Every finding on record at The Village

Based on clinical record review, resident and staff interview, the facility failed to ensure each resident is treated with dignity and respect and cared for in a manner and environment that promotes maintenance or enhancement of his or hers quality of life for 2 of 3 residents reviewed. (Residents #1 and #2) The facility reported census was 43.Findings include: 1.According to a Minimum Data Set (MDS) with a reference date of 7/5/25, Resident #1 had a Brief Mental Status (BIMS) score of 14 of 15, indicating an intact cognitive status. Resident #1 required maximal to dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was determined as always incontinent of bladder and occasionally incontinent of bowel. Resident #1's diagnosis included Non-Alzheimer's dementia, Parkinson's, renal insufficiency, diabetes mellitus. In an interview on 9/23/25 at 11:15 a.m. Staff C, housekeeping, stated on 8/26/25 at around 3:00 p.m. she was cleaning the shower room near Resident #1's room. She could hear yelling, so she got closer to the door and could hear more clearly, Resident #1 was telling Staff E, Certified Nurse Aide you're hurting me and Staff E stated I have to wipe you. Staff C stated it is not uncommon for Resident #1 to tell staff they're hurting him when they are doing cares he doesn't like. Staff C stated she has never known Resident #1 to use profanity. Staff C stated it then escalated and Staff E told Resident #1 to shut the fuck up and you're a fuckin jerk. Staff E then told Resident #1 to shut the fuck up again and that's when Staff C stated she left to report the interaction. Staff C stated she first informed the charge nurse, Staff D, who went to the room, while she went and told the DON and ADON. Staff C stated Staff E had always been quiet and she never knew her to use profanity or mistreat a resident.In an interview on 9/23/25 at 11:45 a.m. Staff D, Registered Nurse stated on 8/26/25 at 3:05 p.m. she was approached by Staff C, housekeeper, who reported an aide (Staff E) was telling a Resident #1 to shut the fuck up and yelling at him. Staff D immediately went to the room and noted it was quiet as she entered the room. There was no cursing or yelling. Staff E appeared calm, face unflushed. Resident #1 was still in his bed, seemingly anxious to get out of his bed, but not showing any signs of distress. Staff D offered to help and together they finished care. As they were stepping out of the room, the DON and ADON were at the doorway. Staff E went with the DON and ADON. A little while later Staff E approached her crying, stating I know better than that. Staff D stated she wasn't too familiar with Staff E, but Resident #1 will holler out, but not use profanity.In an interview on 9/23/25 at 1:00 p.m. Staff E, Certified Nurse Aide, stated she was totally in the wrong in what she did on 8/26/25 involving Resident #1. Staff E stated it was change of shift and she was trying to get Resident #1 cleaned up from incontinence. Resident #1 was not being cooperative and he began cursing at me, so I cursed back, telling him to shut the fuck up. Staff E stated it was not an excuse, but I was dealing with a lot. My father in law passed earlier that month and I'm now taking care of my mother and was up the last three nights leading up to the incident. I just should have not come back to work so soon. In an interview on 9/23/25 at 1:30 p.m. Resident #1 was observed sitting in his wheelchair, just after being assisted with toileting, Resident #1 was alert and pleasant. When asked if staff treated him well and were kind, he stated I supposed so. Resident #1 could not recall any incidents in which he was mistreated. 2.According to a Minimum Data Set (MDS) with a reference date of 8/13/25, Resident #2 had a Brief Mental Status (BIMS) score of 13 of 15, indicating an intact cognitive status. Resident #2 required moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was determined as frequently incontinent of bladder and bowel. Resident #2's diagnosis included Non-Alzheimer's dementia, Compression fracture T5-T6, atrial fibrillation, coronary artery disease, congestive heart failure, renal insufficiency, arthritis, chronic obstructive pulmonary disease, respiratory failure, gastroesophageal reflux disease. In an interview on 9/23/25 at 2:20 p.m. Staff G, Certified Nurse Aide, stated upon arriving to work on 7/24/25 at 6:30 a.m. she entered Magnolia quietly and immediately saw Staff F, Licensed Practical Nurse, standing in the doorway of Resident #2's room, yelling at her to stay in bed. Staff G stated she could hear Resident #2 crying. All the lights were off, including Resident #2's. Staff G stated she made some noise, alerting Staff F that she was there. It was then Staff F's tone changed and she started talking about not being able to find her aides. Staff G stated she would get Resident #2 up for breakfast. Staff G stated she got Resident #2 into her bathroom and started providing care. Her nasal cannula was off and her lips were blue. Resident #2 was crying as Staff G got her toileted, groomed and dressed. Staff G was asked about Staff F and she stated she is why I left overnight shifts. Staff G stated Staff F insisted the residents were not to get up on overnight shift. Staff F did not what people up that may fall. Staff F was rude and wouldn't help aides, but expected aides to help her. Later while Staff F was still giving report, Staff F stated thank you. Upset with what had happened, Staff G stated if you had turned on the lights and entered the room instead of standing there yelling, you would have known Resident #1's oxygen was off her nose.In an interview on 9/24/25 at 10:30 a.m. Staff H, Speech Pathologist stated on the morning of 7/24/25 she completed a visit with Resident #2. Resident #2 complained about the overnight staff, stating, the gal last night was like a soldier to me. She yelled at me, telling me to get my shit together. Staff H stated Resident #2 was visibly upset and she passed on the concern to the social worker.In an interview on 9/24/25 at 9:00 a.m. Resident #2 reported to ADON that she was having difficulty sleeping last night because she was feeling short of breath. The nurse was being very bossy and mean. The nurse did not like me trying to get out of bed.In an interview on 9/24/25 at 9:30 a.m. Resident #2 was sitting in her recliner watching TV. She was well groomed and appropriately dressed in preparation for a reunion (62yrs). Alert and pleasant. Resident #2 was queried regarding care givers and how she feels she has been treated. Resident #2 stated there was a nurse about a month ago that refused to help her one day. She stated she told the nurse she was going to report her. Resident #2 was unable to identify the nurse by name or the specifics of her request. Resident #2 stated otherwise the staff have been wonderful, very kind and respectful.

Based on direct observation, staff interview, facility documentation, and facility policy review, the facility failed to implement measures to ensure safety for each resident identified at risk of injury to themselves for 1 of 4 residents reviewed. The facility reported a census of 49. Findings include: The Quarterly Minimum Data Set (MDS) for Resident#26, dated 10/02/24, documented relevant diagnoses of heart failure, hypertension, history of fractures, Non-Alzheimer's Dementia, seizure disorder, depression, and a history of falling. It documented her brief interview for mental status (BIMS) score as 03, which indicated severely impaired cognition. It further documented a need for a wheelchair or walker for supportive items, and functional ability to walk score of 03, indicating the resident required moderate assistance to walk. The Care plan, last revised on 10/04/24, recorded the resident used a front wheeled walker in her room and a wheelchair for mobility that required longer distances. It documented the resident required an assist of one for ambulation, with the use of a gait belt and front wheeled walker and the resident was an assist of one for wheelchair mobility. It also recorded the resident was an assist of one for transfers. Additionally, it documented fall prevention interventions for Resident #26 included her bed being placed in the standing position, not the low position, to assist the resident in standing from her bed, as well as her wheelchair placed at the foot of her bed to allow her to use it. Review of nursing progress notes dated 08/05/24 revealed Resident #26 fell during the overnight shift at approximately 12:20 am attempting to self-ambulate. She was found by Staff K, Certified Nurse's Aide (CNA), and assessed by Staff L, Registered Nurse (RN). The resident required transportation to the hospital where she was diagnosed with a fractured right wrist. The nursing progress notes do not detail the position of the resident's bed or location of her wheelchair at the time of the incident. Further review of nursing progress notes dated from 07/01/24 until 11/14/24 documented Resident #26 had fallen on at least four documented occasions during the lookback period with the most recent fall having occurred on 10/09/24. Review of hospital discharge records, dated 08/05/24 , confirm Resident #26 sustained a right wrist fracture. During a direct observation on 11/14/24 at 08:32 AM with Staff J, Certified Medication Aide (CMA), Resident #26 was seen sitting in her bed. Her bed was in the low position, as confirmed by Staff J, and her wheelchair was placed in her bathroom behind a closed door. Staff J acknowledged to the surveyor at this time the bed was in the wrong position and that the wheelchair needed to be at the foot of her bed, not in the bathroom. In an interview on 11/14/24 at 09:09 AM with Staff K, CNA he noted he found Resident #26 shortly after midnight on 08/05/24. He was unable to recall what specific care plan interventions the resident had in place to prevent falls, and did not recall the location of her wheelchair at the time of the incident. In an interview on 11/14/24 at 09:50 with Staff L, Registered Nurse she stated she believed the resident was trying to walk to her recliner or the bathroom at the time of the fall. She stated she had been summoned to Resident #26's room shortly after midnight on 08/05/24 by Staff K, who had found her on the floor with an obvious bend in her wrist. She stated she believed the bed was in the low position and the resident's wheelchair was across the room from her bed, placed near the recliner the resident appeared to be attempting to ambulate to. She assessed Resident #26 and found the resident was unable to move the fingers on her right hand, and the resident was complaining of pain in that arm. There was also a clear bend in the arm near her right wrist that led Staff L to believe she had broken her arm. She contacted the Director of Nursing (DON) after having called for an ambulance transport to the emergency room . She could not recall what interventions Resident #26 had in place to prevent falls. In an interview on 11/14/24 at 01:05 PM with Staff I, CNA, she stated she knows the expectation is to follow the documented interventions in the electronic health record (EHR) for all residents. She stated she knows Resident #26 is prone to falling if her care planned interventions aren't followed, and was able to list the care planned interventions from memory. She stated she had seen prior times in the morning when she noted the care planned interventions for Resident #26 had not been followed, though she could not offer exact dates. In an interview on 11/14/24 at 01:14 PM with Staff H, CNA, she was able to accurately state the care planned interventions for Resident #26. She noted Resident #26 is prone to falls and at risk for injury if her care planned interventions are not in place, as she is non-compliant with things like the call lights system, and she has been harmed in the past falling. In an interview on 11/14/24 at 01:32 PM with the Director of Nursing, she stated it was her expectation that staff follow care planned interventions to enhance resident safety. She agreed that not implementing care planned interventions can lead to harm and injury for residents, and she agreed that not following the care planned interventions on the evening of 08/05/24 could have contributed to Resident #26's fracture. In an interview on 11/14/24 at 10:12 AM with the Advanced Registered Nurse Practitioner (ARNP), she stated that while she believes the residents dementia and poor physical condition were the primary factors in the 08/05/24 fracture, she agreed not following care planned interventions could have contributed to her injury. Review of the facility provided document titled CNA Orientation Checklist directs facility staff members to use the Kardex/Care Plan to guide care for residents identified as at risk for falls.

Based on record review, observations, staff interviews, and policy review, the facility failed to implement Enhanced Barrier Protection (EBP) practices for residents with indwelling medical devices and wounds for 4 of 4 residents reviewed (Resident #3, Resident #21, Resident #39, and Resident #109) reviewed for infection control. The facility failed to sanitize a multi-resident use mechanical lift in-between use for 2 of 3 households (Juniper and Magnolia) observed for equipment sanitation. The facility failed to provide infection prevention practices during urinary catheter cares for 1 of 2 residents (Resident #21) observed for catheter cares. The facility reported a census of 49. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Documented diagnoses include neurogenic bladder, obstructive uropathy, and paraplegia. The MDS indicated the presence of an indwelling catheter. The Care Plan with a targeted date of 1/14/25 revealed Resident #21 with an activities of daily living (ADL) performance deficit with total dependence on staff for use of wheelchair. The resident utilizes a mechanical lift for all transfers and relies on at least one staff member for personal cares. An indwelling catheter is present related to the diagnosis of neuromuscular dysfunction of bladder. The Care Plan lacked directives for staff to use EBP but noted the resident declines use of EBP (initiation date of 4/30/24). During observations on 11/12/24 at 12:05 PM, Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA, both donned on a pair of gloves prior to initiating cares. Staff B proceeded to empty Resident #21's urinary catheter bag. A graduate was placed on the floor without a barrier. Staff B cleansed the catheter port with an alcohol swab and emptied the bag. Due to the Resident #21's shared bathroom being occupied by the roommate, the graduate full of urine could not be emptied at that time. Staff B placed the graduate on the floor next to the bed, without a barrier. No hand hygiene or glove change observed from Staff B when transitioned from catheter cares to pericares. Staff A and Staff B both completed pericares, which included the handling of the urinary catheter. After all resident cares finished, Staff B completed hand hygiene and glove change and emptied the graduate in the toilet. The graduate was placed in a plastic bag for storage without rinsing. Staff A and Staff B completed hand hygiene when exited the room. Neither staff member wore gowns while the catheter was cared for and handled. The resident's room lacked signage to indicate the use of EBP or the required Personal Protective Equipment (PPE). During an interview on 11/13/24 at 3:50 PM, the Director of Nursing (DON) acknowledged the lack of EBP throughout the facility. The DON reported the facility's Medical Director uses an algorithm to determine if a resident needs to be placed on EBP. The resident has to be colonized multi-drug resistant organism (MDRO) or have an infection to meet this criteria. A Resident Choices and Mitigating Risk Assessment completed if a resident does not want staff to utilize EBP. During an interview on 11/14/24 at 09:50 AM, Staff C, CNA explained resident-specific information is available to staff. For those residents with EBP, Staff C reported gown and gloves are to be worn when touching or doing anything with a catheter or if a resident has a wound. Staff C acknowledged training was provided a while ago but have not used gowns. Staff C confirmed the facility has adequate personal protective equipment (PPE) available for staff use. The policy Enhanced Barrier Precaution revised 4/2024 revealed Enhanced Barrier Precautions are a method for reducing the spread of MDROs by using a gown and gloves to prevent contamination of healthcare personnel hands and clothing during the activities that have demonstrated the highest risk for transfer of MDROs to the hands and clothing of healthcare personnel. Enhanced barrier precautions may be used for residents that have any of the following: a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply b. Wounds and/or indwelling medical devices including: indwelling urinary catheters and chronic wounds including, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Enhanced Barrier Precautions includes the use of gown and gloves for the specific residents during high contact care activities including changing a brief or assisting with toileting, direct care of an indwelling device (such as urinary catheter), performing wound care on a direct opening to the body that requires a dressing, changing linen, or providing personal cares. The policy Catheter-Emptying a Urinary Drainage Bag revised 07/2016 directs staff to: a. Place the graduate cylinder in a plastic basin (or on a plastic bag) under the collection bag's drainage port. The graduate cylinder should not touch the floor and the drainage port should not touch the graduate cylinder b. Fill a disposable cup with tap water, then pour into the graduate cylinder to rinse; empty water into toilet and repeat until the graduated cylinder is thoroughly rinsed c. Place paper towels in graduate to soak up any remaining water. 34817 2. The MDS assessment dated [DATE] revealed Resident # 39 had diagnoses of obstructive uropathy (a condition in which the flow of urine is blocked). The MDS indicated the resident had an indwelling catheter, and had dependence on staff for toileting hygiene, dressing, bed mobility, and transfers. The Care Plan revised 11/3/24 revealed the resident had an Activities of Daily Living (ADL) self-care deficit related to limited mobility, and had an indwelling catheter. The Care Plan directed staff to provide assistance of one with bed mobility and catheter care, use a mechanical lift and assistance of two for transfers, and provide pericare. Resident #39's electronic health record (EHR) lacked a Resident Choices and Mitigating Risk Assessment. During observations on 11/13/24 at 11:12 AM, Staff C, Certified Nursing Assistant (CNA), and Staff D, CNA, washed hands and donned gloves, then transferred Resident #39 from the broda chair to the bed using a mechanical lift. Staff D took disposable wipes and cleansed the periarea and catheter tubing from the entry site toward the bag. Staff D changed gloves, took disposable wipes and cleansed the buttocks area front to back, then placed a clean brief under the resident. Staff C and Staff D changed gloves. At 11:20 AM, Staff C donned a pair of gloves and emptied the resident's catheter contents into a graduate container. Staff C took an alcohol swab and cleansed the port on the catheter bag. Staff C emptied the graduate into the toilet, took a disposable wipe and wiped the inside of the graduate, then placed the graduate into a plastic bag and placed the graduate inside a cabinet. Staff C removed her gloves and washed her hands. The resident's room had no EBP signage or the required PPE. Staff C and Staff D did not wear a gown when they transferred the resident, when performed pericare, or when handled the catheter and performed catheter care. Observation on 11/14/24 at 9:45 AM revealed a plastic bin with drawers containing Personal Protective Equipment (PPE) (gowns and gloves) observed inside the resident's room. During an interview on 11/14/24 at 9:50 AM, Staff C, CNA, reported she looked at her phone to get information about what cares a resident needed done. Staff C reported staff were supposed to wear a gown and gloves for EBP anytime staff touched or did anything with a catheter or if a resident had a wound. Staff C reported the facility staff provided staff training about EBP's a while ago but they haven't used gowns during encounters with residents who had a catheter or a wound. 3. The Clinical Medical Diagnosis List documented Resident #109 had diagnoses of a diabetic foot ulcer, infection to the right ankle and foot, and urinary retention. The Care Plan initiated on 11/8/24 revealed the resident had a risk for pressure injuries and impaired skin related to diabetes and impaired mobility. The resident had a diabetic ulcer on his right heel. The Care Plan directed staff to follow facility protocols for treatment. The CarePplan also documented the resident had an indwelling catheter related to urinary retention. Resident #109's EHR lacked a Resident Choices and Mitigating Risk Assessment. Progress Notes revealed the following: a. On 11/12/24 at 10:03 AM revealed an order to apply betadine soaked gauze to the resident's right heel twice a day (BID), and administer bactrim DS (antibiotic) BID for seven days. b. On 11/13/24 at 1:10 AM, resident on skilled level of care for a diabetic ulcer to his right foot and receiving bactrim as ordered for a foot wound. Dressing in place to the wound. During observations on 11/13/24 at 9:10 AM, Staff E, Registered Nurse (RN), gathered supplies, placed the supplies on an overbed table, washed her hands and donned a pair of gloves. Staff E removed a soiled dressing over the resident's right foot, changed her gloves and sanitized her hands, then cleansed the right foot wound with wound cleanser and gauze. Staff E changed her gloves, applied a betadine gauze and kerlix dressing to the right lateral foot wound, and removed her gloves. The resident's room had no EBP signage or the required PPE, and Staff E did not wear a gown when she performed the wound care and dressing change. Observation on 11/14/24 at 10:40 AM, revelaed a plastic bin with drawers sat outside the resident's room with PPE inside. During an interview on 11/13/24 at 3:50 PM, the DON reported Resident #109 had a diabetic foot ulcer and Resident #39 had a catheter. The Medical Director used an algorithm to determine if a resident needed to be on EBP. The resident had to have a colonized MDRO or have an infection to meet the criteria. Staff filled out a Resident Choices and Mitigating Risk Assessment if the resident did not want staff to use EBP's. 49990 4. The Significant Change Minimum Data Set (MDS) for Resident #3, dated 07/25/24, revealed the resident had a relevant diagnosis of pressure ulcer, hypertension, renal insufficiency, Non-Alzheimer's Dementia, Malnutrition, Anxiety disorder, and depression. It documented a brief interview for mental status (BIMS) score of 05, indicating severe cognitive impairment. The Care Plan for Resident #3, last revised on 11/11/24, documented a stage II medial foot pressure ulcer and advised staff members to administer treatments as directed. It did not document a need for enhanced barrier precautions. In a direct observation on 11/13/24 at 03:38 PM with Staff G, LPN, she applied a barrier treatment to the stage II medial foot pressure ulcer, but did not utilize enhanced barrier precautions. When asked if she believed she was required to use enhanced barrier precautions during wound treatment she indicated she did not believe it was required for Resident #3. In an interview on 11/14/24 at 08:37 AM with the Director of Nursing (DON), she confirmed Resident #3 did require enhanced barrier precautions during wound care. She admitted she had struggled with enhanced barrier precaution and their application. 49698 5. Observations on 11/14/24 revealed the following: 7:55 AM, Staff F, CNA pushed mechanical lift out of a resident ' s room, parking mechanical light in hallway outside of the room then returned to resident ' s room 8:15 AM Staff F, CNA, exited a resident ' s room, crossed the hall, and entered another resident room. Staff C, CNA excited the same resident ' s room pushing the mechanical lift and followed Staff F, CNA into the room. 8:35 AM Staff F, CNA, observed pushing the mechanical lift out of the resident's room and parking the mechanical lift in the hallway of the unit. During an interview on 11/14/24 at 8:43 AM, Staff C, CNA stated the mechanical lifts are cleaned and sanitized when it appears to be dirt. Staff C, CNA thought the mechanical lifts might be cleaned on the overnight shift or during the weekly cleaning, but did not know for sure. During an interview on 11/14/24 at 12:47 PM, DON, stated the mechanical lifts are to be cleaned after each resident's use. Review of facility provided Infection Control Manual: Nursing Weekly Cleaning Tasks, effective date 8/1/2019, stated multiple use items will be cleaned and disinfected between each resident use. Such as: Shower Chairs, Tubs, Bedside Scales, Mechanical Lifts, Commodes, IV or Tube Feedling- Poles/pumps.

Based on observations, staff interview, and policy review, the facility failed to label and store food items in order to maintain food quality and reduce the risk of contamination and food-borne illness. The facility reported a census of 49 residents. Findings include: Initial tour of the main kitchen on 11/12/24 at 10:00 AM revealed the following concerns: a. Unidentified meat wrapped in plastic wrap found in the walk-in cooler without a label or date and stored below a sheet pan of uncooked meat loaf and beef patties b. Plastic storage containers located on a top shelf in dry storage found without a label to identify the product or a date to show when transferred from the original packaging c. Packages of used dry pasta, secured with a knot to close, found without a date to indicate when opened d. Plastic storage container of dry pasta found without a label or date e. Plastic storage container of popcorn kernels found without a label or date; Lid to the container not completely secured f. Used container of popcorn oil observed in the plastic storage bin of popcorn kernels In an interview on 11/12/24 at 2:30 PM, the Director of Food and Beverage acknowledged the presence of the unlabeled meat in the walk-in cooler and the unlabeled plastic storage bins of food and dry pasta in dry storage. All food should have been labeled appropriately. The policy Label & Dating Policy last revised 11/2024, outlines bulk items that have been removed from their original packaging will include the following on the label: a. Food item name b. Date made/prepared or opened c. Use by date-reference [NAME] Life ' s Life of Food Storage and Handling policy d. Food handler's initial

Based on observation, staff interviews, and document review, the facility failed to store and prepare food in accordance with professional standards for 51 of 51 residents. Resident food had not been prepared under sanitary conditions and with clean sanitary equipment. The facility reported a census of 51 residents. Findings include: On 10/30/23 at 11:00 AM an observation during the initial Primary Kitchen tour revealed the following: A Vulcan grill noted to have a buildup of dark brown substance between grates. Edges and sides of the grill were covered with brownish liquid stuck to the surfaces and accumulated directly underneath the grill tile floor. The tile floor underneath the equipment was covered with layers of debris. Two drains located near the grill and the serving table had visible accumulation of debris. The wall behind the backsplash of the grill was covered with brown substance extending up to the hood vents. Inside the hood vents, a pipe located directly above the grill noted to have several drip size brown color substances accumulated along the bottom of it. Two large round waste bins located near the food preparation stainless steel tables were not covered with lids. Sides of the waste bins displayed various splashes and side handles had accumulated debris inside of them. A second observation on 10/31/23 at 09:05 AM had shown all initially observed on 10/30/23 at 11:00 AM contaminated areas had remained unchanged. On 11/1/23 at 10:00 AM a third observation had shown previously observed contaminated areas had remained unchanged. In addition, it was noted that 4 white plastic serving spatulas stored in a utensil drawer of the preparation table were integrally compromised. In an interview with Staff C on 10/30/23 at 11:00 AM, he acknowledged he did not have a cleaning checklist he followed and stated he was expected to clean his workstation after each shift. He further stated that it's been a while since the floor tiles underneath the equipment were cleaned. In an interview with the Food and Beverage Supervisor on 10/30/23 at 1:35 PM, she stated that staff were responsible for cleaning their workstations after each shift. In an interview with the Administrator on 10/31/23 at 2:30 PM while observing the Primary Kitchen she acknowledged that the Vulcan grill, drains and waste bins handles displayed accumulated debris. She also provided the scheduled cleaning lists the kitchen staff used, and stated that they were only kept for 1 week then disposed of. A review of the facility provided document on 11/02/23 at 09:00 AM, titled Facility Dietary Department, Infection Control Manual, effective 8/1/2019, documented: 1. All equipment must be cleaned and sanitized before use. 2. Keep all work areas, floor and dietary equipment as clean as possible throughout the work day. 3. Clean ranges every day. 4. At least one a month, clean hoods over stoves and dishwashing machines. 5. Wet mop floors every day and as needed.

Based on observation, record review, and staff interview the facility failed to ensure 1 of 1 residents (Resident #48) with a colostomy had a comprehensive care plan in place within 21 days from admitted . The facility reported a census of 51 residents. Findings include: Record review of Resident #48 Minimum Data Set (MDS) dated [DATE] documented an admission to the facility on [DATE]. During an observation on 10/31/23 at 9:09 AM revealed Resident #48 has a colostomy site. Record review of a Progress Note dated 10/20/2023 at 7:15 AM documented Resident #48 colostomy bag had a tear this morning and was assisted to the bathroom and her colostomy bag was changed. Record review of Resident #48 Comprehensive Care Plan on 11/2/23 revealed no Care Plan goals or interventions are in place for her colostomy site. During an interview on 11/02/23 at 9:36 AM with the Director of Nursing (DON) revealed she would expect Resident #48 to have her colostomy care on the comprehensive Care Plan if she has been here for more then 21 days.

Based on record review and staff interviews the facility failed to complete an Interdisciplinary Recapitulation of Stay assessment for 1 of 1 residents (Resident #50) reviewed for discharges. The facility reported a census of 51 residents. Findings include: Record review of Resident #50 Electronic Health Record (EHR) Minimum Data Set (MDS) log revealed she discharged from the facility on 10/16/23 and is not expected to return. During an interview on 11/02/23 at 9:35 AM with the Director of Nursing (DON) revealed she would expect the floor nurse who discharges the resident to open the Interdisciplinary Recapitulation of Stay assessment in the residents EHR on the day they discharge. Record review Resident #50 EHR Assessments revealed the facility initiated an Interdisciplinary Recapitulation of Stay assessment on 11/2/2023.

Based on observations, staff interviews, and facility document and policy review, the dietary staff failed to maintain clean and sanitary conditions in the kitchen, failed to label and store food items in order to maintain food quality and reduce the risk of food-borne illness in the main kitchen and in one of two household kitchen units, and a resident's refrigerator for one of three nursing units observed. Facility staff also failed to conceal hair completely in a hairnet to prevent food borne illness. The facility reported a census of 50 residents. Findings include: 1. Initial tour of the main kitchen on 7/6/22 at 2:36 PM revealed the following concerns: a. The Vulcan oven had two large areas of a solidified yellow liquid substance and blackened debris inside. The handle on the oven contained a sticky brown residue/substance. b. The stove back splash revealed a greasy substance and black debris. c. The True freezer had splatters of food on the outside front and lower portion of the freezer. The inside of the freezer revealed an uncovered pie shell, one bag of chicken breasts, one bag of waxed beans, and two bags of ravioli opened but not labeled or dated. The bag of chicken breasts were open to air. d. The red cutting board surface had a white fuzzy surface with a marred appearance. e. Two metal scoops lay on the counter by the pop machine dispenser next to the ice machine. One of the scoops sat on the counter and touched the hoses attached to the pop machine dispenser. f. The microwave had splatters of food and a sticky substance on the door and the glass plate inside the microwave. g. The [NAME] walk-in freezer contained a bag of chicken breasts, a bag of what appeared to be sausage or beef patties, and a bag of cookie dough opened and exposed to air and not labeled or dated when opened. h. The floor of the [NAME] walk-in freezer contained white/yellow crumbs on the floor under the food storage shelves. 2. On 7/6/22 at 3:00 PM, the freezer in the Magnolia household kitchenette had an open and unlabeled bag of french toast, with the food exposed to air. The floor of the freezer revealed a slice of french toast, and a brown and white sticky substance that appeared to be melted ice cream. On 7/7/22 at 2:02 PM, a slice of French toast and spillage that appeared to be melted ice cream and food particles sat on the bottom of the freezer. 3. During observation in the Magnolia household kitchenette on 7/7/22 at 8:41 AM, Staff A, homemaker cook, wore a hairnet over the middle and back of her head with her bangs exposed. Staff A handled food and assisted with meal service during this time. On 7/7/22 at 12:16 PM, in the Magnolia household kitchenette, Staff A wore a hairnet over the middle and back of her head with her hair bangs exposed. 4. During observations on 7/7/22 at 1:20 PM, Staff B, dietary aide, washed dishes and handled plates and utensils in the dishwashing area without wearing a hairnet. 5. Follow-up observations in the main kitchen on 7/7/22 starting at 1:30 PM revealed the following concerns: a. The Vulcan oven continued to have two large areas of solidified grease and black debris inside, and the oven handle had a greasy, brown substance. b. A fan sat on the floor near the food prep counter and the stove. The fan contained large brownish and gray dust particles and blew toward the food prep area. c. The True freezer continued to have an undated a pie crust and bag of ravioli opened to air. The bottom of the freezer revealed spillage and food particles. d. Two metal scoops lay on the counter by the pop dispenser machine next to the ice machine. e. The microwave still contained splatters of food on the glass plate and inside the door. f. The [NAME] walk-in cooler contained an uncovered bag of beef fritters and a pan with what appeared to be beef with a label cooked. The pan of meat was uncovered, not dated, and not labeled with the contents. At the time the Dietary Director (DM) confirmed the contents was a pan of beef and the food needed to be covered. g. The floor in the walk-in freezer had what appeared to be melted ice cream and particles of food/debris on the floor under the food storage shelves. On 7/11/22 at 3:25 PM, observation continued to reveal crumbs and large food particles and what appeared to be melted ice cream on the floor near the walk in freezer doorway. In an interview on 7/7/22 at 1:56 PM, the DM confirmed staff had a cleaning schedule. The DM reported the facility divided cleaning tasks up amongst staff who worked in dietary and household areas and they cleaned whenever staff had time. The staff initialed the cleaning task whenever they completed them. The DM reported the facility did not currently use the Vulcan oven because it did not hold its temperature and took a long time for the food to cook. In an interview 7/11/22 at 3:15 PM, the DM reported they used a cleaning schedule in the main kitchen and in each household. The DM reported he discarded daily cleaning logs after he looked at them and addressed any issues. An undated policy titled Food Storage directed the facility stored food stored in an appropriate manner that correlated to its general storage directions. The infection control manual dated 8/1/19 under section titled Dietary Department revealed the following: a. The dietary department worked to comply with all state, federal, and local infection control standards and regulations concerning food storage, preparation, handling, and equipment sanitization. b. All equipment and work surfaces cleaned and sanitized before and after use. c. All work areas and dietary equipment kept as clean as possible throughout the work day. d. The range cleaned every day. A Hairnet policy dated 10/2019 directed staff to wear hairnets whenever they entered the kitchen or whenever staff worked with or served food or whenever food was present in the household. The policy clarified that the hairnet must cover the entire hair area not just the bun or back of the hair. Review of the Daily Server Cleaning Tasks dated 7/4/22 - 7/10/22 revealed staff last cleaned the cooler and freezer floor on 7/4/22. The cleaning task schedule lacked directives or places to record cleaning of the oven, microwave, or fan. Review of a Homemaker checklist for the Magnolia Household dated 7/9/22 lacked documentation to show staff cleaned the refrigerator freezer. The 2017 Food Code directed staff to wear a hair covering to keep hair from contacting exposed food, clean equipment, and utensils. The 2917 Food Code also directed staff to cover or package food while in cold storage. Ice scoops stored with handles up in an ice bin. 6. During multiple observations at the Magnolia kitchenette and dining area, dietary staff members were not wearing personal protective equipment (PPE) properly while preparing, handling, and serving food for residents, and working close to residents in the dining room, as follows: A. On 7/7/22 at 9:30 AM, Staff D (Homemaker) was moving around the kitchenette area holding dishes, opening the refrigerator (containing food), and removing table cloths at the dining area, with her nose uncovered by her mask while also working in close proximity (at about 2-3 feet) to 2 residents who were still sitting around one table. B. On 7/7/22 at 11:40 AM, while at the kitchenette checking food temperatures, Staff C's (Homemaker) nose was uncovered by his mask. Staff D's nose was also uncovered while recording the temperatures of the food being tested , which were located about a foot away from her. A continuous observation until 12:10 PM, showed Staff C preparing food with his nose still uncovered and Staff D also remained to have uncovered nose while serving food for the residents at the dining area. By the end of the observation at 12:15 PM, Staff C and Staff D continued with their food-handling activities with masks not covering their noses. C. On 7/11/22 at 12:14 PM, Staff C was at the kitchenette preparing and serving lunch food with mask not covering his nose. D. On 7/12/22 at 9:10 AM, Staff D and Staff E were working at the kitchenette with masks not covering their noses. Staff D was preparing food at the food preparation counter while Staff E was washing dishes at the sink area, thereafter, Staff E went to serve food to residents with the mask not covering her nose. On 7/12/22 at 9:15 AM, Staff G, Registered Nurse (RN) who was also in the dining area, verified that Staff D and Staff E were not wearing their masks properly. Staff G said that masks need to cover the mouth and the nose. Staff G approached the 2 dietary staff members (Staff D and Staff E) and reminded them to cover their masks cover their noses. On 7/12/22 at 1:37 PM, the Dietary Director (DD) stated that in order to prevent the potential spread of infections, and also in relation to COVID-19 protocols, dietary staff members have been educated and required to wear PPE including masks. The DD also stated expectations for dietary staff members to wear PPE/masks properly, such as covering their mouths and noses especially when preparing/handling food for residents. The document titled, DIETARY DEPARTMENT effective 8/1/2019, indicated that the dietary department will work to comply with all infection control standards and regulations concerning personnel requirements, and food preparation, handling and serving. 7. An observation of a personal refrigerator in room 1106 on 07/07/22 at 02:56 PM revealed two large styrofoam cups of milk not labeled or dated, dried milk flakes on the bottom of the refrigerator, and approximately 1 inch of ice build up on the inside and bottom of the freezer section. An observation of the personal refrigerator in room 1106 on 07/11/22 at 02:42 PM revealed four pieces of fried chicken in a bag, six pieces of fried chicken in a bag not labeled or dated, dried milk flakes on the bottom of the refrigerator, and approximately one inch of ice build up on the inside and bottom of the freezer section. In a policy titled Resident Food Brought in by Family dated 7/2021 documented refrigerated foods must be labeled with the resident's name, room number and date. Food items will be discarded after 72 hours. --

Based on observation, record review, resident interviews and policy review, the facility failed to provide comprehensive care plans for 2 of 17 residents sampled. (Resident #22 and #44). The facility reported a census of 50 residents. Findings include: 1. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident demonstrated intact cognitive abilities. Review of Resident #22's record revealed it lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 4/18/22 failed to document frequency, transportation, assessments, and other interventions for the management of the resident's [CONDITION(S)]. 2. Resident #44 ' s MDS dated [DATE] revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident demonstrated intact cognitive abilities and was independent with bed mobility. Record Review revealed side rail assessments completed on 10/14/21, 1/14/22, 2/21/22, and 5/31/22, included a side rail consent obtained on 7/23/22. The Care plan dated 6/20/22 lacked staff directives regarding Resident #44's side rails. An observation on 07/07/22 at 01:53 PM revealed upper bedrails in the up position on the right side of bed with the left side of bed against the wall. Resident #44 reported he used the siderails to position himself in bed. In a subsequent interview on 7/12/22 at 7:24 a.m., Resident #22 reported he left the facility three times a week for [CONDITION(S)] services. An interview on 7/12/22 at 7:30 a.m., the Director of Nursing (DON) verified Resident #22 left the faciity on Mondays, Wednesdays, and Fridays for [CONDITION(S)]. On 7/12/22 at 10:00 AM Staff F, Certified Nursing Assistant (CNA) stated she was made aware of Resident #22 ' s [CONDITION(S)] schedule in morning report. She reported that sometimes the facility addresses a resident's siderails on the care plan, sometimes not. On 7/12/22 at 10:15 AM, Staff M CNA stated she expected [CONDITION(S)] to be on her task list. She stated she only used siderails with residents if she had noticed siderails up before. In an interview on 7/12/22 at 2:06 PM, Staff H (Registered Nurse) RN, stated she was unaware of any special assessments related to the management of residents that went to [CONDITION(S)] and was also unaware of the details of transportation related to [CONDITION(S)] or where to find the information. She stated she expected the residents' care plans plan to contain [CONDITION(S)] management and side rail information. A policy titled Care Planning dated 12/21 lacked directives on care areas to be included on a comprehensive care plan.

Based on clinical record review, staff interview, and facility record review, the facility failed to notify the Long-Term Care Ombudsman when a resident transferred to the hospital for 2 of 2 residents reviewed (Residents #14 and #25). The facility reported a census of 50 residents. The Minimum Data Set (MDS) assessment tool dated 12/28/21 for Resident #14 documented the resident readmitted to the facility 12/28/21 from the hospital. The Census List revealed Resident #14's status as hospital paid leave 12/22/21 and returned to the facility on [DATE]. The Progress Note dated 12/22/21 at 6:09 p.m. documented the resident admitted to the facility. The Progress Note dated 12/28/21 at 3:38 p.m. documented the resident readmitted to the facility. 2. Review of Resident #25's record revealed a discharge MDS that documented the resident discharged from the facility on 04/15/21 and an entry . An entry MDS documented a readmission to the facility dated 04/18/22. The Census List revealed Resident #25 status as hospital paid leave 04/15/21 and returned to the facility on 04/18/22. The Progress Note dated 04/15/22 at 3:47 p.m. documented the resident left the facility via Emergency Management System (EMS). Progress Note dated 04/18/22 at 2:09 p.m. documented the resident readmitted to the facility. Review of the notice of transfer form to the long term care ombudsman dated 12/1/21 to 12/31/21 and 4/1/22 to 4/30/22, revealed no mention of Resident #14's or #25's hospitalization s. In an interview on 7/12/22 at 1:00 p.m., the Social Worker (SW) verified the facility did not report either resident's (above) hospital transfer to the ombudsman.

Based on clinical record review and staff interview, the facility failed to accurately complete a Minimum Data Set assessment for one of seventeen residents reviewed in the sample (Resident #45). The facility reported a census of 50 residents. Findings include: The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revised on 6/13/22 revealed Resident #45 had a terminal prognosis related to a severe protein calorie malnourishment. The electronic medical record revealed the resident admitted to hospice on 6/1/22. In an interview 7/12/22 at 1:51 PM, the Director of Nursing (DON) reported Resident # 45 recently had a significant change MDS assessment completed when he admitted to hospice services. The DON stated hospice should've been marked on the MDS under the special treatment section, and a yes marked under the section that pertained to if the resident had a life expectancy less than 6 months. The DON stated she wasn't certain why MDS was coded incorrectly.

Based on record review, review of [CONDITION(S)] policy, and resident and staff interviews, the facility failed ensure staff completed full nursing assessments and monitoring of a resident before and after outpatient [CONDITION(S)] treatments for 1 of 1 resident reviewed for [CONDITION(S)] services. The facility reported a census of 50 residents. Findings included: According to the Minimum Data Set (MDS) dated [DATE], Resident #22's had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the demonstrated intact cognitive abilities and and received [CONDITION(S)] services. The [CONDITION(S)] Process facility policy dated 7/18 directed the nurse will notify the [CONDITION(S)] center and document pre and post [CONDITION(S)] vitals signs in the medical record. The policy also directed the nurse will document medications, nutritional/fluid management, labs, treatments, and assessments on a pre and post [CONDITION(S)] Assessment Form. Record Review revealed a pre-assessment form for 4/27/22 and 4/29/22 and a post-assessment form on 5/11/22. The facility lacked pre and post [CONDITION(S)] vital signs, weights, and assessments. The resident's care plan initiated 4/18/22 failed to direct [CONDITION(S)] care for the resident. Active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/12/22 at 7:24 a.m., Resident #22 reported he leaves the facility three times a week for [CONDITION(S)]. During an interview on 7/12/22 at 7:30 a.m., with Director of Nursing revealed Resident #22 leaves the facility Monday Wednesday and Fridays for [CONDITION(S)]. At 3:00 p.m., the Director of Nursing reported she expected staff to take Resident #22's vital signs before he leaves for [CONDITION(S)] and upon his return, and verified the facility lacked documentation to show this occurred with Resident #22 before and after [CONDITION(S)] within the past 30 days.

Based on staff interviews, facility protocl, and clinical record review, the facility failed to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of two single confirmed infection of COVID-19 on 6/29/22 and 7/7/22. The facility reported a census of 50 at the time of the investigation. During an interview with the Director of Nursing (DON), on 7/6/22 at 1:39 p.m. revealed it is a team effort to notify residents and families of positive COVID results. DON stated the last positive staff member was on 6/29/22. During an confidential interview with an Power of Attorney (POA) of a resident residing in the facility on 7/7/22 at 10:57 a.m. revealed she had not been notified of a COVID positive staff or residents since 6/15/22. During an interview with DON on 7/11/22 at 10:01 a.m. revealed the residents, families, representatives, were not notified of recent COVID positive staff infections on 6/29/22 or 7/7/22. DON stated all would be notified on 7/11/22. During an interview with Social Worker (SW) on 7/13/22 at 10:40 a.m. revealed an email is sent to the team that assist with notifying families along with directives indicating who will call who on the resident list, the resident list is divided up alphabetically. SW stated an email was received indicating the facility was in outbreak status and lacked directives for family notifications on both 6/29/22 and 7/7/22. SW stated she did not notify family of COVID positive infections on either date. During an interview with Staff K, Activities on 7/13/22 at 11:15 a.m. revealed she was not asked to assist with family notification on either 6/29/22 or 7/7/22. During an interview with Staff L, Director of Health and Wellness on 7/13/22 at 11:20 a.m. revealed the activity staff will assist with family notification if requested. Staff L stated activity staff was not requested on either 6/29/22 or 7/7/22. An undated Mechanisms Used for Reporting COVID-19 to Residents and Families policy directed staff designated to inform families and update facility website. The policy lacked specific details with regard to notification. Facility document titled COVID positive list, undated, revealed Staff I, Speech Therapist (ST) tested COVID positive on 6/29/22 and Staff the J, Maintenance tested COVID positive on 7/7/22. Facility lacked notification documentation to inform residents, their representatives, and families of those residing in the facility by 5 p.m. the next calendar day on 6/29/22 and 7/7/22.

Based on clinical record review, observations, staff and physician interviews and facility policy review, facility staff failed to provide timely and complete assessment and intervention for one resident following a significant change in condition (#5) and failed to routinely assess a skin integrity concern for another resident (#4). The facility identified a census of 48 current residents and six residents were reviewed for assessment and intervention. Findings include: 1. Resident #5's Clinical Admission Evaluation documented she entered the facility on 6/25/21. Staff conducted an admission physical assessment, noting abnormals of low blood pressure (diastolic less than 60, new onset [CONDITION(S)], active pain, 1+ pitting [CONDITION(S)] in a lower extremity and cavities/broken natural teeth. Resident #5's Care Plan, initiated on 6/25/21, contained focus areas for a deficit in self-performance of activities of daily living, medication allergies, a potential nutritional problem and the presence of a Foley (urinary) catheter starting 7/3/21. The resident's Geriatrics Care note dated 6/28/21 at 9 am and authored by her physician documented she entered the facility following hospitalization ,d+[DATE] - 6/10/21 for a fall which resulted in a nonoperable distal right fibular (leg) fracture. While hospitalized , Resident #5 developed second degree heart block, acquired a 30-day cardiac event monitor, and discharged to another nursing facility. On 6/12/21, Resident #5 re-entered the hospital with a heart rate of 30 and complete [CONDITION(S)]-ventricular (AV) block. Resident #5 received a pacemaker on 6/17/21 and would follow up with cardiology on 7/8/21. The resident experienced some lightheadedness with standing, but otherwise denied acute concerns that included bleeding. The physician documented that Resident #5 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's Nurses Notes recorded the following information: On 6/26/21 at 4:30 am, staff noted a small amount of pinkish vaginal discharge. On 6/27/21 at 4:33 am, the resident had a small amount of blood in her incontinence brief. On 6/29/21 at 1:04 pm, the resident had light tinged blood during urination. Two nurses assessed the resident's vaginal area and noted a small abrasion to the left of her labia near the vaginal opening that was bleeding. Staff cleansed the area and sent a fax (facsimile) to notify the resident's physician. The facility Director of Nursing (DON) authored the Nurses Note. On 8/26/21 at 2:05 pm, the DON reported Resident #5 stated she had been scratching down there and the abrasion resulted in no new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/29/21 at 11 pm, Staff A, RN (Registered Nurse) documented Resident #5 had a 3 inch by 1/2 inch cylinder-shaped blood clot in her brief when getting up to go to the bathroom this shift. The resident had 4 more large blood clots in the commode after urinating ranging from 2 by 2 inch tennis ball shaped to 3 inch by 1/2 inch cylinder shaped. Resident #5 complained of dizziness and shortness of breath with transfers with a low blood pressure noted. Staff A would continue to monitor. Review of the note, nursing assessment forms and vital signs records revealed no vital sign measurement or further assessment documented by Staff A. During interview on 8/26/21 at 10 am, Staff A stated the resident had less shortness of breath and dizziness with rest and no complaints of pain on 6/29/21 at 11 pm. Staff A stated she took the resident's vital signs, but completed no other physical assessment (no vital signs were recorded). Staff A stated Resident #5 had been having clots (none were previously documented) and stayed in the hospital an extra day to see a gynecologist. Staff A stated the resident's vital signs would be documented in her vital sign record. Staff A did not consider calling the resident's physician as aides said the resident had been having blood clots; Staff A could not recall who told her that. Staff A stated the resident recovered quickly with rest and had shortness of breath and dizziness just during transfers. The Nurses Note of 6/30/21 at 4:13 am and authored by Staff B, RN documented Resident #5 used the bedside commode at that time with the assistance of two. Staff noted two moderate sized blood clots in her brief, none in the commode and active bleeding with wiping, in the commode and in the brief. The resident denied dizziness or light-headedness with standing or pivoting. The note contained no vital sign measurement or further assessment of the resident's bleeding. Staff B noted the resident had pain under her left breast and a reddened crease under both breasts and sent a fax to her provider for a treatment order. The note made no mention of notice regarding blood clots and review of nursing assessment forms and vital signs records revealed no documentation of vital signs or further assessment. On 8/26/21 at 1:45 pm, Staff B stated that on 6/29/21, she remembered talking over Resident #5's blood clots as Staff A was unsure how to documented them. Staff B stated she did not if Staff B called the resident's doctor or not. Staff B remembered Resident #5 had problems with vaginal blood clots and they couldn't get her in to see a OB/GYN (Obstetrics/Gynecology specialist) right away. The facility had a OB/GYN appointment scheduled on 7/13/21, but the resident went to the hospital before that occurred. The Nurses Note dated 6/30/21 at 12:34 pm documented the resident with a moderate amount of bright red vaginal bleeding, no clots noted this morning. The resident denied lightheadedness, dizziness or shortness of breath and her blood pressure measured 133/60. The resident chose to go to the emergency room following discussion with the nurse. The resident's physician ordered Resident #5 to the emergency room for evaluation and treatment. Resident #5 left the faciity on [DATE] at 4:29 pm and returned on 7/1/21 at 1:24 am. The resident's After Visit Summary of 6/30/21 at 9:14 pm documented the reason for the visit as vaginal bleeding with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Condition Change Management policy revised 07/17 defined a condition change as an alteration from normal status. A significant change in resident status refers to observed changes in the resident's condition, warranting immediate nurse assessment, intervention and appropriate documentation in the clinical record. Physician notification and follow-up is necessary. An example of a condition change would be a decline in the resident's condition. The Assessment Process instructed a nurse would complete a head to toe assessment to include full vital signs and report to the resident's physician or the on-call physician after hours. During interview on 8/31/21 at 12:18, the resident's physician recalled Resident #5 had been in and out of the hospital for cardiac and transfusion issues and had a pending OB/GYN appointment when admitted . The resident wanted to and worked towards getting home and did not wish to return to the hospital and the goal was to keep in her the facility, They were working to maintain her hemoglobin (Hgb, a measure of blood's oxygen carrying capacity) and it's still low. The physician stated he and the facility used the resident's vital signs to determine her ability to stay at the facility. Stable vital signs would have helped them decide to keep her in the facility or not. That would have been ordered: every 4 hour vital signs and monitor for respiratory distress. The physician stated it surprised him that no vital signs were done on 6/29/21 at 2300, but if it's not documented, it's not done. The resident's physician concluded that Resident #5 is a complex patient with a lot going on. 2. According to the MDS (Minimum Data Set) assessment of 7/28/21, Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented experienced severely impaired memory and cognition and required the assistance of two staff during transfers. Resident #4 had no ulcers, foot problems or other skin problems documented on the MDS assessment. Resident #4's Care Plan contained a focus area initiated 2/23/21 of skin tear potential and the potential for bruises on his arms and legs. The care plan instructed if a skin tear occurred, treat it per facility protocol. The Nurses Note dated 6/27/21 at 4:34 pm documented Resident #4 obtained skin tears on both lower legs when he transferred with the EZ Stand (as assisted transfer device) this morning. Staff applied dressings to his legs and notified the resident's physician and family. An entry dated 6/28/21 at 2:10 pm documented the dressings to Resident #4's shins were clean, dry and intact. The resident's ARNP (Advanced Registered Nurse Practitioner) ordered initiation of the skin protocol. Resident #4's Treatment Administration Record (TAR) of 6/1 - 6/30/21 documented the skin tear care for the shins initiated on 6/28/21. Point K of the instructions directed staff to update the resident's skin assessment weekly. The resident's Skin and Wound Evaluation in the EMR (Electronic Medical Record) contained skin assessments ending on 3/26/21 and beginning again on 8/11/21. The resident's Non-Pressure Skin Condition Weekly Assessment Forms showed assessment of the resident's right and left leg skin tears on 8/4 and 8/11/21. A Non-Pressure Skin Condition Weekly Assessment form documented staff completed weekly assessments on the resident's right shin skin tear from 6/28 - 7/28/21. On 8/17/21 at 2 pm, the DON (Director of Nursing) stated the facility has a wound assessment section in the EMR. However, not all nurses used it as they should and photos and measurements were off. The facility went back to paper assessments, retrained all staff to the EMR assessment system and went back to using it. On 8/17/21 at 11:45, the DON stated she could not find assessment forms for Resident #4's left shin skin tear and had exhausted all options to search further.

Based on clinical record review, observation, resident and staff interviews and reviews of facility policy and professional reference, facility staff failed to ensure a resident had pressure reduction in her chairs for one of one residents reviewed for pressure ulcers (Resident #2). The facility identified a census of current residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #2's admission MDS assessment of 6/30/21 documented she entered the facility on 6/23/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented Resident #2 had intact memory and cognition, as evidence by a Brief Interview for Mental Score (BIMS) of 14. The MDS documented Resident #2 required the assistance of two staff for transfers and while walking and the assistance of one staff for dressing and hygiene activities. The assessment also documented Resident had one Stage III pressure ulcer present upon admission and that staff provided pressure relief to both her bed and chair. The resident's Care Plan, initiated on 7/7/21, identified the focus area of a Stage III pressure ulcer to the sacrum (a large triangular bone at the base of the spine) upon entry to the facility. The interventions directed to administer treatments, encourage her to eat and drink, inspect her skin during routine cares and monitor for any changes in the wound's status. Resident #2's Pressure Ulcer Weekly Assessment Form of 6/23/21 documented her ulcer measured 3.5 cm (centimeters) long, 1.5 cm wide and a depth of 2 cm. On 8/26/21, the ulcer measured 1.1 cm long, 0.7 cm wide and a depth of 2 cm. During observations on 8/17/21 at 8:10 am and 11:30 am revealed Resident #2 sat in her wheelchair in her room without a pressure relief device/cushion in the chair. On 8/18/21 at 7:40 am, Resident #2 lay in bed on her side. Neither her recliner nor her wheelchair contained pressure relief devices and observation of her room and her open closet revealed no pressure relief devices in the room. Continued observation on 8/18/21 at 12:45 pm revealed no pressure relief in the resident's chairs. During interview at 1 pm, Resident #2 stated she could not remember ever having pressure relief cushions in her chairs. She would like one if possible, for comfort in her wheelchair if nothing else. The facility's Policy and Procedure for the Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #2's Occupational and Physical Therapy records dated 6/29 - 7/26/21 revealed no mention of a seating surface evaluation of the resident's chairs. During observation on 8/19/21 at 9:30 am, Resident #2 sat up in her wheelchair in her room. The resident continued to have no pressure relief in her wheelchair or elsewhere in the room. During interview on 8/19/21 at 9:40 am, when asked how Therapy staff were notified of the need for seating surface evaluations, the Director of Nursing (DON) stated that with skilled resident admissions, Therapy staff had the same information that nursing staff had. Therapy staff would evaluate for seating surface needs and treatment modalities with admission. During interviews on 8/19/21 at 10:50 am, the Physical Therapist (PT) for Resident #2, with the Therapy Department Manager present, stated she had not conducted any evaluations of resident seating surfaces lately. To do so, Nursing staff normally referred Therapy staff of the need and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For Resident #2, her orders were to establish a baseline and functional evaluation of the resident. The PT did not remember being asked lately to evaluate the seating surface for Resident #2 or for any other residents and it would be nice for Nursing staff to notify her to do it. The online reference via [MEDICATION(S)] Plus by the National Institute of Health/ U.S. Library of Medicine (medlineplus.gov/ency/patientinstructions/ 7.htm) instructs that preventing pressure ulcers includes sitting on a foam or gel seat cushion that fits properly for those who require a wheelchair. During observation and interview on 8/24/21 at 9:30 am, Resident #2 sat in the wheelchair in her room. The resident now sat with a pressure relief cushion in her wheelchair and she stated 'it feels really good'.

Based on observation, staff interview, and facility policy review, the facility failed to store and always prepare food in accordance with professional standards for food service safety. The facility reported a census of 39 residents. Findings include: Observation of the initial kitchen and Cafe tour on [DATE] at 10:52 a.m. revealed the following: a. Two expired bottles of lemon juice with an expiration date of [DATE] & [DATE] b. Opened and undated zip lock bag of crushed peppermint c. Boxes on floor outside of walk-in freezer with soda pop and bananas d. Uncovered and undated pan of brownies e. Uncovered and undated glass of milk on counter f. Opened and undated bag of graham crumbs g. Opened and undated large bag of uncooked noodles h. Door to ice machine door left open with ice solidifying i. Staff members not wearing hairnets During a staff interview with Staff A, Chef on [DATE] at 10:52 a.m. revealed the staff relaxed on wearing hairnets when in the kitchen. During an interview on [DATE] at 10:55 a.m., Staff B, Director of Kitchen, questioned if staff who worked in the kitchen required a hairnet. During an interview with Staff B, Director of kitchen on [DATE] at 12:00 p.m. revealed lack of documentation of refrigerator/freezer temperature log for Health Center halls: Willow, Magnolia, and Juniper prior to [DATE]. During an interview on [DATE] at 11:00 a.m., Staff B revealed staff placed the refrigerator thermometer on the door and resulted in high readings. Staff B vacuumed the coils and instructed staff to write any adjustments they made to refrigerators on the temperature logs. During an interview with Staff C, Maintenance, on [DATE] at 8:22 a.m. revealed no work orders for refrigerator/freezers the past year other than routine cleaning auto-generated on [DATE], [DATE], [DATE], and [DATE]. Facility lacked policy regarding infection control and need for kitchen staff to wear hairnets or restrain hair when preparing food. Facility document titled, This Refrigerator/Freezer Houses Resident Food, undated revealed: a) Temperatures must be documented every day b) If refrigerator is above 40 degrees Fahrenheit (F), recheck in 2 hours. If still above 40 degrees F, call maintenance for a check. c) If freezer is above 0 F, recheck in 2 hours. If still above 0 F after 2 hours, call maintenance for a check. Review of facility policy titled, Storage of Food & Beverage, dated [DATE] revealed: refrigerator must be at or below 41 degrees F. Freezers must be at -0. If temperatures are out of range, notify maintenance and dispose of food items. Facility document titled, Temperature Logs, dated [DATE]- [DATE] for Health Center refrigerators and freezers revealed: a. Willow Silver Whirlpool refrigerator: 1 .Temperature not logged: Twice in May, four times in June, and once in July. 2. Refrigerator or freezer was out of range for refrigerator temperature above 41 degrees Fahrenheit and freezer above -0 degrees Fahrenheit: Once in May, ten times in June, and once in July. b. Willow Maytag refrigerator: 1. Temperature not logged: Once in June and once in July. 2. Refrigerator or freezer was out of range for refrigerator temperature above 41 degrees Fahrenheit and freezer above -0 degrees Fahrenheit: Twenty times in May, twenty six times in June, and twenty seven times in July. c. Juniper kitchen refrigerator: 1. Temperature not logged: Five times in May, seven times in June, and five times in July. 2. Refrigerator or freezer was out of range for refrigerator temperature above 41 degrees Fahrenheit and freezer above -0 degrees Fahrenheit: Six times in June, seven times in July. d. Magnolia/Juniper Pantry Silver Refrigerator: 1. Temperature not logged: Twice in May, six times in June, and seven times in July. Refrigerator or freezer was out of range for refrigerator temperature above 41 degrees Fahrenheit and freezer above -0 degrees Fahrenheit: Twice in July e. Magnolia/Juniper Pantry Frigidaire Freezer: 1. Temperature not logged: Four times in June and three times in July. 2. Refrigerator or freezer was out of range for refrigerator temperature above 41 degrees Fahrenheit and freezer above -0 degrees Fahrenheit: Once in May and three times in July. f. Magnolia/Juniper Pantry Whirlpool Freezer: 1. Temperature not logged: Twice in June and four times in July. 2. Refrigerator or freezer was out of range for refrigerator temperature above 41 degrees Fahrenheit and freezer above -0 degrees Fahrenheit: Five times in June. g. Magnolia kitchen white refrigerator: 1. Temperature not logged: Five times in May, four times in June, and five times in July. 2. Refrigerator or freezer was out of range for refrigerator temperature above 41 degrees Fahrenheit and freezer above -0 degrees Fahrenheit: Seven times in May, thirteen times in June, and three times in July. -

Based on observation, menu review, record review, and staff interviews, the facility failed to serve the appropriate portions for 14 of 14 residents on a general diet serving of vegetables. The facility identified a census of 39 residents. Findings include: Review of the facility's untitled diet form for Wednesday of Week 2 identified the following items as part of the planned menu for the dinner (12:00 noon) meal on 07/28/21 for residents ordered general diets: Beef pot roast, liver and onions, mashed potato/gravy, glazed turnips, bread stick, chocolate cheesecake, spiced pear, dinner rolls/margarine, mild, and salad. Observation on 07/28/21 at 11:58 a.m. revealed a black handled, imprinted 3 oz. (ounce) serving scoop placed in the glazed turnips. In an interview prior to dinner service on 7/28/21 at 12:00 p.m., Staff F, Homemaker, stated he did not know the scoop size placed in the glazed turnips. Staff F looked at the untitled diet form and documented serving size of one half cup (#8) scoop. Staff F stated he grabbed the wrong scoop. Staff F failed to follow the menu and continued to serve the residents with the wrong serving size scoop for the entire dinner service. In an interview on 07/28/21 at 12:47 p.m., Staff F acknowledged he served 3 oz. of glazed turnips to all residents who received turnips and the menu directed to serve one half cup. Staff F stated he should have changed the scoop size and followed diet orders. In an interview on 07/28/21 at 01:01 p.m., Staff B, Director of Kitchen, stated the correct serving size for the glazed turnips to be one half cup. In an interview on 7/28/21 at 01:03 p.m., Staff G, Dietician, stated the correct serving size for the glazed turnips to be one half cup. -

Based on interviews, facility call light logs, and clinical record review, the facility failed to provide timely assistance of call lights for residents with fall risks and issues of incontinence by not answering the residents call light in less than 15 minutes for 5 of 12 residents (# 8, #13, #38, #42, and #44) reviewed. The facility reported a census of 39 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. Resident #8 required limited staff assistance with bed mobility, transfers, toileting, and with eating. Resident #8 had occasional urinary incontinence and was continent of her bowels. Fall Risk Assessment completed 6/16/21 score was a 6.0 indicating not at risk for falls although noted orthostatic blood pressures not completed during the assessment. During an interview on 7/27/21 at 8:12 a.m., Resident #8 revealed it had taken a long time for her call light to be answered. She stated she has been frustrated and has thought it had taken longer than 15 minutes. Review of Resident #8 Care Plan, dated 7/14/21 revealed: 1. Problem: The resident is at risk for recurrent falls related to history of falls, history of falls, Poor Balance, Unsteady gait Interventions: Assist with toileting needs as needed. 2. Problem: The resident has bladder incontinence Interventions: The resident would like to be offered to toilet AC (before meals), PC (after meals), HS (at bedtime), and PRN (as needed). Review of facility document titled Device Activity Report dated 6/1/21-6/20/21 revealed Resident #8 waited longer than 15 minutes for staff to answer her call light 9 times, with the longest time being 43 minutes and 25 seconds. 2. The MDS assessment dated [DATE] indicated Resident #13 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13 displayed verbal behaviors occurring 1-3 days of threatening, screaming, or cussing at others. The resident had a BIMS score of 13 indicating minimal cognitive impairment. Resident #13 required limited staff assistance with bed mobility, transfers, toileting, and supervision with eating. Resident #13 had urinary incontinence and was continent of bowels. Fall Risk Assessment completed 5/17/21 score was a 17.0 indicating high risk for falls. During an interview on 7/26/21 at 1:03 p.m., Resident #13 expressed waiting a long time for his call light to be answered or having it answered at all. Review of Resident #13's Care Plan, dated 6/11/21 revealed: 1. Problem: The resident is at risk for recurrent falls related to history of falls Interventions: Assist with toileting needs as needed. 2. Problem: The resident has bladder incontinence r/t (related to) Prostate enlargement Interventions: The resident would like to be offered to toilet AC, PC, HS and PRN Review of facility document titled Device Activity Report dated 6/1/21-7/29/21 revealed Resident #13 waited longer than 15 minutes for staff to answer his call light 21 times, with the longest time being 120 minutes and 23 seconds. 3. The MDS assessment dated [DATE] indicated Resident #38 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 9 indicating cognitive impairment. Resident #38 required limited staff assistance with bed mobility, toileting, extensive assistance with transfers, and supervision with eating. Resident #38 had urinary incontinence and was occasionally incontinent of bowels. Fall Risk Assessment completed 7/22/21 score was a 18.0 indicating high risk for falls. During an interview on 7/27/21 at 8:33 a.m., Resident #38 expressed that told by staff to call for assistance, and had signs posted around her room to call for staff when she needed help. Stated when she called for staff she then waited up to 30 minutes and would eventually wet herself. Resident #38 stated she and her husband have used a clock to time staff while waiting for a response. Review of Resident #38's Care Plan, dated 6/23/21 revealed: 1. Problem: The resident is at risk for falls Interventions: place signs in room to remind resident to use call light 2. Problem: The resident has (Mixed) bladder incontinence/Constipation r/t need for assistance Interventions: The resident needs assist of one with toileting with gait belt. Review of facility document titled Device Activity Report dated 6/1/21-7/31/21 revealed Resident #38 waited longer than 15 minutes for staff to answer her call light 5 times, with the longest time being 30 minutes and 49 seconds. 4. The MDS assessment dated [DATE] indicated Resident #42 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 15 indicating no cognitive impairment. Resident #42 required limited staff assistance with bed mobility, transfers, toileting, and staff supervision with eating. Resident #42 had urinary incontinence and was continent of bowels. A Fall Risk Assessment Form dated 4/1/21 indicated a score of 8, indicating Resident is not at risk for falls. Review of Resident #42's Care Plan, dated 4/21/21 revealed: 1. Problem: The resident is at risk for falls r/t gait/balance problems, incontinence, vision/hearing problems, Meniere's disease, and arthritis of the knees. Interventions: The resident's calls light is within reach and encourage the resident to use it for assistance as needed. 2. Problem: The resident has (Mixed) bladder incontinence r/t impaired mobility Interventions: The resident needs assist of one with toileting when needed Review of facility document titled Device Activity Report dated 6/1/21-7/31/21 revealed Resident #42 waited longer than15 minutes for staff to answer her call light 32 times, with the longest time being 38 minutes and 38 seconds. 5. The MDS assessment dated [DATE] indicated Resident #44 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 10 indicating minimal cognitive impairment. Resident #44 required extensive staff assistance with bed mobility, transfers, toileting, and staff supervision with eating. Resident #44 had a urinary catheter during this lookback period and is incontinent of bowels. A Fall Risk Assessment Form dated 6/20/21 indicated a score of 12, indicating at risk for falls. During an interview on 7/28/21 at 1:19 p.m., Resident #44 revealed that she has sat and waited 45 minutes for staff to take her from the table to her room. She stated she has been embarrassed when she has been incontinent waiting. Review of Resident #44's Care Plan, dated 7/20/21 revealed: 1. Problem: The resident is high risk for fall r/t history of falls Interventions: Assist with toileting needs as needed Review of facility document titled Device Activity Report dated 6/1/21-7/29/21 revealed Resident #44 waited longer than 15 minutes for staff to answer her call light 20 times, with the longest time being 39 minutes and 48 seconds. During an interview on 7/29/21 at 10:46 a.m., Director of Nursing (DON) revealed she expected call lights answered within 15 minutes. She stated when the call light is pushed by a resident; it cannot be visualized from the outside of the room only on staff pagers. Initially it is sent to the Certified Nurse Assistant assigned for that hallway then in 3 minutes if not answered it will page the nurse. The issue staff has is it is difficult to see who pushed the call light first if multiple residents are calling for help at the same time. Review of facility document titled Resident Council Meeting Magnolia dated June 14, 2021 revealed undisclosed resident comments: 1. Not enough help, I wait on the toilet too long. 2. I was having troubles with my bowels and I had my light on so long and the bed ended up covered. That was embarrassing. They also get frustrated and rude to my roommate and there is not a need for that. Review of facility document titled Call System Use dated 6/2016 revealed: 1. To respond promptly to resident's call for assistance 2. Answer ALL call system calls promptly, whether or not you are assigned to the resident 3. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room. -

Based on personnel file reviews, facility policy review, and staff interview, the facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 current employees sampled. The facility reported a census of 39 residents. Findings include: Review of Personnel File for Staff D, housekeeper, with a documented hire date of 10/6/2020 revealed the file lacked documentation of completion of dependent adult abuse training for mandatory reporters, 9 months from hire date. During an interview on 07/29/21 at 8:33 a.m., Administrator stated he realized when reviewing Staff D's employee file that she failed to complete her mandatory reporter training within 6 months of hire. -

Based on observation, facility documentation, and interviews, the facility failed to provide recommended adaptive equipment (plate guard) for 1 of 3 residents reviewed for adaptive equipment (Resident #31). The facility further failed to monitor and provide ongoing assessments on need for adaptive equipment. The facility reported a census of 39 residents. Findings include: A Minimum Data Set (MDS), dated [DATE] indicated diagnoses for Resident #31 included medically complex conditions including Alzheimer's disease, depression, adjustment disorder with mixed anxiety and depressed mood, overactive bladder, and obesity. Resident #31 required set up assistance for eating. According to the MDS, the resident scored a 00 out of on the Brief Interview for Mental Status (BIMS) indicating severely impaired cognition. Observation on 7/28/21 at 11:58 a.m., revealed Staff F, Homemaker, served Resident #31 lunch with no plate guard. Review of the Magnolia Dietary Order form updated 6/25/21, documented Resident #31 required a plate guard assistive device. The care plan reviewed 7/22/21 lacked documentation regarding assistive devices needed for eating. The care plan revised 7/28/21 documented resident would like adaptive equipment at meals as recommended In an interview on 7/28/21 at 12:47 p.m., Staff F acknowledged he forgot to use a plate guard for Resident #31 as directed on the Magnolia Dietary Order form. In an interview on 8/02/21 at 01:53 p.m., Staff F stated the Magnolia Dietary Order form completed by lead homemakers. In an interview on 8/02/21 at 01:05 p.m., the Administrator stated Resident #31 not care planned to have plate guard assistance. Stated typically occupational therapy determined if Resident #31 needed a plate guard. For Resident #31 the Homemaker determined a plate guard needed. Administrator stated that Resident #31 did not receive an occupational therapy evaluation due to the diagnosis of adjustment disorder. In an interview on 08/03/19 at 10:03 a.m., Staff E, Occupational Therapy Assistant, stated Resident #31 is not on Occupational Therapy (OT) case Load. Staff E received an order to evaluate 07/30/2021. Staff E reported if nursing or dietary sees a need for a plate guard or other adaptive equipment, they will sometimes get a therapy referral to assess feeding, and then the therapist makes an assessment to determine need. If it is determined adaptive equipment needed, communication sent to nursing leadership, the MDS (Minimum Data Set) coordinator to add to care plan, and the kitchen. Staff E stated Nursing or dietary can issue a plate guard or built up utensil. Staff E acknowledged a communication breakdown regarding Resident #31 and stated in the future Staff E planned to work with staff to assure OT consulted to evaluate if feeding issues noted to assure proper assistive devices used and assist proper communication and care planning for recommended assistive devices. In an interview on 08/03/19 at 10:12 a.m., DON stated Nursing and dietary made recommendations for adaptive equipment with feeding. Dietary typically let nursing staff know if a problem with resident feeding noted, then nursing or therapy made an assessment and decided what services needed. The needed assistive devices then care planned and communication form sent to dietary with changes. The DON noted Resident #31 case different from the usual case because she did not have therapy services coming in due to adjustment disorder when admitted . The DON stated a communication breakdown occurred as a result. -

The following deficiency relates to facility self report # -I: Based on clinical record review, observations, and staff and family member interviews, the facility failed to recognize a door alarm sounding, leading to the unknown exit (elopement) of one of four sampled residents (Resident #1). The facility reported a census of 52. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 2 indicating severely impaired cognitive skills for daily decision making. Resident #1 walked independently and required assistance with dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. Resident #1 admitted to the facility on [DATE] and resided on a locked memory care unit. Resident #1's care plan initiated on 10/26/18 indicated he will wander into other resident rooms and at times will try to leave the dementia unit. Approaches included moving Resident #1 closer to the nurse's station for safety, redirection and interaction strategies to help keep him calm. Interdisciplinary notes reviewed from 10/1/18 through 11/30/18 revealed several entries in which Resident # 1 wandered and/or attempted exit from the nursing facility. On 10/13/18 at 5:39 p.m. Resident #1 sought exit multiple times and set off facility door alarms. On 10/29/18 at 6:15 a.m. Resident #1 wandered and targeted exit doors. Resident #1 eventually opened an exit door into the stairwell and the exterior door outside. Staff redirected him back into the facility. On 11/18/18 at approximately 7:45 p.m. Resident #1 was escorted onto the memory care unit accompanied by three staff. Resident #1 wore pajamas and slippers and had no visible injuries. On 11/19/18, Resident # 1 woke at 4:00 a.m. and confused stating it was time to milk the cows. Resident #1 made several attempts to open the exit door and attempted to enter other resident rooms. In an interview on 1/14/19 at 3:00 p.m. Staff G, licensed practical nurse (LPN), stated prior to Christmas, Resident #1 was frequently wandering and pushing on doors. Staff G remembered him once exiting into the north stairwell. Staff G stated Resident #1 would not come back in and they left the alarm sounding until additional help arrived. Staff G stated standard protocol when door alarms sound is to respond immediately and verify the cause for the alarm. If there is not a clear reason for the alarm to sound, staff are to step outside and search and if still uncertain, conduct a head count of residents to ensure everyone is accounted for. In an interview on 1/10/19 at 2:31 p.m. a family member of another resident stated that on the evening of 11/18/18 she and her husband visited her father and walked back to the guest residence. As they exited the building through the blue doors into the meditation garden, they saw a male resident (Resident #1) walking towards them dressed in pajamas and slippers. Resident #1 stated he wanted to go home. The family member escorted Resident #1 back into the building and got someone to help. Review of the Device Activity Report on 11/18/18 indicated the south stairwell alarm activated at 7:35.04 p.m. and the front entrance into the memory care unit alerted at 7:39.44 p.m. The time frame from when Resident #1 first activated the south stairwell door alarm until visitors brought him back into the memory care unit measured 4 minutes and 40 seconds. A facility video (copy) of door (blue) in which resident was escorted back into facility did not contain a timestamp, but did record time. Based on video time and known Device Activity Report, Resident #1 exited the south stairwell at 7:35.19 p.m., was discovered by the visiting family at 7:36.30 p.m., escorted into the facility at 7:36.40, staff arrived at 7:37.14, other staff, including the Administrator arrived at 7:38.19 p.m. and escorted Resident #1 into the memory care unit at 7:39.44 p.m. Observation of the distance from the south exit to the blue door entry revealed approximately 115 feet of flat sidewalk with some elevated landscaping along the north edge of the sidewalk. The sidewalk was snow covered and the reported temperature measured 22 degrees Fahrenheit. The other direction lead to a small parking area, open grass field and residential neighborhood. In an interview on 1/15/19 at 12:10 p.m. the Administrator stated the evening of 11/18/18 he was in the facility when he learned that Resident #1 had been discovered outside by some visitors and escorted back in. The Administrator and two other staff responded to the hallway and escorted Resident #1 back to the memory care unit where he resides. Upon entering the memory care unit, the Administrator stated he could hear the south stairwell door alarm sounding. The Administrator stated the staff working on the memory care unit came from the dining room area (opposite side of the unit from south stairwell) and were unaware of the sounding door alarm or that Resident #1 exited. The Administrator had the south door alarm deactivated and tested it again. The south door alarm functioned properly and sounded. Staff A, LPN, stated she didn't hear the alarm and it didn't activate on her pager. Staff B, certified nurse aide (CNA) and Staff C, CNA also stated their pagers did not alert them of the door alarm. The Administrator stated they checked Staff B's pager and it had dead batteries. The Administrator replaced the batteries and then activated the door alarm again, this time noting that all three pagers alerted properly. The Administrator stated the staff were all re-educated on responding to door alarms and on the process of elopements. The facility is in the process of getting a Wanderguard system as a secondary system. The Administrator stated the door alarm volumes cannot be adjusted and they considered some form of an amplification system. The Administrator stated the Director of Nursing (DON) checked on the weather conditions for the evening of 11/18/18 and stated the temperature was 22 degrees Fahrenheit. In a follow up interview on 1/17/19 at 11:10 a.m. the Administrator stated when he had entered the memory care unit on 11/18/18 with Resident #1, he remembered requesting the pager from Staff A and remembered Staff A having to go back to the nurses station to get her pager. On 1/10/19 at 2:00 p.m. Staff A, LPN, stated she worked the evening of 11/18/18 on the memory care unit, in the dining room area supervising a tube fed resident and a couple of others who needed supervision. Her aides, Staff B and Staff C, provided resident cares in a room on the north side of the unit. Staff A stated it was only her second day working alone as a new nurse. She heard a faint buzzing sound but didn't recognize it as a door alarm and didn't respond to the area to investigate the sound. About that same time another resident walked into the dining room area from the south side of the unit. Staff A asked the resident why she was up (resident was in bed earlier). The resident stated because of that loud sound. At that time, Staff D, Staff E and the Administrator walked onto the memory care unit, escorting Resident #1. Staff A learned Resident #1 had exited through the south stairwell and was found outside. Staff A stated she carried the nurse pager and it never went off. In a follow up interview on 1/14/19 at 11:35 a.m. Staff A, stated she had been orientated regarding sounding door alarms and the standard response, but was not given demonstration on what a door alarm sounds like. Staff A stated they had pagers which were suppose to alert them if exit door alarms sound, but hers did not activate when Resident #1 exited through the south stairwell. Staff A stated the Administrator asked if the pagers alerted them and she told him no. The Administrator then tested the door alarm and pagers and Staff A stated her pager again did not activate when the south stairwell alarm was activated. In a follow up interview on 11/17/19 at 11:20 a.m. Staff A reiterated her pager did not sound on the evening of 11/18/18 when Resident #1 exited through the south stairwell. Staff A remembered her pager activated when the Administrator and others entered the memory care unit through the front entrance and she had the pager in her possession. Staff A stated as part of her shift responsibilities she has checked door exits for proper functioning, but noted she only checks to see if the green light is on and doesn't actually activate the alarm. In an interview on 1/14/19 at 8:36 a.m. Staff B, CNA stated she worked a double shift (day/evening) on 11/18/18. At around 7:30 p.m. she and Staff C were in a resident's room (1352 north side) assisting with a transfer and cares. The door was closed and they did not hear a door alarm sound. Once finished they walked into the TV/dining area as Resident #1 was being escorted onto the memory care unit. They were informed Resident #1 had eloped. Staff B stated she has a pager which will activate when door alarms sound, but her pager batteries were dead. In a follow up interview on 1/14/19 at 11:46 a.m. Staff B stated her pager was dead on the evening of 11/18/18. She worked a double shift that day and didn't make sure her pager remained charged. Staff B stated she usually places her pager on vibrate as the sounding alarm bothers residents, especially on the memory care unit. Staff B stated pagers are programmed specifically for each unit, but she did not know whether all pagers are set up to respond to all door alarms. In an interview on 1/10/19 at 3:37 p.m. Staff C, CNA stated she worked the evening shift on the memory care unit on 11/18/18 and around 7:30 p.m. she worked in room [ROOM NUMBER] with another aide (Staff B) putting a resident to bed. The door was closed and Staff C could not hear any door alarms sounding. Staff C stated she left the room a few moments ahead of Staff B. When Staff C walked around the corner into the TV/dining room area, several staff were standing with Resident #1. Staff C learned Resident #1 had exited through the south stairwell and a visitor discovered him outside. Staff C stated she had a pager, but it never activated. Staff C stated she looked at the pager afterwards and it had no entry of the south door alarm sounding. In an interview on 1/10/19 at 10:50 p.m. Staff F, Housekeeping Supervisor, stated she is responsible for monitoring door alarm function each month and as needed issues are identified. Staff F stated a device activity report was printed out for the memory care unit on 11/18/18. Staff F stated when a door alarm activates, it will open after a 15 second delay and show up as cleared on the device activity report, but will continue to sound until manually deactivated by a key. In a follow up interview on 1/14/19 at 11:58 a.m. Staff F stated she checks door alarms each month to ensure door alarms are functioning properly, but does not document the checks. Staff F also runs off a report that will tell her what isn't working. Pagers are set up for each specific unit related to call lights and door alarms. Pagers that are not working will show up on the monthly report. Staff also have extra batteries at the nurse's station on each unit. Staff F stated she does not check alarm volumes at different locations on the unit. During an observation on 1/10/19 at 11:10 a.m. this surveyor, accompanied by Staff F, depressed the south stairwell door bar. The door alarm immediately sounded and opened following a 15 second delay. The alarm continued to sound until manually keyed off. The second door in the stairwell was pushed, but would not open. Staff F stated the door will not open unless keyed open; the facility locked the second door after the elopement incident. When tested , the three pagers on the memory care unit activated properly when the door alarm activated. This surveyor then walked to the far north side of the memory care unit and had Staff F activate the south stairwell door alarm. While in the north hallway, the tone was very faint and inaudible if in a resident room with the door shut. The TV/dining area was a little more audible, but still faint. On 1/14/19 at 12:27 p.m. the pagers were again tested on the memory care unit. All three pagers alerted within 20 seconds of the door alarm activating. In an interview on 1/16/19 at 2:30 p.m. the DON stated nursing staff are to check door alarms each shift and record the functioning status. Starting today, nurses have been directed to include checks of the pagers for proper functioning. The DON provided documentation of door alarm checks in each unit for October, (MONTH) and (MONTH) (YEAR). The elopement incident detailed above resulted in an Immediate Jeopardy (IJ) situation for facility residents. The facility abated the IJ on 1/17/19 through a combination of 15-minute checks for Resident #1, ensuring audibility and function of pager system, all staff education of the facility's elopement procedures, adding audio monitors on south and north stairwells and a Wanderguard system and providing staff direction to check the door alarms, exit doors and bracelets for function every shift.