Every finding on record at The Springs of Avalon

Based on interviews, record review, and facility policy review, it was determined that the facility failed to a keep a resident free from physical abuse for one (Resident #75) of one resident reviewed for resident-to-resident altercations. Specifically, Resident #75 was physically assaulted by Resident #97, after Resident #97 did not receive indicated medication for dementia and delusions. The findings include: Resident #75 A review of the admission Record revealed that the facility admitted Resident #75 on 05/17/2024, with diagnoses that included dementia, malnutrition, anorexia, depression, anxiety, insomnia, restlessness and agitation, altered mental status, and muscle weakness and atrophy. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2025, revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment. The MDS revealed Resident #75 did not display any behaviors such as hallucinations or delusions, used no mobility devices, and was independent with all mobility. Resident #75 did take high risk medications such as antipsychotics on a routine daily basis. A review of Resident #75's Care Plan revealed the resident was admitted to the secured unit, initiated on 06/17/2026, was verbally aggressive towards staff and other residents, initiated on 06/29/2026, had impaired cognitive function, initiated on 07/14/2024, and had the potential for mood problems related to insomnia, initiated on 05/20/2024. Interventions included collecting a urinalysis, as the resident's baseline was being calm and usually mild mannered (as opposed to the new onset verbal aggression), and staff were to administer medications as prescribed. A review of the Clinical Census indicated Resident #75 resided on the secured unit since 05/23/2024. A review of a Skin Check dated 03/15/2025, revealed that Resident #75 had sustained a laceration to the forehead, and Resident #75's right lower jaw exhibited swelling. A review of Resident #75's Medication Administration Record (MAR) for March of 2025, revealed Resident #75 had an order to cleanse laceration to forehead with wound cleanser, pat dry, apply adhesive skin closure strips every day shift, every other day, for laceration starting 03/19/2025 and was discontinued on 06/09/2025, an Alzheimer's disease medication 10mg (milligram) daily, an antianxiety/anorexia medication 30mg at bedtime, and sleeping medication 100mg at bedtime.A review of a Psychiatric Evaluation dated 03/19/2025, revealed Resident #75 reported a recent physical assault by roommate. The Psychiatric Evaluation revealed that Resident #75 was noted to have bruising to the face. Staff reported that resident's roommate was confused and thought they were being robbed. A review of Resident #75's Progress Notes, dated 03/15/2025 at 6:30 AM, revealed Resident #75 walked into their room which was shared with Resident # 97 and was attacked by Resident #97. Resident #97 was on top of Resident #75, hitting Resident #75 on the head with fist. Resident #75 had a laceration to the middle of the forehead, a swollen right check, swollen right eye (unable to open right eye), blood coming from the mouth and nose, and opened areas to both knees. The inside of the mouth was not assessable due to the swelling and Resident #75 was unable to open Resident #75's mouth very well. Resident #75 was assessed by LPN #2. The Medical Director, Administrator, Assistant Director of Nursing, and Resident #75's family were notified. The police department was notified. Resident #75 was transferred to the hospital by ambulance. Resident #97 A review of the admission Record revealed the facility admitted Resident #97 on 02/26/2024 with diagnoses that included dementia with psychotic disturbance and delusional disorder. A review of the annual MDS with an ARD of 02/19/2025, revealed Resident #97 had a BIMS score of 14, which indicated the resident was cognitively intact. The MDS indicated Resident #97 did not show any behaviors within the seven days of the assessment, used no mobility devices, and was completely independent for self-care and mobility. The MDS indicated Resident #97 was not prescribed an antipsychotic high-risk medication and did not take antipsychotics on a routine basis. A review of Resident #97's Care Plan initiated revealed the resident had an activities of daily living (ADL) self-care performance deficit related to stroke that affected the left non-dominant side, initiated on 02/27/2024, had a potential to be physically aggressive related to anger, dementia, poor impulse control towards others (initiated on 12/31/2024), and impaired cognitive function related to dementia, initiated on 02/28/2024. The MDS also revealed that Resident #97 received an antipsychotic medication related to delusional disorder, initiated on 06/04/2024. Interventions included to administer medication as ordered, identifying triggers and de-escalate behaviors. A review of Clinical Physician Orders, revealed Resident #97 had an atypical antipsychotic prescription medication 2.5 mg ordered on 06/04/2024 by the Medical Director (MD), for vascular dementia and delusional disorder and the medication was discontinued on 09/18/2024 by the MD as a Gradual Dose Reduction (GDR).A review of Resident #97's MAR for September 2024-March 2025, revealed that on the September 2024 MAR Resident #97 received a decrease in medication from 1000mg to 500mg of an extended-release anticonvulsant given for dementia. Resident #97's 2.5 mg medication for dementia and delusions was discontinued on 09/18/2024. A review of the October 2024-March of 2025 MAR does not indicate Resident #97 was restarted on or administered the atypical antipsychotic 2.5mg or 7.5mg, the medication used for dementia and delusions. A review of the Psychiatric Evaluation dated 01/13/2025, revealed that Resident #97 had a physical altercation with another resident. The report stated, Medical team restarted Olanzapine (Zyprexa) 7.5mg by mouth at bedtime. A review of the Psychiatric Evaluation dated 01/22/2025, revealed that Resident #97 had a medication review, staff denied any aggressive behaviors, and the plan of care was to continue on the current medication plan. A review of the Psychiatric Evaluation dated 02/23/2025, revealed that Resident #97 had a medication review, staff denied any aggressive behaviors, and the plan of care was to continue on the current medication plan. A review of the Progress Note dated 01/31/2025, revealed that nursing staff reported increased anger outbursts and that the patient had been getting up during the night and disrupting other residents. The Progress Note revealed that Resident #97 was started on [the atypical antipsychotic] previously. However, it seemed that Resident #97 has not been receiving the medication, per discussion with Resident #97 LPN #3.A review of the Progress Note dated 02/25/2025, revealed that Resident #97 had Recent behavior issues. [atypical antipsychotic] has been ordered. Nursing staff requesting from pharmacy. During an interview on 08/13/2026 at 9:37 AM, the Certified Nursing assistant (CNA) #1 indicated two nights prior to the incident on 03/15/2025 Resident #97 was screaming from the room. CNA #1 indicated that Resident #97 was in the room with the light off and in the bed when he (CNA #1) made it to Resident #97. CNA #1 indicated Resident #97 indicated someone was trying to get Resident #97 and that Resident #97 was looking at something that wasn't there. CNA #1 stated Resident #97's behavior was reported to the nurse. CNA #1 indicated Resident # 97 was an aggressive person. During an interview on 08/13/2026 at 10:47 AM, Licensed Practical Nurse (LPN) #2 indicated she was the nurse on duty at the time of the incident on 03/15/2025. She reported Resident #97 was easily set off, quickly angered, not easy to redirect, and a resident that had a temper. During a follow-up interview on 08/13/2026 at 12:59 PM, the MD indicated that Resident #97 was previously on [atypical antipsychotic] 2.5 mg, but the order was discontinued on 09/18/2024. She indicated on the Progress Note for 01/31/2025 she recommended to continue with [atypical antipsychotic] 7.5 mg because she looked at the PNP Progress Note and seen that the PNP started [atypical antipsychotic] 7.5 mg on 01/13/2025 during the psychiatric evaluation consultation. The MD indicated she did look at the current medications list when she made rounds monthly. During an interview on 08/13/2026 at 1:10 PM, the PNP indicated that on 01/13/2025 she wrote to continue [atypical antipsychotic] 7.5 mg but that was entered incorrectly. She indicated she did look at the physical orders when she made her rounds. The PNP indicated two errors were made. She stated she should have entered 2.5mg instead of 7.5 mg and that the Medical Team tapered Resident #97 off of the [atypical antipsychotic] and it was never reordered. The PNP indicated she missed the discontinued order for [atypical antipsychotic] that the MD entered on 09/18/2024. During an interview on 08/13/2026 at 3:00 PM, the Administrator stated that the antipsychotic medication that Resident #97 was supposed to have been on was never ordered. She indicated she spoke with both the Medical Director and the Psychiatric Nurse Practitioner, and both thought the other had prescribed the needed medication for dementia and delusions but neither followed through with giving the order to the nurse. The Administrator was unable to answer if not receiving the needed medication would cause any problems. A review of a facility policy titled Residents Rights revised on 02/2026, revealed that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to a dignified existence, and be free from abuse, neglect, misappropriation of property, and exploitation. A review of the facility's policy titled Abuse and Neglect-Clinical Protocol revised in March 2018, revealed that Abuse is defined as the willful infliction of injury, and Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical pain and harm. It includes verbal abuse, sexual abuse and physical abuse. And The staff, with the physician's input as needed will investigate alleged abuse and neglect to clarify what happened and identify possible causes. A review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised in April 2021, revealed that The resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to, other residents. A review of the facility's policy titled Resident to Resident Altercation revised in December 2016, revealed that If two residents are involved in an altercation staff will identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation.

Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to take an active role in overseeing the resident's total program of care, including medications for one (Resident #97) of one resident's reviewed for resident to resident altercation resulting in the discovery of a medication not being prescribed to Resident #97 for dementia and delusions as the Medical Director (MD) and Psychiatric Nurse Practitioner (PNP) thought. The findings include: A review of the admission Record revealed the facility admitted Resident #97 on 02/26/2024 with diagnoses that included dementia with psychotic disturbance and delusional disorder. A review of the annual MDS with an ARD of 02/19/2025, revealed Resident #97 had a BIMS score of 14, which indicated the resident was cognitively intact. The MDS indicated Resident #97 did not show any behaviors within the seven days of the assessment, used no mobility devices, and was completely independent for self-care and mobility. The MDS indicated Resident #97 was not receiving an antipsychotic high-risk medication and did not take antipsychotics on a routine basis. A review of Resident #97's Care Plan initiated revealed the resident had an activities of daily living (ADL) self-care performance deficit related to stroke that affected the left non-dominant side, initiated on 02/27/2024, had a potential to be physically aggressive related to anger, dementia, poor impulse control towards others, initiated on 12/31/2024, and impaired cognitive function related to dementia, initiated on 02/28/2024. The MDS also revealed that Resident #97 received an antipsychotic medication related to delusional disorder, initiated on 06/04/2024. Interventions included to administer medication as ordered, identifying triggers and de-escalate behaviors. A review of Clinical Physician Orders, revealed Resident #97 had [an atypical antipsychotic] 2.5 mg ordered on 06/04/2024 by the MD, for vascular dementia and delusional disorder and the medication was discontinued on 09/18/2024 by the MD as a Gradual Dose Reduction (GDR).A review of Resident #97's Medication Administration Record (MAR) for September 2024-March 2025, revealed that on the September 2024 MAR Resident #97 received a decrease in medication from 1000 milligrams (mg) to 500 mg of an extended-release anticonvulsant given for dementia. Resident #97's 2.5 mg medication for dementia and delusions was discontinued on 09/18/2024. A review of the October 2024-March of 2025 MAR does not indicate Resident #97 was restarted on or administered [an atypical antipsychotic] 2.5mg or 7.5mg, the medication used for dementia and delusions. A review of the Clinical Census indicated Resident #97 resided on the secured unit since 02/27/2024. A review of the Psychiatric Evaluation dated 01/13/2025, revealed that Resident #97 had a physical altercation with another resident. The report stated, Medical Team restarted [an atypical antipsychotic] 7.5mg by mouth at bedtime. A review of the Psychiatric Evaluation dated 01/22/2025, revealed that Resident #97 had a medication review, staff denied any aggressive behaviors, and the plan of care was to continue on the current medication plan. A review of the Psychiatric Evaluation dated 02/23/2025, revealed that Resident #97 had a medication review, staff denied any aggressive behaviors, and the plan of care was to continue on the current medication plan. A review of the Progress Note dated 01/31/2025, revealed that nursing staff reported increased anger outbursts and that the patient had been getting up during the night and disrupting other residents. The Progress Note revealed that Resident #97 was started on [an atypical antipsychotic] previously. However, it seemed that [Resident #97] has not been receiving the medication, per discussion with [Resident #97] and [LPN #3].A review of the Progress Note dated 02/25/2025, revealed that Resident #97 had Recent behavior issues. [an atypical antipsychotic] has been ordered. Nursing staff requesting from pharmacy. A review of Medication Regimen Review (MRR) on 06/19/2024 indicated Resident #97 was on [an atypical antipsychotic] 2.5 mg every night at bedtime for vascular dementia with delusions. A suggestion was made for a gradual dose reduction (GDR). The MD declined stating, The patient has delusions that cause [pronoun] great fear and anger that can result in harming other residents and/or staff. Since starting the medication, delusions have decreased significantly without adverse effects to the patient. Will continue the medication at the lowest effective dose at this time and continue to monitor closely. Risks of GDR at this time outweigh possible benefits. A review of MRR dated 09/19/2024, revealed Resident #97 was only on [prescription medication used to treat seizure disorders, manic episodes associated with bipolar disorder, and to prevent migraine headaches] ER (extended release) 500mg tab Give 2 tabs (1000mg) every night at bedtime for dementia. A suggestion was made to do a GDR. The MD agreed to make the following dose reduction to [prescription medication used to treat seizure disorders, manic episodes associated with bipolar disorder, and to prevent migraine headaches] ER 500mg every night at bedtime. A review of an Administrator's Statement dated 08/13/2026 revealed that on 08/12/2026 she spoke with the Licensed Practical Nurse (LPN) #3 that made rounds with the MD on 01/31/2025. The Administrator reported that LPN #3 did not recall an order being given for [atypical antipsychotic] during rounds with the MD. The Administrator indicated she spoke with the MD and PNP and that both providers indicated that their documentation was based on and referenced each other's respective Progress Notes. The Administrator concluded, Upon review and follow-up, an actual medication order for [atypical antipsychotic] was not issued or received. Therefore, the [atypical antipsychotic] order was never entered for implementation. During an interview on 08/12/2026 at 5:12 PM, the MD indicated when the PNP refers to the medical team she was referring to the MD. During a follow-up interview on 08/13/2026 at 12:59 PM, the MD indicated that Resident #97 was previously on [atypical antipsychotic] 2.5 mg, but the order was discontinued on 09/18/2024. She indicated on the Progress Note for 01/31/2025 she recommended to continue with [atypical antipsychotic] 7.5 mg because she looked at the PNP Progress Note and seen that the PNP started [atypical antipsychotic]7.5 mg on 01/13/2025 during the psychiatric evaluation consultation. The MD indicated she did look at the current medications list when she made rounds monthly. During an interview on 08/13/2026 at 1:10 PM, the PNP indicated that on 01/13/2025 she wrote to continue [atypical antipsychotic] 7.5 mg but that was entered incorrectly. She indicated she did look at the physical orders when she made her rounds. The PNP indicated two errors were made. She stated she should have entered 2.5mg instead of 7.5 mg and that the Medical Team tapered Resident #97 off of the [atypical antipsychotic] and it was never reordered. The PNP indicated she missed the discontinued order for [atypical antipsychotic] that the MD entered on 09/18/2024. During an interview on 08/13/2026 at 3:00 PM, the Administrator indicated the antipsychotic medication that Resident #97 was supposed to have been on was never ordered. She indicated she spoke with both the MD and the PNP and both thought the other had prescribed the needed medication for dementia and delusions but neither followed through with giving the order to the nurse. The Administrator was unable to answer if not receiving the needed medication would cause any problems.

Based on observations, interviews, and record review the facility failed to provide a smoking apron for 3 (Resident #44, Resident #6, Resident #45) of 4 residents on the secured unit who smoked. The findings are: A review of the facility policy Smoking Policy-Resident with a revision date of July 2024, indicated 7. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring g) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 1. A review of an Order Summary indicated the facility admitted Resident #6 with diagnoses that included dementia, type 2 diabetes, and chronic obstructive pulmonary disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 01/11/2025 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment. A review of Resident #6's Care Plan initiated on 11/28/2023, stated that Resident requires smoking apron while smoking. A review of the Quarterly Smoking Safety Screen revealed that Resident #6 was marked under section 7 for adaptive equipment, 7a was marked for smoking apron. 2. A review of an Order Summary indicated the facility admitted Resident #44 with diagnoses that included chronic obstructive pulmonary disorder, anxiety disorder, and depression. The admission MDS, with an ARD of 1/20/2025, revealed Resident #44 had a BIMS of 00 which indicated severe cognitive impairment. A review of Resident #44's Care Plan initiated on 01/23/2025, indicates that Resident requires supervision with smoking. A review of the Admission Smoking Safety Screen indicated that Resident #44 under section 7 need for adaptive equipment, 7a was marked for smoking apron. 3. A review of an Order Summary indicated the facility admitted Resident #45 with diagnoses that included anxiety disorder, dementia, and depression. The annual MDS with an ARD of 12/12/2024, revealed that Resident #45 had a BIMS of 15, which indicated cognitively intact. A review of Resident #45's Care Plan initiated on 7/10/2023 indicated that The resident needs a smoking apron while smoking. A review of the Quarterly Smoking Safety Screen indicated that Resident #45 under section 7: need for adaptive equipment; 7a was marked for smoking apron. 4. On 02/26/2025 at 10:00 AM, this surveyor observed Licensed Practical Nurse (LPN) #19 unlock the courtyard door on the secure unit for smoke break. Certified Nursing Assistant (CNA) #18 assisted four residents outside. This surveyor observed CNA #18 light cigarettes for each resident and supervise the residents while smoking. This surveyor also observed that Resident #6, Resident #44, and Resident #45 were not wearing smoking aprons while smoking. 5. During an interview on 02/26/2025 at 12:46 PM, CNA #18 stated they were familiar with the residents on 500 Hall (The secure unit in the facility where Residents #6, #44, and #45 resided). CNA #18 stated that the procedure for smoke breaks was that they go get the cigarettes, then wait for the nurse to let them out. Then they light cigarettes for the residents and ensure that everyone is in view for safety. CNA #18 stated that they use a red trash can, and a fire extinguisher was close by. CNA #18 stated they were not aware of any residents on the secure unit that need a smoking apron. CNA #18 then stated that on the halls, the smoking lockbox had a running list of residents who wear smoking aprons and that each one was labelled for the resident that needs it during break. CNA #18 stated that they were not aware that three of the four residents were supposed to wear smoking aprons on the secure unit, and without it they could get burned or hurt while smoking. 6. During an interview on 02/26/2025 at 1:15 PM, LPN #19 stated the procedure on the hallway was to have a list of residents that wore smoking aprons posted on the smoking lockbox, and to have individual smoking apron labeled with the resident ' s name. LPN #19 stated they were not aware of any residents on the secure unit that needed a smoking apron because there was not a list posted, or a smoking apron labeled for residents' use. 7. During an interview on 02/26/2025 at 1:30 PM, the Director of Nursing (DON) stated the facility ' s procedure was to label smoking aprons and to keep an updated list to make staff aware of who needed one. The DON then stated it was important to use smoking aprons to prevent burns because it was really necessary for resident safety.

Based on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure over the counter medications in medication cart #1 were not expired. The findings include: Review of a facility policy titled, Storage of Medications, revised November 2024, indicated Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. During an interview on 02/25/2025 at 2:26 PM, the DON revealed that the facility had a book and garbage can that medications were placed in, within the medication room, for destruction of over-the-counter medication. On 02/25/25 at 3:05 PM, this surveyor observed Licensed Practical Nurse (LPN) #16 during inspection of medication cart #1, which revealed 16 medications that were expired or did not have an expiration date. Medications found that were out of date were Fish oil (no expiration date), Vitamin E 180mg (no expiration date), Bisacodyl laxative 5mg (expired 9/2024), Aspercreme (Pain reliever cream) (expired 4/2024), Preparation-H (hemorrhoidal) cream (expired 1/2025), Spiriva Respimat inhalers (nine expired 11/2024 and two expired 05/2024). During an interview with LPN #16 on 02/25/25 at 3:05 PM, she confirmed it was not appropriate to have expired medication on the medication cart. Normally we discard them. Expired medications can make residents sick. During an interview with the Assistant Director of Nursing (ADON) on 02/05/2025 at 11:37 AM, she confirmed that she handled the process of discarding expired medication. She confirmed that any expired medications, discontinued medications, or over the counter (OTC) medications from the medication carts were pulled from the carts, taken to the medication room and the pharmacist destroyed them. She confirmed the pharmacist did a match back from the medication destruction book and the medication card and then destroyed them. She confirmed if a narcotic had expired or the resident had discharged , the medication was removed, double signed in the narcotic book and removed from the medication cart. She completed a form and put the resident's name on the form along with the dosage, strength, prescriber, and how much medication was left for surrendering. She revealed two people placed the medications along with the form in a box and sent them back to the state for destruction. During an interview with the DON on 02/27/25 at 2:32 PM, she confirmed medication carts were to be checked weekly for expired medication and expired medication should be removed. The process was to have reconciliation and book in place, place the number of the medication in the book, and place medications in a bag in the locked container. The DON stated the expired medications could cause side effects and harm to residents. During an interview with the Administrator on 02/27/25 at 2:34 PM, she confirmed that expired medication should be thrown away. The Administrator stated a possible outcome from expired medication could be less potent and they [residents] would not get the dose they needed. A review of the, Material Data-Aspercreme, revised 08/14/2014 revealed, Dispose in accordance with all local, state, and federal regulations. A review of the Material Data-Bisacodyl, revised 02/22/2025 revealed, The material can be disposed of by removal to a licensed chemical destruction plant or by controlled incineration with flue gas scrubbing. Do not contaminate water, foodstuffs, feed or seed by storage or disposal. Do not discharge to sewer systems. Dispose of content/container to an appropriate treatment and disposal facility in accordance with applicable law and regulations, and product characteristics at time of disposal. A review of the Material Data-Fish Oil, revised 07/15/2019 revealed, The material can be disposed of by removal to a licensed chemical destruction plant or by controlled incineration with flue gas scrubbing. Do not contaminate water, foodstuffs, feed or seed by storage or disposal. Do not discharge to sewer systems. A review of the Material Data-Preparation H, revised 12/15/2008 revealed, Dispose of in accordance with local and national regulations. A review of the Material Data-Spiriva Respimat, revised 01/2025 revealed, After assembly, the Spiriva Respimat inhaler should be discarded at the latest 3 months after first use or when the locking mechanism is engaged, whichever comes first. A review of the Material Data-Vitamin E, revised 10/28/2024 revealed, The material can be disposed of by removal to a licensed chemical destruction plant or by controlled incineration with flue gas scrubbing. Do not contaminate water, foodstuffs, feed or seed by storage or disposal. Do not discharge to sewer systems. Dispose of content/container to an appropriate treatment and disposal facility in accordance with applicable law and regulations, and product characteristics at time of disposal.

Based on observation, record review, and interview, and facility policy review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. On 02/25/25, the supper meal menu revealed the residents who received pureed diets were to receive 1/2 cup of hashbrowns and 2 ounces of country gravy and residents who received regular diets were to receive 2 sausage patties. 2. On 2/25/25 at 5:03 PM, Dietary [NAME] (DC) #5 served 2 sausage patties to 10 residents who received large portion diets and gave one sausage patty to 41 residents who received regular diets, instead of giving 2 sausage patties to all residents. On 2/26/25 at 2:00 PM, DC #5 was interviewed and was asked which residents received 2 sausage patties. DC #5 stated it was the residents on large portion diets. When asked if she had reviewed the menu, DC #5 stated she had not. 3. On 2/25/25 at 5:10 PM, DC #5 used a # 10 scoop (3/8) cup to serve a single portion of pureed hashbrown to the residents on pureed diets, instead of 1/2 cup. There was no gravy served to the residents on pureed diets. On 2/26/25 at 2:00 PM, DC #5 was interviewed and was asked the reason gravy was not served to the residents on pureed diets. DC #5 stated she forgot. 4. On 2/26/25, the noon meal menu documented the residents who received pureed diets were to receive pureed chocolate cake. 5. On 02/26/25 at 12:35 PM, yellow cake was pureed and served to the residents on pureed diets, instead of chocolate cake. At 2:35 PM, during an interview, Dietary Aide (DA) #6 was asked the reason the residents on pureed diets were served yellow cake, instead of chocolate. DA #6 stated there was not enough chocolate cake to go around. We usually make 1 chocolate bag. When we used 2 bags yesterday it overflowed the pan. 6. A review of facility policy titled, Food and Nutrition Services, initiated 2017, provided by the Administrator on 2/27/25 indicated Food and Nutrition Services staff should inspect food trays and make sure the correct meal was provided to each resident. 7. A review of facility policy titled, Food and Nutrition Services Quick Recourse Tool, initiated 9/1/2021, provided by the Administrator on 2/27/25 indicated, Menus should be served as written, unless a substitution was provided in response to preference.

Based on observation, facility document review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The findings are: 1. On 2/25/25 5:46 PM, the following observations were made during the supper meal service: a. Residents on pureed diets were served pureed hashbrown. The consistency was lumpy, thick, and not smooth. There were still pieces of potatoes in the mixture. b. Pureed sausage. The consistency was lumpy, thick, and not smooth. There were pieces of sausage visible in the mixture. c. Pureed beets. The consistency was lumpy and not smooth. The were chunks of beets still in the mixture. 2. On 2/25/25 at 5:49 PM, Licensed Practical Nurse /[NAME] Data Set Coordinator (LPN) #7, during an interview, was asked if she could describe the consistency of the pureed food items served to the residents on pureed diets in the dining room. Pureed beets had chunks of beets in it. Pureed hashbrowns were lumpy and not smooth. Pureed sausage was thick and had pieces of meat in it. She further stated that pureed foods should be smooth like pudding and not contain lumps. 3. On 2/25/25 at 5:51 PM, during an interview with Certified Nursing Assistant (CNA) #8, she was asked if she could describe the consistency of the pureed food items served to the residents on pureed diets. She stated they were all thick and were not ground enough, that they should be a smooth consistency like pudding. 4. On 2/25/2025 at 5:52 PM, during an interview, CNA #9 was asked what the consistency of pureed food should be. She stated it should be pudding-like. 5. On 2/25/25 at 5:53 PM, during an interview with LPN #10 she was asked if she could describe the consistency of the pureed food items served to the residents for supper meal and she stated they were too thick, and the beets and sausage looked like they were not ground all the way. 6. On 2/25/25 at 6:45 PM, Dietary [NAME] (DC) #5 was interviewed and asked if she could describe the consistency of the pureed food items served to the residents for supper meal. DC #5 stated the consistencies were too thick and had solid pieces of food. They should be smooth like mashed potatoes and stated she should have used more water. 7. On 2/25/25 at 6:47 PM, Dietary Manager (DM) #1, during an interview, was asked if she could describe the consistency of the pureed food given to the residents at the supper meal. She stated the beets and sausage were hard to puree, and pieces of beets and sausage were present intact. Ideally pureed should be smooth like mashed potatoes. 8. On 2/26/25 at 8:10 AM, the oatmeal served to the residents for breakfast was too thick. At 8:42 AM, during an interview with DC #5, when asked about the consistency of the oatmeal she stated that it was too thick, and she should have used more water. DM #1 confirmed the oatmeal was too thick. 9. On 2/26/25 at 8:15 AM, CNA #14 was interviewed and asked if she could describe the consistency of the oatmeal served to the residents for breakfast meal. She stated it was too thick. 10. On 2/26/25 at 8:16 AM, CNA #15 was interviewed and was asked if she could describe the consistency of the oatmeal served to the residents for breakfast meal. She stated it was dry. 11. On 2/26/25 at 8:18 AM, LPN #10 was interviewed and was asked if she could describe the consistency of the oatmeal served to the residents for breakfast meal. She stated it was too thick. 12. A review of facility Menu titled, The Springs -Week 3, initiated 9/26/2024 provided by the Dietary Manager #1 on 2/26/2025 indicated, Pureed diets should be pudding consistency and serving size listed on the menu.

Surveyor: [NAME], [NAME] Based on observation, interview, and facility policy review, the facility failed to ensure ceiling tiles, dish washing machine, and door frames were free of stains, rotten and chipped wood; cold food items were maintained at 41 degrees Fahrenheit or below; dietary staff washed their hands before handling food items; foods stored in the dry storage area, refrigerator, and freezer were covered, sealed and dated; and expired food items were promptly removed from stock for 2 of 2 meals observed. The findings are: 1. On [DATE] at 10:40 AM, the following observations were made in the dry storage area: a. An opened 25-pound bag of fish breading spilled over onto the shelf, and onto the top of a 50-pound bag of sweetened cornbread mix. Dietary Manager #1confirmed that the bag was not sealed well. Dietary Manager #1 stated that items should be sealed well to prevent cross-contamination. b. Half of a 10 pound bag of penne noodles at the bottom shelf was partially sealed, exposing it to air. Dietary Manager #1 confirmed findings. c. A gallon of vinegar was on the shelf which expired on [DATE]. Dietary Manager #1 confirmed findings. d. The ceiling in the dry storage area had ceiling tiles with brown rings; all tiles looked affected. The light was dim in the storage area. The small room that held the emergency food supply before the dry storage area had ceiling tiles with brown rings and some of the tiles appeared to be bowing. 2. On [DATE] at 10:50 AM, the following were found in the three-door refrigerator: a. Two cardboard boxes of bacon were located on the second shelf, instead of the bottom. Dietary Manager #1 stated that uncooked items like bacon should be stored on the bottom to prevent dripping and any cross contamination with other food items. b. A clear bag containing 2 ,d+[DATE] blocks of cheese had no date. 3. On [DATE] at 4:38 PM, the temperatures of the cold food items in a pan of ice on the steam table when checked and read by Dietary [NAME] (DC) #5 were: a. Pureed beets were 78 degrees Fahrenheit. The consistency was lumpy and not smooth. There were chunks of beets still in the mixture. b. Regular beets were 67 degrees Fahrenheit. 4. On [DATE] at 4:42 PM, DC #5 dropped the temperature gauge on the floor and picked it up. Then, DC #5 turned on the faucet and rinsed off the temperature probe. After rinsing it, she turned off the faucet with her bare hand, contaminating it. Afterwards, DC #5 removed an alcohol pad from its packet, and used it to sanitize the temperature probe before checking the food temperatures. 5. [DATE] at 5:14 PM, Dietary Aide (DA) #4 who was on the tray line assisting with the supper meal service picked up condiments and spices and placed them on the trays. Without washing her hands, DA #4 picked up glasses that contained beverages by their rims and placed them on the trays. DA #4 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. 6. On [DATE] at 5:15 PM, DA #4 was interviewed and was asked what was in the bowl that she was about to place on the tray. She stated it was yogurt. Dietary Manager #2 was asked if she could check the temperature of the yogurt. She did and stated it was 78 degrees Fahrenheit. 7. On [DATE] at 9:07 AM, upon observation of the dry food storage room with Dietary Manager#1 the following items were found: a. A 25-pound bag of flour was observed to be expired with best by date [DATE], unopened and was received [DATE]. b. A bag of sweet cornbread mix on a shelf in the storage room was torn exposing the cornbread mix to air. Dietary Manager #1stated that the cornbread mix was exposed, and she would toss it. 8. A review of facility policy titled, Hand washing /hand hygiene, initiated 2024, provided by the Dietary Manager #1 on ,d+[DATE], indicated, employees should wash their hands before and after coming on duty.

Based on observation, record review, and interview, it is determined that the facility failed to ensure a resident who was on Transmission Based Precaution had a contact isolation sign in a conspicuous location outside the resident ' s room to alert and instruct staff and visitors to wear personal protective equipment (PPE) while entering the room for 1(Resident #4) of 1 sample mix resident reviewed for Transmission Based Precautions. The findings are: Review of facility policy titled Isolation - Categories of Transmission-Based Precautions dated 08/01/2024, indicated Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents and Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. The policy also indicated When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notifications comply with the resident's right to confidentiality or privacy. c. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. A review of an Admission Record indicated the facility admitted Resident #4 with diagnoses that included pressure ulcers and resistance to vancomycin (VRE). The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) of 00, which indicated the resident was severely cognitively impaired. Review of Resident #4's Care Plan initiated on 02/19/2025, revealed the resident required isolation precautions to include Contact isolation for VRE in their wounds. Review of Resident #4's Order Summary Report dated 02/17/2025, specified contact isolation for VRE wound infection for 10 days. On 02/24/2025 at 10:45AM there was a sign on Resident #4's door that read see nurse before entering. On 02/24/2025 at 11:00 AM, the surveyor observed CNA #12 enter Resident #4's room without wearing a gown. On 02/24/2025 at 2:30PM there was a sign on Resident #4's door that read see nurse before entering. An observation on 02/25/2025 at 8:30 AM, revealed a sign on Resident #4's door that read see nurse before entering. On 02/25/2025 at 11:10AM, during interview with Registered Nurse (RN) #13 she stated Resident #4 was in isolation, but she was not sure why. During an interview, on 02/25/2025 at 11:30AM, Licensed Practical Nurse (LPN) #7 stated Resident #4 should have a sign on the door that read Contact Isolation. See nurse before entering. She stated the reason was to alert staff and visitors to wear a gown and gloves before entering the room to prevent the spread of infections. During an interview with CNA #12, on 02/25/2025 at 12:00PM, she stated that she was not aware that Resident #4 was on Contact Isolation. The Director of Nursing (DON) was interviewed on 02/26/2025 and stated that Resident #4 should have a sign on the door informing staff and visitors that the resident was on contact isolation due to contact isolation requiring a gown and gloves to be worn prior to entering the room.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to initiate a care plan for elopement risk for 1 (Resident #3) of 1 resident reviewed for high risk elopement. Findings include: A review of a facility policy titled, Wandering and Elopements, dated 03/01/2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the Admission Record, indicated the facility admitted Resident #3 on 07/08/2022, with a principal diagnosis of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2024, revealed Resident #3 had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. A review of Resident #3's Care Plan, initiated 07/08/2022, did not address the high risk for elopement. A review of Resident #3's Admission assessment dated [DATE], indicated in Section 13 - Safety, that Resident #3 was at a high risk for elopement with a score of 8. During an interview on 05/21/2024 at 9:31 AM, the Director of Nursing (DON) confirmed the criteria for placement on the secure unit is when a resident scores greater than 1 on the elopement risk assessment, then resident is placed on the secure unit.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 3 residents reviewed for elopement. Findings include: A review of a facility policy titled, Wandering and Elopements, dated 03/01/2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .3. If a resident is missing, initiate the elopement/missing resident emergency procedure .b. If the resident was not authorized to leave, initiate a search of the building and premises; and if the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and volunteer agencies . A review of the Admission Record, indicated the facility admitted Resident #1 with diagnoses that included auditory hallucinations, alcohol abuse, cocaine abuse, age-related cognitive decline. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment and did not exhibit any wandering behaviors. A review of Resident #1's Care Plan, revised on 05/15/2024, revealed Resident #1 was an elopement risk/wanderer related to cognitive decline, history of attempts to leave facility unattended and impaired safety awareness and drug seeking. Interventions included distracting Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversations, television, book and be evaluated for placement on a secure unit, if indicated. A review of a Progress Note dated 04/12/2024, revealed Resident #1 was cursing at staff when the resident was asked to step away from the double doors trying to get off the unit. A review of a Progress Note dated 04/12/2024, revealed Resident #1 was observed by staff going in and out of all the rooms trying to raise the windows to get out. Redirected resident but he continues with this behavior. A review of a Progress Note dated 05/16/2024, revealed Resident #1 had been found in a resident's room trying to crawl out of the window. A review of a Progress Note dated 05/16/2024 revealed Resident #1 was continuing to get out of the doors and windows and an order was obtained for Ativan and medication was administered. During an interview on 05/20/2024 at 10:42 AM, Certified Nursing Assistant (CNA) #1 confirmed picking up Resident #1 on 05/14/2024 around 6:20 PM on the side of the street near the old library, approximately 1 mile away from the facility. CNA #1 confirmed Resident #1 was confused but not injured. CNA #1 confirmed contacting the Administrator regarding Resident #1 being on the side of the street and not at the facility. During an interview on 05/20/2024 at 11:39 AM, the Director of Nursing (DON) confirmed Resident #1 was able to get out of the secure unit and out of the building and go approximately 1 mile from the facility. The DON confirmed CNA #1 brought Resident #1 back to the facility. During an interview on 05/20/2024 at 11:53 AM, the Administrator confirmed Resident #1 was found approximately 1 mile from the facility by an employee that was off work. The Administrator confirmed when Resident #1 returned to the facility the resident was assessed and a root cause analysis was conducted. During an interview on 05/20/2024 at 1:27 PM, the Administrator confirmed Resident #1 was unaccounted for approximately 30 to 45 minutes. During an interview on 05/20/2024 at 2:25 PM, Resident #1 confirmed he walked out of the door because they don't pay attention. Resident #1 pointed to the wooden double doors which exit the secure unit. Resident #1 then stated he used a black chair to climb out the window by the television. During an interview on 05/21/2024 at 10:48 AM, the Administrator confirmed the facility completed head count of everyone, assessed all doors, assessed resident, verbally asked all staff members about residents, started interview process, and made sure everyone was safe and in the building.

37634 Based on observation and interview, the facility failed to ensure foods stored in the dry storage area refrigerator, and freezer were covered, sealed and dated to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness, kitchen wall and door frames, ceiling tiles; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen, kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, dish washer and kitchen walls, door frames and baseboards were free of rotten wood, chipped floor tiles, chipped base board, debris, dirt, grease, grime, rust, stains, and spills; wall tiles were replaced, metal counter supports in the dish washing machine were secured to the wall, and dietary staff washed their hands before they handled clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect - residents who received meals from the kitchen (total census:), as documented on a list provided by the Dietary Supervisor on [DATE] PM. The findings are: On [DATE] 08:44 AM The following observations were made in the kitchen: a. At the entrance door to the kitchen, the floor was chipped exposing the cement. The area had dirt and debris. b. The floor outside the dirty dish window had yellow stains on it. c. The metal facing the dirty dish window has stains on it. d. The floor leading to the kitchen was chipped. The area was corroded with brown residue. d. The door frame was chipped and a buildup of dirt on it. e. The paint on the door frames leading to the kitchen peeled off, exposing the metal. f. The bottom of the door frames was rotten. The areas had a buildup of dirt on them. g. The dirty dish window washing machine frames were chipped, exposing the metal. The areas were covered with rust. h. There were 4 tiles missing from the wall above the dish washing machine, exposing the cement. The area that was exposed had accumulations of sage color. i. There were 3 loose tiles on the wall by the dish washing machine room. j. There was an accumulation of sage color across the trim of the wall tile in the dish washing machine room. k. The legs of the counter on the dirty dish window and on the clean side of the dish machine were covered with black, brown, and gray residue on them. l. The top of the baseboard tile was chipped off, exposing the concert. n. The ceiling tile above the deep fryer was cracked, exposing the concert. m. The facing of the vent hood peeled off, exposing the metal. n. Two of 2 air vents by the food preparation counter had buildup of gray/black lint stuck to the slats. o. The floor tile between the air unit and food preparation counter was missing. The area where the tiles were missing had a mixture of grease buildup and food crumbs on it. p. There were brown liquid b stains on the floor in front of the food preparation counter. q. The floor in front of the ice machine in the room leading to the dining room had black stains. r. The right side of the wall leading to the ice room was chipped, exposing the cement. 3. On [DATE] at 08:59 AM The following observations were made in the freezer. a. An opened box of carrots, there was no opened date on the box. b. An opened box of biscuits, there was no opening date on the box. c. An opened box of corn was on a shelf, there was no opened date on the box. d. An opened box of sugar cookies was on a shelf, no date was on the box. e. An opened box of chocolate cookies was on a shelf, no date was on the box. 4. On [DATE] at 09:07 AM Dietary Employee (DE) #1 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating his hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean rack to be used in serving noon meal to the residents with her fingers touching the interior surfaces of the plates. At 09:20 AM, when (DE) #1 was about to transfer plates to the warmer. The Surveyor immediately asked DE #1 what you should have done after touching dirty objects or before handling clean Equipment? She stated, I should have removed gloves and washed my hands. I will rewash them. 5. On [DATE] at 09:23, two of 2 bags of cornflakes on a shelf in the dry storage room had an expiration date of [DATE]. 6. On [DATE] at 09:27 AM The following observation was made in the refrigerator in the nourishment room on the 500 Hall: a. A bottle of mayonnaise on a shelf documented, Best used by [DATE]. There was no received or opened date on the bottle and no name was on the bottle to identify whom it belongs. b. A bottle of unopened miracle whip was on a shelf with an expiration date of [DATE]. c. A carton of orange juice drink was on a shelf had an expiration date of [DATE]. d. An opened bottle of mustard on a shelf with no date on it. e. A zip lock bag that contained corndog was on a shelf. There was no date on the bag. 7. On [DATE] at 09:29 AM, a box of chicken fettuccine alfredo was on a shelf. There was no received or opened date on the box, and there was no name on the box to indicate whom it belongs to. 8. On [DATE] at 09:56 AM. A box of grilled chicken marinara with parmesan cheese was on a shelf in the freezer in the nourishment room on the 100 Hall, there was no name on the box to indicate whom it longs for. No received or opened date on the box. 9. On [DATE] at 11:30 AM, DE #2 pushed a cart that contained racks with glasses towards the counter. Opened the refrigerator and removed a pitcher of tea and placed it on the counter. She poured tea in the glasses and without washing her hands, she picked up the glasses by their rims and placed them on the trays to be served to the residents for lunch meal. 10. A facility policy titled . Quick Resource Tool Hand Washing provided by the Dietary Supervisor on [DATE] at 01:13 PM documented, When to wash hands, Wash your hands as often as possible. It is important to wash your hands. a. Before starting to work with food, utensils, or equipment. b. Before putting on gloves. c. As often as needed during food preparation when changing gloves. On [DATE] at 11:00 AM during the initial tour of the kitchen the floors were dirty with food crumbs. There was a bag of bacon in the refrigerator that wasn't sealed of dated. There was a package of pancake mix in the pantry that was not sealed.

Based on observation, interview and policy review, he facility failed to post, in a form and manner accessible and understandable to residents, contact information for pertinent State agencies and advocacy groups for 20 residents residing in the facility's secure unit (500 Hall). The findings are: On 01/29/24 at 11:33 AM it was observed that contact information for State agencies and the Ombudsman was not posted in the secure unit in the facility. Doorways into the secure unit were closed and secured to prevent residents from exiting and observing contact information posted in other parts of the facility. On 01/29/2024 at 03:30 PM it was observed that contact information for State agencies and the Ombudsman was not posted in the secure unit in the facility. On 01/30/2024 at 08:00 AM it was observed that contact information for State agencies and the Ombudsman was not posted in the secure unit in the facility. On 01/30/2024 at 3:35 PM it was observed that contact information for State agencies and the Ombudsman was not posted in the secure unit in the facility On 01/31/2024 at 03:25 PM Registered Nurse #1 confirmed that contact information for State agencies and the Ombudsman was not posted on the secure unit but was required to be posted in the manner that it was accessible to all residents. On 01/31/2024 at 03:30 PM the Director of Nursing confirmed that contact information for State agencies and the Ombudsman was required to be posted in the manner that it was accessible to all residents to include those residing on the secure unit. On 01/31/2024 at 03:40 PM the Administrator confirmed that contact information for State agencies and the Ombudsman was required to be posted in the manner that it was accessible to all residents to include those residing on the secure unit. On 02/01/2024 at 01:00 PM the Administrator reported the facility did not have a policy on required postings in the facility.

Based on observation and interview, the facility failed to post the results of the most recent survey in a location where individuals wishing to examine survey results do not have to ask to see them. The findings are: On 01/31/24 at 01:57 PM, four members of the Resident Council (Resident's #3, #19, #20, #42) were asked if they were aware of the location of the survey results binder. All four residents stated they had not been informed of the location of the binder and had never seen it in the facility. On 01/31/24 at 02:19 PM, the Surveyor did not observe the State Survey Results book readily available. On 01/31/24 at 02:23 PM, the Surveyor requested the location of the survey binder from the Administrator. The Administrator said we keep it on the table by the door, but we painted last week, and it was moved to my office. The Surveyor observed the Administrator put the survey binder back in the office. The Surveyor asked is the survey book readily available in its present location? The Administrator confirmed it was not available. A form provided by the Administrator on 2/2/2024 at 8:48 am labeled, Resident Rights showed, .The resident has the right to .examine the results of the most recent survey of the facility conducted by Federal or State surveyors and plan of correction in effect with respect to the facility .

Based on interview, and record review the facility failed to ensure an advance directive were in the electronic record, and readily available for 2 (Resident #31, and Resident #47) of 15 (Resident #9, #17, #19, #23, #24, #28, #30, #31, #32, #46, #47, #49, #52, #57, #265) sampled residents. The findings are: 1. Resident #31 had a diagnosis of TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA. A Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 12/12/23 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status. On 1/30/24 at 11:45 AM, no advance directive was observed in the electronic record. On 1/30/24 at 2:15 PM, the Director of Social Service was asked, Can you tell me why Resident #31 doesn't have an advance directive in the clinical record? She looked in the computer, then she stated, It's not in the admission packet. She was asked, When should an advance directive be formulated? She stated, Right before a patient comes in. 2. Resident #47 had a diagnosis of LEGAL BLINDNESS, VASCULAR DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE. A Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 12/14/23 documented the resident scored 03 (00-03 indicates severe impairment) on the Brief Interview for Mental Status. On 1/30/24 at 11:49 AM, no advance directive in clinical record On 1/30/24 at 12:18 PM the Director of Nurse (DON) provided a form titled, . Resuscitation Designation Order that showed a checked box indicating that a Power of Attorney/Health Care Proxy will be on file. The form was not dated. On 1/30/24 at 2:42 PM the Director of Social Service was asked, , Can you tell me why Resident #47 doesn't have an advance directive in the clinical record? She looked in the computer, then she stated, It's not in the admission packet. I'll go up front and see if it's in the business office. On 1/30/24 at 2:55 PM the Director of Social Service stated, We can't find an advance directive. I'll have to call the family.

Based on observation, interview and policy review, the facility failed to maintain the building in good repair by (1) ensuring that bathroom sinks were properly affixed for the restrooms for resident rooms 513, 514, 515, 516, 517, 519 on the secure unit, (2) ensuring that window coverings were not damaged for room [ROOM NUMBER], and (3) ensured that molding remained attached to the wall for room [ROOM NUMBER]. The findings are: 1. On 01/29/2024 at 11:52 AM, the Surveyor observe the sink in the shared bathroom for rooms [ROOM NUMBERS] was not securely attached to the wall and that a gap was present between the sink and the wall. The Surveyor was able to move the sink vertically and horizontally. a. On 01/30/2024 at 08:45 AM, the Surveyor observed the sink in the restroom for rooms [ROOM NUMBERS] remained loose and insecurely mounted. b. On 01/31/2024 at 09:15 AM, the Surveyor observed the sink in the restroom for rooms [ROOM NUMBERS] remained loose and insecurely mounted. 2. On 01/29/2024 at 11:53 AM, the Surveyor observed the sink in the shared bathroom for rooms [ROOM NUMBERS] was not securely attached to the wall and that a gap was present between the sink and the wall. The Surveyor was able to move the sink vertically and horizontally. a. On 01/30/2024 at 08:55 AM, the Surveyor observed that the sink in the restroom for rooms [ROOM NUMBERS] remained loose and insecurely mounted. b. On 01/31/2024 at 09:17 AM, the Surveyor observed that the sink in the restroom for rooms [ROOM NUMBERS] remained loose and insecurely mounted. 3. On 01/29/2024 at 11:59 AM, the Surveyor observed the sink in the shared bathroom for rooms [ROOM NUMBERS] was not securely attached to the wall and that a gap was present between the sink and the wall. The Surveyor was able to move the sink vertically and horizontally. a. On 01/30/2024 at 08:58 AM, the Surveyor observed that the sink in the restroom for rooms [ROOM NUMBERS] remained loose and insecurely mounted. b. On 01/31/2024 at 09:22 AM, the Surveyor observed that the sink in the restroom for rooms [ROOM NUMBERS] remained loose and insecurely mounted. 4. On 01/31/2024 at 11:20 AM, the Administrator confirmed that the sinks should be firmly mounted to the wall because the sinks could fall. 5. On 01/30/2024 at 10:05 AM, the Surveyor observed the window dressings (blinds) in room [ROOM NUMBER] were heavily damaged with a 24-inch section of the device missing or broken. The window dressings were no longer functional. a. On 01/30/2024 at 02:44 PM, the Surveyor observed the window dressings in room [ROOM NUMBER] to remain damaged. b. On 01/31/2024 at 09:00 AM, the Surveyor observed the window dressings in room [ROOM NUMBER] to remain damaged. 6. On 01/30/2024 at 10:05 AM, the Surveyor observed a 5-foot piece of molding intended to be attached below the window in room [ROOM NUMBER] detached from the wall and lying in the floor of the resident room. a. On 01/30/2024 at 02:44 PM, the molding remained detached from the wall, resting on the floor of room [ROOM NUMBER]. b. On 01/31/2024 at 09:00 AM, the molding remained detached from the wall, resting on the floor of room [ROOM NUMBER]. 7. On 02/01/2024 at 02:00 PM, the Administrator confirmed the window dressings and molding should be maintained in good repair in resident rooms. 8. On 02/01/2024 at 02:20 PM, the Maintenance Supervisor confirmed that the window dressings and molding should be maintained in good repair in resident rooms. 9. On 01/29/2024 at 12:12 PM, room [ROOM NUMBER] the Surveyor observed a 2 by 2-foot section of ceiling tile missing from the ceiling of room [ROOM NUMBER] on the secure unit. The opening was located above the window in the resident room. Pink fiberglass insulation was protruding from the hole and extending into the resident room. a. On 01/29/2024 at 3:35 PM, the ceiling tile remained missing, and the fiberglass insulation continued to protrude from the opening. 10. On 02/01/2024 at 01:00 PM, the Administrator provided a document titled Policy .Preventative Maintenance Program. It documented, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public . 11. On 02/01/2024 at 02:00 PM, the Administrator confirmed that the ceiling tiles should be maintained in good repair in resident rooms to prevent resident exposure to fiberglass insulation.

Based on observation, interview, and record review the facility failed to ensure 1 (Resident 31) of 9 (Resident #9, #19, #23, #28, #31, #32, #46, #47, #265) sampled residents who depended on staff for shaving were shaved, and the facility failed to ensure nails were cleaned and trimmed for 2 (Resident #31, and Resident #47) of 15 (Resident #9, #17, #19, #23, #24, #28, #30, #31, #32, #46, #47, #49, #52, #57, #265) sampled residents whom depended on staff for nail care. The findings are: 1. Resident #31 had a diagnosis of TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA. A Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 12/12/23 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status. A care plan with an initiation date of 9/30/21 documented, . Diabetic toenail [is] to be provided by Licensed Staff . The review of an Activities of Daily Living (ADL) sheet on 2/01/24 indicated that the last time Resident #31 received nail care was 1/07/24. On 1/29/24 at 12:07 PM, Resident #3 ' s beard was approximately 3/4 inches long. He was asked, When was the last time you had a shave? He stated, It's been a while. Every time I ask for a shave, they say they can't find the clippers, or that they don't have anyone to do it. On 1/30/23 at 9:10 AM, Resident #31 beard was approximately 3/4 inches long. He was asked, When was the last time you had a shave? He stated, It's been a while. They said they were going to give me one yesterday, but they never came back. They always say they're coming back, but they never do. Resident #31 ' s nails were approximately 3/4 inches long with a black substance underneath. He was asked, How often do the staff trim and clean your nails? He stated, They don't. On 1/31/23 at 9:10 AM, Resident #31 ' s beard was approximately 3/4 inches long. His nails were approximately 3/4 inches long with a black substance underneath. He was asked, Did the staff give you a shave or trim your nails? He stated, No not yet. On 1/31/23 at 1:55 PM, Resident #31was observed in his wheelchair on the 100 hall. His beard was approximately 3/4 inches long. His nails were approximately 3/4 inches long with a black substance underneath. On 1/31/24 at 2:19 PM, Certified Nurse Aid (CNA) #3 was asked, how often does Resident #31 receive nail care. She said Certified Nurse Aid (CNA) #2 and CNA #6 from restorative goes around and do nail care, and whoever does showers also do nail care. On 1/31/24 at 2:30 PM, CNA #4 was asked, How often does Resident #41 get nail care? She stated, I am in restorative, so I usually do it twice a week if I'm not on the floor. Can you tell me why Resident #47 nails are long and dirty? She stated, I don't why. On 1/31/24 at 2:38 PM CNA #5 was asked, Can you tell me why Resident #31 hasn't had a shave, or his nails trimmed and cleaned? She stated, They were supposed to been doing him. She was asked, Who's responsible for shaving Resident #31? She stated, He gets a shower on whirlpool days, and if not, the CNA assigned to him. On 2/01/24 at 3:37 PM, a policy titled, . Shaving a Resident, documented, .The purpose of this procedure is to promote cleanliness and to provide skin care .The following information should be recorded in the resident's medical record . The date and time the procedure was performed .If the resident refused the treatment, the reason(s) why and intervention taken. The signature and title of the person recording the data .Notify the supervisor if the resident refuses the procedure . On 2/01/24 at 3:37 PM a policy titled, . Fingernails/Toenails, Care of, documented, .The purpose of this procedure is to clean the nailbed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed . The following information should be recorded in the resident's medical record . The date and time that nail care was given .The name and title of the individual(s) who administered the nail care . If the resident refused the treatment, the reason(s) why and intervention taken. The signature and title of the person recording the data .Notify the supervisor if the resident refuses the care . 2. Resident #47 had a diagnosis of LEGAL BLINDNESS, VASCULAR DEMENTIA, BEHAVIORAL DISTURBANCE. A Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 12/14/23 documented the resident scored 03 (00-03 indicates severe impairment) on the Brief Interview for Mental Status. On 1/29/24 at 1:40 PM, Resident #47 ' s fingernails are approximately 1/2 inches long with a black substance underneath. On 1/29/24 at 3:42 PM Resident #47 ' s fingernails are approximately 1/2 inches long with a black substance underneath. On 1/31/24 at 2:19 PM, Certified Nurse Aid (CNA) #3 was asked, Can you tell me why Resident #47 ' s nails haven't been trimmed and cleaned. She stated, I'm not sure. On 1/31/24 at 2:30 PM CNA #4 was asked, How often does the resident get nail care? She stated, I am in restorative, so I usually do it twice a week if I'm not on the floor. Can you tell me why Resident #47 nails are long and dirty? She stated, I don't why.

Based on interview and record review the facility failed to perform a Neurological Assessment after an unwitnessed fall for 1 (Resident #264) of 6 (Resident's #3, #24, #47, #49, #264, #265) sample mix residents were reviewed for falls. The Administrator provided a list at 1:24 PM on 2/2/2024 titled, Resident's with an unwitnessed fall since 9/1/2023. The findings are: Resident # 264's diagnoses showed vascular dementia with other behavioral disturbance; restlessness and agitation; Parkinson's disease without dyskinesia (condition that causes involuntary, erratic movements of different body parts); neurocognitive disorder, muscle wasting, and abnormalities of gait and mobility with unsteadiness on feet. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2023 showed a Brief Interview of Mental Status (BIMS) of 11 (a score of 8-12 points suggests moderate cognitive impairment). The Care Plan showed the resident had an actual fall with minor injury on 9/9/23 with an abrasion to the left side of the face and 1/6/24 with a laceration to the left cheek. Check vital signs post fall and as needed (PRN), report abnormalities to Medical Doctor (MD) and perform neurological checks as required. On 02/02/2024 at 11:32 AM, the Surveyor reviewed Resident #264's Incident report dated 9/13/2023, .the resident rolled out of the bed onto the floor . swelling noted to right side of face . neuro checks initiated . The Surveyor was unable to locate a neurological assessment for this date. On 02/02/2024 at 11:38 AM, the Surveyor reviewed Resident #264's progress note dated 12/3/2023, .General Note .Certified Nursing Assistant (CNA) reported hearing fall in room .they found the resident getting up off the floor .resident reports hitting the back of their head . The Surveyor was unable to locate a neurological assessment for this date. On 02/02/2024 at 11:48 AM, the Director of Nursing (DON) confirmed there were unable to locate neurological assessments performed on 9/9/2023 and 12/3/2023.

48483 Based on observation, interview, and record review, the facility failed to ensure that the resident environment was free from accident hazards for two (Rooms 305-A, 306-B, 506, 514, 516, 517, 518, and 519) resident rooms, one whirlpool room, and one secure unit in the facility. The findings are: On 01/29/24 at 01:59 AM, the Surveyor observed no call light string attached to the call light in the bathroom of room [ROOM NUMBER]-A. On 01/30/24 at 09:35 AM, the Surveyor observed no call light string attached to the call light in the bathroom of room [ROOM NUMBER]-A. On 01/31/24 at 11:03 AM, the Surveyor observed no call light string attached to the call light in the bathroom in room [ROOM NUMBER]-A. On 02/01/24 at 02:01 PM, the Surveyor asked the Director of Nursing (DO), tell me how a resident would call for help when they were in the bathroom? The DON said they should have a call light in the bathroom. The Surveyor accompanied the DON to the bathroom in room [ROOM NUMBER]-A. The DON confirmed there was not a pullcord attached to the call light. On 02/01/24 at 02:08 PM, the Surveyor asked Maintenance how would a resident call for help if they are in the bathroom? Maintenance stated they need a cord if they need help. The Surveyor accompanied Maintenance to the bathroom in room [ROOM NUMBER]-A and asked is there a pull cord attached to the call light? Maintenance said no there is not. On 02/01/24 at 02:15 PM, the Surveyor asked the Administrator How would a resident request help if they were in the bathroom? The Administrator said they would use the call light. The Surveyor asked is there a pull cord? The Administrator stated No. On 01/29/24 at 01:55 PM, the Surveyor observed exposed wires in a wall socket that did not have a plate cover in room [ROOM NUMBER] B. On 01/30/24 at 09:33 AM, the Surveyor observed exposed wires in a wall socket without a plate cover in room [ROOM NUMBER] B. On 01/31/24 at 11:07 AM, the Surveyor observed exposed wires in the wall socket without a plate cover in room [ROOM NUMBER] B. On 02/01/24 at 02:06 PM, the Surveyor asked the DON were you aware of the exposed wires in this room? The DON said no. The DON confirmed the wires were exposed. On 02/01/24 at 02:12 PM, the Surveyor accompanied Maintenance to room [ROOM NUMBER] B and asked Is it appropriate for wires to be exposed? Maintenance said no, they finished up this room Friday and I wasn't aware there wasn't a plug cover on it. The Surveyor asked Should there be exposed wires? Maintenance stated no they should be covered; wires shouldn't be exposed. On 02/01/24 at 02:19 PM, the Surveyor accompanied the Administrator to room [ROOM NUMBER] B and asked were you aware of the exposed wires. The Administrator said no. The Administrator confirmed the wires were exposed, and there should be a cover. On 01/31/2024 at 2:50 PM, the Surveyor observed the door to a room at the end of 400 hall unlocked and accessible by residents. Registered Nurse #1 identified the room as the whirlpool room. Inside the unlocked room was an open, unsecured cabinet full of hygiene supplies that included: a. Three bottles of body fragrance Mist. The label read, .Ingredients: Alcohol .Caution: Flammable . b. Four bottles of aftershave. The label read, .Keep away from children, for external use only .Ingredients .Alcohol . c. Six bottles of hair styling gel. The label read, .Caution .Keep out of eyes and mouth and out of the reach of small children .Use caution .flammable . d. Four bottles of baby oil. The label read, For external use only .Keep out of reach of children. On 02/01/2024 at 08:30 AM, the hygiene products remained unsecured and accessible to residents. On 02/01/2024 at 09:15 AM, Certified Nursing Assistant (CNA) #2 was informed of the unsecured hygiene products and confirmed that the hygiene supplies should be secured where they would not be accessible to residents. On 02/01/2024 at 2:00 PM, the Administrator confirmed that the hygiene products found unsecured in the whirlpool room should not have been left accessible to residents. On 01/29/2024 at 11:34 AM, the Surveyor observed that the toilet in bathroom of occupied room [ROOM NUMBER] was not securely mounted to the floor. The Surveyor was able to easily rock and spin the toilet. On 01/30/2024 at 10:07 AM, the toilet in the bathroom of room [ROOM NUMBER] remained unsecured to the floor. On 01/31/2024 at 09:15 AM, the toilet in the bathroom of room [ROOM NUMBER] remained unsecured to the floor. On 02/01/2024 at 02:00 PM, the Administrator confirmed that the toilets in resident rooms should be securely affixed to prevent falls. On 02/01/2024 at 02:20 PM, the Maintenance Supervisor confirmed that the toilets in resident rooms should be securely affixed to prevent falls. On 01/29/2024 at 11:52 AM, the Surveyor observed that the exterior window of room [ROOM NUMBER], located on the facility's secure unit, was broken. Two pieces of glass were lying on the windowsill. The edges of the broken glass were sharp. The door to the room was open and any ambulatory resident on the secure unit could enter and reach the broken glass. The Administrator was informed of the accident hazard. On 01/30/2024 at 08:30 AM, the Surveyor observed that the broken window of room [ROOM NUMBER] had been covered with a large piece of plywood. The plywood blocked the window from being opened and prevented the window from being utilized as an exit. On 01/31/2024 at 08:00 AM, plywood remained on the window of room [ROOM NUMBER], preventing it from being opened or utilized as an exit. On 01/31/2024 at 11:20 AM, the Administrator confirmed that the plywood in the window of room [ROOM NUMBER] would prevent the window from being used as an exit in the event of a fire. On 01/29/2024 at 11:52 AM the Surveyor observed that the call device mounted on the wall of the bathroom that served occupied rooms [ROOM NUMBERS] did not have a pull cord attached to allow residents to call for help in the case of a fall. The call device was mounted 3 feet 10 inches from the floor. On 01/30/2024 at 09:22 AM, the call device for the bathroom of rooms [ROOM NUMBERS] did not have a pull cord attached. On 01/31/2024 at 11:00 AM, the call device for the bathroom of rooms [ROOM NUMBERS] did not have a pull cord attached. On 01/31/2024 at 11:20 AM, the Administrator confirmed that the call device for the bathroom of rooms [ROOM NUMBERS] required a pull cord and should have one attached. On 01/29/2024 at 11:59 AM, the Surveyor observed that the toilet in the bathroom for occupied room [ROOM NUMBER] was broken. On the right side of the bowl, where the right buttock of a seated resident would rest, a six-inch piece of porcelain was missing. The edges of the break were sharp and jagged. On 01/29/2024 at 03:51 PM, the Surveyor informed the Maintenance Supervisor of the accident hazard. The Maintenance Supervisor confirmed the sharp edges of the broken toilet had the potential to cause harm to residents using the toilet. On 01/31/2024 at 11:20 AM, the Administrator confirmed that the sharp edges of the broken toilet had the potential to cause harm to residents using the toilet. On 01/29/2024 at 12:08 PM, the Surveyor observed an electrical outlet was pulled away from the wall opposite the bathroom in room [ROOM NUMBER]. It was located beside and within reach of, the resident's chair. The outlet was situated at the horizontal midpoint of the wall and one foot above the floor. Exposed behind the outlet was wiring, wire nuts (electrical connections), and the electrical box. The door to room [ROOM NUMBER] was open and any ambulatory resident on the secure unit could enter and reach the electrical components. On 01/29/2024 at 01:29 PM, the Surveyor asked the Maintenance Supervisor to observe the exposed electrical components. He stated, Oh yeah that's not good, I'll get that took care of. On 01/29/2024 at 01:45 PM, the DON stated she was previously unaware of exposed electrical components, but confirmed it was an accident hazard. On 01/31/2024 at 11:20 AM, the Administrator confirmed that the exposed electrical components were an accident hazard. On 01/29/2024 at 12:13 PM, the Surveyor observed the window of room [ROOM NUMBER] covered with plywood. The plywood blocked the window from being opened and prevented the window from being utilized as an exit. On 01/30/2024 at 09:55 AM, plywood remained on the window of room [ROOM NUMBER], preventing it from being opened or utilized as an exit. On 01/31/2024 at 11:25 AM, the Administrator observed the plywood on the window of room [ROOM NUMBER] and confirmed that the plywood in the window of room [ROOM NUMBER] would prevent the window from being used as an exit in the event of a fire. On 01/30/2024 at 9:35 AM the Surveyor observed a door standing ajar on the secure unit. The door was labeled Janitor's Closet. The Surveyor was able to easily open the door and step inside. Inside the room electrical components were mounted to the walls. Immediately opposite the door there was exposed wiring for the telephone system. On the adjacent wall were two electrical breaker boxes, which did not have locks to prevent them being accessed by residents. The self-closing mechanism located at the top of the door was broken, with the connecting arms unattached. a. On 01/30/2024 at 09:53 AM the door labeled Janitor's Closet remained open. Residents that were residing on the secure unit were observed walking past the open door. b. On 01/30/2024 at 10:02 AM CNA #2 was informed of the door being unsecured. CNA #2 confirmed that the door being unsecured was an accident hazard and that the wiring inside the room marked Janitor's Closet could cause harm to the residents on the secure unit. On 01/31/2024 at 11:20 AM the Administrator confirmed that the room marked Janitor's Closet should be closed and locked to eliminate the accident hazard of the electrical components. On 02/01/2024 at 01:00 PM, the Administrator provided a document titled Policy .Accidents and Supervision. It documented, Policy: The resident environment will remain as free of accident hazards as is possible .This includes identifying hazard(s) and risk(s) .Implementing interventions to reduce hazard(s) and risk(s)

Based on observation, interview, and record review the facility failed to ensure 4 (Resident #17, 46, #47, and #57) of 14 (Resident #9, #17, #19, #23, #24, #28, #30, #32, #46, #47, #49, #52, #57, #265) sampled residents received fresh water. The findings are: Resident #17 had a diagnosis of urinary tract infection, and an Annual Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 11/22/23 documented short- and long-term memory problems on a Staff Assessment of Mental Status (SAMS). A care plan initiated 12/12/23 documented, .Encourage fluids throughout the day to prevent dehydration . On 1/30/24 at 1:04 PM, Resident #17 had a pitcher of water on her bedside table. The pitcher was half full of water, no ice. The pitcher had brown particles floating at the bottom. On 1/30/24 at 9:27 AM, Resident #17 had a pitcher of water on her bedside table. The pitcher was half full of water, no ice. The pitcher had brown particles floating at the bottom. On 1/31/24 at 2:19 PM, Certified Nurse Aide (CNA) #3 was asked, Who's responsible for passing water and ice. She stated, We have a person, but I passed my own on yesterday. She was asked, How often do you pass ice? She stated, I pass it in the morning, and whoever is assigned supposed to do the whole hall later. On 1/31/24 at 2:30 PM, CNA #4 was asked, Who's responsible for passing water and ice. She stated, The CNA's. She was asked, How often do you pass ice? She stated, Twice a day and as needed. She was asked, How often are the pitchers cleaned? She stated, I'm not sure, I know they put some new ones out this week. On 1/31/24 at 2:38 PM, CNA #5 was asked, Who's responsible for passing water and ice? She stated, The CNA's. She was asked, How often are the water pitchers cleaned? She stated, They should take them out to dietary every night to be cleaned. On 1/31/24 at 3:25 PM the Regional Dietary manager was asked, How often do the staff bring the water pitchers to the kitchen to be cleaned? She stated, I've been here since Monday, and I haven't seen them. On 1/31/24 at 3:26 PM, dietary staff #1 was asked, How often do the staff bring the water pitchers to the kitchen to be cleaned? She stated, I'm here helping, and I've been here since Monday. I'm just here helping out. On 1/31/24 at 3:28 PM, dietary #2 was asked, How often do the staff bring the water pitchers to the kitchen to be cleaned? He stated, I've been here helping out since Monday, and I haven't seen any water pitchers. 1. Resident #46 had a diagnosis of Chronic Obstructed Pulmonary Disease and A Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 12/18/23 documented the resident scored 07 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS). A care plan with an initiation date of 9/15/23 documented, . Encourage hydration to minimize risk of constipation . On 1/29/24 at 11:56 AM, Resident #46 pulled the lid off her water pitcher. The pitcher was approximately 3/4 full with brown particles floating at the bottom. There was no ice in her pitcher. She was asked, When was the last time the staff provided you with ice and fresh water? She stated, It's been a while. On 1/29/24 at 3:30 PM, Resident #46 had a pitcher sitting on her bedside table that was approximately 3/4 full with brown particles floating at the bottom. There was no ice in her pitcher. On 1/30/24 at 9:02 AM, Resident #46 pulled the lid off her water pitcher. The pitcher was approximately 3/4 full of brown particles floating at the bottom. There was no ice in her pitcher. She took a drink of the water, then she frowned and poured it out. She was asked, When was the last time the staff provided you with ice and fresh water? I don't really know. 2. Resident #47 had a diagnosis of legal blindness, dementia, and behavioral disturbances and a Quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 12/14/23 documented the resident scored 03 (00-03 indicates severe impairment) on the Brief Interview for Mental Status. A care plan with an initiation date of 11/03/22 documented, . Encourage hydration to minimize risk of constipation . On 1/29/24 at 11:39 AM, Resident #47 ' s water pitcher was empty, and not within reach. On 1/29/24 at 3:42 PM, Resident #47 water pitcher was empty. On 01/29/2024 at 11:48 AM, the Surveyor observed Resident (R) #57 lying in bed resting. There were no fluids, or containers for fluids, in the resident's room. On 01/29/2024 at 03:44 PM the Surveyor observed Resident #57 in their room. There were no fluids, or containers for fluids, in the resident's room. On 01/30/2024 at 09:35 AM, the Surveyor observed Resident #57 in the common room on 500 Hall. There were no fluids, or containers for fluids, in the resident's vicinity. On 01/31/2024 at 09:20 AM, the Surveyor observed Resident #57 in their room. There were no fluids, or containers for fluids, in the resident's room. On 02/01/2024 at 03:00 PM, the Surveyor asked Registered Nurse #1 how residents residing on the unit she was assigned received water if there were no cups or pitchers in any of the rooms. She stated, They ask for it. We give them a cup after activities and with med pass. On 02/01/2024 at 03:00 PM, the Surveyor asked if they were receiving plenty to drink. Resident #57 stated, No, not at all. I don't know if anyone else is but I'm not. I'm thirsty. On 02/02/2024 at 8:18 AM, the Administrator confirmed that Resident #57 should have fluids available to them. A Medicare - 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2024 documented on a Brief Interview for Mental (BIMS) a score of 7 (0-7 indicates severe cognitive impairment) for Resident #57. Section GG0170. Mobility documented under the heading, I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space an assessment of, 04. Supervision or touching assistance. Resident #57 had a diagnosis of Urinary Tract Infection documented on 12/29/2023. A Care Plan for Resident #57 initiated 12/30/2023 documented, .Encourage and assist with fluid intake to promote hydration . On 2/01/24 at 3:37 PM, the Director of Nurse (DON) provided a form titled, Resident Hydration and Prevention of Dehydration. It documented, . Nurses aids will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care .

Based on observations and interviews, the facility failed to ensure an ice scoop on the 300 hall was contained to ensure a sanitary environment was maintained. This failed practice had the possibility of affecting 3 (Resident's #19, #23, #265) sample mix residents who receive ice on the 300-Hall according to a list provided by the Administrator on 2/2/2024 at 8:24 am. The findings are: On 01/29/24 at 01:39 PM, the Surveyor observed the 300-hall ice chest scoop was not contained. The scoop tray had thick dark matter along the edge of the tray. On 01/29/24 at 02:21 PM, the Surveyor observed the ice scoop was not contained. There was thick dark matter along the edge of the scoop tray. On 01/30/24 at 09:16 AM, the Surveyor observed the ice scoop was not contained. There was thick dark matter in and along the edge of the scoop tray. On 01/31/24 at 10:56 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 Where do you fill the ice chest? CNA #1 said we take it to the kitchen to the ice machine. The Surveyor asked if this ice chest is used? CNA #1 said yes, we use it on the 300 Hall. The Surveyor asked how the scoop should be stored. CNA #1 said it should be in a bag. The Surveyor asked is the scoop contained? CNA #1 said no. The Surveyor asked how would you describe the area the scoop is laying on? CNA #1 said it looks like dirt or something. The Surveyor asked CNA #1 to open the ice chest and describe the inside of the ice chest. CNA #1 stated the inside is light brown and looks dirty. On 01/31/24 at 03:13 PM, the Director of Nursing confirmed the ice scoop was not contained and the scoop tray had thick dark matter on it.

Complaint # (AR 662) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure resident transfers and positioning via a mechanical lift were conducted with the care planned number of staff to prevent potential accident and injury for 1 (Resident #1) of 1 case mix residents who required mechanical lift transfers. The facility also failed to ensure a shower gurney was maintained in safe operating condition to prevent potential injury for 1 (Resident #1) of 1 case mix residents who required the use of a shower gurney. The failed practices resulted in Immediate Jeopardy, which was likely to cause serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm for 7 residents who were transferred by a mechanical lift and positioned on a shower gurney, as documented on a list provided by the Director of Nursing (DON) on 11/18/14 at 2:06 p.m. The facility was informed of the Immediate Jeopardy Condition on 11/18/14 at 11:10 a.m. The findings are: Resident #1 had a [DIAGNOSES REDACTED]. a. The Resident Plan of Care dated 7/15/14 documented, " ...Problem: The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) quadriplegia from spinal cord injury ... The resident is totally dependent on 2 staff for repositioning and turning... The resident is totally dependent on staff for transferring with Hoyer lift with two ppl (people)". b. The Fall Risk assessment dated [DATE] documented the resident's total fall risk score was 6, with a total score of 10 or above representing a high risk for falls. c. The Concern/Compliment Referral Form submitted by the resident to the facility on [DATE] documented, "Shower bed is not stable while in whirlpool room. When shower bed is locked, I still move." The person reporting was documented as Resident #1. There was no documentation in the "resolution/comments" section or the "findings communicated to" section. The form was signed by the Administrator and not dated. d. The Nurse's Notes dated 11/12/14 at 6:45 p.m. documented, "Addendum to previous note. Actual time of incident reported by C.N.A. to nurse was at 6:45 p.m. Upon arrival to room, resident was observed lying supine on the shower bed. Assessment included thorough body audit. VS (vital signs) 118/54 (blood pressure), 98.1 (temperature), 72 (pulse), 18 (respirations). AAO (awake, alert and oriented) x (times) 3, No change in mental status. PERRL (pupils equal, round, reactive to light) directly and consensually. No bumps, bruises or abnormalities noted to head. No difficulty in head or neck movements. No deformities noted to upper and lower extremities. Hip aligned with no deformities noted. Neuro (neurological) checks initiated per protocol. During interview with resident he stated he slid to the floor from the shower bed hitting the right side of his head on the floor. Responsible party notified. She seemed very concerned and stated 'I will be making a trip to the facility soon.' MD (Medical Doctor) notified of incident. DON notified at 10:00 p.m. Resident transferred to bed x 2 assist per mechanical lift. Will continue to monitor. Report off to oncoming nurse." 1) An Incident Report dated 11/12/14 at 6:45 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Called to R (resident's) room by C.N.A. (Certified Nursing Assistant). She stated she used the Hoyer lift to put R onto the shower bed. She also stated once the R was on the shower bed, she proceeded to remove the lift pad from underneath him. She stated once she began to turn him, he began to slide onto the floor. She also stated that she got him up off the floor by herself using the lift without notifying the Charge Nurse first. Upon assessment, no visible injuries were noted. R denied any pain at that time. The C.N.A. was asked why she didn't call for help or why did she move the R without notifying the nurse first and she stated that her coworker went to another hall to help with another resident and the Charge Nurse was passing meds and she moved the R because he had showed her the way to get him up. C.N.A. was asked to write up a statement describing exactly what happened. The Charge Nurse states that she does not know exactly how long the R was on the floor because of lack of communication from C.N.A." The report documented that the responsible party and the physician were notified of the incident. 2) On 11/18/14 at 10:03 a.m., the Director of Nursing presented the following statement dated 11/12/14 and signed by CNA #1: "I, (CNA #1), entered (Resident #1's) room at approximately 6:30 p.m. to prepare him for a bath which was scheduled. (CNA #2) was supposed to assist me. However, she was paged over to (another hall) to assist with (another named resident). I positioned the right side of the shower bed against the closet for support and locked the bed. Due to time delay, I proceed to position (Resident #1) on the lift pad, connected it to the Hoyer Lift and begin transfer to the shower bed. Once I transferred and positioned him onto the shower bed, I proceeded to take the lift pad from under him, standing on the left side of shower bed. When I turned him toward me, I begin pushing the pad under him. As I was pushing the pad under him, he began to slide toward me and onto the floor, landing on his right side with right side of head on floor. I tried to use my weight to push him up from falling but it wasn't enough. I did as much as I could to lessen the fall by holding onto his arms and pushing him against the shower bed. I panicked. I moved the shower bed out of the way and repositioned the lift pad behind him. I slowly turned him right into the lift pad. Then I unlocked and pushed his bed over. I lowered the Hoyer lift as low as it would go, open the legs of the lift, his head and shoulders in between, and positioned it over him. He was still positioned on the floor for approximately 10 minutes. I connected the pad to the Hoyer lift and proceed to lift him back up and onto the shower bed. Once done, I covered him up because he was nude and went to get the nurse and nurse followed up from there. After nurses looked at him, I and (CNA #2) took resident to the whirlpool. After whirlpool me and (CNA #2) took resident back to room and assisted him to bed per Hoyer lift and positioned him in the bed." 3) On 11/18/14 at 10:12 a.m., when asked about the 11/12/14 accident of Resident #1, LPN #1 stated, "To transfer or position (Resident #1), two persons are required to assist. (CNA #1) told me, 'We had an accident. I was trying to remove the lift pad from underneath (Resident #1) and when I went to roll him, he fell to the floor.' I asked her who was with her and she said, 'No one'. I asked her why she didn't come get me and she said she was waiting on the other aide. (Resident #1) was in his room on the gurney supine. I assessed him and did neuro checks. I asked him to go to the hospital. He stated, 'No'. He said, 'I am ok, it wasn't a hard fall, I actually slid to the floor'. I asked him if he hurt. He said 'Yes, the right side of my head'. I took his vital signs, notified the doctor and she said 'Neuro-checks per protocol and if headache continues, transfer to the ER.' I notified his mother and the Director of Nursing. I did not do anything with (CNA #1). The Director of Nursing came in about 2 hours later. (CNA #1) was supposed to have another person assist and was supposed to notify the nurse of the incident before moving the resident." 4) On 11/17/14 at 2:31 p.m., Resident #1 stated, "On 11/12/14 around 9:00 p.m., I was in bed. (CNA #1) came with a lift and then went and got a stretcher. She was by herself. She used the lift to transfer me to the shower bed. She went to remove the lift pad. When she rolled me over, the stretcher moved. I fell on my right side to the floor. I am supposed to be a two person assist, as they were told by the Director of Nursing the week prior. I said it was unsafe for me and the aide. After this happened, (CNA #1) rolled me over and put the lift pad under me and lifted me back up and put me on the shower bed. Then she went and got (LPN #1). (LPN #1) looked at me and did not move my arms, legs, body or head. Then (CNA #1 and CNA #2) took me to the shower. When I fell , my elbow, hip and knee was sore and my head and neck were aching. I told (LPN #1). She wanted me to go to the hospital. I didn't want to go then. I wanted to wait till morning. e. The Nurse's Notes dated 11/12/14 at 10:50 p.m. documented, "I, (Director of Nursing) entered facility at approximately 10:50 p.m. I went directly to (Resident's Room Number) to assess resident. Upon arrival to room resident was lying supine in bed. Awake and alert. Deny any pain or discomfort at present time. Resident stated '(C.N.A. #1) was about to take me to the shower and she was in here by herself and she transferred me to the shower gurney with the hoyer lift. She then attempted to get the lift pad out from under me and I slid off shower gurney onto the floor onto my right side. I did hit the right side of my head. She then got me off floor and put me back on the shower gurney. I am fine. I did not fall hard. ' Resident remains without any visible s/s (signs/symptoms) of bruises or injuries. No change in mental status at this time. Resident informed at this time that DON had spoken with MD and MD gave an order for [REDACTED]. Resident stated 'I do not want to go at this time. I am fine. If I start having some problems I will go then if not I will wait until tomorrow.' Resident informed at this time of the purpose of getting evaluated to have a CT (Computerized Tomography) Scan and resident persistent he will be alright and do not want to go to the ER. MD notified at this time. Reported off to on duty nurse. Will continue to monitor closely. Will f/u (follow up)." f. The Nurse's Notes dated 11/13/14 at 9:15 a.m. documented, "Resident c/o (complained) HA (headache). 3/10 (3 on a pain scale of 0 -10). Requested pain med (medicine). Administered Norco per MD order. Tolerated well. Call light in reach." g. The Nurse's Notes dated 11/13/14 at 10:00 a.m. documented, "VS 127/79, 69, 18, 97.8, 93% (oxygen saturation). Resident alert and oriented x 3. Lying in bed on right side watching TV. Continues to complain of headache unrelieved by pain med, 3/10. Assessed resident's head with no hematoma, bruising or edema noted. No grimacing or yelling with palpation. No injury noted. Neuro-checks WNL (within normal limits) Resident stated he had not rested well last night. Reassured resident. Resident verbalized an understanding. Educated resident of MD order to transport to ER for evaluation. Resident stated he would like to go at this time. Attempted to call resident's mother x 2 attempts. Left voicemail to call facility. Called report to (Local Hospital) RN (Registered Nurse). Called (Emergency Medical Transport) for transport." On 11/17/14 at 2:31 p.m., Resident #1 stated, " ...The following morning, I agreed to go. I went to the ER. They did a MRI (Magnetic Resonance Imaging) of my head and no other x-rays. The ER sent me back. Later that night, I started hurting in my hip and my elbow. I requested to go to the ER. The nurse sent me to the ER. They found no broke bones and sent me back. I was never comatose. (CNA #1) cared for me the remainder of 11/12/14. She has not cared for me since. One problem is the brakes on the shower bed and another is, she was by herself." h. The Nurse's Notes dated 11/13/14 at 10:17 p.m. documented, "Resident with complaint of pain to right side. Resident rates pain a 7/10. Denies any pain to head. No other complaints voiced. No distress noted. Call bell in reach. Will monitor." i. The Emergency Department (ED) Physician Documentation dated 11/13/14 at 12:06 p.m. documented, "The patient fell from a supine position, out of bed and struck on a tile surface. The patient was discovered at time of or immediately after the incident. The symptoms/episode began/occurred this morning. Associated injuries: The patient sustained injury to the head and pain. Associated signs and symptoms: Pertinent positives: blurred vision, dizziness, headache. Pertinent negatives: nausea, vomiting, loss of consciousness: the patient experienced no loss of consciousness. Pt (patient) is a quadriplegic post spinal cord injury. Pt is anticoagulated on Coumadin." The physician documented an order for [REDACTED]. The CT interpretation documented, ""normal". On 11/13/14 at 1:19 p.m., the disposition documented, "discharged to home. Impression: Head Injury." j. The Nurse's Notes dated 11/13/14 at 3:30 p.m. documented, "Resident returned from (Local Hospital) per ambulance..." k. The Nurse's Notes dated 11/14/14 at 12:22 a.m. documented, "PRN (as needed medication) administration was ineffective. Resident rates pain a 7/10 and now has complaint of numbness to his right side. Will notify MD". l. The Nurse's Notes dated 11/14/14 at 12:27 a.m. documented, "(Physician) aware of resident's complaint of numbness to right side and pain level still being a 7 out of 10. Orders given to transfer to (Hospital)." m. The Nurse's Notes dated 11/14/14 at 1:37 a.m. documented, "Resident transferred via stretcher by two EMT's (Emergency Medical Technicians) to (Hospital)." n. The ED Provider Note dated 11/14/14 at 2:37 a.m. documented [DIAGNOSES REDACTED]. Contusion of right leg." o. The Nurse's Notes dated 11/14/14 at 6:54 a.m. documented, "Resident returned from (Hospital) via stretcher and accompanied by two EMT's. Resident AAO x 3 with no complaints at this time. Vitals: BP (blood pressure) 94/65, HR (heart rate) 51, T (temperature) 97.9 and R (respirations) 20." p. On 11/17/14 at 3:00 p.m., the Administrator, Director of Nursing, Maintenance Director and the two surveyors assessed the safety factors of the shower gurney, with the Administrator lying supine on the gurney. When the wheels were horizontal to the gurney and locked, the gurney brakes held the gurney in place and the gurney did not move; however, when the wheels were vertical to the gurney and locked, the gurney would slide sideways with very little pressure applied to induce movement. The Administrator and Maintenance Director measured the height of the shower gurney from the top of the gurney pad to the top of the side rails. It measured 5 1/2 inches. The Director of Nursing was asked about staff training on the use of the gurney and mechanical lift and stated, "No in-service on shower gurneys this year. We do not have straps for the gurney. We have not in-serviced on how to remove a lift sheet when a resident is on the shower gurney before this incident. We instruct our staff to have two staff present when using a mechanical lift. When a person falls, the person is to stay with the resident, call for assistance and the professional nurse is to assess resident before moving the resident." 1) On 11/18/14 at 9:40 a.m., when asked about Resident #1's concern of 10/23/14, the Administrator stated, "The Maintenance Supervisor checked the shower gurney. He stated the stability was fine. No further action was taken. We did look at a potential purchase of a bariatric shower gurney, which we did not purchase." 2) On 11/18/14 at 3:33 p.m., the Director of Nursing's signed statement documented, "This is a statement to confirm that (Resident #1) has received a shower on the shower gurney on 11/13/14, 11/14/14 and 11/16/14 since incident on 11/12/14. Resident did not receive a shower on the shower bed on 11/15/14." 3) On 11/18/14 at 4:40 p.m., the Maintenance Director, in the presence of the surveyor, measured the shower gurney from the top of the pad/mattress to the floor. The measurement was 30 inches. 4) On 11/19/14 at 9:55 a.m., the Maintenance Director stated, "Around 10/20/14, I checked the shower gurney for instability. I did check the locks on the wheels. There was no problem. There is no documentation (of this safety check)." q. On 11/18/14 at 4:40 p.m., CNA #1 stated "On 11/12/14 about 6:30 p.m., I was trying to prepare (Resident #1) for a shower. I used a mechanical lift to transfer him from his bed to the shower bed. I was aware he was a 2 person assist. I have in the past successfully transferred him from bed to shower bed with a mechanical lift by myself. So I felt it was safe. Once he was on the shower bed, I positioned him on his left side and I began pushing the lift pad under him. I did not have the side rail up and he began to slide towards me and off of the shower bed. He hit the floor on his right side. I rolled him on the lift pad and used the Hoyer to lift him back on the shower bed. This all happened in his room. I covered him up and went and got the Charge LPN. He said his head hurt. The Charge Nurse came right down and assessed him. Since I have been hired here, I was taught to use the Hoyer lift and how the shower bed works and not to move a resident post-accident before LPN assessment. I panicked. The Charge Nurse, the oncoming Charge Nurse and the Director of Nursing told me what I had done wrong." An Employee Performance Expectation Disciplinary Action dated 11/13/14 at 8:22 a.m. documented CNA #1's, "Suspension pending investigation". 1) On 11/19/14 at 9:00 a.m., Resident #1 stated, "(C.N.A. #1) had put me on the shower gurney by herself. She was the only one. I did not tell her not to move me by herself. I don't think it was safe for her to do, but I did not tell her no. I knew I had a right to refuse." On 11/19/14 at 9:45 a.m., Resident #1 stated, "Really, (CNA #1) and 3 others have lifted me with the mechanical lift to the shower bed, showered me and put me back to bed by themselves. I told a nurse (no longer employed at facility) about it. I told the Director of Nursing before the fall that people were transferring me by themselves. That was a week before the accident. I complained about the shower gurney because the brakes weren't working right." 2) On 11/19/14 at 10:00 a.m., the Director of Nursing stated, "(Resident #1) around 10/23/14 told me that, well, gave me a specific name (CNA #3) was taking him to the whirlpool by herself and used the mechanical lift alone. I talked to her on 10/24/14. I did not monitor afterwards. There was no documentation of his concern." 3) On 11/19/14 at 10:05 a.m., the Director of Nursing presented a document signed by the Director of Nursing and CNA #3. It documented, "I, (Director of Nursing) spoke with (CNA #3) on 10/24/14 in reference to getting assistance with (Resident #1). Employee informed me she did (Resident #1) the other day by herself because when she asks for assistance co-workers have attitudes. (CNA #3) informed to notify charge nurse or DON immediately but under any circumstances is she to bathe (Resident #1) by herself. Employee informed on the risk she is taking, that she could seriously hurt herself and/or resident. Employee verbalizes understanding. Employee also re-educated that she must follow resident's plan of care without fail. Employee informed that next occurrence could lead to disciplinary action." r. The Immediate Jeopardy was removed on 11/18/14 at 3:50 p.m. and the scope/severity reduced to "E", after the facility implemented the following Plan of Removal: 1) Administrator/designee removed shower gurney from operation on 11/17/14 at approximately 5:00 p.m. and new shower gurney was ordered on [DATE] and verified by Administrator. 2) Per facility census and condition review, six other residents have the potential to be affected. Resident with potential to be affected will be given bed baths until new shower gurney is received and staff in-serviced. Facility has no other shower gurney in operation. Maintenance Supervisor made rounds to ensure no other shower gurney was in use as of 11/18/14, no negative findings were documented. 3) All nursing staff in-serviced at beginning of each shift beginning on 11/18/14 at 1:30 p.m. and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON/designee and in-service sign-in sheets used. Training will include return demonstration on the use of mechanical lifts and proper use of shower gurney to ensure safety and manufacturer guidelines are followed prior to working their next scheduled shift and C.N.A.s report any falls to charge nurse and not move resident until assessed by professional nurse, effective 11/18/14. 4) Maintenance Supervisor will perform weekly inspections of mechanical lifts and new shower gurney times one month, then bi-weekly thereafter per company policy. Any negative findings will be reported to Administrator and corrected immediately, then discussed in monthly and in quarterly QAA (Quality Assessment and Assurance) meeting. DON/designee will monitor proper use of mechanical lifts and shower gurney five times weekly on residents that use shower gurney and mechanical lifts then three times weekly thereafter. Any negative findings will be reported to Administrator and corrected immediately. Administrator/designee will monitor weekly inspections by Maintenance Supervisor of mechanical lifts and shower gurney and DON reports of proper usage of said equipment weekly times one month then bi-weekly thereafter to ensure compliance. Any findings will be corrected immediately and discussed monthly then quarterly in QA & A meeting effective 11/18/14. 5) DON will review physician orders [REDACTED]. Any negative findings corrected immediately and reported to Administrator. This information will be discussed monthly, then quarterly in QA & A effective 11/18/14."