Every finding on record at The Heights of Summerlin, LLC

Based on observation, interview, and document review the facility failed to ensure 1) the kitchen was maintained in a sanitary manner, 2) there was no backed up water on the kitchen floor due to a broken drain line in the dishwasher area and a broken sewer line in the beverage area, 3) a nourishment refrigerator did not contain opened food items which were undated, and snacks were stored in proper temperature. The deficient practice placed residents at risk for foodborne illness.Findings include: On 03/24/2026 at 7:40 AM, an initial tour of the kitchen with the Assistant Dietary Manager (DM) revealed the following findings:1. Kitchen- Floor in food prep area had crumbs and other food debris more pronounced at corners and sides of food prep table. - Shelves underneath steam table dirty with dust, food crumbs and stains of unknown origin- Food transport carts dirty with stains and buildup of unknown origin- Back of oven heavy with dust and old food debris- Second food prep table dirty with old food debris and stains of unknown origin- Dirt build-up inside broiler located behind the tray line- Bulk container labeled Sugar was contaminated with oats - Top and bottom oven with heavy buildup of food debris and grease stains on glass door making it unable to visualize contents of oven.- By the two-compartment sink area, there were six clean pitchers inverted downwards on a dirty surface which was dusty with food debris.- Floors were sticky and dirty inside the walk-in freezer and refrigerator- Another gray food transportation cart was found to be dirty.- An 18-quart container of salt was dusty and dirty on the exterior. - Heavy buildup of food debris on top of the commercial dishwasherOn 03/24/2026 at 3:35 PM, the Dietary manager (DM) explained a form was created and finalized on 03/10/2026 which would ensure all kitchen tasks would be completed for kitchen cooks and dietary aides. The DM provided the forms titled: 1) Deep Cleaning schedule, 2) [NAME] cleaning schedule, and 3) Washer Daily schedule. The DM indicated the forms could not be utilized until in-services for staff were completed but the DM had not been able to provide staff in-services.The facility's Environment policy revised June 2025, documented all food preparation areas would be maintained in a clean and sanitary condition. The Dietary Manager would ensure the kitchen was maintained in a clean sanitary manner, including floors, ceilings, food service equipment and surfaces. A routine cleaning schedule would be in place for all cooking equipment, food storage areas and surfaces.2. Backed up water in kitchen due to broken drain/sewer lineOn 03/24/2026 in the morning, there was backed up water pool surrounding a drain spout in the dishwasher area. The beverage area/coffee station flooring black soot and accumulated dirt visible on the red tiles. Heavy water backed up from broken sewer line was causing the floor on the left side of beverage/coffee station to become wet.On 03/24/2026 at 8:45 AM, the Director of Maintenance (DOM) indicated being aware of the broken sewer drain causing flooding in the beverage area. According to the DOM, the drain was being vacuumed manually to evacuate water until the sewer line or main drain line could be replaced. The DOM indicated a work order had been submitted, and estimates had been obtained and was waiting on corporate approval. The DOM indicated not being informed of the broken drain line in the dishwashing area of the kitchen.The facility's Equipment policy revised September 2017, documented the Dietary Manager would submit requests for maintenance or repair to the Administrator of Director of Maintenance as needed. 3. Nourishment RoomOn 03/24/2026 at 8:15 AM, the Director of Staff Development (DSD) accompanied survey team to the East unit nourishment room. Inside a small refrigerator was a thermometer which read 60 degrees Fahrenheit. The refrigerator contained partially consumed butter and cream cheese with no open date, 15 cups of fruit cups, puddings and yogurt and two 46-oz thickened apple juice. The internal temperature of sampled yogurt was 52.7 degrees Fahrenheit while the apple juice 44.8 degrees Fahrenheit. The DSD indicated the unit clerks were responsible for maintaining temperature logs for nourishment room refrigerators.On 03/23/2026 at 8:50 AM, the Unit Clerk provided the temperature log for the East Unit which revealed the refrigerator temperature was 39 degrees Fahrenheit earlier in the morning. According to the Unit Clerk, the reading was taken at 8:05AM. The Unit clerk could not speak to how the temperature changed from 39 degrees Fahrenheit to 60 degrees Fahrenheit in 10 minutes. On 03/24/2026 at 8:55AM, the Dietary Manager indicated the refrigerator temperature could not have changed from 39 degrees Fahrenheit to 60 degrees Fahrenheit in 10 minutes. The DM indicated it appeared to be a case of mechanical documentation on the part of the Unit Clerk. The facility's Cold Foods policy revised February 2023 documented all perishable foods would be maintained at a temperature of 41 degrees Fahrenheit or below except during periods of preparation and service. A written record of daily temperatures would be recorded. All foods would be wrapped or stored in covered containers, labeled and dated.

Based on observation, interview and document review, the facility failed to ensure food was not served late and at appropriate temperatures per facility policy. The deficient practice had the potential to negatively impact residents' quality of life.Findings include: On 03/24/2026 in the morning, the facility's census was 170.On 03/24/2026 at 7:40 AM, there were three kitchen staff members preparing meal trays for breakfast meal service. One staff member introduced themself as the Assistant Dietary Manager (DM) and indicated the other two were dietary aides.On 03/24/2026 in the morning, five residents in the 100-Hall, four residents in the 200-Hall and six residents in the 300-Hall complained about meals being served late, food was cold and often not good (unpalatable).On 03/27/2026 in the morning, the Dietary Manager (DM), cook and a dietary aide were on the service line where temperatures were taken for the following food items:Oatmeal: 197 degrees FahrenheitRegular Ham: 186 degrees FahrenheitPureed Ham: 183 degrees FahrenheitPancakes: 101 degrees FahrenheitThe Meal Delivery Times document revealed the 200-Hall was the last unit served with breakfast service scheduled from 8:10 AM to 8:35 AM.On 03/27/2026 at 8:45 AM, the last cart arrived at the 200-Hall. After the last resident was served at 9:02 AM, internal temperatures for the regular and mechanically altered test trays were taken by the District Manager with the surveyor, as follows:Regular ham: 109.9 degrees FahrenheitPureed ham: 120.5 degrees FahrenheitPancake: 101 degrees FahrenheitFresh milk: 52.0 degrees FahrenheitApple juice: 39.7 degrees FahrenheitThe facility's Food Preparation policy revised February 2025, documented all foods would be held at appropriate temperatures, greater than 135 degrees Fahrenheit for hot foods and less than 41 degrees Fahrenheit for cold foods.On 03/27/2026 at 9:48 AM, the Dietary Manager indicated the facility had nine carts with one transporter assigned to deliver carts to units. The District Manager confirmed the last cart arrived at the 200-Hall at 8:45 AM which was considered late. The Dietary Manager and District Manager indicated hot foods were ideally served at 135 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit, both confirmed breakfast service was delivered late, and food was served not at appropriate temperatures per facility policy.On 03/27/2026 at 1:30 PM, a Licensed Practical Nurse (LPN) and three certified nursing assistants (CNAs) were standing by the elevator of the 200-Hall. The staff members indicated they were waiting on the lunch cart to arrive, but they were used to it being delivered late. Resident 150 was sitting outside room and overheard the discussion and interrupted stating I have been here a long time, and the food is always late and cold.

Based on observation interview, record review and document review, the facility failed to ensure, a baseline care plan was developed for a resident admitted with an indwelling catheter for 1 of 38 sampled residents (Resident 199). The deficient practice placed residents at risk for inadequate Foley catheter care and potential for infection. Findings include: Resident 199 (R199) was admitted on [DATE], with diagnoses including prostate cancer, benign prostatic hyperplasia and urinary tract infection (UTI).On 03/24/2026 in the morning, R199 lay awake in bed with family at bedside. A urine meter bag (a specialized drainage device with an integrated calibrated chamber attached to a larger drainage bag) hung on the left side of the bed, filled with 350 milliliters (ml) of clear yellow urine. R199 reported no one had emptied the urinary bag this morning, the Foley catheter had not been replaced since admission and no one cleansed R199's insertion site routinely. A family member indicated visiting R199 often and personally took care of R199's cleaning needs by themselves because staff were not providing care consistently.The admission minimum data set (MDS) dated [DATE], revealed R199 had intact cognition, and was admitted with an indwelling catheter. A nursing documentation evaluation completed on 03/04/2026, documented R199 was admitted with a Foley catheter device.The medical record lacked documented evidence, a baseline care plan was developed for R199's indwelling urinary catheter.On 03/24/2026 at 10:41 AM, A Registered Nurse (RN) assigned to R199 reviewed the electronic health record (EHR) confirmed R199's baseline care plan did not include the resident's indwelling urinary catheter.On 03/26/2026 at 1:45 PM, the Director of Nursing (DON) reviewed R199's EHR and confirmed there was no baseline care plan for the indwelling catheter and there should have been.

Based on observation interview, record review, and document review, the facility failed to ensure care plan interventions for an indwelling catheter were implemented for 1 of 38 sampled residents (Resident 199).The deficient practice placed Resident 199 at risk for inadequate Foley catheter care and potential for infection.Findings include: Resident 199 (R199) was admitted on [DATE], with diagnoses including prostate cancer, benign prostatic hyperplasia and urinary tract infection (UTI).On 03/24/2026 in the morning, R199 lay awake in bed with family at bedside. A urine meter bag (a specialized drainage device with an integrated calibrated chamber attached to a larger drainage bag) hung on the left side of the bed, filled with 350 milliliters (ml) of clear yellow urine. R199 reported no one had emptied the urinary bag this morning, the Foley catheter had not been replaced since admission and no one cleansed R199's insertion site routinely. A family member indicated visiting R199 often and personally took care of R199's cleaning needs by themselves because staff were not providing care consistently.The admission minimum data set (MDS) dated [DATE], revealed R199 had intact cognition, and was admitted with an indwelling catheter. A nursing documentation evaluation completed on 03/04/2026, documented R199 was admitted with a Foley catheter device.R199's indwelling catheter care plan initiated 03/16/2026, revealed R199 had a Foley catheter due to obstructive uropathy with a goal of not having UTI. Interventions included monitor for signs and symptoms of infection, monitor for skin irritation with daily care, monitor urine for sediments, cloudy, odor, blood and amount and report abnormalities to physician immediately and catheter care twice a day and use 16 French Foley catheter.The medical record lacked documented evidence care and management orders were obtained from the attending physician, transcribed into medical record and routine care was documented for R199's Foley catheter.On 03/26/2026 at 1:46 PM, the Director of Nursing (DON) confirmed R199's care plan for indwelling catheter initiated 03/16/2026 included interventions which were not implemented due to care orders not being entered into the medical record. The facility Comprehensive Care plan policy dated 08/25/2021, documented the inter-disciplinary team (IDT) in coordination with resident and resident's representative must develop and implement a comprehensive care plan for each resident designed to identify problem areas. Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, record review and document review, the facility failed to ensure a comprehensive care plan for skin integrity was reviewed and updated when a resident with existing pressure ulcers and assessed to be at high risk for developing and worsening pressure ulcers returned from hospitalization to treat an infected wound for 1 of 38 sampled residents (Resident 15). The deficient practice placed the resident at risk for recurrent wound infection. Findings include: Resident 15 (R15) was admitted on [DATE] and readmitted on [DATE], with diagnoses including quadriplegia, acute sepsis, and presence of pressure ulcers. A quarterly minimum data set (MDS) dated [DATE], documented R15 had intact cognition, was a quadriplegic, and was at risk for developing pressure ulcers, had unhealed pressure ulcers, specifically, two stage three pressure ulcers, and four unstageable pressure ulcers.A change of condition document dated 03/04/2026, revealed R15 was transferred to the hospital due to fever, weakness, confusion and drowsiness.A hospital Discharge summary dated [DATE], revealed R15 was admitted for acute sepsis and altered mental status. R15 was found to have a right hip wound with significant purulent discharge and secretions concerning osteomyelitis and septic arthritis. Infectious disease treated sepsis. Discharge to skilled nursing facility.The medical record lacked documented evidence R15's comprehensive care plan for skin breakdown was reviewed and updated when R15 returned from the hospital on [DATE].On 03/25/2026 at 11:14 AM, a House Supervisor reviewed R15's medical record confirmed R15's care plan for skin integrity was not updated by wound team upon readmission on [DATE]. According to the House Supervisor, the wound care team would have been responsible to conduct a reassessment upon return and update the care plan accordingly. The facility Comprehensive Care Plan policy dated 08/25/2021, documented assessments of residents were ongoing, and care plans were reviewed and revised as information about the resident's condition changed and when a resident was readmitted from a hospital stay.

Based on observation, interview, record review, and document review, the facility failed to ensure a scheduled shower was provided for a resident who required assistance with bathing for 1 of 38 sampled residents (Resident 231). The deficient practice placed the residents at risk for infection and worsening of skin breakdown.Findings include: Resident 231 (R231) was admitted on [DATE], with diagnoses including lymphedema (swelling in body tissues usually arms and legs caused by lymphatic system not working properly), and bilateral chronic venous stasis ulcers.On 03/26/2026 in the morning, R231 indicated being admitted on [DATE] in the late afternoon but no one had provided nor offered the resident a shower since admission. R231 expressed worry over chronic wounds on bilateral legs which had been infected in the past.The admission minimum data set (MDS) dated [DATE], revealed R231 required maximal assistance with bathing.On 03/26/2026 in the morning, a certified nursing assistant (CNA) checked the shower book for R231's unit and indicated R231's showers were scheduled for Monday and Thursday afternoons. The CNA indicated not being able to locate a shower sheet for R231.On 03/26/2026 at 11:53 AM, the wound physician assistant (PA) indicated it was unfortunate the resident missed scheduled shower because it would have been an opportunity to do a skin check, relieve the resident from the compression device and cleanse and moisturize the resident's legs. On 03/26/2026 at 12:02 PM, the Registered Nurse (RN) assigned to R231 indicated reviewing the shower book and interviewed CNAs. The RN was able to confirm R231 had not been provided, offered nor re-offered a shower since admission on [DATE]. The RN indicated the resident had a scheduled shower on 03/23/2026 but the RN could not speak as to why the resident's assigned CNA did not offer or provide one. The RN verbalized the shower was missed opportunity to perform a skin assessment, relieve the resident from compression device, ensure the resident's legs were cleaned and moisturized.

Based on observation, interview, record review, and document review, the facility failed to ensure 1) appropriate care and services were provided to prevent recurrent gastrostomy tube dislodgement for 1 of 38 sampled residents (Resident 239) and, care and management orders were obtained for a compression device for 1 of 38 sampled residents (Resident 231). The deficient practice placed Resident 239 at risk for repeat G-tube dislodgement and Resident 231 at risk for recurrent cellulitis. Findings include: Resident #239 (R239) was originally admitted on [DATE] and re-admitted on 02/2202026, with diagnoses including functional quadriplegia and dysphagia. The resident had a G-tube. The medical record revealed a change of condition evaluation dated 02/20/2026, indicating the G-tube was dislocated. The resident was sent to the hospital for a G-tube placement following a physician's order. Hospital records revealed R239 transferred from the nursing facility for evaluation and replacement of a gastrostomy tube that reportedly fell out spontaneously without trauma or manipulation. Facility staff and the emergency medical services (EMS) reported the patient has been at their baseline; R239 was nonverbal due to severe cognitive impairment and exhibited no acute changes in mental status. There were no reported symptoms such as fever, abdominal pain, vomiting, diarrhea, cough, or congestion. The medical record revealed three similar episodes of changes in condition related to G-tube displacement that occurred on 10/03/2025, 06/16/2025, and 05/05/2025, requiring R239 to be hospitalized for G tube replacement. A physician order dated 10/09/2025 included the following G tube care instructions: Change the closed system feeding spike set every shift. Administer free water flushes of 50 mL every hour. Flush the feeding tube with 5 mL of water between each medication and 30 mL of water before and after medication administration. Maintain the head of the bed elevated at least 30 degrees during feedings and for one hour afterward. Cleanse the gastrostomy site every shift. Check residuals and verify tube placement prior to each feeding, flush, or medication administration. Change the feeding syringe every night shift. The physician order did not include instructions to prevent displacement of the G tube. On 03/27/2026 at 12:10 PM, a Registered Nurse confirmed the G-tube was found displaced when medications were about to be administered on 02/20/2026. The RN indicated the displacement was not trauma related and there was no evidence to explain how the tube was dislocated. The RN indicated R239 was transported the hospital for G-tube placement and returned on 02/22/2026. The RN confirmed the history of R239's G-tube displacement and could not explain how the device was dislocated several times since the resident was quadriplegic and unable to use their hands or move. On 03/27/2026 at 12:15 PM, an observation was conducted with the RN to confirm the status of R239's G-tube. It was found R239 did not have an abdominal binder in place to prevent further G-tube dislocations. The facility did not provide a policy for G-tube care or management of G-tube dislocation. The Director of Nursing indicated staff provided G-tube care following the physician orders. Resident 231 (R231) was admitted on [DATE], with diagnoses including lymphedema (swelling of body tissues usually arms and legs caused by lymphatic system not working properly), and bilateral chronic venous stasis ulcers. On 03/24/2026 at 10:01 AM, R231 was seated in wheelchair with a pair of red socks over white compression device on bilateral lower legs. R231 expressed concerns with wound care at the facility. R231received daily wound treatments at the hospital but had been seen once by a wound nurse in the facility on 03/23/2026. R231 reported the wound nurse removed honey sheets and gauze from their legs which were from the hospital and informed R231 they were no longer needed. The resident indicated the wound nurse applied compression stockings without explaining the purpose. On 03/26/2026 at 10:33 AM, R231indicated being upset over not seeing anyone from wound care since 03/23/2026. R231 pointed to their legs and stated no one had come to remove the compression stockings since the wound nurse put them on the resident on 03/23/2026. R231 reported severe pain of 10 out of 10 (10/10) on pain scale from the compression device. A physician encounter note dated 03/23/2026, revealed the resident was admitted to the facility on [DATE] after being treated in the hospital for progressive lower extremity edema, pain, and weeping stasis with superimposed cellulitis. Antibiotic course was completed. The medical record lacked documented evidence of a physician order for a compression device and management thereof such as a wearing schedule. On 03/26/2026 at 11:11 AM, a surveyor asked the House Supervisor to remove R231's compression device and examine R231's lower extremities, the House Supervisor responded, that's not me, I won't be unwrapping anything. On 03/26/2026 at 11:24 AM, a treatment nurse knelt in front of the resident and removed the compression device with gloved hands. The nurse inspected the resident's calves and indicated there were no open lesions or discoloration but just very dry skin and significant pitting edema. The treatment nurse was present when the resident asked for pain medication due to 10/10 pain on lower legs. On 03/26/2026 at 11:53 AM, a wound physician assistant (PA) reported personally examining R231's skin and removing the honey sheets after determining the skin was intact with no open lesions. The PA stated the skin was very dry and required moisturizer and that Tubi grips (a type of compression device) were applied for edema and venous insufficiency management. The PA explained Tubi grips should be changed daily or every other day due to loss of elasticity and was unaware the device had not been removed or replaced since 03/23/2026. The PA stated the missed shower was a missed opportunity for a skin assessment, removal of the compression device, and cleansing and moisturizing of the resident's legs On 03/26/2026 at 11:27 AM, the treatment nurse indicated not being certain of use of a Tubi-grip required a physician's order and care plan, and the nurse did not clarify a wearing schedule with the PA. On 03/26/2026 at 11:44 AM, the RN assigned to R231 indicated the Tubi-grip was a compression device used for edema management and post-surgery. The RN indicated the device cannot be worn 24 hours because this could cause injury to the patient. The RN explained when encountering a resident wearing a Tubi-grip, the RN would seek clarification orders for wearing and the RN would not be applying any compression device without a physician's order. The RN Indicated Tubi-grip needed to be care planned and interventions should include, wearing schedule, cleaning the device, skin assessment daily on compressed site, report abnormality to physician. On 03/26/2026 at 2:25 PM, the Director of Nursing (DON) indicated if the device was for the purpose of compression such as edema management and venous insufficiency then a physician order would be required. According to the DON, an edema care plan should be initiated to include the use of the compression device as an intervention, putting on/removing schedule, skin monitoring and cleansing and moisturize as needed. The DON confirmed there was no order for use of a compression device for R231 with proper interventions for the management. The facility Physician Orders policy dated 03/22/2022, documented treatment orders would include a description of the treatment, including treatment site, frequency of treatment and duration of order and the condition/diagnoses for which the treatment was ordered. Orders would include description clearly enough to ensure clarity of the physician's order.

Based on observation, interview, record review and document review, the facility failed to ensure a comprehensive skin assessment was performed by the wound care team upon readmission of a resident who had existing pressure ulcers and the resident was assessed as a high risk for developing and worsening pressure ulcers for 1 of 38 sampled residents (Resident 15). The deficient practice placed the residents at risk for recurrent wound infection. Findings include:Resident 15 (R15) was admitted on [DATE] and readmitted on [DATE], with diagnoses including quadriplegia, acute sepsis, and presence of pressure ulcers. A quarterly minimum data set (MDS) dated [DATE], documented R15 had intact cognition, was a quadriplegic, and was at risk for developing pressure ulcers, had unhealed pressure ulcers, specifically, two stage three pressure ulcers, and four unstageable pressure ulcers.A change of condition document dated 03/04/2026, revealed R15 was transferred to the hospital due to fever, weakness, confusion and drowsiness.A hospital Discharge summary dated [DATE], revealed R15 was admitted for acute sepsis and altered mental status. R15 was found to have a right hip wound with significant purulent discharge and secretions concerning osteomyelitis and septic arthritis. Infectious disease treated sepsis. Discharge to skilled nursing facility.The facility admission Assessment and Follow up: Role of the Nurse revised September 2012, documented an admission physical assessment would be conducted which would include a skin assessment. Supplemental assessments would be conducted following facility forms and protocols. The Nursing Documentation Evaluation dated 03/09/2026, revealed a body check by the admitting nurse identified: 1) a moisture-associated skin damage (MASD) on coccyx, 2) right hip wound with foam dressing, 3) left hip wound with foam dressing, 4) dressing on left side of neck, 5) right outer ankle wound with protective dressing, and 6) left outer ankle wound with protective dressing.The medical record lacked documented evidence a comprehensive skin assessment was completed by the wound care team upon the resident's readmission to the facility.On 03/25/2026 at 9:37 AM, R15 permitted the surveyor to be present for an activity of daily living (ADL) care observation by a certified nursing assistant (CNA). R15 was turned to left side during care which revealed a beige foam dressing over coccyx area dated 03/07. In addition, R15 had a beige protective dressing on lateral right foot dated 03/04, on right heel dated 03/04, left lateral foot dated 03/04 and left heel dated 03/04. The bilateral foot dressings were coming loose at the edges. A foul odor was evident during care in the absence of urine or feces.On 03/25/2026 at 9:37 AM, the CNA assigned to R15 indicated the foam dressing on R15's coccyx did not appear to be new, and a foul odor was more pronounced when the CNA rolled R15 to left side and came closer to visualize the foam dressing on coccyx. The CNA confirmed bilateral foot dressings were all dated 03/04/2026 and were starting to come off. The CNA indicated the dressings were most likely placed at the hospital because R15 was not in the facility on 03/04/2026 and 03/07/2026. The CNA could not speak to why the dressings had not been removed by the nurses or wound care team.On 03/25/2026 at 9:47 AM, the Registered Nurse (RN) assigned to R15 indicated not being well-versed on R15's wounds because the resident was followed by the wound care team. The RN acknowledged awareness of R15's history of a coccyx pressure ulcer and bilateral foot wounds but was uncertain whether the wounds were active or resolved. The RN expected CNAs to report any abnormalities such as old wound dressings with foul odor to the nurse who would either perform the wound care themselves or report the findings to the wound care team.On 03/25/2026 at 10:01 AM, a treatment nurse indicated being the only wound nurse for the day and had 40 residents on case load. The treatment nurse indicated the wound care team rounded on R15 yesterday to treat R15's right hip wound. The treatment nurse indicated the dressings dated 03/07 on the coccyx and 03/04 on the coccyx were most likely placed at the hospital because R15 was at the hospital during this time.On 03/25/2026 at 10:14 AM, the treatment nurse reviewed R15's electronic health record (EHR) and confirmed the wound care team did not complete an admission skin assessment when R15's was readmitted on [DATE]. The treatment nurse explained there were two ways to inform the wound care team regarding residents needing to be seen by wound care upon new admission or readmission. First, a wound care team member could generate a report of new admissions and secondly, when a floor nurse completed a wound consult report in EHR.On 03/25/2026 at 10:21 AM, the RN assigned to R15 corroborated the treatment nurse's interview and stated a new admission report could be generated and nurse could complete a wound consult report within EHR which would alert the wound care team to see the resident but this did not appear to be done for R15.On 03/25/2026 at 10:23 AM, the treatment nurse indicated if they were informed R15 had returned to the facility, the wound team would have done a thorough skin assessment and obtain orders for any new or existing skin impairments. The treatment nurse confirmed there was no documented evidence clarification was sought by any nurse regarding R15's dressings on coccyx and bilateral feet.On 03/25/2026 at 10:54 AM, the treatment nurse indicated the the admitting nurse did not complete a wound consult report to alert the wound team R15 had returned from hospital and did not communicate the presence of old dressings on coccyx and bilateral feet which could be identified during care. On 03/25/2026 at 10:51 AM, the treatment nurse came out of R15's room and confirmed there was an old foam dressing dated 03/07 underneath was a healed area over bony prominence. The wound nurse confirmed R15 had old dressings dated 03/04 on bilateral feet with edges coming loose. The treatment nurse indicated R15 was at high risk for developing and worsening pressure ulcers due to being quadriplegic, poor nutrition, incontinence and other co-morbidities. The treatment nurse stated the oversight placed R15 at risk for recurrent wound infections.A Braden scale for pressure ulcer risk dated 03/23/2026, revealed R15 scored six (very high risk for developing or worsening pressure ulcers due to bedfast status, being constantly moist, completely immobile, very poor nutritional status, and friction and sheer.On 03/25/2026 at 11:14 AM, the House Supervisor reviewed R15's EHR and confirmed a comprehensive skin assessment should have been completed by the wound care team upon R15's readmission on [DATE] but this was not performed.On 03/26/2026 at 1:49 PM, the Director of Nursing (DON) indicated the admitting nurse completed a head-to-toe on 03/09/2026 identifying multiple wounds. According to the DON, a wound consult report would need to be completed for new admissions with wounds or an existing resident with new wounds therefore a wound consult form was not necessary for R15 who was already on the case load for wound care. The DON could not speak to why the hospital dressings were still on R15's lower back and bilateral feet. On 03/27/2026 in the morning, the wound physician assistant (PA) indicated wound care team typically removed hospital dressings to be able to visualize and evaluate skin condition underneath. The PA could not recall if they themselves had seen R15 recently but stated if R15's foam dressings on coccyx and bilateral feet were being used for protection, they should not be on longer than seven to 10 days as standard of practice otherwise this would place R15 at risk for recurrent wound infection.The facility's Skin Integrity Management policy dated 05/26/2021 documented the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of wounds. A comprehensive skin evaluation was to be completed upon admission or readmission, and the physician was to be notified to obtain orders. Nursing staff were to observe any signs of potential or active pressure injuries daily or while providing nursing care.

Based on observations, interviews, record review and document review, the facility failed to ensure proper foot hygiene and podiatry care for 1 of 38 sampled residents (Resident R86). This deficient practice placed the resident at risk for pain and foot infection. Findings include:Resident 86 (R86) was admitted on [DATE] with diagnoses including scar condition fibrosis of the skin, and chronic kidney disease stage 3A.On 03/24/2026, observation of R86's bilateral feet revealed and a brown buildup underneath the toenails on both feet. R86 reported their toenails were long and dirty and had also not been addressed.On 03/25/2026 at 11:50 AM, R86's great toenails extended approximately 1.5 inches beyond the nail bed, with brown buildup noted underneath. All toenails appeared thickened. A significant amount of brown debris was also observed on the plantar forefoot (metatarsal) areas. R86 attributed the condition to not receiving routine podiatry care. R86 reported being unable to perform personal skin care and relied on staff for assistance. R86 received bed baths on Wednesdays and Saturdays, staff had not washed the legs and feet with soap and water or applied lotion. R86 had not been seen by podiatry services for approximately four to five months.On 03/25/2026 at 12:10 PM, Certified Nurse Assistant (CNA) reported the residents' nails were thickened, discolored, and very long, and acknowledged the resident required services for nail care. On 03/25/2026 at 12:20 PM, a Registered Nurse (RN confirmed there was no documentation indicating when the resident was last seen by podiatry, nor was the resident listed for podiatry services.On 03/25/2026 at 12:35 PM, the Unit Clerk stated nursing staff notified when residents needing podiatry services. The Unit Clerk then entered the request into the podiatry log. The Unit Clerk indicated the Social Services Director was responsible for scheduling podiatry appointments for the residents.On 03/25/2026 at 1:30 PM, the Social Services Director stated nurses maintained a podiatry binder to identify residents requiring podiatry services, and social services scheduled the appointments. The Social Services Director indicated the podiatrist visited the facility once per month. Record review revealed R86 was last seen by the podiatrist on 12/17/2025. The Social Services Director confirmed the resident was due for podiatry care.The facility's policy titled foot care dated October 2022 stated residents were provided with foot care and treatments. Foot care, personal care, residents were assisted in making appointments and with transportation to and from specialists (podiatrists) as needed, and trained staff may provide routine foot care, for residents without complicating disease processes.

Based on observation, interview, and record review, the facility failed to ensure a resident with non weight bearing status was safely transferred from bed to wheelchair using a mechanical lift harness in good repair for 1 of 38 sampled residents (Resident #132). This deficient practice placed the resident at risk for an accident, fall, and injury during transfer.Findings included:Resident #132 (R132) was admitted on [DATE], with diagnoses including bilateral acute ischemic stroke.The minimum data set assessment dated [DATE] revealed R132 was dependent for chair-to-bed transfers.On 03/26/2026 at 9:49 AM, two Certified Nursing Assistants (CNA #3 and CNA #4) were observed transferring R132 from the bed to a wheelchair using a mechanical lift to assist the resident to stand. It was noted the safety straps of the grip sling were not secured, and one strap was missing its buckle. During the transfer, R132 used their arm strength to self-support by holding onto the sling loops. CNA #3 stated the safety strap was not used because the buckle clip was missing. Inspection of the mechanical lift confirmed the buckle clip for the safety strap was absent. CNA #3 acknowledged the safety strap should have been secured to prevent a potential fall.On 03/26/2026 at 11:50 AM, a Physical Therapist (PT) explained R132's last PT evaluation was in 2024 and R132 was discharged from PT services on 03/25/2024 due to reaching maximal potential and was totally assisted with transfers. The PT verbalized R132 needed maximum assistance and was dependent for bed-chair-bed transfer, the resident might have had non weight bearing to stand and transfer, and the harness's safety strap should have been used to prevent a fall.On 03/26/2026, in the afternoon, the Administrator confirmed the buckle clip for the harness's safety strap was missing. The Administrator acknowledged the harness should not have been used in this condition, as it created an unsafe transfer.The facility's policy titled Using a Lifting Machine (undated) documented before using the mechanical lift, the resident should be assessed to determine whether the resident could assist with the transfer, and all hooks, clips, and fasteners should be examined.

Based on observation, interview, record review and document review the facility failed to ensure care and management orders for indwelling Foley catheter were obtained and implemented for 2 of 38 sampled residents (Resident 226 and Resident 199). The deficient practice had the potential to place residents at risk for infection. Findings include:Resident 226 (R226) was admitted on [DATE] and discharged on 01/11/2026 with diagnoses including polyneuropathy, acute respiratory failure and acute pulmonary edema. A Nursing Documentation Evaluation dated 12/19/2025 documented urinary devices: Foley catheter. The admission Minimum Data Set (MDS) dated [DATE] documented R226 had an indwelling Foley catheter. R226's medical record lacked physician orders for the care and management of the Foley catheter. On 03/27/2026 at 9:16 AM, the Director of Nursing (DON) reviewed R226's medical record and confirmed R226 lacked physician orders regarding care and maintenance of the Foley catheter. The DON expected monitoring and maintenance orders for the Foley catheter to have been implemented. Resident 199 (R199) was admitted on [DATE], with diagnoses including prostate cancer, benign prostatic hyperplasia and urinary tract infection (UTI). On 03/24/2026 in the morning, R199 laid awake in bed with family at bedside. A urine meter bag (a specialized drainage device with an integrated calibrated chamber attached to a larger drainage bag) hung on the left side of the bed, filled with 350 milliliters (ml) of clear yellow urine. R199 reported no one had emptied the urinary bag this morning, the Foley catheter had not been replaced since admission and no one cleansed R199's insertion site routinely. The family member indicated visiting R199 often and personally took care of R199's cleaning needs by themselves because staff was not providing care consistently. On 03/24/2026 at 10:32 AM, a certified nursing assistant (CNA) indicated not being assigned to R199 and confirmed R199's urinary bag was full and should have been emptied at start of shift by the assigned CNA. The CNA lifted blanket which revealed R199 had a French 16/10 ml balloon sized Foley catheter with white stabilizer attached to left thigh. The CNA indicated the stabilizer was undated with edges coming loose at the edges. The admission minimum data set MDS dated [DATE], revealed R199 had intact cognition, and was admitted with an indwelling catheter. An admission history and physical dated 03/03/2026, revealed R199 was treated for urinary tract infection (UTI) at the hospital. A Foley catheter was placed which improved urine retention. A nursing documentation evaluation completed on 03/04/2026, documented R199 was admitted with a Foley catheter device. The medical record lacked documented evidence, care and management orders for R199's Foley catheter were obtained, transcribed into electronic health record (EHR) and carried out. On 03/24/2026 at 10:40 AM, a Registered Nurse (RN) working in the unit indicated not being assigned to R199's but accessed the resident's EHR and confirmed there were no care orders entered for R199's indwelling catheter since admission on [DATE] and therefore no documented routine care. On 03/24/2026 at 10:41 AM, the RN assigned to R199 entered the room while the CNA was emptying the resident's urinary bag. The RN confirmed the stabilizer on R199's left thigh was undated and was loose at the edges. The RN was present when R199 and family stated the Foley catheter had not been replaced since admission and cleansing of site was not being routinely performed. On 03/24/2026 at 10:41 AM, the RN left the resident's room and reviewed R199's EHR. The RN indicated being aware R199 was admitted with a Foley catheter and was treated for UTI at the hospital prior to admission. The RN confirmed care and management orders for R199's indwelling catheter were not obtained from the physician, transcribed into EHR, and therefore there was no documentation routine care was performed for the resident's Foley catheter. On 03/24/2026 at 10:44 AM, the RN explained when a resident was admitted with a Foley catheter, the nurse would obtain the following from the attending physician: 1) justification for continued use, 2) perineal cleansing every shift, 3) Foley and balloon size when device needed to be replaced for dislodgement or leakage, 4) record output if needed, and 5) assessment of site and urine characteristics and reporting abnormal findings to physician. The RN indicated there was an oversight on the part of the admitting nurse which placed the resident at risk for recurrent UTI. On 03/26/2026 at 1:32 PM, the Director of Nursing (DON) confirmed care orders were not obtained and entered by the admitting nurse which would include: 1) general order for Foley size, 2) justification for use 3) irrigation as needed 4) twice daily catheter care which included cleaning around insertion site and emptying the bag. According to the DON, no orders resulted in no documented care in the medication administration record. The Urinary Catheter policy dated 11/15/2021, documented each indwelling catheter must have a valid medical justification for use. Catheters would not be replaced on a routine basis but rather when there was leakage, dislodged or clogged. The facility's admission Assessment and Follow Up: Role of the Nurse policy (undated), documented an admission assessment would be conducted on all new residents and communicate findings of the initial assessment to the attending physician and obtain admission orders based on these findings. Complaint 2715581

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%, as required. This deficient practice placed residents at risk for adverse drug outcomes, decreased therapeutic effectiveness, and compromised safety.Findings include: Resident #191 (R191) was originally admitted on [DATE] and re-admitted on [DATE] with diagnoses including chronic pain syndrome.On 03/25/2026 in the morning, medication administration observations were conducted with R191 and a Registered Nurse. Medications administered included oxycodone hydrochloride (HCl) 10 milligrams (mg) and aspirin 81 mg (enteric coated), both administered orally.A review of the physician's orders revealed the following:Oxycodone HCl 10 mg oral tablet: give one tablet by mouth every 6 hours as needed for moderate to severe pain. The order did not document Oxycodone was to be the immediate release formulation that was administered.Aspirin 81 mg by mouth once daily for coronary artery disease. The order did not specify the aspirin was to be the enteric coated form.On 03/25/2026 at 11:00 AM, a Registered Nurse (RN) verified the oxycodone order did not specify immediate release and the aspirin given was enteric coated rather than regular aspirin. The RN acknowledged the orders should have been confirmed prior to administration.The facility's policy titled Administering Medications (undated) documented medications were administered in accordance with the prescriber's order, and the individual administering the medications should check the label three times to ensure the correct medication before administering.

Based on observation, interview, record review and document review the facility failed to ensure medications were secured for 1 of 38 sampled residents (Resident 175) expired medication was disposed of. The deficient practice had the potential for the facility staff to administer expired and contaminated medications.Findings include: Resident 175 (R175) was admitted on [DATE] with diagnoses including spina bifida with hydrocephalus, chronic respiratory failure with hypoxia, paraplegia, type 2 diabetes mellitus and dysphagia. On 03/24/2026 at 10:56 AM, the refrigerator in Resident 175's (R175) room contained: -one opened bottle of Latanoprost Solution 0.005% eye drops dated 09/06/2025. -one opened bottle of Latanoprost Solution 0.005% eye drops dated 02/11/2026. On 03/24/2026 at 11:17 AM, a Licensed Practical Nurse (LPN) confirmed the medication bottles were in the resident's refrigerator and should have been kept securely in the medicine room refrigerator. On 03/27/2026 at 8:33 AM, the Director of Nursing (DON) explained the expectation for medication storage was for medications to be safely stored on medication cart for staff to administer unless the resident had an order for self-administration of medications. The DON confirmed R175 did not have an order to keep medications at the bedside or in the resident's refrigerator. The DON stated the eyedrops should have been in the medication cart or in the refrigerator in the medication room if needed to be refrigerated. On 03/27/2026 at 12:02 PM, during an inspection of the third floor 300 high medication cart with the Assistant Director of Nursing (ADON), two bottles of Visine eye drops labeled date open 02/22/2026 were in the top drawer of the cart. The ADON explained the eye drops should have been disposed of one month after opening. The facility policy titled Storage of Medication, revised 11/2020, documented drugs and biologicals used in the facility were stored in locked compartments under proper temperature, only persons authorized to administer medications would have access to locked medications. The nursing staff was responsible for maintaining medication storage, and medications requiring refrigeration were stored in a refrigerator located in the drug room at the nurses' station or other secured locations. Medications were stored separately from food and were labeled accordingly. Discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed.

Based on observation, interview and document review, the facility failed to ensure expired food items were discarded from 2 of 38 sampled resident refrigerators (Resident 151 and Resident 175). The deficient practice had the potential for expired foods to be consumed, which could lead to foodborne illness.Findings include:Resident 151 (R151) was admitted to the facility on [DATE] with diagnoses including epilepsy, pneumonia, dysphagia, type 2 diabetes mellitus, schizophrenia and dementia.On 03/24/2026 at 10:34 AM, the refrigerator in Resident 151's (R151) room contained:-one opened 1.89-liter bottle, Lucerne reduced fat milk, expired 03/19/26.-one unopened six-ounce container, Yoplait original yogurt, strawberry cheesecake flavored, expired 02/25/26. On 03/24/2026 at 10:45 AM, a Certified Nursing Assistant (CNA1) confirmed the expired findings in R151s refrigerator. CNA1 was unsure who removed expired food items from the resident refrigerators. CNA1 stated expired items would be discarded as the items were inedible and R151would get ill if the items were consumed.On 03/24/2026 at 10:50 AM, a Licensed Practical Nurse (LPN1) confirmed the expired items remained in R151's refrigerator. LPN1 explained staff on light duty were responsible for checking expiration dates and removing expired food items from residents' refrigerators. LPN1 explained expired items needed to be removed to prevent severe diarrhea, vomiting or hives in the residents. LPN1 stated if a resident consumed expired food items a change of condition form would be completed and an incident report followed.Resident 175 (R175) was admitted to the facility on [DATE] with diagnoses including spina bifida with hydrocephalus, chronic respiratory failure with hypoxia, paraplegia, type 2 diabetes mellitus and dysphagia.On 03/24/2026 at 10:56 AM, the refrigerator in Resident 175's (R175) room contained:-one opened 14 ounce bottle, French's yellow mustard, expired 02/10/2026.-two opened 12 fluid ounce bottles, [NAME] tartar sauce, expired 10/16/2024 and 10/18/2024.-one opened 16 fluid ounce bottle, [NAME] ranch dressing, expired 09/23/2025.-one opened 12 fluid ounce bottle, [NAME] real mayo, expired 02/27/2026.-two butterscotch pudding pack containers, expired 03/16/2026.On 03/24/2026 at 11:15 AM, a Certified Nursing Assistant (CNA2) confirmed the expired findings in R175's refrigerator. CNA2 explained CNAs were responsible for discarding expired items from the resident refrigerators. CNA2 stated expired items were kept in resident refrigerators if they had no odor and would not be thrown out but would instead notify a nurse.On 03/24/2026 at 11:17 AM, a Licensed Practical Nurse (LPN1) confirmed the expired items in R175's refrigerator. LPN1 explained the expired items must be discarded to prevent illness.On 03/27/2026 at 8:33 AM, the Director of Nursing (DON) was unsure of the expectation and process for expired foods in resident rooms. The facility policy titled Food Brought by Family/Visitors, revised on 03/31/2025, documented when food items were intended for later consumption, the responsible staff member labeled foods with the resident's name, and the current date and use by date. Items would be thrown out after 48 hours. Items not open followed the manufacturer's use by date.

Based on observation, interview, and document review, the facility failed to ensure there was sufficient number of kitchen personnel to provide the residents with meals delivered timely, and at proper temperature. The deficient practice placed residents at risk for negatively impacting quality of life.Findings include: The facility assessment tool updated 08/29/2025 and reviewed by the quality assurance committee on 12/30/2025, revealed the facility was licensed for 190 beds with an average daily census of 160 residents. The staffing plan was based on resident population and their needs for care and support, with sufficient staff to meet the residents needs which included: 1) a director of dining services 2) undetermined number of cooks to prepare all meals and snacks (one to four cooks per day) and dining services aides/servers were scheduled to set up, serve and clean up meals and snacks (one to five aides/servers per meal). Staffing levels were adjusted based on census or center needs.On 03/24/2026 in the morning, the facility's census was 170.On 03/24/2026 at 7:40 AM, there were three kitchen staff members preparing meal trays for breakfast meal service. One staff member introduced themself as the Assistant Dietary Manager (DM) who indicated the other two were dietary aides.On 03/24/2026 in the morning, five residents on the 100-Hall, four residents on the 200-Hall and six residents on the 300-Hall complained about meals being served late, the food was cold and often not good (unpalatable).A tray line observation conducted on 03/27/2026 during the breakfast meal service revealed meals were served late based on the facility's delivery schedule and not at appropriate temperatures per facility policy (135 degrees Fahrenheit for hot foods and less than 41 degrees Fahrenheit for cold foods).On 03/27/2026 at 9:52 AM the dietary manager (DM) indicated the average daily census ranged from 170 to 175 residents per day. The DM reported the kitchen was staffed with one dietary manager, one assistant dietary manager who doubled as a cook and two dietary aides who also served as transporters.The dietary manager job description (undated), indicated the position was full time (40 hours per week) and responsible for managing food and kitchen supply budgets, interviewing, hiring, and orienting new dietary staff, recommending dismissals, conducting supply inventories, touring the kitchen multiple times daily to assess work quality, and performing essential duties of dietary aides, cooks, and dishwashers for training or in the event of call ins.The assistant dietary manager job description (undated), indicated the position was hourly and responsible for assisting with staff orientation, maintaining adequate staffing levels, supervising and coordinating dining services staff during food preparation, service, and cleaning, and supporting the dietary manager with planning, budgeting, purchasing, inventory management, and required recordkeeping.The [NAME] job description (undated) described main duties included preparing and serving food including texture-modified and therapeutic diets based on facility menu. The [NAME] reviewed menus, processed diet changes, coordinated with other departments, supervised dietary aids, maintained meal schedules, prepared food conserving its nutritive value and flavor and ensured foods are palatable. Perform administrative requirements and other duties assigned by the DM.The job description of the dietary aide (undated) revealed this was an hourly position and were responsible for assisting the [NAME] during food preparation and food service. Reviewed meal tickets prior to preparing food trays, ensured appropriate equipment and utensils were provided, inspected special diets, served authorized substitute foods, transported delivery carts, cleaned food preparation area and followed cleaning schedule.On 03/27/2026 at 9:58 AM, the DM explained the facility needed one full-time DM, an assistant DM who did not double as a Cook, one full-time [NAME] and an Assistant [NAME] or food preparer, three dietary aides not counting the ones responsible for transporting food. The DM indicated there were two call-ins today and staff turnover was high, specifically, there had been 12 kitchen staff who had quit since December 2025 stating, hard work and low pay. The District Manager was present when the DM verbalized the kitchen was short-staffed and delivery times were hard to meet which impacted quality of food served.On 03/27/2026 at 10:00 AM, the District Manager was aware of the DM's concerns regarding short-staffing and resident food concerns. The District Manager tried to resolve issues with the Administrator and the Director of Operations for the third-party vendor, but the agreement allocated 59 budget hours (total hours worked by all kitchen staff per day). The District Manager indicated covering six facilities in the area and stated 59 budget hours was low compared to other facilities.On 03/27/2026 at 10:41 AM, the Administrator indicated kitchen services were provided by a third-party vendor responsible for staffing the kitchen. The Administrator hired by the facility in August 2025, had been communicating with the Executive Director of the contracted vendor. The Administrator explained the former DM lacked the capacity to fulfill the role and separated from the company. The current DM was already working in the kitchen under a different role and started as DM in December 2025.On 03/27/2026 at 10:50 AM, the Administrator indicated not being made aware there had been 12 kitchen staff who resigned since the new DM started in December 2025 which the Administrator found concerning. The Administrator had expressed disappointment regarding the third-party vendor and was aware of resident food concerns which were constantly being communicated to senior leadership of the third-party vendor.On 03/27/2026 at 11:05 AM, the Administrator emphasized kitchen staffing concerns had not been brought to their attention. The Administrator expected to be informed of staffing levels and budgeted hours could be discussed. The Administrator indicated if the facility were not relying on a third-party vendor, kitchen staffing would be based on the facility assessment. For an average daily census of 170, the Administrator would staff one DM, four cooks, five aides/servers/transporters and an assistant DM who will not double as a cook. The Administrator indicated adequate staffing levels would allow meals to be delivered on time and at proper temperature.

Based on observation, interview, record review, and document review, the facility failed to appropriately assess residents who smoked upon admission/readmission, secure smoking materials, including lighters, and establish a policy outlining guidelines on how to address smoking among residents in a non-smoking facility, and ensure safety measures were implemented for 3 of 13 sampled residents (Residents 66, 104, and 65). This deficient practice had the potential to place residents at risk of self-inflicted burns, fire hazards, or other safety concerns. Findings include: Resident 66 (R66) R66 was admitted on [DATE], and readmitted on [DATE], with diagnoses including shortness of breath and heart failure. The Minimum Data Set, dated dated dated [DATE], documented R66's brief interview of mental status a score of 15/15, and R66 was a current tobacco user. The Nursing Progress Notes dated 03/06/2025, documented R66 expressed unwillingness to use the Nicotine patch and intention was to continue smoking. The Assistant Director of Nursing (DON), Director of Nursing (DON), and Administrator were notified. On 03/14/2025 at 3:40 PM, Residents 66 and 65 were in the lobby and appeared upset. Both residents expressed a desire to smoke but had been informed staff assistance was required to smoke outside. Both residents verbalized cigarettes and lighters were kept in pouches in their possession and indicated since admission, the facility had been aware both residents were smokers. On 03/14/2025 at 4:00 PM, a Licensed Practical Nurse (LPN) indicated the facility was non-smoking and confirmed R66 was a smoker. The LPN expressed it had been noticed a smell of smoke was present, especially after returning from outside the facility. The LPN explained the facility is a non-smoking facility, but if a resident was a smoker, an assessment should have been conducted upon admission, smoking items should not have been in the resident's possession, and an alternative, such as a nicotine patch, should have been offered. On 03/14/2025 at 4:25 PM, R66 was in a motorized chair and expressed satisfaction after having smoked outside with R65 and a staff member. R66 verbalized cigarettes and a lighter were kept in a pouch in possession. The assigned LPN checked R66's pouch and found 18 cigarettes and three lighters. On 03/14/2025 at 4:45 PM, a Registered Nurse (RN) confirmed R66 and R65 were accompanied outside the facility to smoke and stated both residents kept cigarettes and lighters in their possession. The RN was uncertain about the process for managing residents who smoked, as only was asked to accompany the residents. The RN confirmed there were residents at the facility who were actively smoking. On 03/18/2025 in the morning, the Director of Nursing (DON) indicated there were 13 residents who were smokers at the facility; their cigarettes, including the lighters, were confiscated after it was reported by the survey team, and an alternative had been offered. The DON indicated the facility remained a non-smoking facility. R66's medical records lacked documented evidence a smoking assessment was completed in a timely manner upon admission or readmission, smoking items including the lighters, were secured for safety, and safety measures and smoking protocols were outlined and implemented to address smoking among residents in a non-smoking facility. On 03/18/2025 at 11:30 AM, the Nurse Practitioner (NP) indicated residents who smoked should have been assessed in a timely manner upon admission and should not have been allowed to keep smoking items and lighters in their possession to prevent self-inflicted burns and fire hazards. The NP verbalized an alternative should have been offered, but if smoking persisted, transitioning the resident to another facility for safety should have been considered. 41903 Resident 104 (R104) R104 was admitted [DATE] and readmitted [DATE], with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes with unspecified complications, and acute kidney failure. On 03/12/2025 at 11:33 AM, R104 was sitting in a wheelchair in the room. R104 reported was a smoker. R104 explained a few days ago was told the facility was a non-smoking facility. R104 reported used to go unaccompanied by staff, to the entrance of the park outside the facility to smoke but was no longer allowed to do so. R104 reported kept cigarettes and a cigarette lighter in their possession in the room. A Smoke-Free Center Acknowledgement Form was signed by R104 on 03/15/2022. The form stated the facility was a smoke-free environment and agreement was not to smoke while residing at the facility. A facility document titled, The Heights of [NAME] is a non-smoking facility, but the residents listed below have expressed a desire to smoke, undated, listed R104. A Care Plan dated 11/21/2024 documented R104 was not to smoke at non-smoking facility. R104 was non-compliant with facility smoking policy. A Smoking Evaluation dated 03/03/2025, documented R104 was not allowed to smoke per facility policy. A monthly Inservice dated February 2025, documented under No Smoking, this was a non-smoking facility, included the entire campus. Smoking was not allowed anywhere on campus, including any vehicles, if the vehicle was parked on campus. On 03/14/2025 at 11:04 AM, a Registered Nurse (RN) reported the facility was a non-smoking facility. The RN explained at admission residents were told the facility was non-smoking. On 03/14/2025 at 11:51 AM, the Admissions Director reported at admission, residents were provided the admission agreement, a document titled Smoke-Free Center Acknowledgement Form. The form notified residents the facility was smoke-free. Residents acknowledged and agreed not to smoke by signing the form. On 03/14/2025 at 4:19 PM, the Administrator and the Director of Nursing (DON) were informed R104 had cigarettes and a cigarette lighter in their possession in the room. The Administrator and the DON reported would speak to R104 and collect the smoking materials. On 03/14/2025 at 4:58 PM, R104 confirmed the cigarettes, and the cigarette lighter were confiscated by the facility's Social Worker the same day. 50513 Resident 65 (R65) R65 was admitted on [DATE] with diagnoses including anxiety disorder, depression, muscle weakness, and nicotine dependence. Review of R65's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/2024 indicated under J1300 Current Tobacco Use indicated Yes, R65 was a tobacco user. Review of R65's Comprehensive Care Plan initiated on 03/26/2024, included a smoking care plan initiated on 09/27/2024. On 03/12/2025 at 12:46 PM, R65 was lying in bed, alert and oriented. R65 verbalized being unhappy because the facility was no longer allowing R65 to go outside the front door to smoke as of 03/10/2025. On 03/13/2025 at 1:45 PM, the Social Services Director verbalized the facility had always been a non-smoking facility, and if a resident was in possession of smoking materials, the social services department would lock it up for the resident. On 03/13/2025 at 1:45 PM, the Administrator verbalized the facility was a non-smoking facility, but the facility had not been actively enforcing the non-smoking policy until that week. The Administrator advised all identified smokers would have a smoking care plan and a smoking assessment conducted. If a resident did not want to comply with the facility's non-smoking policy, the resident would be offered a nicotine patch, tobacco cessation, or the facility could find the resident a smoking facility. On 03/14/2025 at 3:56 PM, R65 and R66 were outside the facility doors by the 100-hall entrance/exit, going across the parking lot to a covered patio area. Two surveyors followed R65 and R66 to the covered patio. The LPN from the facility was with the two residents outside smoking cigarettes. On 03/14/2025 at 4:02 PM, R65 verbalized the unit clerk in the 100-hall had permitted R65 and R66 to sign out of the facility to go smoke off the property, under the supervision of the LPN. R65 stated the Assistant Administrator had specifically verbalized R65 and R66 could go out to smoke if they had a CNA, LPN, RN, or anyone over 18 who can dial 911 accompany them. On 03/14/2025 at 4:13 PM, the Administrator and Director of Nursing (DON) were informed R65 and R66 were outside under the covered patio smoking under the supervision of the LPN. The Administrator verbalized the covered patio was the property of the public park and was not a part of the facility grounds. On 03/18/2025 at 11:03 AM, upon entering Resident 65's room, the resident was observed lying in bed, alert and oriented. The resident expressed frustration because the resident's cigarettes and lighter were confiscated by management on 03/14/2025 after R65 and R66 returned from smoking outside under the covered patio with the LPN. R65 stated the facility had let R65 keep the cigarettes and lighter in the resident's possession since being admitted on [DATE]. The facility policy titled Smoking with an effective date of 08/09/2022, documented for Centers who wish to be smoke-free: A. Obtain approval from the VPO. B. Determine the date the facility would become smoke-free. C. Residents who smoke and have been in the Center before the effective date would be permitted to continue to smoke in the designated areas only. D. Starting on the effective date, new admissions and staff, volunteers, contractors, and visitors would not be permitted to smoke. The Admissions designee would explain the smoke-free policy to new residents and their families. Potential employees would be informed of the smoke-free policy during the interview process. Volunteers, contractors, and visitors would be informed of the smoke-free policy. E. The Resident/Responsible party would sign the Smoke-Free Center Acknowledgement Form and the form would be placed with the admissions paperwork. F. Failure to comply with this policy would result in disciplinary action up to and including termination for employees, initiation of a discharge plan for residents, and a request to leave the premises for volunteers, contractors, and visitors. On 03/18/2025 at 3:52 PM, the Administrator verbalized upon admission, residents were told the facility was non-smoking. Personal effects were inventoried, but a physical search of the resident's belongings was not conducted. Smoking paraphernalia was not routinely searched for during the personal effects inventory. If smoking paraphernalia, such as lighters or cigarettes, was discovered later, the items were collected. The facility had not developed a formal policy regarding the securement of smoking paraphernalia. The Administrator mentioned if a resident had been smoking and their smoking materials were not identified, there had been a risk of setting the building on fire, which had posed a serious safety concern for the facility.

Based on observation, interview, and document review, the facility failed to ensure snacks were available to residents outside of scheduled mealtimes. The failed practice had the potential to cause residents to remain hungry in between meals and the resident's nutritional needs not met. Findings include: On 03/12/2025 in the morning, the snack tray at the 1st floor east nursing station was observed empty. On the 2nd floor nursing station, the snacks refrigerator had a bottle of dark colored soda and no snacks available for residents. On 03/12/2025 in the morning, the Dietary Director reported resident snack refrigerators were replenished daily after breakfast and again in the afternoon. On 03/12/2025 in the morning, Resident 109 (R109) reported did not know how to request food alternatives or snacks. On 03/12/2025 at 12:17 PM, R74 reported had been at the facility for six years. R74 explained sometimes there were crackers available, however, there were no sandwiches or other snacks for residents between meals. R74 explained residents able to visit the kitchen could have requested a sandwich but unfortunately for those residents unable to go to the kitchen, there were no snacks. On 03/12/2025 at 11:08 AM, R22 reported snacks were an issue, there were never any sandwiches available during the day or night. R22 explained would order food from outside the facility to be delivered or would go to the kitchen in person to request a sandwich. On 03/12/2025 in the morning, R46 reported there was no food or snacks available for residents in between meals. R46 explained there was only juice available after dinner and until 9:00 AM. On 03/12/2025 in the afternoon, a Registered Nurse (RN) reported the lack of snacks was a concern at the facility. If residents requested a snack such as a sandwich, staff could call the kitchen and sometimes would get the sandwich and sometimes would not. On 03/13/2025 at 2:01 PM, the District Kitchen Manager, reported the expectation was snacks at the units needed to be replenished 7:00 AM and 2:00 PM daily. On 03/18/2025 at 8:42 AM, the 300-hall nursing station snack refrigerator was observed empty. The snack tray on top of refrigerator was also empty. There were no snacks available for the 3rd floor residents. On 03/18/2025 at 8:52 AM, at the 200-hall nursing station, the resident snacks refrigerator was empty, and the snack tray on top of refrigerator was also empty. There were no snacks available for the 2nd floor residents. On 03/18/2025 in the morning, a Unit Clerk reported during the previous two weeks snacks were not consistently being brought to the unit. If residents asked for a snack, staff would have had to go to the kitchen. The Unit Clerk reported it was a struggle to get snacks at the facility. On 03/18/2025 in the morning, a Registered Nurse (RN), reported had one resident that asked for snacks. The RN explained would go to the kitchen to find a snack for the resident. Sometimes there were snacks available and sometimes none. On 03/18/2025 in the morning, a Licensed Practical Nurse (LPN) reported there were no snacks for the residents. The LPN explained if residents would request snacks, the LPN would send a request to the kitchen sometimes without success. On 03/18/2025 at 9:03 AM, there were no snacks available for residents at the 100 East nursing station. A Certified Nursing Assistant (CNA) confirmed if there were snacks available, they would have been placed on a tray on the counter at the nurse's station. The CNA confirmed there were no snacks available. On 03/18/2025 at 4:15 PM, the Administrator reported concerns regarding snacks availability had not been brought to the Administrator's attention. The Administrator reported the expectation was snacks at all units be replenished twice daily, morning and afternoon, and snacks were to be available as requested by residents. A facility policy titled Snacks (Between Meal and Bedtime) Serving undated, documented the purpose of the procedure was to provide the resident with adequate nutrition. The policy included a description of preparation, equipment and supplies, steps in the procedure, documentation, and reporting.

Based on observation, interview, record review, and document review, the facility failed to ensure the accuracy of assessment reflected the resident's status regarding the harness and straps being used for safety rather than as a restraint for 1 of 31 sampled residents. This deficient practice had the potential to result in the improper use of restraints, restricted mobility, and diminished quality of care. Findings include: Resident 60 (R60) R60 was admitted on [DATE], and readmitted on [DATE], with the diagnoses including spastic quadriplegic cerebral palsy and epileptic seizures (episodes of abnormal electrical activity in the brain that cause sudden changes in behavior, movement, or consciousness). On 03/18/2025 at 7:50 AM, R60 was in the activity room seated in the tilted wheelchair. R60 was incoherent, non-verbal and appeared comfortable. The harness and straps were in place securing R60. A physician order dated 01/09/2025, documented to ensure harness and strap were secured and on properly while in wheelchair for safety. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented an incomplete brief interview of mental status due to R60's cognitive function being severely impaired. The assessment was coded; a restraint was used daily. A Care Plan (undated), documented R60 was at risk for complications from seatbelt use, wheelchair harness, and foot straps. The intervention included applying a four-point seat belt with a chest guard for safety and mobility with foot straps adjusted to ensure proper positioning. Additionally, regular assessments were scheduled to monitor comfort and prevent any potential skin irritation or pressure sores. straps while up in the wheelchair and as needed. To complete restraint assessment/reduction review per protocol. On 03/18/025 at 12:35 PM, the DON indicated the harness, and straps were not considered restraint or restrictions on R60's freedom, for it was needed for R60's safety. The DON explained there was no restraint assessment or reduction required because it was not considered a restraint due to R60's involuntary movements. The DON indicated the MDS assessment was inaccurately coded. On 03/18/2025 at 3:31 PM, the MDS Nurse confirmed the assessment was coded inaccurately because the harness and straps were being used for R60's safety and not for restrictions. A facility policy titled Comprehensive Care Plan revised 08/25/2021, documented the Interdisciplinary Team (IDT), in coordination with the resident and/or family, to develop and implement a person-centered care plan addressing identified needs. The plan included measurable objectives and timeframes, with concerns evaluated using specific tools, such as Care Area Assessments, before adding interventions. Assessments of residents were ongoing, and care plans were reviewed and revised as information about the resident changed. The IDT was responsible for evaluation and updating of care plans.

Based on observation, interview, record review, and document review, the facility failed to develop comprehensive care plans to reflect new interventions, specifically a smoking care plan for 1 of 13 sampled residents (Resident 65). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being. Findings included: Resident 65 (R65) R65 was admitted on [DATE] with diagnoses including anxiety disorder, muscle weakness, and nicotine dependence. Review of an Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/2024 indicated under J1300 Current Tobacco Use, R65 was a tobacco user. The assessment under Section I: Active Diagnoses indicated the resident had seizure disorder or epilepsy, anxiety disorder, and depression. Review of R65's Comprehensive Care Plan initiated on 03/26/2024, included a smoking care plan initiated on 09/27/2024. On 03/18/2025 at 2:59 PM, the Minimum Data Set (MDS) Nurse verbalized upon admission of a new resident, an MDS assessment was conducted for the resident. The MDS Coordinator advised if questions were marked Yes, a care plan should be triggered. The MDS Nurse verbalized the assessment under J1300 Current Tobacco Use was marked Yes for R65. The MDS Nurse indicated the resident should have had a smoking assessment and smoking care plan conducted upon admission on 03/26/2024, but one was not conducted until 09/27/2024. On 03/18/2025 at 3:50 PM, the Director of Nursing (DON) verbalized the facility had 21 days to conduct a comprehensive care plan for a resident. The DON indicated if the resident had been marked as Yes under J1300 Current Tobacco Use for the admission MDS, the resident should have had a comprehensive care plan. The facility policy titled Comprehensive Care Plan, with an effective date of 08/25/2021, documented the facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, would develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs identified in the comprehensive assessment. Each resident's comprehensive care plan would be designed to build on the resident's individualized needs, strengths, and preferences. Areas of concern triggered during the resident assessment would be evaluated using specific assessment tools (including Care Area Assessments) before interventions were added to the care plan.

Based on observation, interview, record review and document review, the facility failed to ensure showers or a bath, were provided as scheduled for 1 of 4 unsampled residents (Resident 471). The deficient practice had the potential to increase skin breakdown, infections, odor and bacteria buildup. Findings include: Resident 471 (R471) R471 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, anemia, left foot cellulitis, gastritis, and stroke. The Minimum Data Set (MDS) in section GG dated 12/24/2024, indicated partial/moderate assistance with showering and bathing self. Review of R471's Care Plan initiated on 12/19/2024, indicated resident was dependent for Activities of Daily Living (ADL) care. R471's medical record for December 2024 and January 2025 lacked documented evidence the resident received either a shower or bath on the following dates: - 12/21/2024 (Saturday) - 01/01/2025 (Wednesday) R471's medical record lacked documented evidence the resident refused a shower or bath during the above-mentioned dates, and shower or bath were provided on other days to compensate for the missed shower or bath as scheduled. On 03/14/2025 at 8:24 AM, a Certified Nursing Assistant (CNA) indicated showers were provided to residents twice a week dependent on the shower schedule for each floor. Weekly Bath and Skin Report sheets were utilized to document if a shower or bath was provided to the resident. If the shower or bath was denied by the resident, the CNAs would document the refusal on the weekly bath and skin report sheet and place the report in the binder. Another means of documenting the shower or bath was in the electronic medical record. 03/18/2025 at 8:28 AM, another CNA verbalized showers were offered to residents twice a week. CNAs would either document the shower on the weekly bath and skin report or the electronic medical record. Ultimately, the electronic medical record was the main source of documentation. If a resident refuses the shower or bath, this was reported to the nurse. On 03/18/2025 at 8:30 AM, an observation of the updated 2025 shower schedule on the unit where the resident was housed, indicated showers were designated twice a week for room [ROOM NUMBER], which were Wednesday and Saturday evenings. On 03/18/2024 at 10:50 AM, the Director of Nursing (DON) indicated the provided shower schedule located at the front desk in the [NAME] Hallway marked as 2025 updated did not change from 2024. According to the shower schedule, room [ROOM NUMBER] was to shower on the evening shift on Wednesday and Saturdays. R471's documented showers throughout the resident's admission were reviewed with the Director of Nursing (DON). There was no documented evidence the resident was offered a shower or bath on 12/21/2024 and 01/01/2025. The DON confirmed the findings and indicated there was no documentation R471 had refused or was unavailable during the shift. The policy titled, Activities of Daily Living (ADLs), Supporting, revised on 03/2018, documented appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene.

Based on observation, interview, and record review, the facility failed to ensure residents were adequately supervised to prevent elopement for four of 67 sampled residents (Resident (R) 16, R260, R261, and R309) and failed to prevent an injury for R16 when she was found in the parking lot on the ground with a [MEDICAL CONDITION] after eloping from the facility. Immediate Jeopardy (IJ) was identified on 08/01/18 and was determined to exist starting on 07/24/18, in 42 CFR 483.25(d) Accidents at F689, when the facility discovered R16 eloped from the building and sustained a [MEDICAL CONDITION] resulting in hospitalization . The facility (Executive Director, Director of Nursing, Assistant Director of Nursing, and the Regional Vice President of Operations) was notified on 08/01/18 at 11:40 AM the failure to provide adequate supervision to prevent four of 67 sampled residents from eloping from the building constituted IJ (Resident (R) 16, R260, R261, and R309). The IJ at F689 also constituted Substandard Quality of Care at 42 CFR 483.25. The facility presented an acceptable IJ removal plan on 08/02/18 at 1:30 PM, which included: -implementing 24 hours per day one to one sitter with R16 until a care conference with the family occurs in (MONTH) (YEAR); -implementing a 48-hour activity journal to establish a pattern of the R16's activity and wandering patterns to identify a root cause; -R260, R261, and R309 were already discharged from the facility; -all residents were immediately accounted for; -Elopement Risk Evaluations were completed for 100% of the residents in the facility; -care plans were updated with immediate interventions for any residents found at risk for elopement; -all elopement binders at each nurse station and the front desk were updated so staff will be aware of residents at risk for elopement; -staff participated in elopement drills on all three shifts; -employees were educated on elopement; nursing staff were educated on a resident's right to obtain a Leave of Absence order granted by the physician prior to leaving the facility; -alarms will be installed on each door to the outside by 08/07/18 and staff will be educated on how to respond to the alarms once they are installed; -the front lobby door will be monitored by the receptionist daily from 8:00 AM until 9:00 PM and will be locked from 9:00 PM until 8:00 AM. The survey team validated the IJ removal plan was implemented as of 08/02/18 at 2:00 PM. On 08/02/18 at 2:00 PM the facility (Executive Director, Director of Nursing, Assistant Director of Nursing, and the Regional Vice President of Operations) was informed IJ was removed as of 1:30 PM on 08/02/18; however, deficient practice remained at the H (actual harm at a pattern) level. Findings include: Review of facility policy titled, OPS 111 Elopement of Patient, Manual Title: Center Operations Policies and Procedures . Effective Date: 06/01/96, Revised Date 05/15/14, Policy: Patients will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. 1. On 07/30/18 at 9:30 AM, during entrance into the facility, R16 was noted being pushed in her wheelchair by staff past the dining room. R16 had dark bruises of green and blue color on her forehead and around her eyes, with stitches on the cheek under her left eye. On 08/01/18 at 1:15 PM, R16 was in the sitting area in her wheelchair alone. Review of the electronic medical record (e-mar) for R16 revealed an initial admission date of [DATE] and a recent admission date of [DATE], with [DIAGNOSES REDACTED]., unspecified cataract, unspecified [MEDICAL CONDITION], and unqualified visual loss in one eye. Review of the progress notes revealed the following: Effective Date: 7/24/2018 at 07:15, Type: General, Note: Dr Fall announced by CEO who found (name of resident) lying on the left side in the parking lot near front entrance of the facility. Had apparently been brought down to dining room in her wheelchair and placed at her usual spot in the formal dining room with the wheelchair and scooted out the building. Physical examination is limited r/t (related to) c/o (complaint of) head pain, left arm pain, and bilateral leg pain. Neuro: Awake, slow to answer questions but does complain of left sided forehead pain. There is a large hematoma and bleeding noted. Resp: Breathing is slightly increased to about 30 per minute. CV: BP 147/97, heart rate 80. Temp 96.6 orally. Blankets placed under head, right arm. 911 called with lights and sirens. Signed by Registered Nurse (RN) 23. On 08/01/18 at 9:30 AM, during an interview, the Executive Director stated he pulled into the parking lot about 7:10 or 7:15 AM, before 7:30 AM. The resident was in his parking space, lying on the ground. He stated it must have just happened, because there was not a pool of blood on the ground. The resident was in an awkward position. He stated that he ran into the building and yelled that he needed help; staff came out and began giving aid until the ambulance arrived. He stated that the Assistant Director of Nursing (ADON) had seen R16 safely inside, just 5 minutes before the resident was found by him on the ground outside. On 08/01/18 at 10:45 AM, the ADON and Director of Nursing (DON) were asked about the incident. The ADON stated that he had not seen the resident prior to the incident; he was the first to respond after the Executive Director came in yelling for assistance. The staff member who saw her in the dining room prior to the incident was Nurse Practice Educator, Licensed Practical Nurse (LPN) 10, not the ADON. The DON was asked what was being done since R16's elopement to ensure this did not happen again; the DON stated that reinforcement of the toileting schedule was now being done. She was asked what reinforcement meant. She said that the resident has always been taken to the restroom when she needed to go, but this time, We are enforcing this with the staff and making sure she is taken to the restroom. The DON also stated that this was the first time the resident had gotten this far and was usually redirected prior to getting outside. The DON stated the resident had not had this behavior so early in the day. It usually occurs in the evening. On 08/01/18 at 11:10 AM, during an interview, LPN10 stated she had seen the resident that morning at the dining room table with other residents. She stated, they had not passed out breakfast yet, so it was before 7:30 AM. She was asked how the resident got down from the second floor to the dining room. She stated that she must have brought herself down. LPN10 was asked if this was something the resident did on her own. LPN10 stated that the resident, knows where she wants to go when she wants to go. LPN10 also stated that she was not aware of eloping behavior for this resident. On 08/01/18 at 11:30 AM, during an interview, Nurse Unit Manager, LPN29, stated that the resident had, lived here for a few years and she has days when she forgets and wants to go home. The resident will try to get out and is not easily redirected. LPN29 also was asked how often this occurred and she said a few times a week. LPN29 was asked what was being done for the resident since she left the building on 07/24/18; she said that the Certified Nursing Assistants (CNAs) have i-pads in which they document. LPN29 stated that she had put in the i-pad that she should be toileted every 2 hours on the even numbered hours. When asked to see if that was being followed, LPN29 brought the program up and went into the toileting category. She was asked to look at the evening of 07/29/18. The documentation indicated that the resident had not been checked on between the hours of 5:43 PM and 9:35 PM; the LPN confirmed that was not following the toileting every 2 hours on the even numbered hours. LPN29 was asked how the resident got down stairs. LPN29 stated the staff had to bring her down, Everyone knows to keep eyes on the resident because of her seeking a way out. On 08/01/18 at 1:10 PM, during an interview, CNA30 was asked what to do for R16. CNA30 stated she knew the resident usually ate in the downstairs dining room. CNA30 was asked if she worked with the resident the day she got outside and was hurt. CNA30 stated that she did not work with her that morning, but she was surprised to hear about the incident. CNA30 stated the resident can tell you when she needed to use the restroom and she did not walk. CNA30 was asked if she was instructed to do something different with the resident since the elopement, CNA30 stated, No. today she just been in the bed. During an interview on 08/01/18 at 1:40 PM, CNA31 was asked if there were any new instructions when caring for R16. CNA31 stated, Nothing new. Just make sure and keep an eye on her. That's what we have always had to do. During an interview on 08/01/18 at 1:45 PM, LPN13 stated she was R16's nurse for the day and there were no new instructions or monitoring. LPN13 stated she did not know of any care plan for the resident and eloping. On 08/01/18 at 1:50 PM, CNA32 was the staff member who was working the morning of the elopement. CNA32 stated that she had arrived about 6:30 AM and the resident was already up and out of bed in her wheelchair. CNA32 stated she took her to the restroom and cleaned her up, dressed her, and left her sitting in the hall in front of her room. CNA32 stated she had to work with residents that were around the corner and that was why the resident was not in her line of sight. CNA32 stated, everyone knows to watch her. CNA32 stated, She would go down to the first floor for breakfast and lunch and sometimes she would take herself down. CNA32 said the next thing she heard was the resident was found outside. CNA32 stated that she did not document anything about the resident and was not aware of what the resident was care planed for requiring. During an interview on 08/01/18 at 2:00 PM, CNA33 stated that he was at work the morning of the elopement. CNA33 stated that no one had taken R16 to the dining room and the resident must have taken herself down. CNA33 stated, The resident usually wants you to do for her and does not do for herself. It was a surprise that she went downstairs on her own. During an interview on 08/01/18 at 4:55 PM, the Primary Physician stated she had worked with the resident since her admission into the facility in 2010. The physician stated R16 had dementia and had always been a wanderer. The physician also stated the resident had behaviors and received medication that helped reduce behaviors. The physician added, But every now and then she will become exit seeking and there is no indication of why she does this. Review of the Behavior Monitoring and interventions sheets revealed for the month of (MONTH) (YEAR), R16 had wondering behaviors three times on 02/01/18, three times on 02/02/18, and one time on 02/02/18. In (MONTH) (YEAR), on 03/03/18 the resident had two episodes of wandering. In (MONTH) of (YEAR), on 04/05/18 the resident exhibited one episode, on 04/10/18 two episodes, on 04/14/18 four episodes, and on 04/21/18 two episodes. In (MONTH) (YEAR), on 05/01/18 one episode, on 05/12/18 three episodes, on 05/21/18 two episodes, and on 05/22/18 one episode. In (MONTH) (YEAR), on 06/03/18 two episodes, on 06/08/18 one episode, and on 06/09/18 one episode. In (MONTH) (YEAR), on 07/9/18 one episode and on 07/11/18 two episodes. Review of R16's annual Minimum Data Set (MDS) assessment, dated 11/17/17, under Section C, indicated R16 scored 8 out of 15 on the Brief Interview for Mental Status (BIMs), indicating moderate cognitive impairment. Section E indicated the resident had wandering behavior 1 to 3 days; the resident was at significant risk of getting to a potentially dangerous place and the behavior had become worse. Section G indicated the resident required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, and toilet use. Section G also indicated was the resident did not walk. The last MDS assessment completed was a quarterly dated 05/09/18. The BIMs score of 4 indicated severe impairment. Section E indicated the behavior of wondering did not exist. Review of the care plan indicated an initial date of 11/30/15, Focus: Resident is at risk for elopement related to dementia and h/o (history of) attempting elopement. Goal: resident will not leave the building without an escort x90 days. Interventions: Educate health care decision maker and staff of elopement potential, triggers and prevention measures, telephone daughter (name) when Resident is attempting to exit facility. Encourage participation in positive meaningful activity programs of choice. Engage resident in active conversation as a form of redirection. If unable to redirect resident, stay with resident and provide support and supervision until able to redirect. In the event of elopement follow search and reporting protocols. Redirect resident when security system sounds and/or resident attempts to leave the building. On 07/27/18 an intervention added was, Resident will not be woken & dressed before 8A daily so that receptionist will be at front desk next to main entrance. 2. Review of an undated Event Log for the last six months indicated three more elopements, one on 04/25/18, one on 06/14/18, one on 07/29/18, and one on 07/30/18. The last occurring after R16's elopement on 07/24/18. a. Review of R260's Admission Record dated 04/25/18 revealed an initial admitted [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a statement dated 04/25/18 revealed, At, 1345 (1:35 PM) CNA reported unable to locate patient in room [ROOM NUMBER] . The facility staff look around inside and outside the facility . Patient was last seen by RNA (Restorative Nurse Aide) staff with his son in the parking lot just before lunch time . 1515 (3:15 PM) daughter called that patient is with the brother heading back from eating out. b. Review of R261's Progress Notes dated 07/29/18 at 4:15 PM, Brought up at nursing desk and has purse and wants to call her brother and go home . Somehow she was able to leave the building and was apparently walking down the street. A passerby Nurse Practitioner picked her up in her car and brought her back to the facility . Review of a later entry dated 07/29/18 at 9:37 PM, Note: Was able to run out back door. c. Review of R309's Progress Notes dated 07/30/18 at 4:30 PM, revealed the resident's physician came in to see resident and she was not found to be in the building. Staff stated they had seen the resident last at 3:30 PM with her husband. R309 was not in the building and found to have gone home.

Based on interview, record review and document review, the facility failed to ensure the physician's orders were followed to monitor one resident's (Resident #2) caloric intake to provide proper nutrition, prevent significant weight loss and evaluate the intake and output weekly for one month. Findings include: Resident #2 Resident #2 was admitted [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The re-admission Dietary/Nutritional assessment dated [DATE] documented Resident #2 was 67 inches with a weight of 110 on admission. The resident's ideal body weight was 133-163 pounds. Resident #2 estimated nutrient needs were documented as, "...Calories (K cal) 1500-2000 kcal (30-40 kcal/kg (kilogram). Protein (gm) 60-70 gm (1.2-1.4 gm/kg). Fluid: (cc) 1500-1750 (30-35 ml/kg)..." Resident #2's admission weight on 3/25/12 was documented at 110.2 pounds (lbs.) The weight Record for Resident #2 documented the following: 3/29/12-110.2 lbs. (no re-weight) 4/5/12-93.2 lbs. wt. down 15 % 4/12/12-89.8 lbs. (indicated physician notified) 4/19/12-78.2 lbs. wt. down 29 % 4/26/12-77.2 lbs. wt. down 29 % 5/2/12-79.6 lbs. (physician orders daily weights) wt. down 27 % 5/3/12-77.0 lbs. 5/4/12-77.4 lbs. 5/5/12-77.2 lbs. 5/6/12-77.6 lbs 5/7/12-78.4 lbs. 5/8/12-78.2 lbs 5/9/12-80.2 lbs. 5/10/12-78.3 lbs. 5/11/12-78.3 lbs. 5/12/12-77.6 lbs. 5/13/12-77.4 lbs. 5/14/12-77.2 lbs. 5/15/12-78.4 lbs. 5/16/12-79.0 lbs. 5/17/12-80.1 lbs. 5/18/12-77.8 lbs. 5/24/12-78.6 lbs. 5/31/12-77.8 lbs 6/7/12-77.8 lbs 6/14/12-80.7 lbs. On 3/26/12, Resident #2's physician ordered [MEDICATION NAME] 1.2 at 65 cc (cubic centimeter) per hour for 20 hours via gastrostomy tube and evaluate intake and output (I&O) every shift weekly for four weeks stop date 4/25/12. The caloric intake for Resident #2 was calculated at 1300 cc=1560 calories for [MEDICATION NAME] 1.2 at 65 cc per hour for 20 hours per physician's order on 3/26/12. There was no documentation of I and O monitoring for Resident #2 as per physician's order from 3/26/12 through 3/31/12. The daily intake for Resident #2's tube feeding was measured in cc's. Resident #2 was to receive 1300 cc per day in order to receive the 1560 calories per day as ordered by the physician on 3/26/12. The I and O sheet for Resident #2 documented the following cc's per day. The amount of Resident #2's caloric intake was calculated by the amount of cc's the resident received daily. 4/1-540 cc=648 calories (cal.) 4/2-0=0 4/3-520 cc=624 cal. 4/4-1445 cc=1734 cal. 4/5-1000 cc=1200 cal. 4/6-1080 cc=1296 cal. 4/7-1096 cc=1315 cal. 4/8-420 cc=576 cal. 4/9-500 cc=600 cal. 4/10-1335 cc=1648 cal. 4/11-845 cc=1014 cal. 4/12-1295 cc=1554 cal. 4/13-530 cc=636 cal. 4/14-520 cc=624 cal. 4/15-1325 cc=1638 cal. 4/16-1040 cc=1248 cal. 4/17-1395 cc=1674 cal. On 4/17/12, the physician for Resident #2 ordered [MEDICATION NAME] 1.2 at 75 cc per hour for 20 hours. The caloric intake for Resident #2 was calculated at 1500 cc=1800 calories. The I and O sheet for Resident #2 documented the following cc's per day. The amount of Resident #2's caloric intake was calculated by the amount of cc's the resident received daily. 4/18-1210 cc=1452 cal. 4/19-1235 cc=1482 cal. 4/20-1200 cc=1440 cal. 4/21-860 cc=1032 cal. 4/22-1340 cc=1608 cal. 4/23-500 cc=600 cal. 4/24-925 cc=1110 cal. There was no I&O documentation for 4/25; 4/26; 4/27; 4/28 and 4/29/12. On 4/30/12, the physician for Resident #2 ordered [MEDICATION NAME] 1.2 at 85 cc per hour for 20 hours. The caloric intake for Resident #2 was calculated at 1700 cc=2040 calories The I and O sheet for Resident #2 documented the following cc's per day. The amount of Resident #2's caloric intake was calculated by the amount of cc's the resident received daily. 5/1-1020cc=1224 cal. 5/2-1700cc=2040 cal. 5/3-1700cc=2040 cal. 5/4-1700cc=2040 cal. 5/5-1700cc=2040 cal. 5/6-1700cc=2040 cal. 5/7-1700cc=2040 cal. 5/8-1700cc=2040 cal. 5/9-1700cc=2040 cal. 5/10-1700cc=2040 cal. 5/11-1020cc=1224 cal. 5/12-1700cc=2040 cal. 5/13-1020cc=1224 cal. 5/14-1700cc=2040 cal. 5/15-2040cc=2040 cal 5/16-1700cc=2040 cal. 5/17-680cc=816 cal. The facility failed to follow the physician's order for weekly monitoring of Resident #2's intake and output. There was no documentation in the nurses notes, the dietary notes and the interdisciplinary team notes that indicated Resident #2 received the proper amount of caloric intake. The facility policy on Tube Feeding /TPN (total [MEDICATION NAME] nutrition) (effective date 7/31/12) documented: "...PROCEDURE 2. It is recommended that commercial tube feedings not be less than 1500 calories per day for females and 1800 calories per day for males unless contraindicated by the physician. 3. The Dietician is to review tube feedings/TPN routinely to ensure nutritional adequacy.. There was no documentation in the Nurses Notes, Dietary Notes or the Interdisciplinary Team note that indicated Resident #2's caloric intake was being monitored for 4 weeks as the physician had ordered on [DATE]. On 5/1/12, the Physician's Orders for Resident #2 documented, "...1) DC (discontinue) Prostat 30 ml (milliliters) via (by) G/T (gastrostomy tube) QD (every day) per RD (Registered Dietician) recommendation receiving adequate protein via G/Tube feeding of [MEDICATION NAME] 1.2. 2) Daily wts. (weights) X (times) 2 wks. (weeks)/record results in NN (nurses notes)..." The Dietary Progress Notes for Resident #2 dated 5/6/13, indicated the Prostat should be discontinued secondary to Resident #2 receiving 2.7 grams/kilogram of protein via the GT. Noted MD order to DC. A review of the Physician's Orders for Resident #2 revealed the physician ordered Prostat on 4/24/12. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/1/12 at 10:50 AM, the Registered Dietician (RD) indicated Resident #2 was in and out to the hospital several times. The RD indicated she recommended the physician order [MEDICATION NAME] due to the resident's continued weight loss. The physician ordered [MEDICATION NAME]. The RD indicated when Resident #2 came back from the hospital he did not weigh 110 pounds. The RD indicated she meet with Resident #2's mother who was concerned he was getting dehydrated. The RD indicated she recommended to Resident #2's physician the resident should be placed on Zinc Sulfate and Vitamin C for wound healing. The Interdisciplinary Team (IDT) Notes dated 4/05/12, for Resident #2 documented, Resident #2's weight dropped down to 93 pounds. Resident #2 had lost 17 pounds in one week. The IDT indicated the weight loss was related to the resident's recent hospitalization . Resident #2's tube feeding order dated 3/25/12, indicated the resident received [MEDICATION NAME] 1.2 via gastrostomy tube at 20 cc's per hour on at 1:00 PM and off at 9:00 AM the rate of the tube feeding was to be increased by at a rate of 20cc's per hour until the feedings were at 65 cc per hour. The IDT documented Resident #2 had orders for liquid Multivitamins and Calcium [MEDICATION NAME] suppliments. The IDT documented a complete blood count and metabolic panel and an x-ray of the kidneys/ureters and bladder were ordered on [DATE] in the morning. On 4/12/2012, the IDT indicated Resident #2's weight dropped down to 89.8 pounds, a weight loss of 3.4 pounds in one week. The IDT team documented the weight loss was shared with Resident #2's physician and family. On 4/12/12, The IDT indicated a Pre-[MEDICATION NAME], Blood Urea Nitrogen and Creatinine were ordered in the morning for Resident #2. The IDT documented Resident #2 remained on TF the same as the resident received on 4/05/12. The IDT indicated they would continue with the plan of care recommended by the Registered Dietician. On 4/20/12, the IDT documented Resident #2 weighed 78.2 pound and dropped down 11.6 pounds in one week. The IDT documented Resident #2 continued on [DEVICE] feedings of [MEDICATION NAME] 1.2 at 75 ml (milliliters) /hr times 20 hours with 100 ml flush every shift and 30 ml flush with medication. The IDT indicated the Registered Dietician recommended the resident's physician order blood work due to the resident's weight loss would continue to monitor Resident #2's weekly weights. On 4/27/12, the IDT documented Resident #2 weighed 77.2 pounds. The team indicated the resident dropped 1.0 pounds in one week. The team documented Resident #2 continued with TF [MEDICATION NAME] 1.2 at 75 ml/hr times 20 hours with 100 ml flush every shift which was changed as of 4/25/12 to 150 ml of water flushes every shift. The team indicated they continued to monitor weekly weights to establish a stable weight gain for Resident #2. Resident #2 was transferred to the acute care hospital on [DATE]. The History and Physical dated 6/14/12 for Resident #2 documented the resident had a sodium level of 158 (normal 133-144) and a blood urea nitrogen of 40 (normal for men 8-24). Resident #2's [DIAGNOSES REDACTED]. Complaint #NV 584