Every finding on record at The Stewart Health Center

Based on observations, record review, and staff, On-Call Nurse Practitioner, Medical Director interviews, the facility failed to provide care in a safe manner when staff assisted a resident with dementia and contractures (permanent tightening of muscles resulting in loss of range in motion) of both lower extremities. The resident was assisted off the side of the bed onto the mat in the floor and laid on her back. While staff left room to get assistance, the resident rolled into fetal position and hit right eye on bed wheel. Resident #63 suffered a skin tear/abrasion to her right eyelid and received treatment at the facility. The deficient practice occurred for 1 of 3 residents for the prevention of accidents (Resident #63). Findings included: Resident #63 was admitted to the facility on [DATE] and discharged on 5/20/26. Diagnosis included Alzheimer's disease, dementia, pain, and contractures of both lower extremities. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was severely cognitively impaired, had been assessed as being dependent on staff for all activities of daily living (ADL), transfers, mobility, and was always incontinent of bladder and bowel. Review of revised care plan dated 2/07/26 revealed Resident #63 required assistance with all activities of daily living related to history of dementia, impaired balance, and limited mobility. Interventions included Resident #63 required moderate to maximum assistance with care to include one person staff assistance for bed mobility. A telephone interview with Nurse Aide (NA) #1 on 7/09/26 at 1:09 PM revealed she had worked 3rd shift (7:00 PM to 7:00 AM) at the facility, was scheduled for the evening of 4/15/26 through the morning of 4/16/26 and had been assigned to work with Resident #63. NA #1 stated on the morning of 4/16/26 around 6:15 AM she had rolled Resident #63 towards her in bed while providing care. NA #1 revealed that as she was reaching for a wipe, Resident #63 moved or rolled forward toward the edge of the bed, and she thought Resident #63 might continue and fall off the side of the bed, so NA #1 cradled her in her arms and lowered her down onto the mat located in the floor. NA #1 stated that she had placed Resident #63 on her back and believed that she did use the call light, but when no one came NA #1 left Resident #63's room and went out into the hallway to get Nurse #1 for assistance. NA #1 revealed when she and Nurse #1 entered the room Resident #63 had moved from lying on her back into a fetal position and appeared to have hit her eye on the bed wheel. NA #1 stated Nurse #1 immediately began assessing Resident #63's eyelid and applied treatment, assessed for any further injuries and none were noted. NA #1 stated Resident #63 was able to talk, open and close both eyes and she did not complain of any pain at that time. NA #1 revealed that she and Nurse #1 provided Resident #63's personal care and assisted her back into her bed and that she stayed with Resident #63 while Nurse #1 contacted the on-call physician. NA #1 revealed that when she left Resident #63 was resting comfortably in bed. NA #1 stated the incident that occurred was an accident, and she knew that she should have stayed with Resident #63 instead of leaving her to find Nurse #1. NA #1 revealed that night was her first time ever working with Resident #63 and she panicked and wanted to find Nurse #1 as quickly as she could instead of yelling for help or waiting for Nurse #1 to answer the call light. Review of nursing progress note dated 4/16/26 written by Nurse #1 revealed NA #1 was changing Resident #63 in bed and as she reached for a wipe, Resident #63 rolled towards the edge of the bed. NA #1 was able to slowly assist Resident #63 to the floor onto mat. Resident #63 rolled into fetal position while on the mat, hit the right side of face on bed wheel, and had a slight skin tear/ abrasion to right eye lid. Assessed Resident #63 for injuries and no other injuries were noted, no complaints of pain, vitals were within normal limits and was able to talk and to open eyes. Resident #63 right eye lid was cleaned with normal saline and 4x4 gauze applied. NA #1 and Nurse #1 were able to provide Resident #63 personal care and placed back into bed. Called on-call Nurse Practitioner (NP) who advised continued monitoring and leave communication for facility physician for further evaluation. Nurse #1 also asked if neurological checks were needed and the on-call NP advised they were not needed at this time, due to Resident #63 not suffering a fall and not hitting her head. Responsible Person (RP) also notified. Resident #63 resting in bed and will continue to monitor. A telephone interview with Nurse #1 on 7/09/26 at 10:17 AM revealed she worked at the facility on 3rd shift (7:00 PM to 7:00 AM), was scheduled to work the evening of 4/15/26 through the morning of 4/16/26, NA #1 came down hallway asking for help. She stated NA #1 reported that while she was assisting Resident #63 with her care, she started to roll off the side of the bed, so NA #1 had assisted Resident #63 to floor onto her bedside mat. She revealed NA #1 had stated that she had laid Resident #63 onto her back, but when she and NA #1 had entered the room, Resident #63 had moved into the fetal position and appeared to have hit her eye on the wheel of the bed. Nurse #1 stated she immediately assessed Resident #63 and found a skin tear/abrasion to the right eye lid with a small amount of blood which she cleaned with normal saline and applied a gauze bandage. She revealed she also assessed Resident #63 for any other injuries and found that she was able to move her extremities, was able to talk and move her eyes, and there were no further injuries noted at that time. She stated she assisted NA #1 with providing Resident #63 with her personal care and placing her back into her bed. Nurse #1 revealed she contacted the on-call NP who advised continued monitoring of Resident #63 for any changes, contact facility physician for follow-up evaluation, and did not recommend neurological checks due to Resident #63 not suffering from an actual fall and not striking her head. She stated she left a voicemail for the facility physician, notified the Director of Nursing and Resident #63's RP, and also placed an incident note in the facility physician folder. Nurse #1 stated she felt the incident was an accident but their facility protocol does stated that anytime a resident has a fall or found lying in the floor staff should stay with the resident and use the call light for assistance, yell for help, and never move resident until assessed by a nurse. Review of on-call NP progress note dated 4/16/26 revealed received call from Nurse #1 who reported around 6:15 AM, NA #1 was providing Resident #63 with bed care when she rolled toward the edge of the bed. NA #1 was able to catch Resident #63 and assist her to the floor. While on the floor Resident #63 was initially lying on her back and then curled into a fetal position; during this movement Resident #63's head moved and her left eye struck the bottom of the bed near the wheel. Resident #63 had a slight skin tear described as more of an abrasion near the left eye with minimal bleeding (small amount on gauze). The abrasion was cleaned with normal saline and 4x4 gauze applied. Resident #63 was talking, stated she was hungry, and asked why she was on the floor. Resident #63 did not complain of pain, was able to move all of her extremities; no other injuries were noted. Nurse #1 stated Resident #63 did not fall and did not hit her head. Recommended treatment was to continue to monitor Resident #63 and the abrasion to her eye and to notify facility physician for follow-up evaluation. A telephone interview with the on-call NP on 7/10/26 at 2:30 PM revealed she had received a telephone call from Nurse #1 on the morning of 4/16/26 around 6:50 AM stating NA #1 was providing bed care to Resident #63 when she rolled toward the edge of the bed and NA #1 assisted her to the floor. The On-call NP stated Nurse #1 reported that Resident #63 was initially lying on her back when she had been assisted to the floor but then moved into the fetal position causing her to hit her eye on the wheel of the bed and suffering a skin tear or an abrasion to the eyelid. She stated Nurse #1 reported the injury to Resident #63's eyelid had minimal bleeding, was cleaned with normal saline, and a gauze bandage had been applied. She revealed Nurse #1 also reported that Resident #63 had been assessed and was able to talk, had no complaints of pain, was able to move her extremities, and there were no other injuries reported at that time. The On-Call NP stated that she recommended no further treatment other than continuing to monitor Resident #63 for any changes and to notify the facility physician for further follow-up evaluation. She revealed Nurse #1 did ask about completing neurological checks on Resident #63 and she stated that since Resident #63 did not suffer from an actual fall and did not strike her head that neurological checks were not needed but just continue to monitor for any changes. An interview with the Medical Director on 7/8/26 at 1:30 PM revealed he was familiar with Resident #63 and had no issues or concerns with the care she had received at the facility. He stated he was aware of Resident #63 incident on 4/16/26 but could not really recall any of the details from the assisted fall other than Resident #63 did not sustain any major injuries. He revealed the on-call physician was notified by nursing staff on 4/16/26 when the fall occurred and the facility NP completed a follow-up evaluation and he had no concerns with their recommended treatment. An interview with the Administrator on 7/09/26 at 1:26 PM revealed she was familiar with Resident #63. She stated on the morning of 4/16/26 she was notified by the Director of Nursing that while NA #1 was providing bed care to Resident #63, she rolled forward toward the edge of the bed and NA #1 assisted Resident #63 to the floor onto the bedside mat. She revealed Resident #63 was initially lying on her back when NA #1 left the room to get Nurse #1 for help, and when they both returned Resident #63 had moved into the fetal position and had struck her eye on the bed wheel causing a skin tear to her eyelid. The Administrator stated Resident #63 was assessed by Nurse #1 and was able to move her extremities, had no complaints of pain, and no further injuries were noted at the time. She revealed Nurse #1 cleaned and treated Resident #63's eyelid and assisted NA #1 with completing Resident #63's personal care and placing Resident #63 back into her bed. She stated Nurse #1 also notified the on-call physician, Resident #63's RP, and left a message for the facility NP and placed a note in the physician folder for the Medical Director for follow-up evaluation. The Administrator revealed that she reviewed the video footage from 4/16/26 and observed that NA #1 had left Resident #63's room for approximately 30 seconds to get help from Nurse #1. The Administrator stated she did feel this incident was an accident, but that staff do need to make sure they are following all fall procedures whether the fall was an assisted fall or not. She revealed staff should never leave a resident alone after a fall or while lying on the floor and that NA #1 should not have left Resident #63 alone to get help from Nurse #1, but instead should have turned on the call light, yelled for help, or called on her cell phone. An interview with the Director of Nursing (DON) on 7/09/26 at 2:00 PM revealed she was familiar with Resident #63. She stated on the morning of 4/16/26 she was notified by Nurse #1 that while NA #1 was providing bed care to Resident #63, she rolled forward toward the edge of the bed and NA #1 assisted Resident #63 to the floor onto the bedside mat. She revealed Resident #63 was initially lying on her back when NA #1 left the room to get Nurse #1 for help, and when they both returned Resident #63 had moved into the fetal position and had struck her eye on the bed wheel causing a skin tear to her eyelid. The DON stated Resident #63 was assessed by Nurse #1 and was able to move her extremities, had no complaints of pain, and no further injuries were noted at the time. She revealed Nurse #1 had cleaned and treated Resident #63's eyelid and assisted NA #1 with completing Resident #63's personal care and placing Resident #63 back into her bed. She stated Nurse #1 also notified the on-call physician, Resident #63's RP, and left a message for the facility NP and placed a note in the physician folder for the Medical Director for follow-up evaluation. The DON stated she agreed with the Administrator and also felt this incident was an accident, but that staff do need to make sure they are following all fall procedures whether the fall was an assisted fall or not. She revealed staff should never leave a resident alone after a fall or while lying on the floor and that NA #1 should not have left Resident #63 alone to get help from Nurse #1, but instead should have turned on the call light, yelled for help, or called on her cell phone.

Based on observations, pictures captured of video footage, record review, and staff, family member, resident, and Medical Director interviews, the facility failed to ensure the necessary supervision was provided to prevent a cognitively impaired resident who was care planned as having a history of attempting to leave the facility, had impaired safety awareness, and hearing loss and aphasia (a language disorder that affects a person's ability to communicate) from exiting the building without staff knowledge. On Saturday 09/06/25, Resident #1 entered a conference room area where the inside entrance doors had been propped open by the Dietary Manger. The Dietary Manger then went to the kitchen and the left the conference room area unattended. Resident #1 entered the conference room area and exited the facility through a wanderguard alarmed door at 1:45 PM. The wanderguard alarm system did not alarm or sound, which allowed Resident #1 to exit the facility without staff knowledge. Resident #1 walked down the main road to the facility and passed a security gate at 1:54 PM. He was found lying on the sidewalk near a very busy intersection of Park Road and Park South Drive that was a 4-lane highway with a posted speed limit of 35 miles per hour by a bystander at 2:02 PM who notified police. Resident #1 was transported to the hospital and assessed to have a contusion of the face and skin tear of the right hand. This deficient practice had a high likelihood of causing serious harm or serious bodily injury to Resident #1 including serious head injury, fractures, or internal injuries. The deficient practice affected 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Immediate jeopardy began on 09/06/25 when Resident #1 exited the facility unsupervised and without staff knowledge. Immediate jeopardy was removed on 09/12/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective and education is completed.Findings included: An interview was conducted with Family Member #1 on 09/22/25 at 1:10 PM. Family Member #1 stated that Resident #1 had memory issues and could not take care of himself. She stated when she visited Resident #1 in his independent living apartment prior to admission on [DATE], she would find burned pans and burned coffee machine, and he could not make food for himself. One time he went to the dining room and could not remember how to get back to his apartment. An interview with Family Member #1 on 09/10/25 at 3:01 PM revealed Resident #1 had previously lived on campus in an independent living setting; however the resident was becoming more forgetful such as leaving his coffee pot on during the day. Family Member #1 stated she did not feel comfortable with him living alone so the family decided to place him in a more assisted environment. Resident #1 was admitted to the facility on [DATE] from his independent living apartment on the same campus with diagnoses of aphasia, atrial fibrillation, hearing loss and mild cognitive impairment.Review of Clinical admission dated 07/21/25 at 12:50 PM revealed that Resident #1 wore hearing aids and indicated his level of cognitive impairment was mild impairment (some confusion) and was alert and oriented x 3 (fully aware of person, place and time), communicated verbally, speech is clear, is able to understand and be understood when speaking. The clinical admission was completed by Nurse #4. An Elopement Evaluation dated 07/21/25 at 1:07 PM revealed that Resident #1 had a history of elopement or attempted leaving the facility without informing staff, verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door, wandered, and had been recently admitted or readmitted . The evaluation gave him a score of 3 and any score 1 or higher indicated risk of elopement. The evaluation was completed by Nurse #4. Nurse #4 was interviewed via telephone on 09/23/25 at 10:10 AM and confirmed that she has completed the admission assessment and elopement evaluation risk assessment for Resident #1 on 07/21/25. Nurse #4 stated that Resident #1 used to live in the independent apartments on campus and would come daily to visit his spouse who lived on the skilled unit. Nurse #4 stated that she had seen a decline with Resident #1 during his visits with his spouse prior to his admission on [DATE]. Nurse #4 stated that Resident #1 even prior to admission on [DATE] while living in the independent living had a sitter and one day as the sitter was leaving she noted Resident #1 walking towards the health center where his spouse resided and called the family, the family then called the health center and asked the staff to make sure he got home safely because the family was worried he would wander off. Nurse #4 stated that during the admission process Resident #1 did not understand that he was going to be moving into the unit, but he was essentially non-verbal so knowing for sure what he understood and did not understand was very difficult. She explained that she completed the elopement evaluation, and he was at risk and so a wanderguard bracelet (bracelet that causes the door to alarm if a resident exits a door that was equipped with wanderguard alarm sensor) was placed on his wrist like a watch in hopes that he would be compliant with it and was also placed on every 2-hour checks. Nurse #4 explained that when Resident #4 admitted on [DATE] he was placed in a room very near a door but soon after admission they swapped rooms with his spouse and Resident #1 was moved closer to the nurse's station and further away from the exit door. Nurse #4 stated that on the day of admission Resident #1 had intermittent confusion and at times would nod his head appropriately to questions and directions and at other times he had no response to questions and directions, and you could tell by the blank expression on his face that he did not understand what was being said to him. Nurse #4 added that Resident #1 attempted to exit any door he could find but did seem to focus on the main door of the facility and did not ever indicate where he wanted to go. Nurse #4 stated that the elopement risk assessment was a set of questions on the computer that she answered and generated a score, she could not recall what the questions were or if they were specific to his cognition or not as she did not have the assessment in front of her.An Elopement Evaluation dated 07/21/25 at 7:15 PM revealed that Resident #1 had a history of elopement or attempted leaving the facility without informing staff, had verbally expressed the desire to go home or packed belongings to go home or stayed near an exit door, wandered, goal directed wandered, and was recently admitted or readmitted . The risk assessment score was a 5 and any score 1 or higher indicated risk of elopement. The evaluation was completed by Nurse #5. Nurse #5 was interviewed via telephone on 09/23/25 at 10:32 AM and confirmed that he had completed the elopement risk evaluation on 07/21/25 at 7:15 PM. Nurse #5 stated that on the day Resident #1's admission [DATE] was the first time he had met the resident. Nurse #5 stated he was not familiar with Resident #1 or his baseline at that time; however, the staff reported to him that even prior to admission Resident #1 was at risk of elopement and that he often wandered off and staff had to watch him closely. Nurse #5 could not recall who had informed him of this, but he was aware on 07/21/25 that Resident #1 was an elopement risk. After reviewing the progress notes from 07/21/25 he recalled completing the elopement risk evaluation because Resident #1 continued to try to exit the facility from any door he could find and was constantly being redirected by staff. Nurse #5 stated that Resident #1 had no intelligible conversation that day to indicate where he wanted to go but continued to try and exit the door and required frequent redirection from staff. Nurse #5 again stated he was not familiar with Resident #1's baseline so it was difficult to ascertain if his confusion was acute due to the move or if this was his baseline. Nurse #5 again stated he did have an understanding that Resident #1 was a flight risk and a wanderguard bracelet had been initiated as well every 2-hour checks.A nursing progress note dated 07/21/25 at 4:04 PM written by Nurse #2 revealed Resident #1 attempted to exit the building however his wanderguard device alarmed the front door and he was easily redirected back to his room. Resident #1 was placed on every 2-hour safety monitoring.A Social Services note dated 07/21/25 at 7:59 PM written by the Social Worker revealed Resident #1 was observed walking outside of the building through the front doors despite the wanderguard alarm going off at the door. Resident #1 pushed through the emergency exit and stepped onto the sidewalk outside of the front door. A nurse and security guard met the resident, and it took a duration of 20 minutes to get Resident #1 to agree to reenter the facility.A Social Services note dated 07/22/25 at 12:41 PM revealed the Social Worker and Administrator spoke with the Medical Director in regard to Resident #1's adjustment to admission into the facility. The Medical Director recommended a room move to the facility's locked unit based on him being an elopement risk and independently ambulatory.On 09/10/25 at 1:00 PM an interview was conducted with the Social Worker. During the interview she stated Resident #1 was admitted as a long-term care resident at the end of July 2025 and had a hard time adjusting. She stated on 07/21/25, the same day he was admitted , Resident #1 pushed through the front door entrance and security had to assist him back into the building. She stated he was just confused as to why he couldn't go back to his independent living apartment that he previously lived in. He would become frustrated with himself and others not being able to clearly understand him. The Social Worker explained she had spoken with his Family Members on the day of admission [DATE]) and the day after (07/22/25) about his attempts of elopement and the possibility of placing him on the locked memory care unit. She stated the Family Members did not want him on the locked memory care unit and offered to hire a private sitter to sit with the resident with hopes to minimize Resident #1's exit seeking behavior. She stated it was successful for some time however the Family Members knew if the exit seeking behavior continued, he would need to be placed in a secure area.A Social Services note dated 07/22/25 at 2:35 PM written by the Social Worker revealed the Social Worker, Assistant Director of Nursing (ADON), and Administrator observed Resident #1 attempting to exit the facility through the front door. He was able to be redirected but while walking down the hallway he was noted to aggressively shake his cane in the ADON's face. Family Members of Resident #1 arrived during the episode and agreed to provide a private sitter for one-on-one supervision beginning overnight.A nursing progress note dated 07/25/25 at 8:41 PM written by Nurse #2 revealed Resident #1 had walked out of the front door of the facility and was standing outside of the building with two staff members. The note revealed Resident #1 had manipulated the door to be able to exit the building despite having a wanderguard bracelet in place on the right wrist. He was redirected back into the building without incident.A current care plan initiated on 07/25/25 revealed a focus area for Resident #1 as an elopement risk/wanderer related to disorientation to place, history of attempts to leave the facility unattended, and impaired safety awareness. The goal was for Resident #1's safety to be maintained through the next review date. Interventions included engaging the resident in purposeful activity, identifying the pattern of wandering, increased supervision of a one-on-one sitter and a wanderguard bracelet to the resident's right wrist.Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired and was independent for ambulation, sit to stand transfers and chair to bed transfers. Wandering behavior was exhibited 4 to 6 days during the assessment reference period. Resident #1 used a cane as an assistive device and had no functional impairments with range of motion to the upper or lower extremities. He did not receive an anticoagulant during the assessment period. Resident #1 used a wander/elopement alarm daily. An elopement assessment dated [DATE] revealed Resident #1 to be a level 5 (high risk of elopement). Resident #1 was noted to have verbally expressed the desire to go home, wandered in the facility, had a pattern of wandering behavior and a history of elopement in the facility.A physician order dated 07/30/25 revealed Resident #1 had a wanderguard. Nursing staff were to check placement of the bracelet to right wrist every shift and monitor the wanderguard each shift.A nursing note dated 07/30/25 at 10:11 AM written by Nurse #2 revealed Resident#1 had cut off his wanderguard bracelet and had attempted to elope through the front door. He was redirected back to his room and a new wanderguard bracelet was placed on his right wrist.On 09/10/25 at 1:25 PM an interview was conducted with Nurse #2. During the interview he stated he had written the nursing progress notes dated 07/25/25 and 07/30/25 when Resident #1 had attempted to elope from the facility. The interview revealed Resident #1 was previously in the independent living housing on the facility campus and would come into the facility to visit his spouse. Nurse #2 indicated the resident was used to coming and going freely from the building and had a difficult time adjusting when he was admitted to the facility in July 2025 due to a decline in health. Nurse #2 explained each time Resident #1 went through the front door he was redirected back into the building accompanied by a staff member and was never outside of the building alone prior to 09/06/25. Nurse #2 stated the resident always attempted to walk out the front entrance of the facility during his shift and he had never seen him at the conference room door. Nurse #2 stated Resident #1 became frustrated with not being able to exit the facility and at one point obtained scissors in his room from an unknown source and cut off his wanderguard bracelet. The wanderguard bracelet was immediately replaced.A communication note dated 08/05/25 at 8:41 AM written by the Social Worker revealed the Administrator, Director of Nursing (DON) and Social Worker spoke with Resident #1's Family Member to discuss room placement. The interdisciplinary team recommended relocating the resident to a room closer to the nurses' station due to increased wandering behaviors and the resident's current room being in close proximity to an exit door. The Family member agreed to the relocation.A nursing progress note dated 08/07/25 at 7:38 PM written by Nurse #3 revealed Resident #1 was seen attempting to go out of the back door of the unit. The nurse quickly went and redirected the resident to his assigned room. Resident #1 had pushed onto the exit door until it alarmed.On 09/10/25 at 1:00 PM an interview was conducted with Nurse #3. During the interview she stated on 08/07/25 Resident #1 had gone through the back door of the dining area exiting into a courtyard area. She stated he would often be observed pushing on the exit doors until they would alarm. Nurse #3 stated the behavior slowed down when the private sitter was with him starting the day after he arrived on the unit (07/22/25) during first shift but on the other shifts he had to be closely monitored.A nursing progress note dated 08/11/25 at 9:04 AM revealed at approximately 8:30 AM Resident #1 was observed by the Administrator, ADON and Receptionist exiting the front door while pushing his spouse in a wheelchair. Staff made several verbal redirection attempts; however, the resident declined to return inside. A Nurse Aide (NA) accompanied Resident #1 for safety until he re-entered the building. The residents' wanderguard bracelet was confirmed to be in place.Review of Resident #1's Medication Administration Record dated September 2025 revealed an order for staff to check placement of the bracelet to right wrist every shift and monitor the wanderguard each shift. The order was initialed as completed on each shift by the nursing staff.A nursing note dated 09/06/25 at 1:02 PM written by Nurse #1 revealed Resident #1 was in his room with a private sitter.A nursing progress note dated 09/06/25 at 2:25 PM written by Nurse #1 revealed she was notified Resident #1 had been found on the road outside of the facility campus and was taken to the hospital for an evaluation.A nursing progress note dated 09/06/25 at 2:35 PM written by Nurse #1 revealed Resident #1's medical information was provided to Emergency Medical Services (EMS) with a police officer present at the facility. EMS stated Resident #1 was found at the corner of a busy intersection and sustained some lacerations and was immediately sent to the hospital for an evaluation. EMS provided pictures and Resident #1 was noted with a wanderguard bracelet on.An incident report dated 09/06/25 at 2:25 PM completed by Nurse #1 revealed the nurse was notified Resident #1 was found on the road outside of the facility campus and was immediately taken to the hospital for an evaluation. EMS/Police were noted to be on the unit and provided with Resident #1's medical information. EMS provided the nurse with a picture of Resident #1; it was noted he had a wanderguard on and appeared to have a laceration to his right cheek. Injuries noted on the incident report included laceration to left hand, laceration to right knee, laceration to left knee and laceration to face. Resident #1 was documented to be confused with impaired memory and an active exit seeker.On 09/11/25 at 9:32 AM the surveyor was able to speak with a representative from the Police Department who stated a police officer had responded to the incident on 09/06/25 at 2:02 PM however a formal police report had not been filed because the resident was sent to the hospital by EMS. The incident had been filed in the miscellaneous system, and no formal report could be obtained regarding the incident. The surveyor left contact information for the responding policer officer, but no additional communication was received.On 09/10/25 at 11:45 AM an interview was conducted with Nurse #1. During the interview she stated she was working on Resident #1's unit for the 7:00 AM to 3:00 PM shift on 09/06/25. She stated around 2:25 PM she had received a call from the security office that Resident #1 was found on the main intersection outside of the campus and was taken to the hospital for an evaluation. Nurse #1 confirmed she did not know Resident #1 was missing until she received the phone call, she thought he was asleep in his room. Nurse #1 stated she had last seen Resident #1 at 1:00 PM with his private sitter and at 1:15 PM the private sitter had stopped her in the hallway and stated she was leaving for the day. She stated she had not observed any exit seeking behaviors on that day however on previous shifts he had attempted to elope from the front entrance of the facility and the wanderguard system alarmed. Nurse #1 stated she had seen the double doors to the conference room open that morning, leading to the door Resident #1 was able to exit through but that the Dietary Manager was in her office, so she did not think anything about it. Nurse #1 explained when the incident happened the Dietary Manager was in the kitchen and did not see Resident #1.On 09/10/25 at 10:08 AM an interview was conducted with Nurse Aide (NA) #1. During the interview NA #1 stated she worked in the facility as the Medical Record's staff member, however had picked up an extra shift on 09/06/25 and was responsible for Resident #1 during the 7:00 AM to 3:00 PM shift. The interview revealed Resident #1 had a private sitter that arrived at the facility shortly after breakfast and remained with the resident until around 1:45 PM. NA #1 stated Resident #1's private sitter came into the dining room and stated she was leaving for the day, and Resident #1 was asleep in his room. NA #1 stated approximately 5 minutes later NA #2 entered the dining room returning from her meal break and stated to NA #1 she could now take her meal break. NA #1 did not recall telling NA #2 Resident#1's private sitter had left the facility for the day prior to clocking off shift for her meal break. She stated she went into the facility break room to warm up her food and eat. Around 2:25 PM Nurse #1 entered the break room and told her Resident #1 was found off campus and sent to the hospital. NA #1 stated she immediately went onto the unit to see what was happening. When she got to the nurses' station, she saw EMS and Police in the hallway. The police officer had a picture of Resident #1 sitting in a wheelchair with a laceration on his face and his wanderguard bracelet on his right wrist. NA #1 stated at that point she left the conversation and returned to caring for her assigned residents. She stated Resident #1's room was on the ground level floor and the side door which he exited the facility through was directly down the hall from his room. NA #1 stated, it would have taken him less than 5 minutes to get there. Resident #1 was independent with walking and transfers. She stated he had not shown any signs of exit seeking or wandering that morning because he had a private sitter with him. NA #1 stated the facility was completing every 2-hour rounding on Resident #1 and the last time she saw him was around 1:15 PM. The interview revealed the staff typically did not communicate when Resident #1's private sitter arrived at the facility or left because the resident was on every 2-hour monitoring regardless of her presence.On 09/11/25 at 10:26 AM an interview was conducted with NA #2. During the interview she stated she was working on the adjoining hallway Resident #1 resided on 09/06/25 during the 7:00 AM to 3:00 PM shift. She stated she had just returned from her meal break around 1:45 PM and told NA #1 she would watch her residents. NA #2 stated NA #1 did not tell her Resident #1's private sitter had left for the day but told her Resident #1 was asleep in his room. NA #2 stated she passed by Resident #1's room at 2:00 PM and his door was halfway closed; she could not see inside of the door but that was not unusual because his door was typically closed. NA #2 stated she did not go inside of the room to check on him because his next 2 hour rounding time would have been 3:00 PM and she thought he was asleep. NA #2 stated the last time she physically saw him was around 12:50 PM he was sitting in the dining room with his private sitter. She stated around 2:20 PM she was in the hallway completing rounding when Nurse #1 came to her and stated Resident #1 was found outside of the facility. She stated she was shocked because most of the time the doors to the conference room were locked on the weekends and she had never seen Resident #1 attempt to exit the facility through those doors. She stated he was alert at times but had confusion and was used to coming/going freely in the facility because he was once in the independent living section and would come to the unit to visit his spouse and leave.The surveyor reviewed pictures captured video footage of the incident with the DON on 09/10/25 at 11:40 AM. The pictures of the video footage revealed Resident #1 dressed in a light blue polo shirt, tan shorts and tennis shoes exiting the conference room door at 1:45 PM. A second view showed Resident #1 walking up the sidewalk without difficulty passing the security guard gate at 1:54 PM.An observation and interview were conducted on 09/10/25 at 10:29 AM with NA#1. The observation started at Resident #1's room that was observed to be directly down the hall from a set of double doors leading to a conference room with an exit door. The double doors were noted to be unlocked during the observation with two offices located inside of the room for the Dietary Manager and Business Office Manager who was noted to be in his office at the time of the observation. The exit door was observed to be unlocked from the inside, with a wanderguard alarm system device noted to the left side of the door mounted onto the wall with a keycode. NA #1 explained that anyone could get out of the exit door from the inside unless they had a wanderguard bracelet on, then the door would alarm, otherwise the door would not alarm. She stated from the outside the door required a badge to get inside of the building. NA #1 and the Surveyor exited the unlocked door, no alarm sounded. Once outside of the door there was a straight sidewalk approximately 50 feet from the door to the main road entrance of the facility. The sidewalk made an L shape back to the left and lead directly to the road leading out of the facility past the guard gate. NA #1 stated the road leading from the door was the main entrance to the facility parking lot. Resident #1 was found 870 feet from the facility on the sidewalk of Park South Drive. On 09/10/25 at 3:18 PM an observation of the conference room exit door and interview were conducted with the Director of Nursing and Facility Maintenance Director. A total of 3 wanderguard bracelets (one new out of the pack) were tested with the alarm system and none of the three devices triggered the system to alarm. The Facility Maintenance Director stated the wanderguard alarm system was malfunctioning and needed to be repaired for a second time. He stated his expectation was for the door to alarm if the wanderguard device entered the conference room. The functionality of the front entrance door was also checked and alarmed accordingly with the wanderguard device. The interview revealed the door systems were monitored at least on a weekly basis prior to the incident, however, since the incident they were monitored on a daily basis.EMS records dated 09/06/25 revealed medics arrived at the intersection at 2:17 PM to observe Resident #1 sitting down on the curb. He was located a short distance from the facility and had been walking around as if lost prompting a bystander to call 911 emergency services. Resident #1 had abrasions to his right cheek, left hand, and right knee. The resident could answer some questions such as his name but would/could not answer most other questions. Resident #1 was placed in a c-collar (medical device that supports the neck) due to possible head injury and age. He was transported to the hospital by EMS services at 2:33 PM.On 09/10/25 at 2:53 PM attempts to speak the EMS medic were unsuccessful.Hospital records dated 09/06/25 at 7:14 PM revealed Resident #1 had experienced an unwitnessed fall after being found 0.25 miles from the facility in which he resided with lacerations to his right check, left hand and right knee. The hospital note revealed a staff member was with Resident #1 who stated the resident had a monitor on that triggered the alarm systems when he attempted to leave the facility but unfortunately it was a system failure and Resident #1 managed to leave the facility. He was found by a bystander outside near the facility after an apparent fall. Resident #1 was noted to be acting at his baseline and did not appear in pain. The residents' vital signs were the following: blood pressure 193/106 (normal range 120/80), pulse 97 (normal range 60-100), oxygen saturation level 99% (normal range greater than 92%), temperature 97.9 (normal range 97-99). A computed tomography (CT) scan was completed of Resident #1's head resulting in no intracranial bleed or skull fracture. The after-visit summary diagnoses included contusion of the face, skin tear of the right hand, abrasion to right knee, fall from ground level and severe dementia without behavioral disturbance. Resident #1 was discharged from the hospital in stable condition.Resident #1 returned to the facility on [DATE] at 8:00 PM and was placed on the locked memory care unit.On 09/10/25 at 1:14 PM an interview was conducted with the facility security guard. During the interview he stated he was working on 09/06/25 but did not see Resident #1 walk by the security guard stand or through the gate. He explained that community members often walk on the sidewalk, and he would not have recognized Resident #1, or that the resident would have stood out. He explained the police arrived at the facility with a picture of the resident and asked if he resided on the campus. The interview revealed it was confirmed he was a resident at the facility, and the officer and Emergency Medical Services was directed to the facility for further assistance.On 09/11/25 at 10:10 AM an observation and interview were conducted with Resident #1. Resident #1 was observed on the facility's locked memory care unit sitting in a recliner chair. During the interview he stated he did recall leaving the facility and having a fall but could not recall the details of the incident. Resident #1 was observed to nod his head yes in response to questions with a delay in communication answering questions in a low tone whisper. Resident #1 pointed to his right check when asked if he had a fall but was difficult to understand. He was observed following direction from staff and standing/ambulating with his walker.On 09/10/25 at 3:01 PM an interview was conducted with Family Member #1 and Family Member #2. During the interview they stated the facility had contacted them regarding the incident on 09/06/25. The interview revealed that the facility had discussed issues with Resident #1 attempting to elope from the facility with them since admission on [DATE] and they hired a private sitter to sit with him originally on 07/22/25 during the night and day. Family Member #1 stated on 09/01/25 the family gradually started to reduce the time frame to 4 hours a day. Family Member #1 stated the facility wanted to move Resident #1 to the locked memory care unit on 07/22/25 and she strongly protested it because she wanted him near his spouse who was also located on the unit. Resident #1 was very strong-willed and was confused as to why he could not leave the facility as he typically did prior to admission to the facility. The Family Members explained they did not have contact information for the private sitter and stated they would attempt to gain the information and let the surveyor know. The interview revealed Resident #1 had previously lived on campus in an independent living setting, however the resident was becoming more forgetful such as leaving his coffee pot on during the day. Family Member #1 stated she did not feel comfortable with him living alone so the family decided to place him in a more assisted environment. On 09/10/25 at 11:41 AM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview she stated on 09/06/25 Nurse #1 notified her Resident #1 had gone out of the conference room door and they were notified by the Police Department that he was on the main road outside of the facility campus. She stated Resident #1 was alert, he had an abrasion to his right cheek and hand and was sent to the hospital for an evaluation. The DON accompanied him to the hospital while she went to the facility to assist staff members. The ADON explained typically on weekends the double doors leading to the conference room were locked, however the Dietary Manager had come in that morning and unlocked the doors. The Dietary Manager was in the kitchen at the time of the incident and did not see the resident walk by and go out of the door. The interview revealed Resident #1 had several attempts to exit the facility prior to 09/06/25 and he was placed on every 2-hour monitoring, and the facility had discussed the incident at length with the Family members.On 09/10/25 at 9:45 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #1 was previously in the independent living housing on the campus however due to a decline in cognition, he was moved into the skilled nursing home for increased supervision. The DON shared for exam

Based on record review, and Responsible Party, Pharmacist, Hospice Nurse and staff interviews, the facility failed to administer a probiotic ordered for 1 of 5 residents reviewed for unnecessary medications (Resident #7). The findings included: Resident #7 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of physician order dated 1/14/2025 revealed, Saccharomycesboulardii 250 Milligram (MG) Oral Capsule (a probiotic). Give one capsule by mouth one time a day until 01/21/2025. Review of physician order dated 1/15/25 revealed, Doxycycline Hyclate Oral Tablet 100 MG (an antibiotic). Give one tablet by mouth two times a day for upper respiratory infection. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she was moderately cognively impaired, her diagnoses were Alzheimer's disease, dementia, anxiety and depression, lobar pneumonia. Review of the medication administration record (MAR) dated January 2025 revealed Nurse #1 had initialed the (MAR) on 1/15/25 for the probiotic administration and Nurse #2 had initialed the MAR for the probiotic administration on 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25. An interview with Nurse #1 via telephone on 5/15/25 at 7:00 PM indicated she was familiar with Resident #7 and had no memory of the probiotic order in January. Several attempts were made to contact Nurse #2 with no success. An interview with the Responsible Party on 5/15/25 at 11:15 AM revealed Resident # 7 was prescribed a course of antibiotics to treat pneumonia. Resident #7 had a history of developing yeast infections when taking antibiotics and a probiotic was prescribed to prevent a yeast infection. On 1/20/25 Resident #7 verbalized she was itching down there the nurse on duty checked and Resident #7 had a red rash in her groin area. She indicated she had not provided the facility with any probiotics. An interview with the Pharmacist, on 5/16/25 at 10:30 AM revealed a Physician order for probiotics was received on 1/14/25 for six capsules. On 1/31/25 six capsules were returned to the pharmacy by a staff nurse, unopened. An interview on 5/16/25 at 1:30 PM with a Hospice Nurse revealed a probiotic was ordered on 1/14/25 and discontinued on 1/20/25. The Hospice Nurse revealed a medicated vaginal cream was ordered on 1/21/25 to treat an active yeast infection caused by the administration of an antibiotic. An interview with Director of Nursing (DON) on 5/16/25 at 1:16 PM revealed she felt like the Responsible Party brought in the probiotic from home and that was why the medication from the pharmacy was not used. She reported there was documentation on the January MAR that the probiotic was administered. The DON indicated she could not explain the discrepancy with the MAR and the unused probiotic that the pharmacy received.

Based on observations, record review, family and staff interviews the facility failed to maintain privacy during care and failed to obtain written consent for the use of cameras in residents' rooms for 2 of 2 samples residents reviewed for privacy (Resident #13 and #38). A reasonable person would expect privacy when care was being provided and not have a monitor screen showing them with private areas exposed and would feel humiliated and dehumanized. Findings included: 1. Resident #13 was admitted to the facility on [DATE]. The admission MDS dated [DATE] revealed Resident #13 was moderately cognitively impaired and had not exhibited any behaviors. A review of Resident #13's medical record revealed that no written consent for camera usage was obtained. An observation was conducted on 3/4/2024 at 12:34 pm. Resident #13 did not have a roommate and a camera was visualized on top of the cabinet in Resident #13's room. A monitor for the associated camera in Resident #13's room was left unattended on the edge of an un-enclosed office desk. The camera monitor was able to be visualized approximately one foot away and was visible to visitors as they approached the desk. A telephone interview was conducted 3/4/2024 at 2:54 pm with Resident #13's Representative. The RR reported that nursing staff at the family had reached out to her about placing a camera in Resident #13's room because she had been getting up at night and had tried to get out of the facility. She reported that staff were so busy at night that having a camera in the room was an easy way for them to make sure Resident #13 did not get out of bed. The RR stated that she had agreed to placing a camera in the room and did not recall signing a consent form. An interview was conducted on 3/6/2024 at 9:50 am with Nurse #1. Nurse #1 stated Resident #13 had a camera since she had been in her room. He reported that Resident #13 had fallen approximately two to three times prior to the camera being installed. Nurse #1 reported that camera monitors were never left unattended at the nurses station and that the monitors were portable and could be taken with the nurse if they had to leave the nurse's station. An interview was conducted on 3/6/2024 at 10:40 am with the Director of Nursing (DON). The DON stated several residents had cameras in their rooms. She reported that cameras remained on 24 hours per day and were not turned off. She reported that camera monitors should not be left unattended at the nurse's station, however there were times when a staff member would not be present at the nurse's station and camera monitors would be visible to visitors. The DON did report that anyone who approached the desk could potentially observe incontinence care on the camera monitor. The DON was not certain if a consent was obtained for camera usage for Resident #13. An interview was conducted on 3/6/2024 at 12:39 pm with NA #3. NA #3 reported that Resident #13 had always had a camera in her current room. She reported that Resident #13 had been having issues with balance and had been visualized walking backwards with her walker, which had caused staff to be concerned about falling. NA #3 reported that the camera would be turned off, moved, or covered during incontinence care. An observation was conducted on 3/7/2024 at 7:50 am. Resident #13 did not have a roommate. The camera monitor was able to be visualized approximately one foot away and was visible to visitors as they approached the un-enclosed desk at the nurse's station. Resident #13 was observed sitting on the side of the bed with no brief, no pants, and her private areas were exposed as Nurse Aide Student #1 assisted her getting dressed. An interview was conducted on 3/7/2024 at 10:16 am with NA #3. NA #3 reported Nurse Aide Student #1 had provided care for Resident #38 when she arrived on first shift (7:00 am to 3:00 pm). NA #3 stated she was not aware that Resident #13 had been exposed during care. She verbalized that a nurse was typically at the desk with the monitor and would move the camera angle away from the resident during care. An interview was conducted on 3/7/2024 at 2:06 pm with the Administrator. The Administrator reported that several residents do have cameras in their rooms. She reported that cameras remained on for 24 hours per day, were never turned off, and that camera monitors were always to be attended at the nurse's station or at least out of view of visitors. She reported that facility staff did not obtain consent for camera usage because it was viewed as an extra level of supervision. The Administrator was unaware written consents were required for the usage of cameras. 2. Resident # 38 was admitted to the facility on [DATE]. Resident #38's care plan dated 1/11/2024 revealed goals and interventions for falls which included staff being educated about not leaving camera monitors unattended. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired and had not exhibited any behaviors. A review of Resident #38's medical record revealed that no written consent for camera usage was obtained. An interview was conducted on 3/6/2024 at 10:01 am with Nurse #1. Nurse #1 reported that Resident #38 had a camera in his room since he started working at the facility in November of 2022. He reported that Resident #38 was able to walk at the time the camera was installed. He verbalized that Resident #38 would attempt to walk around in his room without assistance and had attempted to leave the facility to go home. Nurse #1 reported that camera monitors were never left unattended at the nurses station and that the monitors were portable and could be taken with the nurse if they had to leave the nurse's station. He stated that he thought either verbal or written consent was obtained for the usage of cameras but was unable to locate the consent for Resident #38. An interview was conducted on 3/6/2024 at 10:40 am with the Director of Nursing (DON). The DON stated several residents had cameras in their rooms. She reported that cameras remained on 24 hours per day and were not turned off. She reported that camera monitors should not be left unattended at the nurse's station, however there were times when a staff member would not be present at the nurse's station and camera monitors would be visible to visitors. The DON was not certain if a consent was obtained for camera usage for Resident #38. An interview was conducted on 3/6/2024 at 12:47 pm with Nurse Aide (NA) #3. NA #3 reported that Resident #38 had a camera in his room for as long as she could remember. She reported that in the past Resident #38 would try to leave the building and expressed a desire to leave the facility. NA #3 reported that the camera would be turned off, moved, or covered during incontinence care. An observation was conducted on 3/7/2024 at 7:50 am. Resident #38 had a camera mounted on the wall in his room and did not have a roommate. The camera monitor for Resident #38 was left unattended at the nurse's station. The camera monitor was able to be visualized approximately one foot away and was visible to visitors as they approached the un-enclosed desk at the nurse's station. Resident #38 was observed with his brief on and his pants around his ankles with both legs exposed while lying in bed as he received incontinence care by NA #3. An interview was conducted on 3/7/2024 at 10:16 am with NA #3. NA #3 reported that she performed incontinence care for Resident #38 when she arrived on shift (3/7/2024). NA #3 stated she did not move the camera when she provided incontinence care, because the camera was positioned too high on the wall for her to reach. She verbalized that a nurse was typically at the desk with the monitor and would move the camera angle away from the resident during incontinence care. An interview was conducted on 3/7/2024 at 2:06 pm with the Administrator. The Administrator reported that several residents do have cameras in their rooms. She reported that cameras remained on for 24 hours per day, were never turned off, and that camera monitors were always to be attended at the nurse's station or at least out of view of visitors. She reported that facility staff did not obtain consent for camera usage because it was viewed as an extra level of supervision.

Based on record review, Physician, and staff interviews, the facility failed to implement an infection prevention and control program plan, failed to implement an infection surveillance plan for monitoring and tracking infections in the facility, and failed to review infection control policies annually. This practice had the potential to affect 60 of 60 residents in the facility. Findings included: The Infection Prevention and Control program policy (Revised October 2018) documented The infection prevention and control program was coordinated and overseen by the infection prevention specialist (infection preventionist), indicated Infection Control Policies should be reviewed at least annually, and Process surveillance and outcome surveillance are used as measures of the infection prevention control program (IPCP) effectiveness. The facility's infection control policy and procedure manual was provided by the administrator on entrance to the facility. The first page of the manual indicated The [NAME] Health Center has approved the following manual as its Infection Control Policy and Procedures Manual. The front page of the manual indicated Version Date April 1, 2014. The bottom of the front page indicated the policy manual had been reviewed and approved by the Medical Director, Director of Nursing, and Administrator on 5/1/2019. An interview with the IP was completed on 3/6/24 at 4:30 PM. The Infection Preventionist (IP) stated she had been assigned to the IP role since September 2023 when the prior Director of Nursing (DON) left. She was unable to explain the surveillance process for tracking/ trending of infections or completing the antibiotic line listing. The IP was unable to provide policy and procedures for the facility's infection prevention and control program plan, surveillance of infections, or a list of reportable communicable diseases. A follow up interview was conducted on 3/7/24 at 9:40 AM with the IP. She stated she completed the North Carolina State Program for Infection Control and Epidemiology (NC SPICE) training online in April of 2023. She explained she became the facility's infection preventionist in September of 2023 after the Director of Nursing (DON) left. She stated that before September 2023 the prior DON had performed infection control duties. She stated she did not have much training on how to perform infection control duties, surveillance, line listing, or tracking/ trending of infections outside of NC SPICE training class. She said that the Regional Clinical Director would send new policies to the facility when they had updates. She stated when new policies were sent to the facility the facility would mark the review date at the top of the policy and sign the policy. She explained she did not have policies, but she would ask the Regional Clinical Director to send her the policies for: The Infection Prevention and Control Program Plan, Surveillance Policy, list of reportable communicable diseases, and Antibiotic Stewardship policy. The IP stated the Administrator, and the Director of Nursing (DON) were responsible for reviewing the facility's infection control policies annually. 3/7/24 11:00 AM The IP provided the following policies and indicated she had received the policies from the Regional Clinical Director today: Surveillance for Infections (Revised September 2017), Infection Prevention and Control Program (Revised October 2018), Outbreak of Communicable Disease (Revised September 2022), Reporting Communicable Diseases (Revised July 2014), Reportable Disease (Revised September 2022). The IP was not able to provide a list of reportable communicable diseases. There was not a review date or reviewer signature present on any of the above policies provided. The IP stated if staff needed to access an infection control policy there was a copy of the Facility's Infection Control Policy and Procedures Manual located at the Nursing station. An Interview was conducted on 3/7/24 at 11:18 AM with Nurse #3. She was unable to locate the facility's Infection Control Poly and Procedure Manual at the nurse's station. She stated if she needed access to an infection control policy, she had to ask the IP nurse. An interview with the Medical Director was completed 3/6/24 at 5:22 PM. He stated the facility reviewed infection control during their quality assurance performance improvement meetings. He verbalized the facility notified him when an outbreak occurred. He explained the facility notified him of the COVID-19 outbreak that occurred from December 2023-January 2024 and stated he felt the facility did a good job with infection control and managing the outbreak. An Interview was performed on 3/7/24 at 11:45 AM with the Administrator and the DON. They explained the IP was responsible for reviewing infection control policies annually. The Administrator stated the facility's infection control policies and procedures should be reviewed annually and with changes. They voiced they were unaware that the facilities infection control policies and procedures were not being reviewed annually. The Administrator stated she thought the failure occurred partially due to the facility's focus on transitioning to the new electronic computer system. They voiced they were unaware the IP was not completing a line listing for tracking/ trending of infections or obtaining diagnostic results for infections. The Administrator explained she thought the process failure was a result of the IP being trained in spring 2023 and at that time the prior DON was still doing IP duties. She stated when the prior DON left, they thought the new IP new how to do infection control, since she had completed the NC SPICE training. The Administrator voiced the new IP hesitated to ask questions and this got missed with the DON transition and the facility's focus on transitioning to the new electronic computer system. She stated when the facility was transferring to the new electronic computer system, they were focused on getting everything into the new system and things that should have gotten followed up on were not overseen well. She explained the components of the facility's infection control program not being completed and in place was likely related to the IP being new to the IP role.

Based on record review and staff interviews the facility failed to develop an infection prevention and control program that established an antibiotic stewardship program with written protocols on antibiotic prescribing, documentation of the indication, dosage, and duration of use of antibiotics. This was evident in 4 of 4 monthly surveillance data reviewed (December 2023, January 2024, February 2024, and March 2024.) Findings included: On 3/7/24 the Infection Preventionist (IP) provided the policy sent to her by the Regional Clinical Director. The Policy provided titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes was revised December 2016. The policy documented the antibiotic stewardship program will monitor and review all clinical infections treated with antibiotics, antibiotic utilization, identify specific situations not consistent with appropriate antibiotic use, and document all resident antibiotic regimens on the facility- approved antibiotic surveillance tracking form. The policy indicated the facility- approved antibiotic surveillance tracking form should include resident name, unit/ room number, date symptoms appeared, site of infection, date of culture, name of antibiotics, start date, stop date, total days of therapy, pathogen identified, outcome, and adverse events. During an interview with the Infection Preventionist (IP) nurse on 3/6/24 at 4:30 PM. The IP stated she had been assigned to the IP role since September 2023. The IP stated she had just started using an antibiotic line listing form in January. She stated prior to January she had not completed an antibiotic line listing form. A request to see the tracking of antibiotic use in the facility from December 2023 to March 2024 revealed the IP did not have an antibiotic line listing for the month of December 2023 and had an incomplete antibiotic line listing for the month of January 2024. She stated she did not have the information for February 2024 and was currently working on the antibiotic line listing for the month of February 2024. She did not have an active current list of residents who were receiving antibiotics. During the interview she was able to search through the orders in the electronic computer system and provided a list of residents in the facility who were currently receiving antibiotics. The IP was unable to provide culture result information for residents who had received treatment for urinary tract infections. She stated if the antibiotic was started at the hospital or by a doctor's office, she did not request diagnostic or culture results. The IP nurse was unable to identify or describe the components of an antibiotic stewardship program or the infection surveillance process. An Interview was performed on 3/7/24 at 11:45 AM with the Administrator and the DON. They explained they were not aware the facility did not have an active antibiotic stewardship program. They voiced that they were unaware the Antibiotic Stewardship policy was not being followed. The Administrator stated she thought the failure occurred partially due to the facility's focus on transitioning to the new electronic computer system. They voiced they were unaware the IP was not completing infection control tasks related to antibiotic stewardship, an antibiotic line listing for tracking/ trending of infections or obtaining diagnostic results for infections. The Administrator explained she thought the process failure was a result of the IP being trained in the spring 2023 and at that time the prior DON was still doing IP duties. She stated when the prior DON left, they thought the new IP new how to do infection control, since she had completed the North Carolina State Program for Infection Control and Epidemiology (NC SPICE) training. The Administrator voiced the new IP hesitated to ask questions and this got missed with the DON transition and the facility's focus on transitioning to the new electronic computer system. She stated when the facility was transferring to the new electronic computer system, they were focused on getting everything into the new system and things that should have gotten followed up on were not overseen well. She explained the components of the facility's infection control program not being completed and in place was likely related to the IP being new to the IP role.

Based on observations, record reviews, and staff interviews the facility failed to develop and implement a person-centered care plan for residents on anticoagulants (Resident # 209 and Resident #20), residents on psychotropic medications (Resident #210, #20, and #259), and a resident with a wander/elopement alarm (Resident #13) for 5 of 5 residents reviewed for development and implementation of a comprehensive care plan. Findings included: 1) Resident #209 was admitted to the facility on [DATE] with diagnoses which included chronic atrial fibrillation (irregular heart rhythm). Resident 209's care plan dated 2/15/2024 did not include goals and interventions for the use of anticoagulants. A record review revealed Resident #209 had active orders dated 2/15/2024 for apixaban (blood thinner) 5 milligrams to be administered twice a day and was to be monitored for signs and symptoms of bleeding. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #209 was moderately cognitively impaired. A review of Resident #209's Medication Administration Record (MAR) for February 2024 and March 2024 revealed he had taken apixaban 5 milligrams twice daily since 2/5/2024. An interview was conducted on 3/6/2024 at 10:10 am with Nurse #1. Nurse #1 stated that Resident #209 was on apixaban and verbalized the resident should be monitored for signs and symptoms of bleeding. Nurse #1 reported he was unsure if the use of anticoagulants were included in the care plan for Resident #209. An interview was conducted on 3/6/2024 at 10:32 am with the Director of Nursing (DON). She stated that the MDS Coordinator was responsible for completing resident-specific care plans with goals and interventions. The DON stated any resident on an anticoagulant should be monitored for signs and symptoms of bleeding. She reported the use of anticoagulants should be care planned and include goals and interventions. The DON was not aware Resident #209 did not have a care plan for anticoagulants and verbalized that he should have. An interview was conducted on 3/6/2024 at 2:49 pm with the MDS Coordinator. The MDS coordinator stated she was responsible for creating and updating care plans. She stated if a resident was prescribed anticoagulants, the care plan should include goals and interventions for anticoagulants. The MDS Coordinator verbalized she was not sure why goals and interventions for anticoagulants were not included on Resident #209's care plan. An interview was conducted on 3/7/2024 at 2:22 pm with the Administrator. The Administrator stated the MDS Coordinator was responsible for completing resident-specific care plans with goals and interventions. She stated residents who received anticoagulants should have goals and interventions for anticoagulants on their care plan. The Administrator was not aware that goals and interventions for anticoagulant usage had not been care planned for Resident #209 and reported that it should have been. 2) Resident #210 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder and delirium. Resident #210's care plan dated 1/22/2024 did not include goals and interventions for psychotropic medications. An admission Minimum Data Set MDS dated [DATE] revealed Resident #210 was taking antipsychotic and antianxiety medications, and was cognitively intact. A review of Resident #210's record revealed active orders dated 2/15/2024 for quetiapine fumarate (antipsychotic medication) 12.5 milligrams to be administered daily and every twelve hours as needed. A review of Resident #210's Medication Administration Record (MAR) for February 2024 and March 2024 revealed she had taken quetiapine fumarate 12.5 milligrams daily since 2/16/2024. An interview was conducted on 3/6/2024 at 10:32 am with the Director of Nursing (DON). She verbalized the MDS Coordinator was responsible for completing resident-specific care plans with goals and interventions. The DON stated when a resident was prescribed a psychotropic medication, they should be monitored for behaviors and included in their care plan. The DON was not aware that Resident #210 did not have a care plan with goals and interventions for psychotropic medications. She verbalized that it should have been care planned. An interview was conducted on 3/6/2024 at 3:20 pm with the MDS Coordinator. The MDS coordinator stated she was responsible for creating and updating care plans. She stated any resident taking psychotropic medications should have goals and interventions for psychotropic medication use in their care plan. The MDS Coordinator did not know why goals and interventions for antipsychotic use were not included in Resident #210's care plan. An interview was conducted on 3/7/2024 at 2:22 pm with the Administrator. The Administrator stated the MDS Coordinator was responsible for completing resident-specific care plans with goals and interventions. She stated residents who received psychotropic medications should have goals and interventions for psychotropic medication use in their care plan. The Administrator was not aware that goals and interventions for psychotropic medication use had not been care planned for Resident #210 and reported that it should have been. 3) Resident #13 was admitted to the facility on [DATE] with diagnoses which included insomnia. Resident #13's care plan dated 1/5/2024 was not updated to include goals and interventions for a wander/elopement alarm. An admission Minimum Data Set MDS dated [DATE] revealed that Resident #13 was moderately cognitively impaired. A record review revealed Resident #13 had active orders dated 2/5/2024 to check the functionality and placement of wander/elopement alarm every shift. An observation was conducted on 3/4/2024 at 12:34 am. Resident #13 was observed sitting in a chair in her room with a wander/elopement alarm on her left ankle. An interview was conducted on 3/6/2024 at 10:40 am with the Director of Nursing (DON). She verbalized the MDS Coordinator was responsible for completing resident-specific care plans with goals and interventions. She was not aware that Resident #13 did not have goals and interventions for a wander/elopement alarm on her care plan and indicated that she should have. An interview was conducted on 3/6/2024 at 2:53 pm with the MDS Coordinator. The MDS coordinator stated she was responsible for creating and updating care plans. She stated goals and interventions for wander/elopement should be included in Resident #13's care plan and was not sure why it was not. An interview was conducted on 3/7/2024 at 2:12 pm with the Administrator. The Administrator stated the MDS Coordinator was responsible for completing resident-specific care plans with goals and interventions. She stated a care plan should include goals and interventions for wander/elopement if a resident wore a wander/elopement alarm. She was unaware that Resident #13's care plan did not include goals and interventions for wander/elopement and indicated that it should have. 50046 4.) Resident #20 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment 1/6/2024 indicated Resident #20 was cognitively impaired and had received anticoagulant and psychotropic medications. The MDS also indicated Resident #20 had exhibited physical and verbal behaviors. Review of Resident #20's physician orders from January 2024 through March 7, 2024, revealed he had an active order for daily apixaban (a blood thinning medication), quetiapine (an antipsychotic medication), and trazodone (an antidepressant medication). Review of Resident #20's current Care Plan dated 1/14/24 did not reveal a care plan for monitoring anticoagulant or psychotropic medications, or behaviors. An interview was conducted with the Minimum Data Set Nurse (MDS Nurse) on 3/6/24 at 3:15 PM. She stated if a resident was receiving anticoagulant or psychotropic medications, there should be care plans addressing their use and for monitoring behaviors. The MDS nurse reviewed the care plans for Resident #20 and verified there were no care plans for anticoagulant or psychotropic medication use or behaviors. An interview was conducted on 3/7/24 at 11:45 AM with the Administrator and the Director of Nursing (DON). They both stated if a resident received anticoagulant or psychotropic medications, they should have care plans in place which include monitoring. The Administrator explained this had been an oversight. 5.) Resident #259 was admitted to the facility on [DATE] The Admission Minimum Data Set assessment dated [DATE] indicated Resident #259 was cognitively impaired and had received antianxiety and antidepressant medications. Review of Resident #259's physician order dated 2/12/24 revealed she had active orders for as needed alprazolam (antianxiety medication) and daily escitalopram (antidepressant medication). Review of Resident #259's current Care Plan 2/12/24 did not reveal a care plan for monitoring psychotropic medications. An interview was conducted with the Minimum Data Set Nurse (MDS Nurse) on 3/6/24 at 3:15 PM. She stated if a resident was receiving psychotropic medications, there should be care plans addressing their use. The MDS nurse reviewed the care plans for Resident #259 and verified there were no care plans for psychotropic medication use. An interview was conducted on 3/7/24 at 11:45 AM with the Administrator and the Director of Nursing (DON). They both stated if a resident received psychotropic medications, they should have care plans in place which include monitoring. The Administrator explained this had been an oversight.

Based on observations, record review and staff interviews the facility failed to maintain a clean ice cream freezer, label and date perishable food items stored in the walk-in cooler, and label and date perishable items in the reach-in refrigerator and ensure frozen items were sealed in the walk-in freezer. These practices had the potential to affect food served to residents. Findings included: 1. The initial observation of the ice cream cooler conducted on 3/4/2024 at 9:48 am revealed pink and brown-colored substances on all four walls of the cooler. An interview was conducted with the DM on 3/7/2024 at 8:51 am. She reported the ice cream cooler was cleaned and sanitized daily. The DM stated the ice cream cooler was cleaned on 3/3/2024 and must have gotten dirty after she left. An interview was conducted with the Administrator on 3/7/2024 at 2:12 pm. The Administrator reported the ice cream cooler should be clean and sanitary. She was not aware of the pink and brown-colored substance on the walls of the ice cream cooler. 2. The initial observation of the kitchen was conducted with the Dietary Manager (DM) on 3/4/2024 at 9:55 am. The initial observation of the walk-in cooler contained the following: -A package of crumbled blue cheese that had been opened with no label or date. -A package of shredded white cheddar cheese that had been opened with no label or date. - A package of shredded white/yellow cheese that had been opened with no label or date. An interview was conducted with the DM on 3/7/2024 at 8:51 am. The DM stated food is to be labeled and dated after being opened. She reported she had audited all food items in the kitchen on 3/3/2024 but the dietary aides must have opened items without labeling and dating them after she left. An interview was conducted with the Administrator on 3/7/2024 at 2:12 pm. The Administrator stated all opened food packages were required to have a label and date. She was not aware of the opened packages of cheese without a label or a date. 3. The initial observation of the reach-in refrigerator conducted on 3/4/2024 at 10:06 am revealed a package of sliced American cheese that had been opened with no label or date. An interview was conducted with the DM on 3/7/2024 at 8:51 am. The DM reported she had audited all food items in the kitchen on 3/3/2024 and a dietary aide must have opened the package of sliced cheese after she left. An interview was conducted with the Administrator on 3/7/2024 at 2:12 pm. The Administrator stated all opened food packages were required to have a label and a date. She was not aware of the opened sliced cheese without a label or a date. 4. The initial observation of the walk-in freezer conducted on 3/4/2024 at 10:10 am revealed the following: -A package of hashbrowns that had been opened with no label or date. -An unsealed bag of okra with no label or date. An interview was conducted with the DM on 3/7/2024 at 8:51 am. The DM stated opened food packages were to be sealed, labeled, and dated. She stated she was not sure why the package of hashbrowns had no label or date and why a bag of okra was unsealed without a date in the walk-in freezer. An interview was conducted with the Administrator on 3/7/2024 at 2:12 pm. The Administrator stated all opened food packages were required to have a label and a date. She was not aware of the opened package of hashbrowns had no label or date and a bag of okra was unsealed without a date in the freezer.

Based on observations, record review, and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) for functional limitations in range of motion, and anticoagulant medication for 2 of 4 residents reviewed for accuracy of assessments (Residents #38 and #209). Findings included: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses which included muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #38 had severe cognitive impairment, no impairment of the lower extremities, and required partial to moderate assistance from sitting to standing. An observation was conducted on 3/5/2024 at 2:43 pm. Nurse Aide (NA) #1 and NA #2 were observed using a sit-to-stand mechanical lift to transfer Resident #38 from the wheelchair to the toilet and back to his wheelchair during incontinence care. An interview was conducted on 3/5/2024 at 2:47 pm with NA #1. NA #1 reported that Resident #38 required the use of a mechanical lift during transfers due to his inability to walk. An interview was conducted on 3/6/2024 at 2:55 pm with the MDS Coordinator. The MDS Coordinator reported she was aware that Resident #38 required maximal assistance during transfers. She reported she would only code impairment of the lower extremities if an extremity was broken, deformed, or paralyzed. An interview was conducted on 3/6/2024 at 10:40 am with the Director of Nursing (DON). The DON reported the MDS Coordinator was responsible for accurately completing MDS assessments. The DON was not aware that Resident #38's MDS was not coded for impairment of the lower extremities and verbalized that it should have been. An interview was conducted 3/7/2024 at 2:18 pm with the Administrator. The Administrator stated the MDS Coordinator was responsible for accurately completing MDS assessments. She stated impairment of the lower extremities should be coded on the MDS. 2. Resident #209 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm). A review of Resident #209's medical record revealed an active order dated 2/15/2024 for apixaban (anticoagulant medication used to prevent blood clots) 5 milligrams to be administered twice a day. A review of Resident #209's Medication Administration Record indicated Resident #209 had received apixaban daily starting on 2/15/2024. The admission Minimum Data Set (MDS) dated [DATE] did not indicate Resident #209 had received anticoagulation medication. An interview was conducted on 3/6/2024 at 11:02 am with the Director of Nursing (DON). The DON reported that the MDS Coordinator was responsible for accurately completing MDS assessments. The DON was not aware that the use of anticoagulants had not been coded on Resident #209's MDS and verbalized that it should have been. An interview was conducted on 3/6/2024 at 3:27 am with the MDS Coordinator. The MDS coordinator reported she was aware that Resident #209 was on apixaban. She stated it was not coded correctly because she thought apixaban was an antiplatelet medication. An interview was conducted on 3/7/2024 at 2:22 pm with the Administrator. The Administrator stated the MDS Coordinator was responsible for accurately completing MDS assessments.

Based on record review and staff interviews the facility failed to ensure that the resident's Medical Order for Scope of Treatment (MOST) form was signed by the resident or resident representative for 1 of 2 residents reviewed for Advanced Directives (Resident #38). The findings included: Resident # 38 was admitted to the facility on [DATE]. A review of Resident #38's paper medical record located at the nursing station revealed a MOST form dated 6/8/2023. The MOST form indicated Resident #38 was a DNR and was signed by the Nurse Practitioner (NP). The MOST form did not have the required resident or resident representative signature on the front page of the document. A review of the active physician's order dated 11/30/2023 revealed Resident #38 was a DNR. Resident #38's care plan dated 1/11/2024 revealed goals and interventions for DNR (Do Not Resuscitate) to be implemented. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired. An interview was conducted on 3/6/2024 at 9:55 am with Nurse #1. Nurse #1 reported that DNR and MOST forms were kept in a book at the nurse's station. He verbalized that the Medical Doctor (MD) or Nurse Practitioner (NP) and the resident or resident representative were required to sign the MOST form after it was completed. Nurse #1 reported that if the resident was unable to sign and the resident representative was not physically in the facility during the discussion of code status that a member of management would obtain the representative's signature the next time that they came to visit the resident. Nurse #1 was unaware that there was no resident or resident representative signature on Resident #38's MOST form and indicated that it should have been on the front of the MOST form. An interview was conducted on 3/6/2024 at 10:49 am with the Director of Nursing (DON). The DON reported that on admission, the Social Worker (SW) was responsible for identifying if the resident had an advanced directive in place. The SW would then get a copy of the advanced directive. She stated if a resident did not have an advanced directive, the SW would notify the MD to have them discuss advanced directives with the resident and/or resident representative. The DON reported that education about advanced directives was provided by the MD or NP and should be dictated within their note on admission. The DON was unaware that there was not a resident or resident representative signature on Resident #38's MOST form and verbalized that there should be a signature by the resident or resident representative. An interview was conducted on 3/7/2024 at 9:48 am with the SW. The SW reported that prior to admission, if a resident has an advanced directive, she would ask the resident or their representative to provide a copy of the document. She reported that the MD or NP would review the code status and advanced directives with the resident and/or resident representative on admission, provide education about code status, and complete the MOST form or DNR at that time. The SW verbalized that consent could be obtained over the phone and that the family would sign the document when they came into the facility, or telephone consent should be indicated on the MOST form, itself. The SW indicated that if the resident was unable to sign and their representative was not available, a golden DNR form was usually completed. An interview was conducted on 3/7/2024 at 2:20 pm with the Administrator. The Administrator stated prior to a resident being admitted to the facility, the SW would obtain copies of any advanced directives that were already in place. If a resident did not have an advanced directive on admission, the SW would reach out to the MD or NP to have them discuss and educate the family about code status. The Administrator verbalized that a lot of conversations regarding code status occurred over the phone. She stated that they would try to get a resident representative to sign the MOST form the next time they came to visit. The Administrator was not aware that Resident #38's MOST form did not have a resident or resident representative signature and verbalized that it should be signed.

Based on record review and staff interviews the facility failed to provide a stop date for an psychotropic medication that was prescribed as needed for 2 of 2 residents reviewed for unnecessary medications (Resident #210 and #259). Findings included: 1) Resident #210 was admitted to the facility on [DATE] with a diagnosis of delirium. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #210 was prescribed antipsychotic medications, was cognitively intact, and had not exhibited any behaviors. Resident #210 was prescribed Seroquel (antipsychotic medication) 12.5 milligrams every 12 hours as needed for behaviors on 2/15/2024 with no end date. A review of the Pharmacist's Medication Regimen Review dated 2/21/2024 was conducted. The Pharmacist had recommended discontinuing the as needed order for Seroquel by 2/29/2024. A review of Resident #210's Electronic Medication Administration Record (EMAR) revealed Seroquel 12.5 milligrams every 12 hours as needed for behaviors was active from 2/15/2024 through 3/5/2024. An interview was conducted on 3/6/2024 at 9:33 am with Nurse #1. Nurse #1 stated residents who received antipsychotics were monitored for behaviors. He reported antipsychotics normally had an end date of 90 days or were indefinite. Nurse #1 reported he typically did not see end dates with Seroquel. He was unaware Resident #210's Seroquel order did not have a stop date. An interview was conducted on 3/7/2024 at 10:55 am with the Pharmacist. The Pharmacist stated she was aware that Resident #210 had an active as needed order for Seroquel with no stop date. She reported that she had sent a recommendation on 2/21/2024 to the facility to stop the as needed order for Seroquel after 14 days (2/29/2024). An interview was conducted on 3/6/2024 at 10:32 am with the Director of Nursing (DON). The DON stated residents prescribed antipsychotic medications should be monitored for behaviors and antipsychotic medications ordered on an as needed basis required a 14 day stop date. She was unaware Resident #210's as needed Seroquel order did not have an end date. An interview was conducted on 3/7/2024 at 2:03 pm with the Administrator. The Administrator stated residents who were prescribed as needed antipsychotic medications required a 14 day stop date. She reported she was made aware on 3/5/2024 Resident #210 had an antipsychotic medication ordered with no stop date and had the issue addressed. 50046 2.) Resident #259 was admitted to the facility on [DATE] with diagnoses that included: depression, anxiety, and unspecified dementia without behavioral disturbances. Review of Resident #259's Care Plan dated 2/12/24 revealed Resident #259 did not have a care plan for psychotropic medication use or behaviors. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #259 was cognitively impaired and coded for antianxiety and antidepressant medication use. The MDS Indicated Resident #259 did not have any behaviors or rejection of care. Review of Resident #259's physician order dated 2/12/24 revealed an order for Alprazolam (antianxiety medication) 0.25 mg every 24 hours as needed (PRN) for anxiety. The physician's order did not contain a stop date for the medication. Review of Resident #259's electronic Medication Administration Record (eMAR) for the month of February 2024 revealed she received doses of Alprazolam on 2/18/24, 2/27/24, and 2/28/24. An interview was performed with Nurse #1 on 03/06/24 at 9:33 AM. Nurse #1 stated there was usually an end date for PRN psychotropic medications that was usually 90 days or indefinite. On 03/06/24 at 10:32 AM an interview was completed with the Director of Nursing (DON). The DON stated PRN psychotropic medications should have a stop date and the stop date should be 14 days. An interview was conducted on 03/06/24 at 5: 22 PM with the Medical Director. He stated PRN psychotropic medications should have a stop date and the stop date should be 14 days. He stated he reviewed psychotropic medications during resident visits. He explained if he found a psychotropic medication that did not have a stop date, he would add a stop date or would discontinue the psychotropic medication whenever able. He stated the pharmacy did a wonderful job reviewing psychotropic medications for 14 day stop dates. He verbalized the nurses would also monitor for stop dates on psychotropic medications and notified him when they saw a PRN psychotropic medication that needed a stop date. An interview was performed on 3/7/24 at 3:45 PM with the Administrator. The Administrator explained that PRN psychotropic medications should have a stop date. She stated the stop date for PRN psychotropic medications should be 14 days.

Based on observations and staff interviews, the facility failed to secure resident medications left in an unattended medication cart for 1 of 2 medication carts (Dogwood Avenue medication cart). The findings included: A continuous observation of Dogwood Avenue was conducted on 03/04/24 from 11:51 am to 11:57 am. The Dogwood Avenue medication cart was observed with the lock not engaged as evidenced by the red dot on the lock being visible. There was no staff member at the medication cart. Several staff members, residents, and visitors were observed walking past the medication cart. On 03/04/24 at 11:57 am, Nurse #2 was observed approaching the Dogwood Avenue medication cart. An observation and interview were completed with Nurse #2 upon her return to the Dogwood Avenue medication cart. She placed her key in the unengaged lock and was stopped by the surveyor. The surveyor asked Nurse #2 to open the medication cart drawer prior to turning the key, and the drawer opened. The observation revealed various prescribed and over-the-counter medications and supplies, including eye drops, injectables, and oral medications for the residents on her unit. Nurse #2 explained that her normal practice was to lock the medication cart when she was not in its presence. She continued to explain that she would have pressed the lock in, ensured that the computer screen was locked, and kept the medication cart keys in her pocket at all times. Nurse #2 reported that she was not certain why she did not engage the lock when she stepped away from the medication cart. An interview with the Director of Nursing (DON) on 03/06/24 at 3:32 pm was completed. The DON reported that the medication cart should have been secured and locked unless the nurse was present at the cart. She stated that staff who noticed that the cart was unlocked should have immediately pressed the lock. Then, that staff member should have notified the nurse assigned to the cart that the unattended medication cart was unlocked. The DON verbalized that the nurse to which the medication cart was assigned was responsible for the medication cart and ensuring that it was secured.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services for 1 of 3 residents (Resident #29) reviewed for beneficiary protection notification. The findings included: Resident #29 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was issued on 01/16/2024 to Resident #29's Responsible Party (RP) which explained Medicare Part A coverage for skilled services would end on 01/18/2024. Resident #29 was residing in the facility during the recertification survey conducted from 03/04/2024 through 03/07/2024. A review of the medical record revealed a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided to Resident #29 or their RP. An interview was conducted with the Social Worker and the Administrator on 03/06/24 at 10:05 AM. The Social Worker confirmed Resident #29 remained in the facility after their Medicare Part A benefit ended and a CMS-10123 NOMNC was issued to the RP however a CMS-10055 ABN was not provided. The Social Worker indicated she was unaware of the circumstances in which a CMS-10055 ABN was required to be issued to a resident and/or RP. The Administrator stated when a resident's Medicare Part A benefit was ending and they remained in the facility, a CMS-10123 NOMNC and a CMS-10055 ABN should be issued to the resident and/or RP.

Based on observations, record review, and staff interviews the facility failed to secure a mechanical lift and wheelchair during a transfer for 1 of 2 residents reviewed for Accidents (Resident #38). Findings included: Resident # 38 was admitted to the facility on [DATE] with diagnoses which included lack of coordination, muscle weakness, and essential tremors. The Minimum Data Set (MDS) dated [DATE] revealed Resident #38 required partial to minimal assistance for sit-to-stand and toileting transfer, had no impairment of upper and lower extremities, did not require the use of a mechanical lift, and was severely cognitively impaired. Resident #38's care plan dated 1/11/2024 did not include goals or interventions for using a mechanical lift. An observation was conducted on 3/5/2024 at 2:43 pm of Resident #38 as he received incontinence care. Nurse Aide (NA) #1 and NA #2 were observed as they transferred Resident #38 from his wheelchair to the toilet using a mechanical lift. As Resident #38 was moved from a sitting to standing position using the mechanical lift, the wheels on both the mechanical lift, the wheelchair remained unlocked, the NAs did not steady the lift or the wheelchair. Resident #38 was transferred to the toilet and NA #1 was observed lowering the lift without locking the wheels on the mechanical lift. After incontinence care was performed by NA #2, Resident #38 was raised using the mechanical lift by NA #1 and the wheels remained unlocked. Resident #38 was then transferred back to his wheelchair using the mechanical lift. As he was lowered back into his wheelchair, the wheels on both the mechanical lift and the wheelchair remained unlocked, and NAs were standing away from the lift and wheelchair during the process of raising and lowering the lift. An interview was conducted on 3/5/2024 at 2:47 pm with NA #1. NA #1 reported she typically worked on Resident #38's hall during the dayshift (7:00 am to 3:00 pm) and verbalized she had received education on using a mechanical lift and transferring residents. NA #1 verbalized she was aware that wheels on both the mechanical lift and wheelchair should be locked during a transfer. She reported she did not think that it was necessary because there were two NA's present during the transfer. NA #1 verbalized she would have used the locks on the lift and wheelchair if she had been doing the transfer by herself. An interview was conducted on 3/5/2024 at 2:52 pm with NA #2. NA #2 reported that while using a lift and transferring residents, the wheels on both the wheelchair and mechanical lift should be locked. NA #2 verbalized the wheels were not locked because two NA's were present during the transfer. She reported she would have locked the wheels on the lift and wheelchair if she was by herself. An interview was conducted on 3/6/2024 at 10:54 am with the Director of Nursing (DON). The DON reported all staff completed competency checks when they were hired and annually. She reported NA's are educated about the use of mechanical lifts and transfer of residents, which included locking the wheels on the mechanical lift and wheelchair prior to transferring the resident. The DON confirmed that NA #1 and NA #2 received education on mechanical lifts. An interview was conducted on 3/6/2024 at 5:16 pm with the Staff Development Coordinator (SDC). The SDC reported NA's completed competency checks, which included the use of mechanical lifts and transferring residents, upon hire. She verbalized staff were educated about locking the wheels on the mechanical lift and wheelchair during transfers. An interview was conducted on 3/7/2024 at 2:18 pm with the Administrator. The Administrator stated staff received education about mechanical lifts and transfers upon hire and on an as needed basis. She stated staff had received education about locking the wheels of a mechanical lift and wheelchair during transfers.

Based on record reviews and staff interviews, the facility failed to complete and transmit a discharge and a death Minimum Data Set (MDS) assessment within the required timeframe for 2 of 3 residents reviewed for resident assessments (Resident #52 and Resident #18). The findings included: 1. Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's medical record revealed that she was discharged to assisted living on [DATE]. A review of Resident #52's medical record revealed the last completed MDS was an admission MDS assessment dated [DATE]. There was no discharge MDS assessment completed or transmitted. During an interview on [DATE] at 3:19 pm with the MDS Coordinator, she checked both the former electronic medical record system and the current electronic medical record system, and was not able to locate a discharge MDS in either system. She stated that she was not sure why a discharge MDS assessment was not completed or transmitted for Resident #52. During an interview on [DATE] at 1:07 pm with the Administrator, she stated that Resident #52's discharge MDS should have been completed or transmitted within 14 days, per the regulatory guidelines. 2. Resident #18 was admitted to the facility on [DATE]. A review of Resident #18's medical record revealed that she expired in the facility, with her family at her bedside, on [DATE]. A review of Resident #18's medical records revealed the last MDS completed was her annual MDS assessment dated [DATE]. There was no death MDS assessment completed or transmitted. During an interview on [DATE] at 3:19 pm with the MDS Coordinator, she checked both the former electronic medical record system and the current electronic medical record system, and was not able to locate a death MDS assessment in either system. She reported that a death MDS assessment was probably not done due to the trainings being completed on the facility's new electronic medical record system. During an interview on [DATE] at 1:07 pm with the Administrator, she stated that Resident #18's death MDS assessment should have been completed and transmitted within 14 days, per the regulatory guidelines.

Based on a family interview, resident interviews during a Resident Council Meeting (Residents #4, #21, #24, #45 and #46), an observation of a lunch meal tray line service, a lunch meal dining service and a test tray evaluation, the facility failed to provide palatable foods per resident preference for taste and temperature as evidenced by spinach and soup served cold and fresh fruit served warm and without flavor per resident and staff interviews. The findings included: 1. During an interview with Family Member A on 7/9/2019 at 3:41 PM, she stated food temperature (foods were cold) and food quality was a concern. She explained there needed to be a system in place to ensure foods remained hot when being transported to the units for those residents that ate in their rooms. She verbalized management was aware of her concern. 2. A Resident Council meeting was completed during the recertification survey on 7/11/2019 at 11:00 AM. The following residents, Resident #21, #4, #24, #45 and #46, verbalized concerns regarding food palatability, specifically cold food and quality of the food. The residents verbalized if they were eating in the main dining area, then the food was hot. If they chose to eat in their rooms, their food was cold. The residents indicated since they were choosing to eat in their rooms then they understood their meals may be cold when delivered by staff. A follow up interview with Resident's #4, #21, #24, #45 and #46, after the lunch meal, on 7/11/2019 at 12:30 PM was completed. The residents verbalized the soup was cold and lacked flavor. The residents stated they understood everyone had a different diet and different tastes but soup was soup. The residents further stated the main meal was warm to luke warm. An interview was completed with the Activities Director (AD) on 7/12/2019 at 8:23 AM. The AD stated she was aware of the residents having food concerns, specifically, meats being overcooked, hot dogs were too big/hard to manage, and spaghetti noodles were hard to manage. The AD verbalized the residents had not voiced concerns regarding food temperature. She further stated that all food concerns were discussed in food forum with the Registered Dietician. An interview was completed with the Registered Dietician (RD) on 7/12/2019 at 12:11 PM. The RD stated she was aware of food concerns since the dietary department made a change in cooks. She stated the change in cooks occurred within the last 6 months. She further explained she was not aware of any recent food concerns from resident council. All previous concerns had been addressed. The RD verbalized she typically followed up with food concerns at the next scheduled food forum meeting. Approximately 2 months ago, the RD expressed the residents that had meals in their rooms were complaining about meals being cold and not warm. The RD stated she evaluated meal service in the dietary department. The RD discovered the plate warmer was not functioning properly and the plates were not warming sufficiently. The RD explained she discussed this concern with the Executive Chef. The determination was made last week (week of (MONTH) 1 through (MONTH) 5) to invest in a hotbox for meal service delivery versus purchasing another plate warmer. The RD stated this could have led to food being cold when meals were delivered to residents in their rooms. An interview was completed with the Administrator on 7/12/2019 at 6:00 PM. The Administrator stated cold food had not ever come up as a concern. The Administrator further stated the dietary department has had a major overhaul with new staff in place, in conjunction with the plate warmer not fully warming the plates properly, could have contributed to foods being cold. The Administrator explained the determination was made not to replace the plate warmer, but rather to purchase a new hotbox (warming system for food delivery). The delay in ordering the new hotbox required a capital expenditure due to the cost. The Administrator communicated the new hotbox had been ordered and once the new hotbox arrived, cold food concerns should decrease. 3. An observation of the lunch meal dining service on the Memory Care unit occurred on 07/10/19 at 11:56 AM. Individual bowls of fresh fruit was delivered from the satellite kitchen to the Memory Care unit on one tray with a large piece of plastic wrap covering the bowls of fruit. Coffee was delivered in individual insulated cups with a lid. Roasted red pepper soup was delivered in a water pitcher and covered with one piece of plastic wrap. A thermometer was not available on the unit and had to be obtained by the nurse. The following temperatures were obtained on the Memory Care unit at the request of the surveyor by dietary aide (DA) #1. The coffee was served in individual insulated cups and the fruit and soup were served in individual bowls to residents without reheating or cooling: · Coffee - 115 degrees Fahrenheit (F) · Fresh cut melon and pineapple - 68 degrees F · Roasted red pepper soup - 119 degrees F An interview with the Registered Dietitian (RD) occurred on 07/10/19 at 12:15 PM. The RD stated the soup should be delivered in individual insulated bowls with a lid and not in a plastic pitcher because the plastic pitcher would not keep the soup hot. The RD stated that the temperature of the fresh cut fruit was too high and that she would remove the fruit from the residents and give them colder fruit. The RD was observed to remove the fruit from the residents. A follow up interview occurred on 07/11/19 at 1:32 PM at which time the RD stated that approximately 2 months ago residents who ate meals in their rooms complained that their food was cold and not hot. As a follow up to this, the RD noted that the plate warmer was not getting plates hot enough to maintain hot food temperatures during meal delivery. The RD discussed this with the Food and Beverage Director with a decision made to order a hot box instead of another plate warmer. The hot box was ordered on [DATE] with delivery expected in the next day or two. The RD stated that the plan was to use the hot box to heat the insulated dome lids/bottoms to help maintain hot food temperatures during meal delivery. The RD further stated that until the hot box arrived, dietary staff were expected to use insulated containers for meal delivery and continue monitoring food temperatures at the tray line, keeping hot foods at 135 degrees F or above and cold foods at 41 degrees F or below. An interview with the cook occurred on 07/12/19 at 10:09 AM and revealed he cut the fresh fruit for the fruit salad served on 07/10/19 at the lunch meal. The cook stated that he did not take the temperature of the fruit before sending the cut fruit to the satellite kitchen, but that the fruit was maintained under refrigeration, prior to cutting, with a usual temperature range between 35 - 38 degrees Fahrenheit. An interview with the assistant dietary manager (ADM) occurred on 07/12/19 at 10:36 AM. The ADM stated fresh fruit was cut and prepared in the main kitchen and delivered in bulk to the satellite kitchen. The ADM stated dietary staff were trained to place the fruit in refrigeration in the satellite kitchen until it was ready to be plated in small bowls, covered with plastic wrap and then taken to the units for service. The ADM also stated dietary staff should check temperatures of foods on the tray line and keep cold foods at or below 41 degrees Fahrenheit and hot foods at or above 135 degrees Fahrenheit during the tray line meal service. During an interview on 07/12/19 at 10:41 AM, DA #1 stated that she did not check the temperature of the fresh cut fruit before the lunch meal service on 07/10/19. She stated when the fresh fruit was received from the main kitchen that day, she placed the fruit in refrigeration but did not check the temperature. DA #1 also stated that it was not her practice to check the temperature of foods once the foods reached the dining areas, but that all temperature monitoring was conducted in the main and satellite kitchens. 4. A continuous observation of the lunch meal tray line service occurred in the satellite kitchen on 07/11/19 from 11:20 AM - 12:20 PM. Dietary Aide (DA) #2 was observed plating mashed potatoes for residents on a pureed diet. DA #2 stated the plates were for residents on the skilled and Memory Care units with a physician's orders [REDACTED]. After plating mashed potatoes, DA #2 left the plates on the prep counter uncovered. At 11:45 AM, DA #3 removed spinach from the tray line, placed it in a commercial blender to puree and added a serving of pureed spinach to each plate of mashed potatoes. DA #3 then removed pureed ham from the tray line and added a serving of pureed ham to each plate of pureed spinach and mashed potatoes. The plates of pureed foods remained uncovered on the prep counter until 12:02 PM. The plates were then placed in the microwave, reheated and then placed on the delivery cart by DA #4 for delivery to residents, without temperature monitoring. At 12:08 PM, DA #4 began to move the lunch cart out of the kitchen for delivery to the residents. At the request of the surveyor, temperature monitoring was conducted in the satellite kitchen by DA #4 with the following results: · Pureed ham - 126.2 degrees F · Mashed potatoes - 127.1 degrees F · Pureed spinach - 131.5 degrees F DA #4 was interviewed on 07/11/19 at 12:14 PM and stated that the hot food temperatures for the pureed foods were okay for delivery to residents, she further stated the temperature range for hot foods was 120 - 140 degrees F. The temperatures obtained for the pureed foods were communicated to the ADM by the surveyor on 07/11/19 at 12:15 PM, the delivery cart of pureed foods was taken to the Memory Care unit by DA #4 and the plates were served to residents. An interview occurred with DA #4 on 07/12/19 at 10:00 AM. DA #4 stated that she had not received prior instruction to monitor the temperature of hot foods when reheated in the microwave and so she did not take the temperature of the pureed foods on 07/11/19 prior to delivery to residents for the lunch meal service. An interview was conducted with DA #3 on 07/12/19 at 02:52 PM. During the interview, DA #3 stated that plating pureed foods and leaving the plates on the counter until meal delivery was the typical practice. DA #4 further stated that she did not conduct temperature monitoring of the pureed foods on 07/11/19 while she prepped the foods for the meal service as this was not her typical practice. DA #3 stated temperature monitoring was conducted in the main kitchen and when the foods were initially received in the satellite kitchen, after that she did not further monitor the temperature of pureed foods. The Assistant Dietary Manager (ADM) was interviewed on 07/12/19 at 10:36 AM. The interview revealed fresh fruit was prepped in the main kitchen and sent to the satellite kitchen in bulk in a plastic bowl. The ADM stated dietary staff were trained to obtain a temperature of the fruit and then place the bowl of fruit in refrigeration until it was plated into small bowls covered with plastic wrap and taken to the units for service. The ADM also stated the soup should have been transported in an insulated container to keep it hot. The ADM further stated staff should monitor the temperature of foods to maintain cold foods at or below 41 degrees F and hot foods at or above 135 degrees F until service. 5. A test tray was requested in the satellite kitchen by the surveyor on 07/11/19 at 12:10 PM. The test tray was plated at 12:12 PM and left the satellite kitchen for delivery to the Memory Care unit at 12:20 PM. The last resident was served, and the test tray was evaluated at 12:37 PM. The ADM and surveyor both conducted a taste evaluation of the test tray on the Memory Care unit. Temperature monitoring was conducted by DA #4. The following concerns were noted by the ADM/surveyor: · Ham and cheese sandwich had a temperature of 105.1 degrees F. The ADM described the sandwich as having a good flavor, but that it was not hot, and the bread was tough/hard. The surveyor agreed. · Spinach was 102.7 degrees F. The ADM described the spinach as having a good flavor, but that it was not hot. The surveyor agreed. · Fresh fruit (melon and pineapples) had a temperature of 68.2 degrees F. The ADM described the pineapple as Not the best tasting pineapple and that it was warm and not cold. The surveyor agreed. The ADM was interviewed on 7/11/19 at 12:45 PM regarding the test tray and stated that had the foods been hot, the foods would have tasted better. The ADM stated she attributed the concerns with food temperatures to having to reheat the ham/cheese sandwiches once they were received from the main kitchen, reheating pureed foods for residents and obtaining colder fruit. The ADM stated these delays were typical activities that occurred during meal delivery and meal service. The cook from the main kitchen was interviewed on 07/12/19 at 10:09 AM and stated he was new in his role for the past 3 weeks and that he was still learning the process. He stated he prepped the ham/cheese sandwiches at the main kitchen, using cold ingredients which included a fully cooked deli ham product and a pasteurized cheese product. He grilled the sandwiches to a temperature of 138 degrees F and asked the RD to have staff place the sandwiches back on the grill at the satellite kitchen and grill them until they reached 145 degrees F. The cook stated going forward he would send sandwiches prepped but, uncooked and have the staff in the satellite kitchen grill them for better presentation and taste.

Based on observations of the lunch meal tray line and a lunch meal dining service, the facility failed to maintain the temperature of potentially hazardous hot foods at 135 degrees Fahrenheit or above (red pepper soup and pureed spinach) and cold foods at 41 degrees Fahrenheit or below (fresh cut fruit) prior to delivery. The facility also failed to monitor the temperature of the dish machine, while in use, for a wash cycle temperature of 150 degrees Fahrenheit and a rinse cycle temperature of 180 degrees Fahrenheit, per manufacturer recommendations. The findings included: 1. An observation of the lunch meal dining service on the Memory Care unit occurred on 07/10/19 at 11:56 AM. Roasted red pepper soup and fresh cut fruit were delivered to the Memory Care unit on a tray. The soup was in plastic water pitcher covered with plastic wrap and the fresh cut fruit was in individual bowls with one large piece of plastic wrap covering the tray of fruit. A thermometer was not available on the unit and had to be obtained by the nurse. The following temperatures were obtained at the request of the surveyor by dietary aide (DA) #1 and these foods were plated and served to residents. · Fresh cut melon and pineapple - 68 degrees Fahrenheit (F) · Roasted red pepper soup - 119 degrees F. This food item was plated and heated in the microwave on the Memory Care unit with no temperature monitoring prior to service. Review of the food temperature logs for 07/10/19 revealed there was no temperature recorded for the fresh cut fruit. Review of the recipe for the roasted red pepper soup revealed the following ingredients were used: water, canned roasted red peppers, canned coconut milk, fresh peeled potatoes (potentially hazardous food) and spices. An interview with the Registered Dietitian (RD) occurred on 07/10/19 at 12:15 PM. The RD stated the soup should be delivered in individual insulated bowls with a lid and not in a plastic pitcher because the plastic pitcher would not keep the soup hot. The RD stated that the temperature of the fresh cut fruit was too high and that she would remove the fruit from the residents and give them colder fruit. A follow up interview occurred on 07/11/19 at 1:32 PM at which time the RD stated that approximately 2 months ago residents who ate meals in their rooms complained that their food was cold and not hot. The RD followed up with this concern and noted that the plate warmer was not getting plates hot enough to maintain hot food temperatures during meal delivery. The RD discussed this with the Food and Beverage Director with a decision made to order a hot box instead of another plate warmer. The hot box was ordered on [DATE] with delivery expected in the next day or two. The RD stated that the plan was to use the hot box to heat the insulated dome lids/bottoms to help maintain hot food temperatures during meal delivery. The RD further stated that until the hot box arrived, dietary staff were expected to transport foods in insulated containers and continue monitoring food temperatures at the tray line, keeping hot foods at 135 degrees F or above and cold foods at 41 degrees F or below. An interview with the cook occurred on 07/12/19 at 10:09 AM and revealed he cut the fresh fruit for the fruit salad served on 07/10/19 at the lunch meal. The cook stated that he did not take the temperature of the fruit before sending the cut fruit to the satellite kitchen, but that the fruit was maintained under refrigeration, prior to cutting, with a temperature range between 35 - 38 degrees F. An interview with the assistant dietary manager (ADM) occurred on 07/12/19 at 10:36 AM. The ADM stated fresh fruit was cut and prepared in the main kitchen and delivered in bulk to the satellite kitchen. The ADM stated dietary staff were trained to place the fruit in refrigeration in the satellite kitchen until it was ready to be plated in small bowls, covered with plastic wrap and then taken to the units for service. The ADM also stated dietary staff should check temperatures of foods on the tray line and keep cold foods at 41 degrees F or below and hot foods at 135 degrees F or above during the tray line meal service. During an interview on 07/12/19 at 10:41 AM, DA #1 stated that she did not check the temperature of the fresh cut fruit before the lunch meal service on 07/10/19. She stated when the fresh fruit was received from the main kitchen that day, she placed the fruit in refrigeration but did not check the temperature. DA #1 also stated that it was not her practice to check the temperature of foods once the foods reached the dining areas, but that all temperature monitoring was conducted in the main and satellite kitchens. 2. A continuous observation of the lunch meal tray line service occurred in the satellite kitchen on 07/11/19 from 11:20 AM - 12:20 PM. Dietary Aide (DA) #2 was observed plating mashed potatoes for residents on a pureed diet. DA #2 stated the plates were for residents on the skilled and Memory Care units with a physician's orders [REDACTED]. After plating mashed potatoes, DA #2 left the plates on the prep counter uncovered. At 11:45 AM, DA #3 removed spinach from the tray line, placed it in a commercial blender to puree and added a serving of pureed spinach to each plate of mashed potatoes. DA #3 then removed pureed ham from the tray line and added a serving of pureed ham to each plate of pureed spinach and mashed potatoes. The plates of pureed foods remained uncovered on the prep counter until 12:02 PM. The plates were then placed in the microwave, reheated and then placed on the delivery cart by DA #4 for delivery to residents, without temperature monitoring. At 12:08 PM, DA #4 began to move the lunch cart out of the kitchen for delivery to the residents. At the request of the surveyor, temperature monitoring revealed the pureed spinach was 131.5 degrees F. A review of the recipe for the pureed spinach revealed the following ingredients were used: fresh spinach (potentially hazardous food), olive oil, fresh chopped garlic and water. DA #4 was interviewed on 07/11/19 at 12:14 PM and stated that the hot food temperatures for the pureed foods were okay for delivery to residents, she further stated the temperature range for hot foods was 120 - 140 degrees F. The temperatures obtained for the pureed foods were communicated to the ADM by the surveyor on 07/11/19 at 12:15 PM, the delivery cart of pureed foods was taken to the Memory Care unit by DA #4 and the plates were served to residents. An interview occurred with DA #4 on 07/12/19 at 10:00 AM. DA #4 stated that she had not received prior instruction to monitor the temperature of hot foods when reheated in the microwave and so she did not take the temperature of the pureed foods on 07/11/19 prior to delivery to residents for the lunch meal service. An interview was conducted with DA #3 on 07/12/19 at 02:52 PM. During the interview, DA #3 stated that plating pureed foods and leaving the plates on the counter until meal delivery was the typical practice. DA #4 further stated that she did not conduct temperature monitoring of the pureed foods on 07/11/19 while she prepped the foods for the meal service as this was not her typical practice. DA #3 stated temperature monitoring was conducted in the main kitchen and when the foods were initially received in the satellite kitchen, after that she did not further monitor the temperature of pureed foods. 3. The dish machine was observed in use on 07/11/19 at the following times without staff monitoring the temperature of the wash and rinse cycles. The temperatures recorded below were based on digital thermometer readings. Manufacturer instructions posted on the dish machine, read in part, Wash cycle temperature - 150 degrees Fahrenheit; Minimum rinse cycle temperature - 180 degrees Fahrenheit: 07/11/19 11:38 AM dish machine in use, 140 wash, 178 rinse (utensils) 07/11/19 11:46 AM dish machine in use, 130 wash, 182 rinse (utensils) 07/11/19 11:51 AM dish machine in use, 130 wash, 179 rinse (insulated cups) 07/11/19 11:56 AM dish machine in use, 146 wash, 181 rinse (utensils) 07/11/19 11:59 AM dish machine in use, 143 wash, 179 rinse (insulated cups) An interview occurred on 07/11/19 at 01:12 PM with the assistant dietary manager (ADM). During the interview, the ADM stated that if staff noticed that dishes were being washed but not getting clean, staff would check to make sure the dish machine was reaching the correct temperatures for the wash/rinse cycles. The ADM stated that she expected dietary staff to check the wash/rinse cycle temperature of the dish machine once per meal, but that she did not expect dietary staff to monitor the dish machine temperature with each use. During an interview on 07/12/19 at 10:00 AM, DA #4 stated that she had not received instruction to monitor the wash/rinse cycle temperature of the dish machine while in use. DA #4 further stated that she thought the wash cycle should be 210 degrees F and the rinse cycle should be 180 degrees F, but that she was not certain. An interview occurred on 07/11/19 at 01:20 PM with the Administrator who stated dietary staff would use a thermometer to check temperatures of the wash/rinse cycles when they noticed that the dish machine was not reaching manufacturer recommended temperatures and he expected staff to report any concerns. During a follow up interview on 07/11/19 at 03:45 PM, the Administrator stated that the service technician assessed the dish machine on 07/11/19 as a result of the fluctuating wash/rinse cycle temperatures identified by the surveyor and found a malfunctioning compressor. He further stated that the temperature of the dish machine was likely being monitored by staff at the end of the meal which meant staff might not catch problems with temperatures. An interview occurred on 07/11/19 at 05:51 PM with the service technician who stated that he checked the dish machine monthly and as needed, for any problems. He stated he was called that day to assess the dish machine as a result of the fluctuating temperatures identified that day and when assessed the dish machine earlier that afternoon, he found a bad compressor. He further stated that the only way staff would have known there was a problem would have been with monitoring the wash/rinse cycle temperatures while the dish machine was in use.

Based on observation, policy review, and staff interviews the facility failed to have expired food dated in 2 of 2 walk-in refrigerators and 1 of 1 dry storage area, were discarded and not available for consumption by residents and use in residents ' meals and failed to ensure male staff wore facial hair covering while preparing food items. The findings included: 1. Review of undated, Label and Dating Policy, provided by facility, revealed the following guidelines for refrigeration and dry storage: - All items must be dated when opened. - All items made in house must be dated with a 4 day shelf life. - All other items must be dated with a 7 day shelf life. - All exceptions in by chef and sous-chef approval only for guidance with food safety standards. During the initial tour of the main kitchen on [DATE] from 11:32am to 11:54am the following items were observed in refrigeration and available for use. a. Walk-in refrigerator #1: - One quart size carton of liquid egg whites open with no date. The manufacturer 's expiration date was [DATE]. - One quart size carton of orange juice open with no date. The manufacturer ' s expiration date was [DATE]. - One quart size carton of orange juice with spout open and no date. The manufacturer ' s expiration date was [DATE]. - One large, closed container of ham bones with a written label that revealed an open date of [DATE] and discard date of [DATE]. b. Walk-in refrigerator #2: - One large, closed container of shrimp with a written label that revealed an open date of [DATE] and discard date of [DATE]. c. Dry storage area: - One large bag of dried onions on a shelf in the dry storage room with a written label that revealed an open date of [DATE] and a discard date of [DATE]. - One large, closed container of icing on a shelf in the dry storage room with a written label that revealed an open date of [DATE] and a discard date of [DATE]. Observation of the main kitchen on [DATE] at 10:35am the following items were observed in the dry storage area and available for use: - A partially full bag of tortilla chips on a shelf in the dry storage area that had been opened and reclosed with tape that was peeling off. There was no open date on package. - One 5 pound bag of flour sitting on a shelf in the dry storage area with top of bag opened and partially covered with plastic wrap. There was no open date found on package. During an interview with the Executive Chef on [DATE] 11:32am - 11:54am, he stated that many food items were good for much longer than the 3 or 4 day discard dates and some of them up until manufacturer ' s expiration date. He stated that his expectation was for kitchen staff to stop putting written labels with discard dates on food items as this is a waste of food and not required. He stated that he will re-educate his staff. He stated he does not know what the facility policy is for food storage. Interview with the Executive Chef on [DATE] revealed that the dry storage room items were checked weekly for expiration dates but there was not a schedule or designated person to perform this task. He stated that a person had been hired that would be performing that task routinely and that person was to start working tomorrow. 2. Review of undated policy labelled, Employee - Personal Cleanliness, provided by facility, revealed the following guidelines that included, hair nets or caps should always be worn in food preparation areas and during food preparation. Facial hair covers to be worn when appropriate. During an initial tour of the kitchen on [DATE] at 11:32am - 11:54am revealed 6 male kitchen employees with facial hair uncovered. The 6 male kitchen staff were observed to be directly handling and prepping food items for the lunch meal. Observation of the main kitchen on [DATE] at 10:35am revealed three male employees with facial hair uncovered. They were actively prepping food items for residents. Interview on [DATE] 11:32am - 11:54am with the Executive Chef revealed that his expectation was that all staff working in the kitchen would wear hair and beard covers if facial hair present. He stated that hair nets and beard covers were available for staff use.

Based on observations and interviews, the facility failed to maintain the walls in the residents' rooms in good repair for 4 of 14 sampled resident rooms: 109, 207, 205, and 209 and the facility failed to fix a hole in the wall located in the main living room utilized as a common area for residents on hall 100. The findings included: 1. An observation on 11/28/17 at 11:23 AM of room [ROOM NUMBER] revealed a large hole in the wall behind the door in the area of contact with the door knob (measuring 2 (inches) X 4). An interview with a family member was conducted on 11/28/17 at 11:23 AM. The family member indicated staff had told the family the hole was from a disgruntled family member of a prior resident no longer allowed in the facility. The current resident had lived in the room since June 2016 and the hole had always been noticeable. An observation on 11/29/17 at 3:56 PM of room [ROOM NUMBER] revealed the hole behind the door had been partially patched with an open area still visible. An observation on 12/01/17 at 9:24 AM of room [ROOM NUMBER] revealed the hole behind the door that had been partially patched on 11/30/17, had a large hole through the patch. An interview on 12/01/17 at 9:24 AM with the Maintenance Supervisor, indicated the wall was weak in room [ROOM NUMBER] and he would place wood over the spot to prevent further damage. He stated he was not aware the area was damaged since 6/2016. He stated he was aware the area had been a concern. 2. An observation on 11/28/17 at 10:50 AM of room [ROOM NUMBER] revealed an area behind the bed exposing sheet rock (measuring 3 X 2). An interview with Nurse #1 conducted on 11/30/17 at 2:58 PM revealed she was unaware of any concerns on Hall 200 pertaining to areas on the wall needing maintenance. An interview with maintenance personnel on 12/01/17 at 10:45 AM, revealed his responsibility to inspect each hall weekly and log had not included wall integrity. 3. An observation on 11/28/17 at 10:58 AM of room [ROOM NUMBER] revealed 2 areas exposing sheet rock behind the bed (measuring 6 X 0.75 and 0.5 X 1) and 1 area exposing sheet rock behind the head board (measuring 1.5 X 1). An interview with Nurse #1 conducted on 11/30/17 at 2:58 PM revealed she was unaware of any concerns on Hall 200 pertaining to areas on the wall needing maintenance. An interview with maintenance personnel on 12/01/17 at 10:45 AM, revealed his responsibility to inspect each hall weekly and log had not included wall integrity. 4. An observation on 11/28/17 at 3:43 PM of room [ROOM NUMBER] revealed 3 areas on the wall to the right-side of the bed marred with intermittent scratching (measuring 10 X 6, 6 X 4, and 5 X 15) and 1 area behind the rocking chair marred with exposed drywall (measured 2 X 1.5). An interview was conducted with Nurse #1 for Hall 200 on 11/30/17 at 2:58 PM. Nurse #1 stated the process for maintenance requests was to complete a slip kept at the nurses station and then to take the completed slip to the main nursing station downstairs to be processed. She had no maintenance requests or concerns at the time of the interview. An interview with the Maintenance Supervisor on 11/30/17 at 3:15 PM, revealed the new process for maintenance requests started about 2 years ago and anyone including staff, residents, or family called the dispatcher or emailed directly work orders. The Maintenance Supervisor stated the usage of maintenance slips had been part of the old process. He continued to indicate the holes behind the beds and chairs, and in common areas for residents were very hard to keep up with because it happened so frequently. He stated he had ideas for improvement related to usage of a better product and would share with his Administrator to better manage concerns for wall integrity. 5. An observation on 11/30/17 at 3:15 PM, revealed an area with a large hole in the wall behind the desk in the main living room. In an interview with the Administrator on 12/01/17 at 9:48 AM, he stated the hole behind the desk in the main living room (measuring 1.25cm X 3.75cm) was from a refreshment station that had been removed a while ago. He could not specify how long a while ago meant. He stated the facility was told to remove the refreshment station and a cover had not been placed to the date. In an interview and facility round with the Administrator and Maintenance Supervisor on 12/01/17 at 9:48 AM, both stated the wall integrity had been an ongoing concern and difficult to keep up with. The Administrator explained ongoing meant, a long time. During the facility round, areas with damaged wall integrity were measured by the Maintenance Supervisor. An additional interview with maintenance personnel on 12/01/17 at 10:45 AM revealed he had the responsibility for inspection of each hall weekly for maintenance concerns and reported to the dispatcher. He stated he had a log of his findings however wall integrity had not been monitored on the log. He indicated future inspections with the log would include wall integrity and had been added to the QAPI (Quality Assurance Performance Improvement) agenda. He further stated he had been assigned the responsibility. An interview with the Administrator on 12/01/17 at 12:08 PM revealed his expectation was for staff to report maintenance requests related to wall integrity using the new process and for maintenance to ensure requests were processed timely.

Based on observation of the dinner meal, staff interviews, and record review, the facility failed to follow the pureed diet menu for 9 of 9 residents in the facility who received a pureed diet (Residents #4, #7, #14, #15, #21, #33, # #39, #44 and #51). The findings included: Review of the therapeutic diet spreadsheet for the dinner meal on 01/18/17 revealed residents on a pureed diet were to receive pureed southwest white bean stew, pureed ham, pureed mashed sweet potatoes, pureed black eyed peas, and pureed stewed tomatoes. Observation on 01/18/17 at 3:40 PM revealed pureed ham and mashed sweet potatoes available on the steam table. Observation on 01/18/17 at 3:54 PM revealed dietary assistant specialist (DAS) #1 pureed the black eyed peas and the stewed tomatoes. Observation on 01/18/17 at 4:02 PM revealed DAS #1 plated pureed ham, pureed black eyed peas and pureed stewed tomatoes onto a divided plate with three compartments. DAS #1 did not plate the mashed sweet potatoes. There was no pureed southwest white bean stew available. DAS #1 prepared 9 pureed meals for delivery. Interview with the assistant dietary manager (DM) on 01/18/17 at 4:40 PM revealed residents on a pureed diet did not receive the soup/stew course. The assistant DM explained the practice of pureeing a soup menu item stopped after a resident who liked soup left the facility several months ago. Interview with DAS #1 on 01/18/17 at 5:15 PM revealed she omitted the sweet potatoes because the divided plate could not contain more than 3 food items. DAS #1 explained she plated the lunch and dinner meals on a full time basis and always plated one protein, one starch and one vegetable. DAS #1 reported she chose which food item to omit. Interview with the Registered Dietician (RD) on 01/18/17 at 5:16 PM revealed she was not aware of the regular omission of food items from the pureed menu. The RD explained residents should receive the pureed stew and the choice between the black eyed peas and stew did not adversely affect the nutritional content of the meal. The RD reported staff should follow the menu to ensure receipt of a nutritionally balanced meal.