the bed and a wheelchair. b. A Nurse's Note dated 2/24/17 at 6:45 a.m. documented, At about 0645 (6:45 a.m.) nurse (Registered Nurse #1) was leaving room . and heard a page over the intercom for assistance outside the 4 hall door. Arrived outside 4 hall door, there were several staff tending to (Resident #1), who was on his left side in a drainage ditch. Assisted to a sitting position, moved several times about a foot each time up the embankment. Placed in his wheelchair then to a bed in (room number), removed wet clothes, assessed to find vital signs 122/68 (right arm lying), pulse 49, respirations 20 and O2 (oxygen saturation) at 98% with O2 (oxygen) at 2 L (liters) via n/c (nasal cannula). No temperature was documented. c. An Incident Report dated 2/24/17 and prepared by Registered Nurse (RN) #1 documented the following: Incident Description: .At about 0645 heard a page over the intercom help needed outside 4 hall. At a fast pace from room 104 arrived outside of said area to see several staff huddling over (Resident #1) whom was on left side in a drainage ditch assisted to a sitting position, no moaning, guarding or grimacing noted, moved from ditch to wheelchair, brought into (room number), put in bed, removed wet clothes, assessed for injuries . Immediate Action Taken: .Patted dry, covered with blankets, no bleeding. Does have several abrasions . Witnesses: (Licensed Practical Nurse (LPN) #1) - At 6:45 a.m. I was walking up to the door at the end of 400 hall and I noticed something black in the ditch and looked closer and saw someone laying (sic) there. I ran into the building and alerted other staff that I needed help out the 400 hall door in the ditch. I told staff to call 911 . Began to take his wet clothes off, get him covered in warm blankets. We did body audit and stayed with him until EMTs (Emergency Medical Technicians) arrived . d. A hospital Emergency Department (ED) Provider Note dated 2/24/17 documented, Patient presents today after he was found outside a local nursing home. Apparently, the patient had fallen into the creek. An estimation was made that the patient was outdoors no more than 45 minutes. The patient is unable to provide a history. Patient has a history of Dementia. Paramedics reported that the patient was cold to touch upon arrival . Physical Exam: BP (Blood Pressure) 157/79 (02/24/17 0740 (7:40 a.m.)), Heart Rate 82 bpm (beats per minute) (02/24/17 0740), Resp (Respirations) 21 (02/24/17 0740), Temp (Temperature) 85.8 degrees F (Fahrenheit) (29.9 degrees Celsius) (02/24/17 0740) . Clinical Impression: Hypothermia (Primary); Hypotension . e. A hospital History and Physical dated 2/24/17 at 10:45 a.m. documented, .91 y.o. (year old) man with Dementia. NH (Nursing Home) resident was apparently found outside the NH this am (morning) around 6:45 a.m. out of his wheelchair and in the creek. EMS was called. He was hypotensive and hypothermic. No details known how he reached there. In the ED, hypothermia was treated with passive warming. 4L (four liters) NS (Normal Saline) infused but BP remained low, so was started on Levophed via peripheral line and transferred to ICU (Intensive Care Unit) . Visit Vitals: BP 76/44, Temp 94.2 degrees F (Fahrenheit) . f. The Office of Long Term Care (OLTC) Incident and Accident Report, Division of Medical Services (DMS) form 7734 dated 2/24/17 documented, During the course of an investigation of a recent elopement incident, it was discovered that (CNA #1) neglected to inform her charge nurse or any other supervisor of a change in condition the evening before the resident's elopement. This would have potentially resulted in an updated plan of care regarding elopement safety . Assessed resident, administered first-aid, and transported EMS to ER. Resident readmitted to the facility on [DATE] and is doing well. Risk assessments and care plans have been updated appropriately . g. A Nsg Admit/Readmit Assessment and Care Plan dated 2/26/17 documented, .Elopement Risk .g. Total Sore .11 . The form documented a total score of 1 and above indicated High Risk to wander. The form also documented the activity of walking in his room did not occur, that the resident required supervision with locomotion on and off the unit via a wheelchair, was not steady and required human assistance when moving from a sitting to standing position, that he was not steady and required human assistance when moving on and off the toilet, was not steady and required human assistance when transferring between the bed and wheelchair. h. The Care Plan dated 2/26/17 documented in the Focus section, The resident is an elopement risk related to his previous elopement attempt. i. On 2/28/17 at 4:01 p.m., LPN #2, who was the resident's assigned nurse for the 3:00 p.m. to 11:00 p.m. (3/11) shift on 2/23/17, was asked about the resident's behaviors during that time and stated, I didn't know anything about the incident until Sunday 2/26/17). I was quite shocked. (LPN #1) found him lying in the ravine. It was such an odd thing. I have never known him to have exit seeking behaviors. I don't understand it. I do know the last time I saw him was around 9 - 9:15 p.m. Thursday (2/23/17) night. I'm just so thankful he's okay. It's a reminder of how quickly things can get out of control. LPN #1 was asked if any staff, including CNA #1, reported any exit-seeking behaviors the resident may have been exhibiting that evening and stated, The CNA . said she came and told me this, but that never happened. I would have remembered that, because that would have been so far out of his normal behavior, I would have checked on him. She also said I told her to take him to his room and change his clothes. I would remember that. Maybe she thought she told me that stuff, because we were busy that night. I don't know of anyone else who saw him doing this. j. On 2/28/17 at 4:33 p.m., CNA #2, who was assigned to the resident for the 3/11 shift on 2/23/17, was asked how the resident was acting on the evening of 2/23/17 and stated, The only odd thing that evening to me was that he didn't want to go to bed. He was very vocal. I noticed he was at the end of 100 hall and he was wheeling himself into another resident's room, so I went to him to see what was going on. I took him to the bathroom, turned his covers down on his bed, and then went to the nurse's station to do something, and I saw him coming back down the hallway. When I went back to his room, I noticed his covers had been fixed, so I thought okay, he's not ready to go to bed. Toward the end of my round, I saw him by the dining room watching people. The CNA was asked if she saw him that evening trying to push on doors or if she had ever seen the resident pushing on the doors or trying to exit the building and stated, He likes to look out the door windows, but that's normal for him. The CNA was asked if the resident verbalized anything that evening about wanting to leave and change his clothes or if he at any time had stated anything about wanting to leave and stated, No. The CNA was asked if the other CNAs on the hall that evening stated anything to her about the resident exhibiting exit-seeking behaviors because he wanted to go change his clothes and stated, I was on the hall by myself for about 2 to 2 1/2 hours and then she (CNA #1) came in to help me. I do not remember her coming up to me at any time telling me about him wanting to leave and change his clothes . The CNA was asked how the resident got out the door and stated, I don't know. I just don't know. k. On 2/28/17 at 5:01 p.m., LPN #3, who worked the 3/11 shift on 2/23/17, was asked about the resident and his behaviors that evening and stated, He has sundowners. He'll go to bed after supper, but he'll get up and come visit at the nurse's station after a while. I saw him at supper. I stayed over that night to do some paperwork and saw him around 12 or 12:30 a.m. before I left. He was sitting in that little area by the dining room in his wheelchair, talking to himself. I didn't see him do anything out of the ordinary that evening. The LPN was asked if she saw him going to the doors or heard him making comments about wanting to leave that evening and stated, No. The LPN was asked if she had ever known him to try to leave and stated, No. l. On 2/28/17 at 3:53 p.m., the ditch outside the 400 hall, where the resident was found on the morning of 2/24/17, was approximately 20-30 feet from the door. There was approximately 2 inches of water in the bottom of the ditch. A fence and bumper guard had been placed in the area to prevent a wheelchair from rolling down the embankment as documented in the facility's Quality Assessment and Assurance plan of correction on 2/24/17 provided by the Administrator on 2/23/17 m. On 3/1/17 at 9:30 a.m., CNA #1, who was assigned to the resident on the 3/11 shift on 2/23/17, was asked about the resident's behaviors that evening and stated, I just remember him saying how can he get out, so he could go change his clothes. The CNA was asked if he pushed on any of the doors and stated, He did go and push on the front door. The CNA was asked how many times he did that and stated, One time, I think. The CNA was asked if the resident had ever said he wanted to leave before and stated, He had never told me before that evening, but I'm PRN (as needed) and I'm not there a lot. The CNA was asked when the resident was exhibiting these behaviors and stated, It was after dinner, but I don't remember him doing it after 9 p.m. The CNA was asked if she reported the resident's behavior to the nurse and stated, I don't remember. I could have, but I'm not sure. It was a busy night. We had a few other residents acting up that night. The CNA was asked if she had been suspended after this incident and, if so, why and stated, Yes. They suspended me because they said I was the only one that night that saw him having that behavior. The CNA was asked if the resident's behavior that evening alarmed her and stated, No. He's wanted to change his clothes before, but I can't remember him wanting to leave. n. On 3/1/17 at 9:45 a.m., CNA #3, who worked the 3/11 shift on 2/23/17 and the 11/7 shift on 2/23/17 into 2/24/17, was asked about the resident's behaviors during that time and stated, I saw him at the nurse's station talking to another resident around 9:30 p.m. That was the last time I saw him. He does get a little messed up on the doors, because he can't see. He'll be looking for the bathroom, so he might accidentally open someone's door. The CNA was asked how she thought the resident got out of the building and stated, I don't know. It blows my mind. I've never seen him attempt to get out. He can't punch a code to get out the door. o. On 3/1/17 at 10:11 a.m., CNA #4 was sitting 1 on 1 with the resident while he was in bed. The CNA was asked how he was doing and she stated, He's okay, but he has changed. Before the incident, he was mostly independent. Now he requires assistance with almost everything. p. On 3/1/17 at 10:18 a.m., all exit doors in the facility were checked for proper functioning. They all worked properly. q. On 3/1/17 at 11:15 a.m., RN #1, who worked the 11/7 shift on 2/23/17 into 2/24/17, was asked how the resident was acting that night and stated, He was his normal self. He does get turned around sometimes. I will see him on the 400 hall trying to find his room. He's not really a wanderer. I know I gave him his meds around 5:15 a.m. Friday morning. He was close to the ladies' bathroom here by the activities board. After that, I just can't remember. The RN was asked how the resident got outside and stated, That's the 64 thousand dollar question. I have no idea. There was no alarm sounding. r. On 3/1/17 at 11:24 a.m., LPN #1, who found the resident outside on the morning of 2/24/17, was asked what happened the morning of 2/24/17 and stated, I got here at about 6:45 a.m. I always park at the very end of the parking lot. I walked to the door at the end of the 400 hall to go in and I saw something black. So I looked a little closer and saw it was a wheelchair. Then I saw somebody down there in the ditch. I ran in the door and yelled for help. I went back out and went down in the ditch and saw he was breathing. We got him out of the ditch, in the wheelchair, got him in a bed and got his clothes off trying to warm him up. I checked the door, because I was wondering how he could have gotten out without someone hearing the alarm, but it was working fine. The LPN was asked how long she had worked at the facility and stated, Eleven years. The LPN was asked if she had ever known the resident to want to leave and stated, No. s. The facility removed the Immediate Jeopardy, corrected the failed practices and reduced the scope and severity to G on 2/24/17, as evidenced by the following: On 2/28/17 at 3:15 p.m., the Administrator provided the following Quality Assessment and Assurance (QAA) plan for corrective action: 1. 2/24/17 resident (Resident #1) was identified by (LPN #1) at 6:44 a.m. lying on the ground outside of the facility 400 hall at the base of a nearby land slope; his wheelchair was located very nearby turned onto its side. Nurse (LPN #1) summoned help from staff in the facility; the resident was immediately assessed and maintained one on one with staff until EMS arrived for transport to the emergency room . The resident's physician and family were immediately notified in addition to the (local) Sheriff's office being notified of the incident. Nursing management initiated facility wide rounds ensuring all residents were present and accounted for at this time. The Administrator initiated a full facility investigation of this incident immediately. Immediate assessment of the environment revealed the following: resident was lying on the ground with an area of his lateral head in a wet area at the base of the nearby land slope. A maximum depth of 3.5 inches of water was present in the center of the base of the slope. It was 59 degrees Fahrenheit at the time of the incident, resident (Resident #1) was wearing wind-suit pants, short sleeve shirt, fleece jacket and closed toe/non slip soled footwear. The 400 hall exit door, door alarm were immediately inspected for operability; no concerns were identified with the safety inspection. All other facility doors were also inspected in the same manner with no concerns identified with door function, alarms or keypads. All keypad door codes were changed as an additional safety precaution at this time. Staff interviews and investigation depict the following as having occurred: Resident (Resident #1) was present in the facility near the dining room/nurse's station at 6:05 a.m. All staff on duty affirmed that the door alarm had not sounded supporting the investigation's conclusion that (Resident #1) unknowingly followed a person(s) through the 400 hall exit door where he propelled his wheelchair down the embankment and fell to the ground. (Resident #1) elopement risk assessments and care plan was reviewed . (Resident #1) was hospitalized at (hospital) and will be assessed upon readmission with the plan of care updated with his now 'at risk for elopement' status. Staff inservices and interviews are ongoing with any concerns identified addressed via retraining or other facility protocols as appropriate. 2. Updated elopement risk assessments were completed for all residents by the facility IDT (Interdisciplinary Team) on 2/24/17. Care plans were audited at the time of the assessments to ensure all appropriate interventions to minimize the potential for elopement were in place. Any assessment or care plan clarifications were implemented at this time. In addition to immediate assessment of all doors, door alarms and key pad operability the facility has initiated additional environmental modifications to reduce the potential for recurrence as follows: Bumper placed on sidewalk side that is adjacent to the downhill embankment to guard against wheelchairs rolling to sloped area. State fire marshal contacted to ensure appropriateness of door egress settings. Contractor secured for fence and gate installation at the end of 100, 200, and 400 halls. Elopement risk binder audited to ensure all residents at high risk for elopement are included. Non-urgent use of 400 hall exit door discouraged until completion of contracted fence and gate. 3. On 2/24/17 staff retraining initiated and will remain ongoing for the following: Being mindful when exiting any facility door re: residents potentially following them out. Response for potential missing residents and appropriate response to any sounding door alarm demonstrations will remain ongoing to encompass all direct care staff members by 3/2/17. Letter composed to be mailed to each resident's primary contact/responsible party on file requesting special focus on safety when exiting doors. 4. Ongoing monitoring to ensure compliance with elopement safety will be initiated as follows: Administrator/designee will sound door alarms unannounced a minimum of 3x (times) weekly x 4 weeks on varying shifts to ensure compliance with response and identify/address any retraining needs immediately. Any abnormal findings or additional concerns identified through the course of the above plan will be corrected immediately and result in additional QAA development as appropriate. ADDENDUM 2/27/17 - Ongoing investigation of the incident/accident involving (Resident #1) on 2/24/17 has revealed certified nurses assistant (CNA #1) observed (Resident #1) approaching an exit door stating that he needed to go home and change clothes. The certified nursing assistant initially stated that she notified her charge nurse, however later retracted that she had notified anyone of this observation. (CNA #1) was immediately suspended pending the outcome of the investigation of potential neglect to report a change in condition. OLTC (Office of Long Term Care) reporting was completed as appropriate. No other staff members are identified as having knowledge of (Resident #1) exit seeking behaviors exhibited on 2/23/17. Administrator/Interim DON (Director of Nursing)/designee(s) implemented staff interviews to identify any other residents exhibiting exit seeking behaviors that may have not been reported to licensed nurse or administration. All residents identified as reported with potential risk factors for elopement were immediately reviewed for appropriate risk assessments and care planning. Training for (CNA #1) was reviewed and current re: reporting changes in condition most recently as with facility inservices completed 2/16/17-2/23/17. Staff inservices/retraining was initiated at this time and will remain re: reporting any possible elopement risk behaviors including exit seeking to a licensed nurse and/or administration immediately; retraining also reeducates point click care behavior documentation capabilities and abuse/neglect. Ongoing monitoring has been implemented by administration/designee(s) by conducting facility observation rounds with direct care staff interviews on 7/3; 3/11; 11/7 shifts twice weekly x 4 weeks and then with ongoing random rounds to ensure that any potential changes in condition observed during care are appropriately addressed via risk assessments and care plans. Point click care clinical alerts will be reviewed daily to identify any areas noted by direct care staff to also ensure appropriate follow up assessment and updates in plans of care were completed as appropriate. Any abnormal findings or additional concerns identified through the course of the above plan will be corrected immediately and result in additional QAA development as appropriate.

Complaint # was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided to maintain the highest practical physical well-being in accordance with the comprehensive assessment and plan of care for Resident #17. The facility failed to ensure licensed staff were knowledgeable and competent in the insertion of a urinary catheter and in the identification of potential problems during placement to reduce the risk of complications for 1 (Resident #17) of 2 (Residents #5 and 17) case mix residents with indwelling urinary catheters. This failed practice resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Resident #17, who was sent to the hospital emergency department approximately 2 to 3 hours after insertion, with blood in urine, chills and decreased blood pressure, received packed red blood cells and surgical insertion of a catheter directly into the bladder and had the potential to cause more than minimal harm for 3 residents who had an indwelling urinary catheter according to the facility's Resident Census And Conditions Of Residents form dated 3/16/15. The facility removed the Immediate Jeopardy on 1/23/15 prior to the survey entrance date; however, underlying deficient practices had not been corrected. The facility Administrator was informed of the Immediate Jeopardy on 3/20/15 at 3:23 p.m. The findings are: 1. The facility procedure received from the Administrator on 3/19/15 titled, Foley Catheter Insertion, Male & Female, documented: "...Insert the catheter gently into the meatus (approximately 5-7 inches) until urine begins to flow from the bladder. When urine begins to flow, advance the catheter another 2 inches. Inflate balloon slowly with 5ml normal saline. If resident complains of any pain or pressure while inflating the balloon, stop, deflate the balloon and call for assistance. Remove syringe after successfully inflating the balloon. Pull gently on catheter to check placement. If slight resistance is met, instruct the resident to take a slow deep breath to relax the perineal muscles and overcome resistance to entry. If resistance continues, do not force the entry. Stop the procedure and notify your supervisor... " 2. Resident #17 had [DIAGNOSES REDACTED]. The 14-Day Minimum Data Set with an Assessment Reference Date of 3/5/15 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status; required total dependence of 2 -3 staff for most Activities of Daily Living, had an indwelling urinary catheter, and 1 stage 4 Pressure Ulcer. a. The January 2015 Physician order [REDACTED]." b. SBAR (Situation Background Assessment Request) Communication Form and Progress Note dated 1/17/15 and signed by Licensed Practical Nurse (LPN) #3 documented, "...F/C (Foley Catheter) was irrigated & (and) then changed on 11-7...(Resident) was having blood in his F/C & in the tubing..B/P (blood pressure) was elevated. After a few minutes he was noted to be having chills. Spoke with APN (Advanced Practice Nurse) c (with) orders to send to ER (emergency room ) for eval (evaluation)...911 called & ER notified." 1) Witness Statement dated 1/21/15 with date of occurrence 1/17/15, signed by LPN #2, documented, "Resident requested this nurse to flush his catheter so I did and could not get it to flush. So he said ' change out the catheter ' . I said I will. I left his room to get the supplies and upon return we were talking and he (Resident #17) had asked ' have you done this a lot. ' I said no but it's an easy procedure, I did the last one in school. He said ok and we proceeded pulling out the old catheter. When I was deflating the balloon he asked if 30 cc (cubic centimeters) of water was in it and I replied, no, only 25 cc was in the balloon. I then proceeded to pull out the catheter and prepare the new kit. Started the sterile field, cleaned the head of the penis c (with) the swabs then lubed the end of the catheter for insertion. Proceeded to insert the catheter until I hit resistance then grabbed the saline filled syringe and inflated the balloon to the 25 cc like the other catheter. At this time the resident said this hurts and how much did I inflate the balloon with. I said the same amount as the last catheter but I can back it to 20 cc. I had asked him how that felt and he replied a lot better. I said ok and noticed that the catheter was still not draining as of yet but I had just drained the bag before the procedure and so told the oncoming nurse that I inserted the new catheter and there was pain to the resident but he was ok by his words when I backed the catheter off to 20cc of saline into the balloon, and if she could keep an eye out on him during the shift, just because I did not get an instant return. On the way out of resident's room we were still talking and still he did not complain about any pain besides the initial inflation of the balloon." 2) On 3/20/15 at 7:00 a.m. LPN #2 was asked about the incident with (Resident #17) urinary catheter insertion and stated, "I remember it. I had went in the room. I was doing med pass and (resident) asked me to flush his catheter...I went and talked to the oncoming nurse, (LPN #3) told her it wouldn't flush and asked if she wanted me to do it, she said yes...(Resident) asked if I had done this before, I said yes, one male and a lot of females...I told him deep breath (and) I took the catheter out. I had the new kit ready...I explained the procedure as I went along. As I was inserting the catheter into the urethra I met some resistance. I tried to push a little bit more, still met resistance. There was a little bit urine." The LPN was asked by the surveyor the color of the urine. He stated, "It was dark yellow." The LPN was asked how much urine did he get. The LPN stated, "It was 15-20 cc (cubic centimeters) very little. I told him I would go ahead and inflate the balloon and when I reached 25 cc that ' s when he said 'I feel a little discomfort', it was starting to hurt. I told him I would take some of the water out of the balloon. I took out 5 cc and it was down to 20. I asked him how did that feel. He said much better. I pulled catheter to make sure it was secure then took the syringe off...I told the nurse (name of nurse) he had complaints of a little pain, I went ahead and decreased the water in the balloon and he had no more pain..." The LPN was asked how long he had been a nurse? He stated, "Two years, licensed in September, 2013." He stated he had worked at the facility since around Christmas 2014. He was asked if he had a skills check off on hire here at this facility? He stated, "No." 3) LPN #3 was interviewed on 3/20/15 at 8:08 a.m. She stated, " ...(LPN #2) asked me where did he get one (foley catheter) and I told him in the supply room ...Started my med pass and I believe the CNAs (certified nursing assistants) came and got me and told me (Resident #17) was not feeling well or something anyway they came and got me ....I went to his room, when I first walked into his room I noticed he had some blood tinged urine in his catheter bag ...probably about 150 cc. I ' m sure I assessed him from there. I can ' t remember exactly but I did call the APN and she said call 911 and send him out ... " c. ED (Emergency Department) Provider Notes dated 1/17/15 at 10:30 a.m. documented, "...This is a [AGE] year-old male...who presents with blood in urine. The patient has a chronic indwelling Foley catheter in place. The catheter was placed by the nursing home staff this morning. After replacing the catheter the patient developed bright red blood in the Foley catheter...He is hypotensive upon arrival here...MEDICAL DECISION MAKING AND PLAN OF CARE...Upon removal of the catheter here the patient had brisk bright red bleeding from the penis...The bleeding decreased after the catheter was replaced but is still present. The patient does complain of significant amount of abdominal pain...His blood pressure continued to drop at one point his systolic blood pressures in the 50s...He dropped his hemoglobin 3 g (grams) on recheck so I went ahead and gave him some packed red blood cells for ongoing bleeding and [MEDICAL CONDITION]. (named) will consult on the patient in the intensive care unit...accepted for admission...Consult Notes 1/18/15...REASON FOR CONSULTATION: Hematuria...severe MS ([MEDICAL CONDITION]) with chronic catheter drainage, who had his catheter changed at the nursing home, began to bleeding profusely, sent him to the emergency room where they changed his Foley and it continued to bleed. His blood pressure was low and felt to have dropped his hemoglobin significantly, so they have hospitalized him. He has never had this type of trouble before. They have been changing his catheter regularly for many years...IMAGING: I reviewed his CT scan, it appears that his bladder has some clot in it. IMPRESSION: Hematuria probably secondary to trauma. I recommended that we cysto him and replace this Foley with a suprapubic tube when clinically stable...OPERATIVE REPORT...FINDINGS AT OPERATION: the urethra was normal up to the deep bulb, which showed hemorrhage, which is apparent side of the balloon inflation. The prostate was very large, had a very high bladder neck..." d. A Nurse Note 1/20/15 at 9:45 p.m. documented, "(Resident) arrived at facility via ambulance at (5:30 p.m.)..." e. On 3/20/15 at 3:15 p.m., the Interim Administrator provided the check-off list for LPN #2 which documented, "Supervisor - Check off each item as completed. Each item is to be fully explained, examples shown, and employees in-serviced on nursing responsibilities regarding: ...Nursing Care & (and) Monitoring... Catheter care..." LPN #2 initialed on 12/23/14 that he had checked himself off on all 131 items and again on 2/3/14. The Director of Nursing (DON) signed once but had no date. The Check-off did not include Urinary catheter insertion for male or female. There was no documentation of any kind of assessment to ascertain nurse proficiency for the nurses skill/knowledge in any of the items on the check list to determine a need for further training. On 3/20/15 at 3:15 p.m., the Interim Administrator was asked if all the nurses had a check-off list. He stated, " Yes, in their personnel files, especiallly the new ones." f. The facility removed the Immediate Jeopardy on 1/23/15 when the following actions were taken: 1) On 3/19/15 at 5:05 p.m., the Administrator stated, " I was going through (Previous Administrator ' s) desk and I found these papers. (LPN #2 ' s) investigation ... " The investigation included the SBAR Communication Form completed by LPN #3; a witness statement signed by LPN #2; an Inservice Education Report dated 1/21/15 conducted by the DON for LPN #2 which documented, "Foley Catheter Insertion, Male & Female"; and witness statements dated 1/21/15 regarding an interview with the resident who stated that he did not feel the nurse was trying to hurt him while changing his catheter, he just felt the nurse did not know what he was doing. 2) INSERVICE EDUCATION REPORT...NURSE INSERVICE AGENDA 1/23/15...Foley catheter insertion procedure..." Twenty one nurse signatures were documented including LPN #2.