Every finding on record at The Woods, A Nightingale Community

Based on record review, interview, and facility policy review, the facility failed to ensure safety straps were placed on all four wheels of a resident's wheelchair before being transported in the facility van which resulted in one resident falling backwards from the wheelchair for one (Resident #1) of three residents reviewed for accidents and hazards. The findings include: Review of Resident #1's Medical Diagnosis revealed Resident #1 had diagnoses that included end stage renal disease, acquired absence of right leg above the knee, type 2 diabetes with chronic kidney disease, dependence on renal dialysis, and acquired absence of left leg below the knee. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS also revealed Resident #1 used a wheelchair for mobility. Review of Resident #1's Care Plan initiated on 02/24/25, revealed Resident #1 had a self-care performance deficit related to a right above the knee amputation and a left below the knee amputation. The care plan indicated Resident #1 required moderate assistance of one staff member with transfers and was dependent on renal dialysis three times weekly. Review of Resident #1's Physicians Orders dated 07/07/25, revealed Resident #1 should be transported to dialysis every Monday, Wednesday, and Friday. Review of Resident #1's Reportable revealed Resident #1 was being transported from dialysis on 09/20/2025 at 10:58 AM by Certified Nursing Assistant (CNA) #1. The document revealed that the wheelchair flipped backwards when the van driver accelerated after being stopped at a red light. Review of the facility's Incident and Accident Report revealed the wheelchair straps were secured to the back of the resident's wheelchair but not the front of the resident's wheelchair. Resident #1 had bilateral lower extremity amputations which contributed to the uneven weight balance and distribution during acceleration of the vehicle. Review of an Office of Long-Term Care (OLTC) Witness Statement Form dated 09/20/2025 at 10:58 AM, revealed CNA #1 secured the two back straps to Resident #1's wheelchair, but did not attach the two front straps to the resident's wheelchair. After sitting at a red light, the light turned green, and CNA #1 accelerated the vehicle, at which point the wheelchair went backwards. When CNA #1 looked back Resident #1 was still in the sitting position laying on their back in the wheelchair. The witness statement revealed CNA #1 called and notified the administrator, who instructed CNA #1 to call emergency medical personnel. Review of a Progress Note titled Post Incident with an effective date and time of 09/21/2025 at 6:13 PM, revealed Resident #1, went backwards in van. Description of injuries included a bump on the right forearm, discomfort in chest, and lower back. Review of an Individual In-Service Training dated 08/24/2024 and signed by CNA #1, revealed the subject as Resident and Wheelchair Securement Education. The document revealed CNA #1 was trained on how to properly secure a resident before transport with return demonstration provided with the Administrator. During an interview on 06/09/2026 at 11:54 AM, CNA # 1 stated that he and Resident #1 were talking when the resident was being loaded onto the facility van. CNA #1 stated that he attached the straps to the back of Resident #1's wheelchair while he and Resident #1 were still talking. CNA #1 then stated he closed the backdoor on the van and went around to the front to attach the straps to the front of Resident #1's wheelchair. CNA #1 stated he forgot to attach the secure straps to the front of the resident's wheelchair and while sitting at a red light, after the light turned green, he accelerated and heard a thump. CNA #1 then stated he saw Resident #1's wheelchair on its back with the resident laying across the wheelchair. CNA #1 stated he called the Administrator. CNA #1 stated the Administrator told him to call 911 and CNA #1 stated he stayed with the resident until Emergency Medical Services (EMS) arrived. CNA #1 stated he did not touch the resident until the resident was loaded onto the EMS stretcher. CNA #1 stated he did receive training on loading and transporting residents approximately two years before the incident occurred. CNA #1 stated that the incident could have been avoided by double checking his work. CNA #1 stated that it was the responsibility of the driver to inspect the straps to ensure they were working correctly. During an interview on 06/10/2026 at 12:33 PM, the Administrator stated CNA #1 was no longer transporting residents. The Administrator also stated that in-services and retraining were conducted by the facility after the incident. The Administrator stated that training in loading and transporting residents was outsourced to another entity, and she had spoken with the representative about conducting an in-service but was unsure when it would take place due to the in-service being conducted at the same time as sister facilities. The Administrator stated that as an intervention to prevent other incidents, two staff members were assigned to out-of-town trips to ensure resident safety. During an interview on 06/10/2026 at 2:18 PM, the Maintenance Director stated his responsibility for the van included using a checklist to conduct daily walk around inspections. This included checking the oil on the van and checking the air pressure in the van's tires. The Maintenance Director stated that inspecting the safety straps was not part of his assigned duties and that drivers had a checklist that they used before transporting a resident and checking the security straps for safety was included on the checklist. The Maintenance Director stated that if a resident was not secured properly while being transported, the wheelchair could turn over, the resident could fall out of the wheelchair, the wheelchair could roll around the back of the van, and someone could become seriously injured. Review of undated facility policy titled Fleet Management revealed, the facility strives to maintain a safe working environment to protect employees and residents from injury and property loss, and the facility is committed to promoting a heightened level of safety awareness and responsible driving behavior in its employees. Elements of this program include training standards and safety regulations. The driver and all occupants are required to wear safety belts when the vehicle is in operation. The driver is responsible for ensuring passengers wear their safety belts. The facility re-educated CNA #1 on how to properly secure a resident before transport with return demonstration provided on 08/28/2024, the CNA was reassigned jobs and was suspended for three days during the time the facility investigated the situation. These actions were performed before the survey team entered the facility, resulting in this finding being cited at past non-compliance.

Based on observations, interviews, record review, and facility policy review, it was determined the facility did not ensure residents were not provided the code to entrance/exit doors to safeguard residents and prevent residents from eloping from the facility for one (Resident #20) sampled resident. The IJ began on 04/01/2025 at approximately 4:30 PM, when Resident #20 used a code for the exit doors provided by facility staff to exit the building without staff knowledge. Resident #20 verified knowledge of codes to the entrance/exit doors of the facility. These findings have been determined to have resulted in Immediate Jeopardy as defined at 42 CFR §483.25. The Administrator was informed of the Immediate Jeopardy on 07/02/25 at 5:34 PM, and a Plan of Removal was requested. The facility provided an acceptable Plan of Removal on 07/03/2025 at 12:15 PM, which was verified to be completed by the survey team on 07/03/2025 at 7:45 PM. The findings include: An “OLTC [Office of Long-Term Care] Incident and Accident Report (I&A)” with a discovery date of 04/01/2025 revealed that on 04/01/2025 at approximately 4:30 PM, Resident #20 exited the facility and walked outside to the north hall end door, where a Certified Nursing Assistant (CNA) observed the resident walking outside a window. The CNA assisted the resident back into the facility. Resident #20 was asked how they had exited the facility, and provided the code to the door, “*234.” A nurse on the hall reported they had last seen the resident at approximately 4:20-4:25 PM, implying the resident was outside unattended and without staff knowledge for 5-10 minutes. There were four exit doors on the secure unit on which Resident #20 resided: one that opened to the courtyard, one that opened to a fenced area, and two that opened to the outside. Resident #20 exited on 04/01/25 through one of the two doors that opened to the outside. The door that the resident exited through passed by the laundry room, then to an area near the laundry room that was observed to contain cleaning equipment, a mop bucket, and boxes that could have caused the resident to fall to the concrete. On 06/30/25 at 1:26 PM, this surveyor observed Resident #275 enter the code to silence the alarm to the courtyard door after several residents went out unattended by a staff member to await their smoke break. On 07/02/25 at 9:57 AM, this surveyor asked several residents sitting near the exit door to the courtyard outside of the main dining room if any knew the code to the exit door. Resident #50 stated “*567.” On 07/02/25 at 10:57 AM, this surveyor asked Registered Nurse (RN) #5 to enter the code to the door at the end of north hall. RN #5 entered code *567 and it unlocked the door. This surveyor asked RN #5 to enter code *234, and this code also unlocked the door. RN #5 stated that code *234 opened the door at the end of the hall, which was three doors from the resident’s room. During an interview on 07/02/25 at 11:19 AM, Certified Nursing Assistant (CNA) #5 stated around mealtime on 04/01/2025 she heard the door alarm sound and observed Resident #20 outside the North door next to the nurse's station, attempting to enter the facility. CNA #5 stated if Resident #20 would not have tried to open the door she would not have seen the resident. CNA #5 stated Resident #20 had exited the door near the laundry room and that the alarm did not work to that door. CNA #5 stated Resident #20 was moved off the secured unit after the incident. CNA #5 stated some of the residents, including Resident #20, knew the code to the doors. CNA #5 stated she observed Resident #20 pushing on the north door since the elopement and she reported it to the Unit Manger. CNA #5 stated Resident #20 has dug in the butt can for cigarettes and that has been reported to the Unit Manger. On 07/02/2025 at 11:55 AM, Resident #20 was asked how they had obtained the code to the exit doors, and stated it was provided by an unknown CNA, but added all CNAs will give them the code to the door. On 07/02/25 at 12:00 PM, this surveyor asked the Unit Director (UD) if they had been informed that Resident #20 had the codes to the exit doors. The UD stated, yes to the courtyard. The UD was asked for the exit code to the courtyard doors and stated, “*567.” This surveyor asked the UD what other door could be opened with code *567, and the UD stated all of them except the door in the unit. This surveyor asked what was preventing Resident #20 from using the code on another door, to which the UD replied, “We just keep a close eye on [the resident].” On 07/02/25 at 12:10 PM, CNA # 6 was asked if they had seen a resident enter the code to any exit door to exit or re-enter the building. CNA #6 stated, “Not through this door on the unit, but I have seen them do it on other halls.” CNA #6 was asked if they had witnessed any resident ever entering the code to exit or re-enter the building to go the courtyard to smoke and stated, “Yes, I have seen them.” On 07/02/25 at 12:15 PM, CNA #7 was asked if they had seen a resident enter the code to any exit door to exit or re-enter the building. CNA#7 stated, “Not in the unit, but on the other side of the building I have.” CNA #7 was asked if they had witnessed any resident ever enter the code to exit or re-enter the building to go to the courtyard to smoke. “On the other side of the building, yes. I have seen them.” On 07/02/25 at 12:27 PM, Resident #48 reported they smoked outside. When asked about the code to the doors, Resident #48 stated, “I know the code to go out, *567.” Resident #48 was asked how they had obtained the door code and stated, “One of the aides gave it to me. Every resident that smokes or wants to go outside has the code. It works on the dining room door and the front door. [Resident #53] will use the code and go out the front door to smoke in the front of the facility. Staff do not go with [the resident]. Staff don't even know [Resident #53] is out there. [Resident #53] went out the back door and no one knew [Resident #53] was out there and hurt their arm bad…I don't have residents asking me for the code because everyone knows the code.” On 07/02/25 at 2:00 PM, Resident #53 was asked about injuring their arm outside the facility, and stated, “I wasn’t out front when I fell. I was in the courtyard smoking and I got dizzy so I got up to go in and when I got to the door I fell.” Resident #53 was asked if there were staff present when the fall occurred and stated, “Yes, I can’t remember any of their names but there were staff out there.” Resident #53 was asked if they knew the code for the exit doors, and stated, “Yes, I do.” On 07/02/25 at 1:20 PM, Licensed Practical Nurse (LPN) #1 was asked what occurred with the incident where [Resident #20] was found outside, and stated, “We saw [Resident #20] outside by the north hall door and several staff saw [Resident #20] at the time walking.” LPN #1 stated Resident #20 reported they were attempting to find [Resident #53] that smoked to get a cigarette. LPN #1 was asked how Resident #20 was able to exit the facility and stated they did not know how they got the codes. On 07/02/25 at 2:40 PM, Resident #275 was asked if they smoked and confirmed they did, four times a day. Resident #275 was asked about the door codes and if residents used them without staff present, and stated, “Sometimes I just go outside to sit. We go out through the dining room. The code is *567 and use the same coming back in. One of the nurses gave it to me. I can go out anytime I want without staff. There is a gate, but I haven't tried to go out. There is a door that goes into that locked unit. Those residents come out at the same time as us. We can go out anytime we want, at any hour we want.” On 07/02/25 at 02:48 PM, the Administrator was asked to elaborate on the incident with Resident #20 eloping from the facility, and stated, “I received a call that [Resident #20] entered the key code to walk around the building to [Resident #53] to get a cigarette.” The Administrator was asked about Resident #20 residing on the secure unit, and stated, “Yes, [Resident #20’s] sister felt [Resident #20] needed to be on the secured unit. We moved [Resident #20] out because [Resident #20] was doing so well and [the resident’s] BIMS was high enough and did not need to be there.” The Administrator reported Resident #20 was moved off the secure unit the day following the elopement. The Administrator was asked how the facility ensured there was not a reoccurrence, and responded stating staff supervise the residents up front, because Resident #20 was not an elopement risk. The Administrator reported no changes were made to the key pads for the exit doors. “[Resident #20] is not an elopement risk, because [Resident #20] has a high BIMS and can tell me if [Resident #20] wants to go or stay.” When asked if Resident #20 currently knew the code to unlock the exit doors, the Administrator stated, “Not that I am aware of.” On 07/02/25 at 03:35 PM, the Director of Nursing stated that the courtyard was the designated smoke area, and Resident #53 continues to try to smoke out front. Resident #53 has the code for the exit doors and lets [the resident] out of the facility. During an interview on 07/02/25 at 05:15 PM, Resident #20 stated they promised the Director of Nursing they would not go outside again, because the resident did not want to get in trouble. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/05/25 revealed Resident #20 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #20 had a diagnosis of non-Alzheimer's dementia. A review of the Care Plan Report (revision date 06/28/25) revealed Resident #20 was a smoker. Resident #20 often attempted to hoard cigarette butts, lighters and other smoking materials rather than giving them to the nurse. The resident's family would bring smoking materials and give to the resident despite staff education that this is against the rules. The Immediate Jeopardy was removed on 07/03/2025 at 12:15 PM when the following plan of removal was implemented by the facility: 1. Identification of Residents Affected or Likely to be Affected: On 07/02/2025 the Director of Nursing (DON)/designee identified all residents at risk or high risk with exit seeking and/or wandering behaviors that scored a 9 or above (33 were identified). 2. Actions to Prevent Occurrence/Recurrence: 3. On 07/2/2025 the DON/designee educated all staff on shift and ongoing as staff reported to work prior to their shift to monitor and supervise residents to prevent elopement. The in-service materials included to only provide the door code to authorized personnel. 4. On 07/2/2025 Resident #20 was directly involved in this deficient practice and had [Resident #20] care plan reviewed and updated by the DON/designee and updated to reflect current wandering and elopement risk. 5. By 07/2/2025 the Minimum Data Set (MDS) Coordinator reviewed section E of the MDS and associated CAA [Care Area Assessments] for all residents. Care plans were reviewed and updated to ensure they reflect audit findings. Concerns were not identified. 6. On 07/2/2025 the DON, designee(s) and /or MDS Coordinator(s) re-evaluated residents at risk for wandering/elopement using an elopement wandering risk scale. (33 residents were reassessed and care plans reviewed updated). 7. All staff received education on wandering, elopement, and resident safety from the Director of Nursing (DON) or designee(s) prior to reporting to their shift. 8. MDS/designee will ensure all residents receive a wandering risk assessment upon admission, quarterly, and with significant change of condition to ensure appropriate monitoring and supervision. Date facility asserts likelihood for serious harm no longer exists: 07/02/2025. Onsite Verification: The IJ was removed on 07/03/2025 at 7:45 PM after the survey team completed an onsite verification that the removal plan had been implemented as follows: 1. A review of a document titled Residents at Risk for Wandering provided by the DON revealed (Score of 9 or higher on Wandering Risk Scale) and 33 resident names were listed. 2. (No corresponding validation to item 2 in the facility’s POR) 3. A review of an in-service conducted by the DON dated 7/02/2025 with a subject of elopement procedures/practices included multiple staff names, signatures and different titles. 4. A review of Resident #20's care plan revealed a focus of [Resident #20] is an elopement risk/wandered related to dementia. [Resident #20] went outside looking for cigarettes. Code to door changed. Revision on: 7/02/2025; interventions included identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something with a date initiated of 07/02/2025. 5. A review of care plans located in the residents' electronic health record (EHR) for 5 randomly selected residents on the list provided by the DON revealed the following: a. Resident #34's care plan indicated the resident is at risk for falls related to weakness, wanders. b. Resident #327's care plan revealed the resident is an elopement risk/wanderer related to wandering risk assessment score 9. c. Resident #64's care plan revealed the resident is an elopement risk/wanderer related to impaired safety awareness related to wandering assessment score 9. d. Resident #4's care plan revealed the resident is at risk for wandering related to dementia, poor sense of self safety. e. Review of Resident #63's care plan revealed the resident is an elopement risk/wanderer related to impaired safety awareness, exit seeking admitted to secure memory unit; wandering risk score 11. 6. A review of wandering risk scales located in the residents' electronic health record (EHR) for five randomly selected residents on the list provided by the DON revealed the following: a. Resident #34's wandering risk scale indicated at risk to wander with a score of 9.0. b. Resident #327's wandering risk scale indicated at risk to wander with a score of 9.0 c. Resident #64's wandering risk scale indicated at risk to wander with a score of 9.0. d. Resident #4's wandering risk scale indicated at risk to wander with a score of 9.0. e. Resident #63's wandering risk scale indicated high risk to wander with a score of 11.0. 7. On 07/03/2025, interviews with different staff either in person or by telephone revealed the following: One Registered Nurse indicated they were trained on and verbalized understanding on how to identify exit seeking behaviors in residents, what to do if a resident elopes, hiding the door code from residents and who to notify if a resident elopes. Three Licensed Practical Nurses from different shifts indicated they were trained on and verbalized understanding on how to identify exit seeking behaviors in residents, what to do if a resident elopes, hiding the door code from residents and who to notify if a resident elopes. Nine Certified Nursing Assistants covering different shifts indicated they were trained on and verbalized understanding on how to identify exit seeking behaviors in residents, what to do if a resident elopes, hiding the door code from residents and who to notify if a resident elopes. One housekeeper and one dietary aide covering different shifts indicated they were trained on and verbalized understanding on how to identify exit seeking behaviors in residents, what to do if a resident elopes, hiding the door code from residents and who to notify if a resident elopes. 8. A review of the EHR for five randomly selected residents (Resident #4, #34, #63, #64 and #327) from the list of 33 residents identified by the DON as at risk for wandering revealed the MDS Coordinator had completed wandering risk assessments for the residents and the care plans were updated to reflect the residents were at risk to wander and interventions were in place. Observation of the facility residents on 07/03/2025 between 1:30 PM and 6:00 PM revealed some residents in their rooms, some residents were in a common area with a television on, and some residents were in the dining area and no residents were observed attempting to exit the facility or pushing or shaking on doors. Residents on the secured unit were observed sitting in either their wheelchairs in a common area with the television on, at the dining room table or ambulating or propelling themselves in a wheelchair on the unit. No residents were observed trying to exit the area or pushing or shaking on the doors.

Based on observations, record review, interviews, and facility policy review it was determined the facility failed to ensure meal service assistance was provided in a timely manner for one (Resident #4) sampled resident, and to ensure staff did not stand while assisting residents with meal service for three (Residents #4, #46, and #49) of nine residents observed for dining. The findings include: Resident #4 On 07/01/25 at 8:24 AM, this surveyor observed Certified Nursing Assistant (CNA) #10 assist Resident #4 with meal service while standing. CNA #10 gave Resident #4 two bites before she stopped and informed the resident that she would return after she passed out trays. On 07/01/25 at 8:28 AM, this surveyor noted that Resident #4 has not been successful at taking a bite of food since CNA #10 walked away. This surveyor observed Resident #4 moved their straw across their plate and stirred in their cereal. The resident appeared confused. All the other residents at the table were eating breakfast. There were two nurses standing approximately 10 feet behind the resident in the dining room at the medication cart, not passing medications, talking amongst themselves, and not making an attempt to assist the resident. The resident struggled without assistance until 8:39 AM, during which time other residents at the table finished eating. On 07/01/25 at 8:38 AM, this surveyor observed Resident #4 with spoon in hand, attempting to eat. The resident was scraping the spoon to the left in an effort to get the meat and eggs, but rather than getting the food on the spoon it was scraped off the plate onto the table. On 07/01/25 at 8:39 AM, this surveyor observed the Registered Dietician (RD) notice Resident #4 was struggling with meal service and walked over to the table. The RD stated to Resident #4, I think we need to get you a new plate and some more eggs. On 07/01/25 at 8:41 AM, this surveyor observed the RD return with eggs and assisted the resident with three bites of the eggs while they stood over the resident. At this time all other residents at the table with Resident #4 had finished dining. The RD asked Resident #4 if they needed some help with eating, and Resident #4 stated, Oh yeah. The RD gave the resident a drink of milk while they stood over the resident. On 07/01/25 at 8:42 AM, this surveyor observed the RD turn to the two nurses standing near the resident at the medication cart and notified them that the resident needed to be assisted with meal service. One of the two nurses informed CNA #10 that the resident needed to be assisted with meal service. On 07/01/25 at 8:43 AM, this surveyor observed CNA #10 sit down to feed Resident #4. CNA #10 realized the resident’s cereal was now soggy and stated, I got to get you more cereal these are soggy. CNA #10 returned later with the cereal, sat next to the resident, and assisted with feeding. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/25, which included a Staff Assessment of Mental Status (SAMS) that indicated Resident #4 had short-term and long-term memory problems and had severely impaired cognitive skills. A review of a Care Plan Report with a revision date of 10/10/24, indicated Resident #4 had an Activities of Daily Living (ADL) self-care performance deficit. Interventions included that Resident #4 (revision date 05/31/23) was able to feed self with set up help but needed cues and assist at times. During an interview on 07/01/25 at 8:51 AM, CNA #10 stated Resident #4 sometimes required assistance with eating depending on the day and today was one of those days. CNA #10 stated when she initially started to assist Resident #4, she felt the resident did not need any assistance, but that was inaccurate. CNA #10 stated when she initially started to assist Resident #4 with feeding she was standing, but she should have been sitting. During an interview on 07/01/25 at 9:00 AM, the RD stated she stood behind the resident and leaned forward to look the resident in the face, at eye level, and between two residents while they assisted the resident with a bite Resident #49 On 07/01/25 at 1:00 PM, this surveyor observed Licensed Practical Nurse (LPN) #1 tap Resident #49, who appeared to be sleeping, on the shoulder. When the resident woke and LPN #1 gave the resident two bites of food while standing over the resident. On 07/01/25 at 1:19 PM, this surveyor observed LPN #1 call Resident #49, who appeared to be sleeping, by name. When the resident woke, LPN #1 gave the resident several bites of food while they stood over the resident. Resident #49 was not observed to feed themselves any food. A review of the annual MDS with an ARD of 04/10/25, indicated Resident #49 had a Brief Interview for Mental Status (BIMS) score of four, which indicated the resident had severe cognitive impairment. A review of a Care Plan Report with a revision date of 01/10/25, indicated Resident #49 had an ADL self-care performance deficit, and required set-up assistance with meals/eating. During an interview on 07/01/25 at 2:25 PM, LPN #1 stated she stood while she assisted Resident #49, but she did not feed the resident. She encouraged the resident. LPN #1 stated her definition of encouraging was giving verbal cues, giving a bite, and handing over the spoon. LPN #1 stated her definition of feeding a resident, is being seated next to a resident feeding the resident the entire meal. LPN #1 stated she did not know how many bites of food were considered feeding rather than encouraging. She stated, I guess next time I will let the CNA do their job. Resident #46 On 07/01/25 at 1:21 PM, this surveyor observed CNA #11 standing while assisting Resident #46 with eating, placing several bites of food in the resident’s mouth. A review of the quarterly MDS with an ARD of 04/08/25, indicated Resident #46 had a BIMS score of three, indicating severe cognitive impairment. A review of a Care Plan Report with a revision date of 01/21/25, indicated Resident #46 had an ADL self-care performance deficit, and required set-up assistance with meals. On 07/01/25 during an interview at 1:43 PM, CNA #11 stated she stood while she assisted Resident #46 with feeding but she should have been sitting. During an interview on 07/02/25 at 4:15 PM, the Director of Nursing stated staff should be eye level with residents when assisting with meal service. A review of a policy titled, “Resident Rights and Responsibilities,” indicated the nursing facility protects and promotes the rights of each Resident/Elder admitted , to provide a dignified existence.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure meals were served in a method that maintained the appearance, nutritive value and taste of pureed foods that were acceptable to the residents to improve palatability and encourage good nutritional intake during two of two meals observed. The findings include: 1.On 07/01/2025 at 8:45 AM, during observation of the noon meal preparation, Dietary [NAME] (DC) #8 placed nine servings of French toast into a blender. Instead of milk as specified per the menu, DC #8 added two cups of water from the coffee machine on top of the French toast inside the blender and pureed. On 07/01/2025 at 8:47 AM, during an observation and concurrent interview, DC #8 poured the pureed French toast into a pan and placed it on the steam table. This surveyor asked DC #8 how much water he used to puree the French toast. DC #8 stated he used two cups of water to puree the French toast, and that he should have used milk. A review of the Facility Recipe on 07/01/2025, indicated for 10 servings of French toast to use 1.25 cups of 2% milk. Prepare the slurry. Process until smooth adding one ounce slurry per portion. 2.On 07/01/2025 during an observation and concurrent interview at 12:01 PM, DC #8 placed 10 servings of meat loaf into a blender. Instead of 1.25 cups of water, DC #8 added two cups of water from the coffee machine on top of the meat loaf inside the blender and pureed the contents. This surveyor asked DC #8 how much water he used to puree the meat loaf. DC #8 stated he used two cups of water to puree the meat loaf. On 07/01/2025 during an observation at 12:04 PM, DC #8 poured the pureed meat loaf into a pan and placed it on the steam table. The mixture was thick and lumpy. On 07/01/2025 during an interview at 1:49 PM, the Dietary Manager (DM) described the appearance of the pureed meat loaf served to the residents for lunch as lumpy and stated the meat loaf needed to be pureed some more. On 07/01/2025 during an interview at 1:50 PM, this surveyor asked how the food would taste if it was pureed with water. DC #8 tasted the pureed meatloaf and stated, it needed seasoning because using water took away from the flavor. The DM tasted the pureed meat loaf and stated it had no taste. A review of the Facility Recipe on 7/01/2025, indicated for 10 servings of glazed meatloaf use 1.25 cups of water or stock add 2 tablespoon plus 1.5 teaspoons of food thickener. Prepare slurry. Process until smooth adding 1 ounce slurry per portion. A review of a facility policy titled “Key Concept,” indicated pureed foods can be prepared in a few simple steps: 1. Process until fine. 2. Thicken, if needed, and continue to process until smooth. 3. Season and flavor. A review of a facility policy titled “Pureed foods,” indicated all employees are trained to follow the spreadsheet for each diet to tell them which foods to provide and the consistency for each.

Based on observation, interview, and facility policy review, the facility failed to ensure expired food items were promptly removed or discarded on or before the expiration or use by date to prevent the growth of bacteria, and dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for two of two meals observed. The findings include: During observation and concurrent interview on 07/01/2025 at 7:38 AM, Dietary Aide (DA) #9 picked up the water hose with her bare hands and used it to spray leftover food from inside the dishes, contaminating her hands. DA #9 placed the dirty dishes on the dirty racks and pushed the racks into the dish washing machine to wash. Without washing her hands, DA #9 picked up pan liners with her bare hands and used them to cover pans that contained deserts to be served to the residents for lunch. DA #9 stated she should have washed their hands. During an observation on 07/01/2025 at 8:18 AM, DA #9 who assisted with the breakfast meal, picked up cartons of syrup, milk, milk shakes, and condiments and placed them on trays. Without washing her hands, DA #9 then picked up glasses with beverages in them by the rims and placed them on the trays to be served to the residents during the lunch meal. During an observation and concurrent interview on 07/01/2025 at 8:38 AM, DC #8 washed and sanitized the blender, bowl, lid and the blade in the 3-compartment sink. After sanitizing the food processor equipment, DC #8 turned off the faucet with a bare hand, contaminating their hand. Without washing their hands, DC #8 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items for lunch. When DC #8 was ready to use the blender, this surveyor immediately asked DC #8 what they should have done after touching dirty objects and before handling clean equipment and DC #8 stated he should have washed his hands. During an observation on 07/01/2025 at 9:14 AM, this surveyor observed bags of chips on a shelf in the storage room used to store food intended to be served to residents. The bags had an expiration date of 06/17/2025. During an observation of the lunch meal on 07/01/2025 at 12:37 PM, without washing their hands, DA #9 picked up glasses with beverages in them by the rims and placed them on the trays to be served to the residents during the meal. DA #9 stated they should have picked up cups from the handles and glasses from below. The DM stated they had seen the DA picking cups and glasses by their rims. A review of a facility policy titled, “Handwashing and Glove Usage in Food service,” indicated hands should be washed as often as possible, and that it was important to wash hands before starting to work, after leaving and returning to the prep area and after touching anything else such as dirty equipment and work surfaces, as often as needed during food preparation, and when changing tasks.

Based on observations, record review, interviews and facility policy review it was determined the facility did not ensure infection control measures were used and staff wore the proper Personal Protective Equipment (PPE) when providing device care for one (Resident #41) of two residents with gastrointestinal feeding tubes reviewed for Enhanced Barrier Precautions (EBP). The findings include: On 06/30/25 during an observation at 11:48 AM, this surveyor observed Resident #41 lying in bed with eyes closed. The resident’s feeding pump was disconnected and was infusing onto the floor. This surveyor noted the tip of the tubing to the feeding tube was in contact with the floor, which caused contamination. On 06/30/25 during an observation at 12:00 PM, this surveyor observed Registered Nurse (RN) #4 without a gown, pick up the tube feeding tube from the floor, without sanitizing or changing the tip, RN #4 reconnected the tubing to Resident #41. A review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date of 05/21/25, included a Staff Assessment of Mental Status which indicated Resident #41 had short-term and long-term memory deficits, and never or rarely made decisions. The MDS also indicated Resident #41 had a feeding tube while a resident of the facility. A review of a Care Plan Report with a revision date of 06/28/2025, revealed Resident #41 required a tube feed related to difficulty swallowing. During an interview on 07/02/25 at 7:20 AM, RN #4 indicated the feeding tube tip should have been sanitized or changed, after picking up from the floor, prior to reconnecting the tubing to Resident #41. RN #4 stated she did not utilize the appropriate PPE for a resident on EBP. During an interview on 07/02/25 4:04 PM, the Director of Nursing (DON) confirmed nurses should sanitize or change the tip of the tubing of the feeding tube, since it touched the floor. The DON indicated the nurse should have worn gown and gloves, because Resident #41 was on EBP. A review of the policy titled “Enhanced Barrier Precautions” indicated gown and gloves are required for high contact activities such as device care to central lines, urinary catheters and feeding tubes.

Based on record review and interview, it was determined the facility did not ensure the quarterly Minimum Data Set Assessment reflected a behavior that the resident exhibited for one (Resident #20) of one resident reviewed for assessment accuracy. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/05/25, indicated Resident #20 had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The MDS also indicated that Resident #20 had diagnoses which included non-Alzheimer's dementia and did not exhibit wandering behavior. A review of a Care Plan Report initiated on 09/24/24, with a revision date of 07/02/25, indicated Resident #20 was an elopement risk and had wandering behaviors related to dementia. During a phone interview on 07/03/25 at 10:59 AM, the MDS Coordinator confirmed Resident #20’s quarterly MDS was completed on 04/05/25, which was after Resident #20 was found outside the building on 04/01/25, without staff knowledge. According to the MDS Coordinator, the quarterly MDS did not indicate Resident #20 had wandering behaviors, but it should have, therefore the assessment was inaccurate. During an interview on 07/03/25 at 11:11 AM, the Director of Nursing (DON) confirmed there was an incident that occurred on 04/01/25, in which Resident #20 exited the building without staff knowledge. The DON stated she did not do the MDS assessment therefore she could not say if it was accurate or not.

Based on record review and interviews, it was determined that the facility did not ensure a Care Plan was accurately revised to reflect a resident's elopement and/or wandering status after an incident that occurred in which a resident left the facility without staff knowledge for one (Resident #20) of one sampled resident reviewed for Care Plan accuracy. The findings include:A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/05/2025, indicated Resident #20 had a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated that Resident #20 had diagnoses which included non-Alzheimer's dementia.A review of a Care Plan Report for Resident #20 on 07/01/2025 did not reveal that Resident #20 had been identified as having previously eloped, having wandering behaviors, nor provide any interventions for staff to utilize in managing behaviors or preventing elopements.A review of a Care Plan Report on 07/02/2025, indicated Resident #20's care plan had been revised to indicate the resident was an elopement risk and had wandering behaviors related to dementia.During a phone interview on 07/03/2025 at 10:59 AM, the MDS Coordinator confirmed that Resident #20 exited the facility without staff knowledge on 04/01/2025. It was not indicated on the care plan that the resident was an elopement risk, had eloped, or had wandering behaviors prior to the revision on 07/02/2025. According to the MDS Coordinator, the care plan initiated 09/24/2024, should have been revised to reflect the resident was an elopement risk and had wandering behaviors, and since it did not it was inaccurate.During an interview on 07/03/2025 at 11:11 AM, the Director of Nurses confirmed there was an incident that occurred on 04/01/2025 in which Resident #20 left the building without staff knowledge.

Based on observation, record review, and interviews, it was determined the facility did not provide appropriate services and treatment to prevent complications for one (Resident #41) of two residents reviewed who received enteral feedings. The findings include: On 06/30/25 during an observation at 11:48 AM, this surveyor observed Resident #41 lying in bed with eyes closed. The feeding pump tubing was disconnected, had fallen and was discharging its contents onto the floor. This surveyor observed that the tip of the feeding tube was in contact with the floor. On 06/30/25 at 12:00 PM, Registered Nurse (RN) #4 was observed picking up the tube feeding tip from the floor and reconnected the tubing to Resident #41's gastrostomy tube without sanitizing or changing the tip. RN #4 did not check placement prior to reconnection and initiation of enteral feeding. A review of 10th edition Lippincott Manual of Nursing Practice, provided by the facility for enteral feedings (intermittent or continuous) indicated best practice would be to make sure residual was within normal limit and stomach placement had been confirmed. A review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date of 05/21/25, included a Staff Assessment of Mental Status, which indicated Resident #41 had short-term and long-term memory deficits and never or rarely made decisions. The MDS also indicated that Resident #41 had a feeding tube while a resident of the facility. A review of a Care Plan Report with a revision date of 06/28/2025, indicated Resident #41 required tube feedings related to difficulty swallowing. The goal with a revision date of 05/29/2025, indicated that Resident #41 would be free of aspiration. The Care Plan also included an intervention with a revision date of 05/16/2025, to check for feeding tube placement prior to any feedings or flushes and check for gastric contents/residual volume as ordered per physician. A review of an Order Summary Report with active orders as of 07/01/25, indicated Resident #41 had a Physician's Order dated 05/09/2025, that stated to check [gastrostomy] tube for proper placement prior to each feeding, flush, or medication administration. On 07/02/25 during an interview at 7:20 AM, RN #4 confirmed placement was not verified prior to initiating the enteral feeding due to the television being on and the resident not allowing her to check placement. This surveyor, who was present at bedside during the incident, did not hear the resident make a statement of refusal of care. RN #4 indicated placement could have been confirmed with aspiration. During an interview on 07/02/25 4:04 PM, the Director of Nursing (DON) confirmed the nurse should have checked placement prior to reconnection to ensure proper placement before initiating the gastric feeding pump.

Based on observation, record review and interview, the facility failed to ensure all areas of the skin were cleansed during incontinent care for 1 (Resident #5) of 1 resident reviewed for incontinence care. The findings are: On 03/13/2025 at 1:23 PM, Certified Nursing Assistant (CNA) #7 propelled Resident #5 to the room to provide incontinent care to the resident. CNA #8 was standing in the resident's doorway. This surveyor, accompanied by another female surveyor, entered the resident's room. After CNA #7 and CNA #8 sanitized their hands, both CNAs put on a pair of gloves. Resident #5 was assisted to a standing position from the wheelchair, a large wet circle was observed on the back of the resident's pants on the buttocks and back of both thigh areas. Resident #5 stated, Oh I smell, and CNA #7 informed the resident they [CNA #7 and CNA #8], were about to clean the resident. After the resident was assisted to bed and pants removed, CNA #7 rolled the resident's wet pants and placed the pants in a clear plastic bag sitting at the foot of the bed on top of the sheet. After the CNAs were finished providing incontinent care to the resident and CNA #7 picked up Resident #5's pants, this surveyor asked her if she was finished providing incontinent care to the resident. She stated she was. This surveyor asked CNA #7 to remove the resident's brief and use a clean wipe and cleanse the resident's genital area and show the wipe to this surveyor. Without changing gloves, CNA #7 unfastened the resident's brief, removed a clean wipe from the package with her left hand and swiped the resident's genital area and there was a brown streak observed on the wipe. CNA #7 discarded that wipe and took a second clean wipe from the package with the same gloved hands and cleansed the resident's genital area again until there were no brown stains observed. Review of Resident #5's Medical Diagnosis Screen revealed Resident #5 had diagnoses of dementia (a decline in a person's cognitive abilities which affects a person's ability to perform everyday activities) with agitation, overactive bladder, and osteoarthritis (a joint disease that affects many tissues of the joint). Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/24/2025, revealed Resident #5 was admitted to the facility on [DATE]. The admission MDS was not completed for review. Review of a Care Plan Report dated 02/25/2025, revealed Resident #5 had an activities of daily living (ADL) self-care deficit and required limited assistance with personal hygiene, toileting and one person assist with transfers. On 03/19/2025 at 2:08 PM, CNA #7 was interviewed and stated, when providing incontinent care to a resident, you should wipe the resident's perineal area from the front to the back of the perineal area to remove feces. On 03/19/2025 at 2:27 PM, CNA #8 was interviewed and stated, she was instructed to cleanse feces from the resident's perineal area by wiping the area until nothing [no feces] is there. On 03/21/2025 at 12:15 PM, the Director of Nursing (DON) was interviewed and stated, all areas of the resident's skin should be cleansed during incontinent care to ensure feces and urine do not sit on the skin. On 03/21/2025 at 12:30 PM, the Administrator was interviewed and stated, all areas of the resident skin should be cleansed when providing incontinent care to prevent infection. Review of a typed statement, provided by the Administrator on 03/17/2025, indicated the facility does not have a policy for resident bathing and hygiene.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure staff performed hand hygiene, changed gloves and did not touch items in the room with gloves used during incontinent care for 1 (Resident #5) of 1 resident reviewed for incontinent care. The findings are: On 03/13/2025 at 1:23 PM, Certified Nursing Assistant (CNA) #7 propelled Resident #5 to the room to provide incontinent care to the resident. CNA #8 was standing in the resident's doorway. This surveyor, accompanied by another female surveyor, entered the resident's room. After CNA #7 and CNA #8 sanitized their hands, both CNAs put on a pair of gloves. Resident #5 was assisted to a standing position from the wheelchair. A large wet circle, that was on the residents ' buttock area and back of thighs, was observed on the back of the resident's pants. Resident #5 stated, Oh I smell, and CNA #7 informed the resident they, CNA #7 and CNA #8, were about to clean the resident. After the resident was assisted to bed and pants removed by CNA #7 and CNA #8, CNA #7 rolled the resident's wet pants and placed the pants in a clear plastic bag sitting at the foot of the bed on top of the sheet. CNA #7, without changing gloves or sanitizing her hands, held a package of un-opened wipes steady with one hand and opened the package with the other hand. CNA #7 then used her left hand to remove clean wipes from the package and with the same gloved left hand, she began providing incontinent care to Resident #5. During the incontinent care process, CNA #8 assisted the resident to the right side and CNA #7, with the same gloves, removed wipes from the package on the table and began cleaning soft brown feces from the resident's rectal area. As CNA #7 continued to clean the feces from the resident's gluteal area, she removed the gloves, sanitized her hands and put on a clean pair of gloves. Once CNA #7 had completed cleaning the feces from the resident's bottom, but without changing gloves, she placed a clean adult brief underneath the resident and both CNAs assisted the resident to lie on back and CNA #7 fastened the resident's brief without cleaning the resident's genital area. CNA #8 did not change her gloves during the entire process. After Resident #5 was assisted to a sitting position in the bed, CNA #7 removed her left glove and realized there was only one clean glove on the over-bed table. She picked up a bottle of hand sanitizer, squirted a small amount into the palm of her right hand and moved the fingers of her right hand against the palm. She picked up the clean glove off the over-bed table using the right gloved hand with hand sanitizer on it, placed the clean glove on her left hand and rubbed her gloved hands together. She looked at CNA #8 and stated, I gotta do what I gotta do. Review of Resident #5's Medical Diagnosis Screen revealed dementia (a decline in a person's cognitive abilities which affects a person's ability to perform everyday activities) with agitation, overactive bladder, and osteoarthritis (a joint disease that affects many tissues of the joint). Review of an entry Minimum Data Set (MDS) with an Assessment Reference Date of 02/24/2025, revealed Resident #5 was admitted to the facility on [DATE]. The admission MDS was not completed for review. Review of a Care Plan report, dated 02/25/2025, revealed Resident #5 had activities of daily living (ADL) self-care deficit and required limited assistance with personal hygiene, toileting and one person assist with transfers. On 03/19/2025 at 2:08 PM, CNA #7 was interviewed and stated, when providing incontinent care to a resident, you sanitize/clean your hands when you go into the resident's room, in between dirty and clean tasks, and when you are done with incontinent care. She stated you do not place hand sanitizer on a glove used during incontinent care or use that same glove to pick up a clean glove or rub the two gloves against each other using hand sanitizer gel because it was that or her hand. On 03/19/2025 at 2:27 PM, CNA #8 was interviewed and stated, when providing incontinent care to a resident, she sanitizes/cleans her hands before going in the resident's room, after placing a bag on the barrier and items on the barrier. She stated when providing incontinent care to a resident, she was instructed to change gloves whenever she rotates the resident (to a different position), and after cleaning the resident's bottom properly. She stated you should not touch items in the room with the same gloves used to provide incontinent care to a resident with, because that was cross contamination. On 03/21/2025 at 12:15 PM, the Director of Nursing (DON) was interviewed and stated, staff should sanitize/clean their hands when providing incontinent care to a resident before providing care, while swiping from dirty to clean, in between glove changes, and after concluding care. She stated staff should not touch items in the room using the same gloves used to provide incontinent care to a resident because it could potentially contaminate items the staff are touching. She stated staff should not place sanitizing gel on the same glove used to provide incontinent care to a resident or place a clean glove on the opposite hand and rub the gloves together using sanitizing gel because that was not the practice, and staff should change their gloves completely. On 03/21/2025 at 12:30 PM, the Administrator was interviewed and stated when providing incontinent care to a resident, staff should sanitize/clean their hands when entering the room, when changing gloves and when exiting a room. She stated staff should change gloves if the gloves become dirty or soiled when providing incontinent care to a resident. Review of A Unit Guide to Infection Prevention for Long-Term Care Staff, dated September 2016, provided by the Administrator, indicated on page 12, to practice hand hygiene, keep hands clean either by washing with soap and water or using an alcohol hand sanitizer. Change gloves frequently and perform hand hygiene each time gloves are changed as dirty gloves can spread germs.

Based on observations, interviews, record review, and facility policy review the facility failed to ensure staff provided proper incontinence care to 1 (Resident #6) sampled resident. The findings include: A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date of 8/31/2024 revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, and indicated the resident was incontinent of bowel and bladder. A plan of care for Resident #6 (revision date: 9/02/2024) revealed Resident #6 had bowel and bladder incontinence related to disease process and used adult disposable briefs. On 9/25/2024 at 2:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #4 improperly clean Resident #6. The resident had experienced an incontinence episode, and when CNA #4 cleaned the resident's genital region with wipes, the CNA wiped back to front, a practice that can spread germs and cause urinary tract infections. CNA #4 did not completely clean the resident's genital area. The surveyor observed that liquid waste had soiled the resident's brief, incontinence pad, and the fitted sheet on the bed beneath. CNA #4 did not remove the soiled pad or sheet before rolling the portion of the resident's body that had been wiped clean into it, exposing the resident to the moisture and liquid waste. On 9/25/2024 at 2:12 PM, CNA #4 stated the genitals were not cleaned properly and Resident #6 had urinated through the brief, incontinence pad, and onto the fitted sheet. On 09/26/24 at 1:15 PM, the Director of Nursing (DON) stated the way in which the genitals were cleaned was improper and could cause the resident to have an infection. A policy titled Accident Hazards Prevention noted the facility is responsible for providing care to residents in a manner that helps promote quality of life.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff used proper hand hygiene while providing care to 1 (Resident #6) sampled resident. The findings include: A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date of 8/31/2024 revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and was always incontinent of bowel and bladder. A plan of care for Resident #6 (revision date: 9/02/2024) revealed Resident #6 had bowel and bladder incontinence related to disease process and used adult disposable briefs. On 9/25/2024 at 2:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #4 touch objects in the room such as the bedside drawer with dirty gloved hands while providing care to Resident #6. On 9/25/2024 at 2:12 PM, CNA #4 stated she had touched the handles on drawer and privacy curtains with dirty gloved hands. On 09/26/24 at 1:15 PM, the Director of Nursing (DON) stated the staff member contaminated the items touched with the dirty gloves. A policy titled Infection Control noted perform hand hygiene after contact with bodily fluids, patient's intact skin or with inanimate objects in immediate vicinity of the patient.

Based on interviews and record review, it was determined the facility failed to notify the State of Long Term-Care Ombudsman in writing of a transfer to the hospital for 1 resident (Resident #1) reviewed for hospitalization . Findings include: A review of a facility policy titled: Transfer and discharge date d 09/26/24 at 11:10 AM provided by Administrator indicated, .The nursing facility shall send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. On 09/26/24 the Administrator was asked to provide proof that the State Ombudsman had been notified of Resident #1 hospitalization s. A review of the Census tab for Resident #1's electronic health record indicated the resident was sent to the hospital four times between the dates 05/23/2024 and 09/05/2024. On 09/26/24 at 12:10 PM, the Administrator reported she was having trouble getting into Assistant Director of Nursing's computer to locate notifications sent to State Ombudsman. On 09/26/24 at 1:40 PM, Director of Nursing reported the Administrator was working on getting the transfer/discharge notifications sent to the State Ombudsman. During an interview on 09/26/24 at 3:34 PM, the Administrator indicated she was now responsible for sending the transfer/discharge letter to the State Ombudsman. The Administrator indicated that before her it was either the Business Office Manager or the Assistant Director of Nursing that sent the letter to the State Ombudsman. The Administrator was not able to provide proof that notification had been sent to the State Ombudsman for the four times Resident #1 had been hospitalized .

Based on observation, record review and interview, the facility failed to ensure an assistive communication device was utilized to facilitate communication between a resident and staff for 1 (Resident #3) sampled resident who required an assistive communication device. The findings are: Resident #3's Medical Diagnosis record was reviewed and indicated diagnoses of an opening in the neck and into the windpipe tracheostomy) an opening in the neck that assists with breathing and abnormal cells in the throat (carcinoma in situ of pharynx). A quarterly Minimum Data Set with an Assessment Reference Date of 07/21/2024 was reviewed and indicated Resident #3 had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact, and had a tracheostomy. Resident #3's plan of care, dated 08/07/2024, was reviewed and indicated the resident had a communication problem and required a [brand name] valve to assist with communication. Staff were to ensure the device was available and functioning. On 09/26/2024 at 9:01 AM, Resident #3 was lying in bed with eyes closed and a tracheostomy (trach) device was observed in resident's neck. There was no assistive communication device observed or valve on the trach. On 09/26/2024 at 10:28 AM, Licensed Practical Nurse (LPN) #1 was interviewed with concurrent observations. Surveyor asked if Resident #3 was able to communicate with staff. He stated he had difficulties understanding the resident, but the resident had a voice box staff could attach to the trach. He was asked where the assistive communication device was located. He stated at the [nursing] desk. He was asked when the assistive communication device was placed on Resident #3. He stated whenever the resident tried to communicate with staff. He was asked if the assistive device was left on the resident. He stated no because the device had been lost before and was in the medication cart when not in use. This surveyor asked to view the device and LPN #1 unlocked the medication cart. In the top drawer, there was a purple, circular container with the words [brand name] Tracheostomy & [and] Ventilator Swallowing and Speaking Valve. Inside the circular container was a small device. LPN #1 placed the assistive communication device back inside the top drawer of the medication cart and locked the cart. On 09/26/2024 at 12:16 PM, Resident #3's call light was on the outside of the room above the doorway was observed and on. The Administrator entered the resident's room and exited the room seconds later and walked to the nursing station. At 12:17 PM, LPN #1 entered the resident's room, and this surveyor followed him. The resident was making sounds from the trach. LPN #1 did not utilize the assistive device to assist the resident in communicating with him. On 09/26/2024 at 12:39 PM, LPN #1 entered the resident's room, and the resident was making sounds from the trach. The resident pointed to a pair of green boots on both legs. LPN #1 was asked if he knew what the resident needed, and he stated he thought the resident may want the boots taken off, but he was not sure. LPN #1 turned off the call light and exited the resident's room. The assistive communication device was not placed on the trach to assist the resident with communicating the need to LPN #1. On 09/26/2024 at 12:57 PM, the call light above the doorway outside Resident #3's room was observed and on. Certified Nursing Assistant (CNA) #3 entered the room. The resident was making sounds from the trach and no assistive device was utilized. CNA #3 left the room shortly after entering and left the area. On 09/26/2024 at 1:22 PM, Resident #3's call light on the outside of the room above the doorway was observed on from the call light being activated. An un-identified female entered the room, and the resident was making sounds from the trach. The un-identified female stated she would get someone and left the room, leaving the call light on. CNA #3 entered the room, and the resident was making sounds from the trach. CNA #3 turned the light off and exited the room. CNA #3 did not utilize the assistive device to facilitate communication between her and the resident. On 09/26/2024 at 3:45 PM, the Director of Nursing (DON) was interviewed and provided a typed statement regarding instructions provided to the staff for Resident #3's assistive communication device. The statement was reviewed and indicated, I advised that the [brand-name device] was to be utilized when [Resident #3] wanted to communicate and then was to be removed, as this is not worn at all times. The statement indicated the assistive communication device was kept in the medication cart. The DON what asked the purpose of the communication device, and she stated to assist the resident with using words. She was asked if staff took the assistive communication device when they entered the resident's room in the event the resident wanted to communicate with them. She stated staff did not take the device in the room every time.

Based on observation, interview, and record review, the facility failed to ensure the enteral feed and flush was administered at the physician's ordered rate for 1 (Resident #3) sampled resident who received enteral nutrition and water through a Percutaneous Endoscopic Gastrostomy (PEG) tube. The findings are: Resident #3 's medical diagnosis screen was reviewed and indicated the resident had a diagnosis of difficulty swallowing (dysphagia) and an opening into the stomach wall (gastrostomy status). A quarterly Minimum Data Set with an Assessment Reference Date of 07/21/2024, was reviewed and indicated Resident #3 had a Brief Interview for Mental Status score of 13, which indicated cognitively intact and had a feeding tube. Resident #3's Order Summary Report was reviewed and indicated a physician's order, dated 09/13/2024, for [brand name] enteral feed to be administered at 53 milliliters per hour (ml/hr.) and flush at 40 ml every 1 hour. On 09/25/2024 at 9:01 AM, Resident #3 was observed lying in bed, awake with the head of bed up. The feeding pump displayed feed 43 ml/hr and flush 40 ml (milliliters) every 1 hr. The feeding and flush bags were not labeled at this time. On 09/25/2024 at 2:29 PM, Resident #3 was observed lying in bed on the back with eyes closed. The feeding pump displayed the feed rate of 43 ml/hr. and a flush rate of 40 ml every 1 hr. and was connected to the resident. On 09/26/2024 at 8:10 AM, Resident #3 was observed lying in bed on back with eyes closed and hob up. The feeding pump displayed feed 43 ml/hr. and flush ml every 1 hr. and was connected to the resident. On 09/26/2024 at 10:28 AM, Licensed Practical Nurse (LPN #1) was interviewed with concurrent observations. He confirmed the pump showed 43 ml/hr for the feed rate and 40 ml/hr for the flush rate. He was asked how often the settings on the pump were checked against the orders. He stated daily. He was asked to check Resident #3's orders in the electronic health record (EHR) but was unable to at the time because the facility's internet system was offline. He stated the nurses could use the paper Medication Administration Record (MAR)s. The paper MAR for Resident #3 was reviewed and indicated the document was printed on 08/21/2024 at 12:56 AM. The physician's order on the document indicated the enteral feed rate was 40 ml/hr, and the flush rate was 43 ml/hr. He was asked who updated the paper MARs to ensure the orders were current. He stated he did not know. On 09/26/2024 at 2:20 PM, LPN #5 was interviewed and asked how she knew what the feed/flush rate was for residents receiving enteral feeding. She stated she looks at the MAR to ensure the pump is set according to the MAR. An enteral feeding procedure guideline, from the [Named] Manual of Nursing Practice 10th edition not dated, provided by the Director of Nursing on 09/26/2024, was reviewed and indicated giving nutrients directly into the stomach was more beneficial than parenteral (giving nutrition through the feeding).

Based on observation and interview, the facility failed to ensure expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods stored in the refrigerator and dry storage area were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated when opened to assure first in, first out usage to prevent potential for food bone illness, cooking equipment, ceiling tiles and air vents were free of greasy food crumbs, stains and rust and were maintained in clean sanitary conditions to prevent potential for cross contamination; dietary staff. washed their hands before handling clean. equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to 69 affect residents who received. meals from the kitchen, (total census: 72). The findings are: 1. On [DATE] at 11:15 AM, the Surveyor observed two 32-ounce boxes of half and half on a shelf, with an expiration date of [DATE]. 2. On [DATE] at 11:23 AM, observed an open box of sausage on a shelf in the 2 door refrigerator. The box was not covered or sealed. 3. On [DATE] at 11:27 AM, observed the deep fryer had a layer of yellow grease that was covered with a film of crumbs. The Surveyor asked the Dietary Supervisor how often she cleaned the deep fryer. The Dietary Supervisor stated, Every week and they had used it on Friday to fry fish. 4. On [DATE] at 11:29 AM, during observation Dietary Employee (DE) #1 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. Without washing her hands, DE#1 picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents on pureed diets for lunch. The Surveyor asked DE #1, What should you have done after touching dirty objects or before handling clean Equipment? DE #1 stated, I should have washed my hands. 5. On [DATE] at 11:46 AM, observed a 46-ounce box of nectar thickened apple juice was on shelf in the storage room. The box had an expiration date of [DATE]. 6. On [DATE] at 12:13 PM, observed an open box of salt was inside a drawer. The box was not covered. 7. On [DATE] at 12:15 PM, the following observations were made in the kitchen areas: a. The air vent in the dish washing machine room had a rusty color. b. The ceiling tile and the air vent had discolored lint on them. c. The ceiling divider throughout the dish washing machine had brownish substances on it. d. The ceiling air vent above the food preparation counter, above the 2-compartment food preparation sink had dirty lint stuck on the slats. e. The ceiling air vent by the door leading to the storage room had lint hanging down from it. 8. On [DATE] at 01:08 PM, observed an opened bag of breakfast cereal on a rack in the unit dining room. The bag was not sealed. 9. On [DATE] at 01:45 PM, during observation the following food items were on a shelf in the refrigerator in the unit dining room and did not have an opened or received date on them: a. A bottle of original syrup. b. A bottle of 32 ounce Italian sweet creamer. c. A plastic storage bag that contained tuna salad. There was no name of whom the tuna salad belonged to or a date when it was stored in the refrigerator. d. An opened plastic storage bag that contained fried fish. There was no name on the bag to indicate whom it belonged to or when it was received or stored in the refrigerator. 10. On [DATE] at 01:46 PM, the following observations were made in the cabinet located in the unit dining room: a. An opened bag of breakfast cereal. The bag was not sealed. b. An opened bag of sugar coated breakfast cereal. The bag was not sealed. c. A 32-ounce container of cheese balls. There was no opened or received date on the container. 11. On [DATE] at 10:28 AM, during observation DE #2 turned on the 3-compartment sink faucet and washed the coffee container. She used her bare hand to turn off the faucet contaminating her hand. She then removed a bag of coffee from the bag and placed it in the brewer basket to be brewed and served to the residents for the noon meal. The Surveyor asked DE #2, What should you have done after touching objects and before handling clean equipment? DE #2 stated, I should have washed my hands. 12. Review of the facility policy titled, Hand Washing and Glove Usage in Food Service, documented, .When to wash hands, wash your hands as often as possible. It is important to wash your hands: Before starting to work. After touching anything else such as dirty equipment, work surface or clothes .

Based on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during meals observed. This failed practice had the potential to affect 6 residents who receive meal trays in their rooms on the East Hall, 6 residents who receive meal trays on the North Hall, and 12 residents who receive meal trays in their room on the South hall. The findings are: 1. On 04/01/2024 at 03:32 PM, during an interview, Resident #55 was asked about the food here and the resident stated the temperature was lukewarm by the time it was delivered to the resident's room and if the resident eats in the dining room, the food is hot. 2. On 04/01/2024 at 08:13 AM, during observation, an unheated food cart that contained 8 trays for lunch was delivered to the front hall by Certified Nursing Assistant (CNA) #1. At 08:27 AM, immediately after the last resident was served in their room on the front hall, the temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with following results: a. Milk - 55 degrees Fahrenheit. b. Biscuit and sausage with gravy - 111.7 degrees Fahrenheit. c. Scrambled eggs - 110 degrees Fahrenheit. d. Hash brown - 101.4 degrees Fahrenheit. 3. On 04/02/2024 at 12:34 PM, during observation, an unheated food cart that contained 12 trays for lunch was delivered to the front hall by CNA #2. At 12:49 PM, immediately after the last resident was served in their room on the South Hall, the temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with the following results: a. Milk - 52 degrees Fahrenheit. b. Mixed vegetables - 108.9 degrees Fahrenheit. c. Meat loaf - 102 degrees Fahrenheit. d. Mashed potatoes - 110 degrees Fahrenheit. e. Ground meat loaf - 113 degrees Fahrenheit.

Based on observation, interview and record review, the facility failed to ensure fingernails were clean, smooth, and trimmed to promote good personal hygiene and grooming for 1 (Resident #49) sampled resident who required staff assistance for nail care. The findings are: 1. Review of the March 2024 Order Summary noted Resident #49 had a diagnosis of Type 2 diabetes, Dementia, and Presbyopia (eyes inability to focus on nearby objects). a. Review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/2024 documented Resident #49 had a Brief Interview for Mental Status (BIMS) score of 03 (00-07 indicates severe cognitive impairment). b. Review of a Care plan revised on 11/08/2023 documented Resident #49 had an ADL [activities of daily living] self-care performance deficit and required limited assistance of one staff member with bathing and personal hygiene. c. Review of the ADL-Bathing sheets documented Resident #49 received physical help in part of the bathing activity on 03/20/2024, 03/22/2024, 03/25/2024, 03/27/2024, 04/01/2024 and 04/23/2024. d. During observation on 04/01/2024 at 12:30 PM, Resident #49 was sitting at the dining room table waiting for the lunch meal to be served. The fingernails on both hands were greater than 0.25 inch in length, jagged and had a dark brown substance underneath the nails. e. During observation on 04/02/2024 at 04:14 PM, Resident #49 was sitting up on the right side of the bed, awake and the fingernails on both hands were greater than 0.25 inch in length, jagged and had a dark brown substance underneath them. f. On 04/03/2024 at 10:29 AM, during an interview, Certified Nursing Assistant (CNA) #3 confirmed that she was familiar with Resident #49's care and was asked to look at the resident's fingernails and describe them. She described them as needing to be clipped down, a little orange and a little brown looking under the nails and they could be shaped. She added that shower aides would do nail care for Resident #49 while in the shower. She confirmed that Resident #49's nails should be trimmed and smoothed because the nails could easily get infected and because of the possibility of germs. If a resident refused nail care, it was reported to the charge nurse. g. During record review the Director of Nursing (DON) provided a single piece of paper that documented the following, Nursing Standards of Care are used regarding nailcare: Nails are checked and cleaned on resident's shower days as well as daily with care. Nails are trimmed as needed by CNAs unless the resident is diabetic. If the resident is diabetic, a licensed nurse must trim nails.

Based on observation, interview, and record review, the facility failed to ensure a raised toilet seat and outer toilet bowl was cleansed of a dark brown substance to promote a clean and sanitary environment for 1 (Resident #173) of 1 sampled resident who used the bathroom in their room. The findings are: 1. Resident #173 had diagnoses of Legal blindness (small amount of useful vision) and Morbid obesity (more than 80 to 100 pounds over your ideal body weight). a. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2024 documented Resident #173 had a Brief Interview for Mental Status (BIMS) score of 11 (08-12 indicates moderately cognitive impaired) and required set-up or clean-up assistance with toileting hygiene. b. Review of the Care Plan with a review date of 12/26/2023 documented Resident #173 had an ADL (activities of daily living) self-care performance deficit and required assistance of staff for personal hygiene. c. Review of the Nurses Note dated 03/29/2024 at 07:04 (7:04 AM) documented, .Resident sleeping up in recliner with feet down. Assisted to bathroom per staff as needed . d. During an observation on 04/01/2024 at 12:02 PM, Resident #173 was not in the room. There was a raised gray toilet seat with a dark brown substance on the front of it. There was a dark brown substance on the outer front area of the toilet bowl. e. During an observation on 04/02/2024 at 04:08 PM, Resident #173 was sitting up in a recliner. There was a raised gray toilet seat with a dark brown substance on the front of it. There was a dark brown substance on the outer front area of the toilet bowl. f. During an observation on 04/03/2024 at 10:52 AM, Resident #173 was not in the room. There was a raised gray toilet seat with a dark brown substance on the front of it. There was a dark brown substance on the outer front area of the toilet bowl. g. On 04/03/2024 at 11:32 AM, during an interview Housekeeper #1 was asked to go to Resident #173's bathroom, look at the gray toilet seat and describe what she saw. She described the dark brown substance as stool (bowel movement). She was asked to do the same regarding the outer front of the toilet bowl and she described the dark brown substance as stool. She confirmed that housekeeping was responsible for cleaning the residents' bathrooms every day because the residents use them, and they could catch something if the bathrooms are not clean. h. Review of the Housekeeping Restrooms policy provided by the Director of Nursing (DON) documented, .Restrooms are a place where germs and bacteria fun wild and proper restroom cleaning can help us to ensure a safe and clean place for our patients, residents and coworkers .Toilet Damp wipe all surfaces of the toilet .Remove any visible soil at the top, bottom, back and front of the toilet .

Based on record review and interview, the facility failed to ensure High risk elopement assessments were appropriately care planned and failed to ensure appropriate elopement interventions were implemented to prevent potential elopements for 1 (Resident #1) of 3 (Residents #1, #3 and #6) sampled residents who were at high risk for elopement. This failed practice resulted in past noncompliance at the level of immediate jeopardy which caused or could have caused serious injury, harm or death for Resident #1 who exited the building through a window on the east hall. This failed practice had the potential to cause more than minimal harm to 3 residents at high risk for elopement. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy and the facility removed the IJ and corrected the failed practice on 7/7/21 prior to the survey. The findings are: 1. Resident #1 (R) was admitted to the facility on [DATE] to a room on the South /REHAB hall with diagnoses of Dementia and Multiple Fractures of Ribs. The Admission MDS documented, Brief Interview for Mental Status (BIMS) score of 10 (8-12 indicates moderately impaired), required limited assistance of one person for transfer, walk in room and walk in corridor, used a walker and wheelchair for mobility and the wandering score was zero (0). a. The Admission Evaluation dated 4/21/21 documented, .B. Elopement Risk Scoring -Score of less than 5 = Low Risk; Score of 5 or greater = High Risk . b. The Care Plan date initiated 4/21/21 documented, Elopement 5/29/21, elopement 7/7/21 revision on 7/8/21 by DON [Director of Nursing] . 5/29/21 every 15 minute checks x [times] 24 hours and asked family to come visit .date initiated 6/4/21 .7/7/21 one on one until bed was available in secure unit, then moved date initiated 7/8/21 . c. The Elopement Risk assessment dated [DATE] documented, . Score 7.0 .4. able to transfer independently: a) Yes.5. History of wandering prior to nursing home placement: a) Yes .7. Expresses desire to go home a) YES .D. 1. C. Care plan initiated or updated: a) YES Comments/Notes . 15 min checks/family ask to come visit resident . d. A Nurses note dated 5/29/21 at 6:35 p.m., documented, [Sister] called back and was notified of Resident #1 trying to leave. Explained we had him on 15-minute checks, and he had not tried to escape again . e. A Nurses Note dated 5/30/21 at 10:14 a.m., documented, Remains on 15 minute checks. Has not tried to exit building just gets agitated and cusses wanting cigarettes. Will continue to observe . f. A Nurses Note dated 5/31/21 at 10:40 p.m., documented, Remains on 15-minute checks. He propels self about facility. Staff is aware of his elopement risk and are helping watch him if he leaves East hall where his room is. He went out to smoke on scheduled smoke break this evening. Will continue to observe him . g. A Nursing Note dated 7/7/21 at 1:15 p.m., documented, Resident was brought to facility by therapy from outside of the building. Resident stated he was going home. He stated he went to end room of hall and knocked the screen out and climbed out. He stated he wished he would have gotten farther. Body audit was done with no skin issues noted. No distress or complaints noted. Family, Dr, and local police contacted . h. On 07/13/21 at 12:20 p.m., Certified Nursing Assistant (CNA) #1 was asked, Explain [Resident #1] elopement incident that occurred on 7/7/21? She stated, I'm new to the facility. I haven't had a chance to work with him yet. This is my third week here. I would ask the lead CNA and she will let me know the interventions. I hadn't heard that he eloped from the facility. i. On 07/13/21 at 12:53 p.m., CNA #2 was asked, Were you here the day R#1 eloped? She stated, Yes, I was here the day he escaped. CNA #2 was asked, Can you recall the surrounding events before he eloped? She stated, He does wander around the building. He was housed on east when he got out the window. She was asked, Had he made attempts to elope before 7/7/21? She stated, No, he hadn't been exit seeking on my shift. She was asked, How often do you round on residents? She stated, Every 15 minutes and if they wandered, like he did. I would have them right by my side. She was asked, Were you aware he tried to exit the facility back in May 2021? She stated, I heard that he tried to leave the facility in May. Intervention were: We put him on 15-minute watch that day and called his family to come to the facility for a visit. He calmed down. He wanted to go home. She was asked, How long was he on 15 minutes watches? She stated, I can't recall but I can find out. She was asked, How did he get out on 7/7/21? She stated, I was told he came thru window in this conference room . She was asked, Is the conference door usually locked? She stated, The conference room door should be locked at all times. She was asked, Who's responsible for making sure the conference room door is locked? She stated, I suppose everyone. Most mornings we do standup meeting in the conference room. She was asked, How far did the resident go before anyone noticed he had left? She stated, I was told he was found in front on the house next door. She was asked, When did you notice the resident was missing? She stated, I never knew he was missing, until I returned from lunch break. I'd been gone about 15 minutes for lunch . j. On 07/13/21 at 01:23 p.m., CNA #4 was asked, Where are R#1 interventions for elopement listed? She stated, On the chart, in our kiosk . She was asked, Were you here the day R#1 eloped? CNA #4 stated, From my knowledge, he escaped from the window in here (conference room). She was asked, How did he get in the conference room? She stated, The door was unlocked, and it supposed to be locked at all times. Department heads have a meeting in here every morning. CNA #4 was asked, Had he made attempts to elope or eloped before 7/7/21? CNA #4 stated, I believe he did elope in May. CNA #4 was asked, What happened in May? She stated, Yes, ma'am, he had got out the door by the laundry department. The nurse that used to work here caught him getting out. I was picking up trays off the unit and stumbled by some staff talking about him escaping. She was asked, What interventions were implemented in May? CNA #4 stated,He was placed on 15-minute checks . k. On 07/13/21 at 01:41p.m., the Physical Therapist (PT) Were you here the day R#1 eloped? The PT stated, It was after lunch, when I seen him down the road. I was driving home headed south and noticed an older gentleman walking, by the house with the pond in front of it. He was talking to a truck driver in the middle of the road. The trucker approached my car window and said, 'I think he belongs at the Nursing Home.' R#1 appeared hot and sweaty. The driver said, 'He was asking me for a ride to [NAME].' PT was asked, How long had he been gone from the facility? PT stated, I'm not for sure how long he had been gone. PT was asked, Had he made attempts to elope in the past? She stated, No, I'm not aware of any other elopement. I'm not familiar with his interventions. I would talk to the Director of Nursing or Charge Nurse to find out his interventions. l. On 07/13/21 at 02:36 p.m., the Director of Nursing (DON) was asked, Did Resident #1 elope from the facility on 5/29/21? She stated, He got out the back-east door. He was found on the property. She was asked was an investigation or reportable completed? She stated, No. She was asked, Can you contact the Nurse that found him outside on the property on 5/29/21? She stated, The nurse no longer works here, and I can't remember the CNA that found him outside. She was asked, Should appropriate intervention be implemented for residents at high risk for elopement? She stated, All he wanted to do was see his family, they came and visited him. She was asked, Should appropriate intervention be implemented for residents at high risk for elopement and residents that have attempted to elope from the facility? She stated, Yes, we could have put more appropriate intervention in place. She was asked, Who's responsible for care planning admission elopement evaluations interventions? She stated, Anybody on the team can do the care plan, but the initial care plan is done by MDS (Minimum Data Set Coordinator). m. On 07/13/21 at 02:45 p.m., the DON was asked, If a resident scores 5 or higher on the elopement assessment/ evaluation, should the care plan reflect intervention for elopement? The DON stated, At that time we put the resident in the elopement book. She was asked, What is the elopement book and where is the book located? The DON stated, It's in the front office and at the back-east nurse's station. The DON exited the room and returned with a white binder. The DON was asked, Where are the intervention listed in the binder? The DON stated, These are pictures of our resident listed as elopement risk. This lets the staff know who they need to watch for. This surveyor reviewed the binder. There were no dates listed that identified when R#1's picture and face sheet were placed in the binder. There were no interventions listed in the elopement book for R#1. The DON was asked, Should the Care plan reflect interventions for residents at high risk for elopement? She stated, Yes. The DON was asked, Were residents at high risk for elopement re-assessed after R#1's elopement on 7/7/21? She stated, We did elopement re-assessment on R#1. n. On 07/13/21 at 02:59 p.m., the Administrator was asked, Who's responsible for making sure the conference room doors are locked. She stated, Prior to R#1 eloping on 7/7/21, the conference room door wasn't being locked. After his elopement, we started keeping it locked and everyone is responsible for keeping the door locked. o. On 07/14/21 at 10:30 a.m., Licensed Practical Nurse (LPN, MDS) #1, was asked, If a resident scores 5 or higher (High Risk) on admission Elopement Evaluation, how is the information generated for care planning? She stated, It automatically pulls over and prints a generic care plan. Then we can go in and make adjustments to the care plan in the computer. p. The Missing Resident Policy & Procedure received from the Administrator on 07/14/21 at 10:15 a.m. documented, .11. Incident . and strategies utilized to prevent recurrence . 14. Care plan updated with diversional approaches, modifications, appropriately timed goals that are specific to the resident's individual wandering habits . 2. The facility initiated corrective action immediately after the incident on 07/07/2021 by implementing the following: a. Resident #1 was placed on one-on-one until a bed became available in the secured unit. b. Resident #1 care plan was updated. c. Elopement inservice was initiated for all staff.

Based on record review and interview, the facility failed to ensure staff used the appropriate transfer technique according to the transfer assessment and care plan to prevent injury for 1 (Resident #2) of 3 (Resident #1, 2 and 3) sampled residents who were transferred with a lift. The failed practices resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #2, who was transferred manually instead of using a lift and sustained a lower right leg fracture. The Administrator was notified of the past Immediate Jeopardy on 10/30/2020 at 12:08 p.m. The findings are: 1. Resident #2 had a [DIAGNOSES REDACTED]., and dependent for transfers of 2 persons. a. A Transfer Evaluation dated 7/9/20 documented, . resident mechanical lift and 2 persons. b. The Care Plan dated 8/13/19 documented (Resident #2) has limited physical mobility r/t disease process . 2 person Marisa lift/medium lift pad. c. A Transfer Evaluation dated 10/5/20 documented, .resident mechanical lift and 2 persons. d. The Resident's Visual/Bedside Kardex Report documented, Transferring 2 person Marisa lift/medium lift pad. Transfers: Mechanical lift during transfers x 2 staff. A DMS 762 dated 10/14/2020 documented, Description of Incident It was noticed by Certified Nursing Assistant (CNA) that (R2)'s knee appeared to be swollen while taking her to breakfast around 7:20 a.m. (Licensed Practical Nurse (LPN) and Treatment nurse look at knee after breakfast, around 8:00 a.m. because she thought it was warm to the touch. LPN then messaged the APRN about the knee. APRN stated she would look at the resident's knee when she came to do rounds later in the day. During this time, the resident did not show any signs of discomfort or pain, leading staff to believe it was a blood clot. APRN looked at the resident's leg and wanted her to be put to bed so she could get a better look at it. When resident was put to bed and pants were removed, the APRN felt the resident had a fracture to the femur. The APRN looked at the resident's leg around 2:00 p.m. While the APRN was examining the leg, the resident did not cry out in pain and would swat your hand if you went to move the leg. Resident was transferred to (hospital) via (by way of) ambulance for evaluation. It was found that (R2) had a displaced mid-shaft fracture on her right leg. (R2) underwent surgery 10/26/2020 to place a pin in right femur . Administrator and DON (Director of Nursing) interviewed employees on North Hall as well. Day shift stated that (R2) was already up in her Geri-chair at the nurses station when she arrived. When night shift were interviewed. CNA.(#1) stated that she got (R2) up that morning. She stated that she didn't notice (R2) leg being swollen. When asked who helped her with getting (R2) up that morning & she stated that she did by herself. CNA #1 stated that she stood (R2) up and pivoted her to feet in the geri-chair. DON asked if she heard a pop or if (R2) showed any signs of pain when she did this and she stated no. e. An APRN Progress Note dated 10/14/20 documented, Today's visit is medically necessary because of right knee swelling. Staff reported to me this morning that resident had swelling of the right knee and grimacing in pain . Assessment: Swelling of knee joint: Looks like femur is fractured resulting in [MEDICAL CONDITION]. Send to ER (emergency room ) stat . f. On 10/29/20 at 11:46 a.m., CNA #5 knocked and entered the resident ' s room. CNA #5 was in the room with full Personal Protective Equipment (PPE) on. I asked the Aide if the resident was on isolation and she stated Yes. The resident was lying on the bed dressed with the lift sling beneath her and the lift connected to the sling. The aide stated she was waiting on someone to come help her transfer the resident since she had a fractured leg. The Surveyor left the room to put on PPE. The sign on the door was turned backwards and there was not an isolation cart outside the room. The Surveyor asked the Nurse if the resident was on isolation and she stated, No. If the sign is turned over backwards, they are not on isolation. That is how the aides know who is or isn ' t on isolation. The Surveyor re-entered the room at 11:51 a.m. and the CNA had the resident lifted up in the lift and the resident was over the wheelchair. The resident had the control to the lift and lower the lift when the aide told her to do so. CNA #5 was asked How do you know how many people are required to transfer a resident? She stated, Basically, I know they only use 1 person on this resident to transfer, because she doesn ' t require total help. g. On 10/30/20 8:30 a.m., CNA #2 was asked, Who trains staff on transfers? CNA #2 stated, I do the training on the transfers. CNA #2 was asked, When do you do the training? The same day they are hired and then they are checked off yearly. CNA #2 was asked, How does the CNA's know if a resident is a lift or manual transfer? CNA #2 stated, It's on the Kardex on the Kiosk system. CNA #2 was asked, What happens if a CNA doesn't follow the Kardex for transfers? CNA #2 stated, They are automatically terminated. CNA #2 was asked, Has there been any incidents where the CNA was not following the Kardex and a resident was injured? CNA #2 stated, Yes. h. On 10/30/20 at 8:51 a.m., CNA #3 was asked, Who trained you on transfers? CNA #3 replied, The lead CNA does the training. CNA #3 was asked, How do you know how to transfer a resident? CNA #3 stated, It would be on the Kardex in the Kiosk. CNA #3 was asked, Has there been any incidents where a resident was injured during transfers because the Kardex was not followed? CNA #3 stated, Yes. CNA #3 was asked, Who was the resident? CNA #3 stated, The incident that I am referring to is R #2. i. On 10/30/20 at 9:12 a.m., CNA #4 was asked, Who trained you on transfers? CNA #4 replied, The lead CNA. CNA #4 was asked, How do you know how a resident is to be transferred? CNA #4 stated, Its on the Kardex in the Kiosk. CNA #4 was asked, What would happen if you did not follow the Kardex for transfers? CNA #4 stated, Disciplinary Action. CNA #4 was asked, Has there been any incidents when a resident was transferred incorrectly that resulted in an injury? CNA #4 stated, Yes R #2. I heard she wasn't transferred with the lift. j. On 10/30/20 at 9:48 a.m., the Director of Nurses (DON) was asked, When are CNA's trained on transfers? The DON stated, They are trained when hired, then yearly and every so often throughout the year. The DON was asked, Who trains them? The DON stated, The lead CNA. The DON was asked, How does a CNA know what type a transfer a resident is? CNA #4 was asked, It's on the Kardex on the Kiosk. 2. The facility removed the immediate jeopardy and corrected the failed practices on 10/16/20, prior to the survey, as evidenced by the following: a. All charts were audited to see what residents were lift, sit to stand, 1 or 2 people assist. This information was put in the Know it all book at each nurse's station. b. In-service on proper lift technique and how to identify which resident uses a lift was started on 10/15/2020. This in-service was completed on 10/16/2020. c. Check offs were started on 10/15/2020 and completed on 10/16/2020 by the lead CNA, to ensure that all CNAs are using lifts correctly. d. Random monitoring will be conducted at least 3 x week x 4 weeks to ensure compliance.