Every finding on record at Trinity Regional Rehab Center

Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from neglect by failing to respond to an exit door alarm and provide supervision to prevent an elopement for one (Resident #1) out of three residents sampled. On 1/11/26, approximately 2:15 p.m., Staff F, Certified Nursing Assistant (CNA), discovered Resident #1 was not in his room. At 2:15 p.m., a Dr. Walker (code announced overhead to indicate a potential missing resident) was called in the facility. Resident #1 exited the facility without staff knowledge from the second-floor hallway next to the Maintenance Directors office into the stairwell leading to the first floor. Resident #1 proceeded down the stairs to the first floor through an unlocked door with no alarm. Resident #1 walked to another door, next to the business office, and proceeded to exit this alarmed door to the parking lot. Resident #1 continued walking North through the parking lot to a road with a 30 mile per hour (mph) speed limit and headed to another street with a 55-mph speed limit. The resident walked approximately 0.6 miles from the facility. Resident #1 was missing from the facility for 10 minutes without staff knowledge. This failure created a situation that resulted in the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/11/26. The findings of Immediate Jeopardy were determined to be removed on 2/12/26 and the scope and severity was reduced to a D after verification of removal of immediacy of harm. Cross reference to F689 Findings included: Review of Resident #1's progress notes revealed:1/11/26 2:50 p.m. Nursing Note The approximate time of 1415 [2:15 p.m.] patient was not reported to be in his room. Last seen by the nurse at 1400 [2:00 p.m.]. Facility search started at approximately 1435 [2:35 p.m.] patient observed on [street name] south of the facility. Patient returned to the facility by staff certified nursing assistant. Patient stated, I was going for a walk and was just about to turn around patient smiling in good spirits. Patient denies pain or discomfort, skin assessment completed without any abnormal findings. Elopement assessment completed. Patient placed on 1:1 monitoring will continue. Review of admission records showed Resident #1 was admitted to the facility on [DATE] with diagnoses to include unspecified sequelae of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, and syncope and collapse. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], Cognitive Patterns, showed a Brief interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Functional Abilities showed he could walk 150 feet with supervision or touching assistance. Restraints and Alarms showed a wander/elopement alarm was used less than daily. Review of Resident #1's Physician orders showed:-Device: Wander management bracelet-check placement every shift. Started: 11/14/25 Ended: 11/20/25. Review of Resident #1's care plan showed a focus area of [Resident #1] at risk for elopement as evidenced by Exhibit exit-seeking behavior-ambulating without assist in hallways, etc. Initiated on 11/10/25. Interventions included: Use diversional activities when exit-seeking behavior is occurring . initiated 11/10/25; - continue frequent visual checks as indicated initiated 1/7/26; and Use audible monitoring system to alert staff of exit seeking behaviors {electronic monitoring device} initiated 11/10/25 resolved on 12/11/25. Review of Resident #1's Elopement Risk Evaluations identified he was an elopement risk on 9/17/25, 11/3/25, and 12/23/25. Review of Resident #1's Progress notes showed:-9/24/25 Palliative care Note: . spoke with [resident representative] who states that patientlives [sic] in an apartment just down the road from her. She does admit that she works during the day. She states that patient's dementia has progressively slowly gone [sic] worse. She also states that she is concerned with patient's wandering during the day and hisoverall [sic] safety . -11/10/25 Nursing Note: Patient exhibited escalating behavioral concerns. Patient refused to sit down and refused redirection or instruction from nurse and cna. Patient repeatedly attempted to leave the unit through exit door. -12/10/25 Psychology Provider Note: The patient is an [AGE] year-old-male with recent episodes of agitation and combativeness secondary to confusion. He has presented with agitation, not following safety instructions, and exit seeking. He continues to present with cognitive decline. The patient was unbale [sic] to provide information about his diagnosis and treatment. Symptoms are reported to have been present for more than two weeks. The patient's current health issues present a barrier to symptom improvement. -12/15/25 Nursing Note: noted periods of agitation and exit seeking, after multiple redirection attempts NSG [nursing] staff was able to comfortably transfer him back to his room without incident, Psych notified, awaiting for further instructions. -1/6/25 Nursing Note: PT [patient] is resting on bed, alert with confusion, up and moving around the hall way [sic] period for a few minutes then back to bed, . -1/10/25 Nursing Note: Pt is up and walking around the hall way [sic] for a short time, then back to bed, meds [medications] take [sic] with supervision, fluid encourage, continue to monitor. The weather on 1/11/26 was 66 degrees Fahrenheit cloudy with brief precipitation and 84% humidity. (https://world-weather.info/forecast/usa/trinity_west/11-january/). During an interview on 2/10/26 at 9:30 a.m. with Staff A, Receptionist, he stated he received elopement training about a week ago and has not had any residents leave on his shift. He stated he updates the elopement book daily with direction from Human Resources (HR) and the Nursing Home Administrator (NHA) when they get a new admit. He stated he confirms the residents who are in the book and checks to see the electronic monitoring devices are working daily. During an interview on 2/10/26 at 10:15 a.m., with Staff C, Licensed Practical Nurse (LPN), she stated she has had elopement training. She stated they did have an elopement recently. She stated Resident #1 asked her to leave multiple times throughout her shift. She stated she redirected him and she let the nurse know. She stated he was found after going missing for about an hour. During an interview on 2/10/26 at 1:10 p.m. with Staff D, Certified Nursing Assistant (CNA), she stated she is unsure how to identify who is an elopement risk or who is supposed to be wearing an electronic monitoring device. She stated she is not sure of the process or know if there are any residents at risk for elopement in the facility. During an interview on 2/10/26 at 1:17 p.m. with Staff E, LPN, she stated they have orders in the Medication Administration Record (MAR) for the electronic monitoring devices. She stated they do a daily huddle [meeting] to notify staff if they have a new resident with exit seeking behaviors and check it daily, and every shift they document they have seen and checked the electronic monitoring device. She stated someone else comes in with a device to check that the electronic monitoring device is working every day. During an interview on 2/10/26 at 1:52 p.m. with Resident #1's primary care physician he stated, Resident #1 was a sneaky guy and had cognitive decline. He stated his mental state varied. He stated if the facility decided to take off the electronic monitoring device, they should have communicated this with him. He stated they were trying to cover the fact that his mentation would vary, and that Resident #1 could not understand the time of day sometimes. He stated he does not have any awareness of Resident #1 having exit seeking behaviors and that was not communicated to him from the facility. He stated he was notified of Resident #1's elopement by the NHA and understands he was found miles away. During an interview on 2/10/26 at 2:38 p.m. with the Nursing Home Administrator (NHA), Regional Nurse and the Regional Director of Operations, the NHA stated, Resident #1 went out the exit door on the second floor and down the stairs. She stated he went by the maintenance office on the second floor, saw the stairs, held the door handle for 30 seconds which opened the door, went down the stairs and when he got downstairs, he opened the exit door and went outside of the facility. She stated the door leading to the outside did not have an alarm at time of the incident. She stated the door locks from the outside, but you can open it from the inside. The NHA stated Resident #1 did not exhibit wandering and exiting behaviors prior to the incident. The NHA stated when interviewing staff nobody noticed the resident trying to leave and nobody heard any door alarms. The NHA stated Resident #1 had an elopement assessment upon admission and was identified as being at risk. The NHA stated Resident #1 left somewhere between 2:00 p.m. and 2:15 p.m. The NHA stated the temperature outside was 70 degrees and was not raining at that time. The NHA stated at one point [in previous months] Resident #1 had an electronic monitoring device but did not have one on at the time of him leaving. The Regional Nurse stated that the electronic monitoring device only works for the front door on the first floor, so it wouldn't have mattered in this situation anyway because it does not alert at any of the other doors. The NHA stated the exit door on the second floor with the delayed press, an alarm normally stays on once it is opened, but this one time it did not work. The NHA stated they tested the door and it was working. During an interview on 2/10/26 at 3:17 p.m. with Staff G, CNA, she stated we had a code Dr. [NAME] (missing resident) called, and everyone went downstairs and got assigned an area to search for the missing resident. She stated she had just gotten back from break and went to the assigned area. Earlier she heard someone, (she thinks it was a visitor) say they had seen someone with a matching description on the road. She stated a couple of staff members left the facility to go look for him. She stated she got in her car and left the facility; she made a left and then a right and saw his clothing description and found the Resident #1. Resident #1 was on the road in front of the plaza with a coffee shop and other stores. She stated she told Resident #1 to get in her car and brought him back to the facility. She stated she asked Resident #1 if he was ok and he stated he did it on purpose and that no one saw him leave. She stated Resident #1 did not remember where he was going. She stated it was raining and the resident was damp from the rain. She stated she did not hear any door alarms. During an interview on 2/10/26 at 3:31 p.m. Staff B, Registered Nurse (RN) stated Resident #1 was assigned to her on the day of the elopement. Staff B, RN stated Resident #1 did not have any exit seeking behaviors. She stated he would walk back and forth from nursing station and his room. She stated she was doing her med pass around 2:00 p.m., saw the resident walking to and from the nursing station and his room. She stated she went to another residents' room to give medication. The CNA came back from break and notified her of not seeing Resident #1 in his room. They both initiated the code Dr. [NAME] (missing resident) and started the search. She stated the search started around 2:15 p.m. She stated she does not know how the resident was found. She stated she saw a team member bring Resident #1 back and assessed resident. She does not remember if it was raining and stated the residents' clothes were a little damp. She stated Resident #1 did not say a word to her when he was back, was just smiling. She stated she does not remember hearing any door alarms. During an interview on 2/10/26 at 3:39 p.m. with Staff F, CNA stated being assigned to Resident #1 on the day of the elopement. Staff F, CNA stated that day she had left the resident at nurse's station around 1:45 p.m. so she could go on her lunch break. When she came back around 2:15 p.m., she went to check on the resident, and he was not in his room. She stated she looked around the building and could not find him. She told the nurse she could not find him and that's when the code Dr. [NAME] was called. She stated the resident was found down towards a plaza about a half mile away. She stated Resident #1 would walk around the facility all the time. She stated she did not hear any alarms. During an interview on 2/11/26 at 9:20 a.m., with the Maintenance and Housekeeping Director. She stated the electronic monitoring devices are checked every day. She stated the main lobby door is the only door that is protected by electronic monitoring devices. She stated the other doors do not use electronic monitoring devices. She stated she checked them every day, to ensure they beeped and locked and the lock is working properly and if it opened it would beep and alarm. She stated they have never had problems with the doors and have never had to have the manufacturers come out and check the doors due to any issues. During an interview on 2/12/26 at 9:28 a.m. Staff H, CNA stated a Dr. [NAME] code (missing resident) was initiated on 1/11/26 around 2:17 p.m. Staff H stated Resident #1 arrived back to the facility around 2:25 p.m. and was a little damp from the rain. Staff H stated Resident #1 has shown behaviors of exit-seeking in November and December. Staff H stated if the staff knew more maybe we could have been more aware of continuing to look out for Resident #1.A review of the facility policy titled Missing Resident/Elopement, with no revision date, revealed the following: POLICYIt is the policy of the facility to provide a safe and secure environment for all residents. In the event of a resident elopement it is the policy of [NAME] to implement its police/procedures immediately to locate the resident in a timely manner. If an at risk of elopement resident is seen attempting to leave the premises the situation will be immediately reported to the DON/designee, documented, and reviewed as part of the facility QA&A.For a Resident attempting to leave the facility:Redirect the resident in a courteous manner.Get help from other staff in the immediate vicinity if necessaryInstruct staff member to inform the Charge Nurse or Director of Nursing Services/designee and review the need for the need to the individual plan of care.Discovery of a Missing Resident:If the resident was not authorized to leave, immediately notify the facility Administrator or highest ranking official/designee. Notify 911/law enforcement (as determined per state guidelines) the Director of Nurses/designee, the resident's legal representative, Regional Manager(s), The attending physician/Medical Director. The facility's immediate actions to remove the Immediate Jeopardy included:-1/11/26 1:1 enhanced monitoring implemented upon Resident #1 return to the facility until discharge 1/12/26- care plan updated-Post Traumatic Stress Disorder (PTSD) evaluation completed 1/11/26 with no concerns.-1/11/26 Review of identified Resident #1 for elopement risk. An updated Elopement evaluation was completed and plan of care update as indicated-1/11/26 Resident #1 was interviewed upon return to the facility and was able to describe to NHA/DON the path that he had taken and what occurred. The Identified door that was used to exit the unit was evaluated at that time for proper function and alarm and no issues were identified-All facility internal exit doors were then evaluated for proper function 1/11/26 and no issues identified. Education on doors and alarms completed on 100% of staff on 1/12/26.-1/11/26 Temporary auditory sensor alarms were placed at identified secondary doors that exit the facility 1/11/26-Ad Hoc [unplanned] Committee meeting 1/11/26 5:45 p.m. with review of the concern and potential corrective interventions and approval of PIP [Performance Improvement Plan]. -Mock elopement drills initiated 1/11/26 at 4:06 p.m. and completed q shift [every shift] x 1 week then q day [every day] x 1 week then every other day ongoing per QAPI [Quality Assurance Performance Improvement] recommendations.-1/11/26 initiated education regarding Missing Resident/Elopement Policy/Procedure, including elopement books, Abuse/Neglect/Exploitation. As of 1/12/26 - 114 of 114 facility staff members and 26 of 26 contract therapy staff have been educated.-1/11/26 - record of previous daily exit door checks were reviewed for past 90 days to validate completion and no concerns identified. Door checks are to continue daily at the direction of the QAPI committee-1/11/26 Elopement books reviewed to ensure proper information is in place and books are easily accessible.-1/11/26 Verification of functioning of current [electronic monitoring device] device check machine-1/11/26 Current residents were evaluated for elopement risk and new Elopement Evaluations were completed with plan of care reviews and updates as indicated-1/11/26 Review of current residents with [electronic monitoring devices] - verified evaluation for accuracy and appropriateness. Verified proper order and documentation for placement. Update evaluation, order, and plan of care as indicated. [Electronic monitoring device] system checked at front door and found to be functioning.-Follow up Ad Hoc Committee meeting 1/11/26 at 10:30 p.m. with members in attendance to review the days' actions, interventions and outcomes. Follow up review and approval of PIP items. The Medical Director participated in the QAPI meeting in facility. -1/12/26 25 of 25 direct care Licensed Nursing staff educated on completion of Elopement Evaluations-1/12/26 Verification of proper functioning of exit doors and alarms by the regional maintenance consultant-1/12/26 Locked exit doors were converted to remove the delayed egress. Exit doors function using key fob/keypad for exiting the facility with Education to staff. 114 of 114 staff members. 26 of 26 contract therapy staff have completed.-1/12/26 Education for 25 of 25 direct care Licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device. -1/12/26 Verification of resident Photos and resident room name door tags completed for identification/verification. Updated as indicated-Ad Hoc Committee meeting 1/12/26 at 2:00 p.m. with members in attendance to review the steps taken above. Follow up review and approval of PIP item completion.-1/15/26 - Ad Hoc committee meeting held. Elopement drill tracking form and process reviewed and updated to promote better organization of the search. Location form updated to ensure all areas of the facility are assigned.-On 1/11/26 Initiated ongoing competency testing in support of continued education related to Resident Elopement Awareness and Prevention with an emphasis on signs and symptoms of exit seeking behavior and including related potential interventions and including notification. Currently 129 of 131 staff have completed. 26 or 26 contract therapy staff members have completed. 2 staff members have not been scheduled to work.2/12/26- Education to licensed staff on Identifying Elopement Risk and locating [electronic monitoring device] status. Verification of the facility's removal plan was conducted by the survey team on 2/12/26.Reviewed the updated care plan for Resident #1. Reviewed sign in sheets for education to staff completed 1/11/26 on doors and alarms with 100% completion. Observed permanent alarms on secondary exit doors. Reviewed sign-in sheet for 1/11/26 Ad Hoc QAPI meeting. Reviewed audits for mock elopement drills. Reviewed sign-in sheets for education to staff on 1/12/26 on abuse and neglect with 100% completion. Reviewed the door checks provided by the Maintenance Director. Reviewed elopement books were updated with the correct information as it pertains to the policy. Observed the Maintenance Director verifying the electronic monitoring device check machine to ensure it is functioning. Reviewed current residents who were identified as elopement risks with updated elopement evaluations and care plans updated. Reviewed education sign-in sheets completed 1/12/26 on elopement evaluations with 100% completion to direct care Licensed Nursing staff. Observed and verified exit doors functioning with a keypad or key fob to exit. Reviewed education sign-in sheets to staff completed 1/12/26 related to the exit doors and use of keypad or key fob to exit with 100% completion. Reviewed Ad Hoc meeting sign-in sheets for 1/12/26 and 1/15/26. Reviewed competency testing related to elopement awareness and exit seeking behavior for all staff. On 2/12/26 interviews were conducted over two shifts, regarding elopement reeducation with 26 staff, 17 Certified Nursing Assistants, 4 Licensed Practical Nurses, 4 Registered Nurses and 1 Physical Therapy staff. The staff members were able to state that they had been trained related to identifying residents at risk for elopement and were knowledgeable about the new policies. On 2/12/26 at 4:10 p.m., the facility was asked to conduct an elopement (Dr. Walker) drill. Staff on both the first and second floors responded promptly after a code was announced via portable radio. Staff were observed saying Dr. [NAME] to their peers. Clinical, non-clinical, and administrative staff that responded checked on residents, and searched inside the facility. A debriefing was conducted, following the drill, to discuss opportunities for improvement. Based on verification of the facility's immediate jeopardy removal plan the immediate jeopardy was determined to be removed on 2/12/26 and the non-compliance was reduced to a scope and severity of D.

Based on observations, interviews and record review, the facility failed to provide adequate supervision to one resident (Resident #1) who was cognitively impaired and identified as an elopement risk, from exiting the facility out of three residents sampled. On 1/11/26, approximately 2:15 p.m., Staff F, Certified Nursing Assistant (CNA), discovered Resident #1 was not in his room. At 2:15 p.m., a Dr. Walker (code announced overhead to indicate a potential missing resident) was called in the facility. Resident #1 exited the facility without staff knowledge from the second-floor hallway next to the Maintenance Directors office into the stairwell leading to the first floor. Resident #1 proceeded down the stairs to the first floor through an unlocked door with no alarm. Resident #1 walked to another door, next to the business office, and proceeded to exit this alarmed door to the parking lot. Resident #1 continued walking North through the parking lot to a road with a 30 mile per hour (mph) speed limit and headed to another street with a 55-mph speed limit. The resident walked approximately 0.6 miles from the facility. Resident #1 was missing from the facility for 10 minutes without staff knowledge. This failure created a situation that resulted in the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/11/26. The findings of Immediate Jeopardy were determined to be removed on 2/12/26 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Cross reference to F600Findings included: Review of Resident #1's progress notes revealed:1/11/26 2:50 p.m. Nursing Note The approximate time of 1415 [2:15 p.m.] patient was not reported to be in his room. Last seen by the nurse at 1400 [2:00 p.m.]. Facility search started at approximately 1435 [2:35 p.m.] patient observed on [street name] south of the facility. Patient returned to the facility by staff certified nursing assistant. Patient stated, I was going for a walk and was just about to turn around patient smiling in good spirits. Patient denies pain or discomfort, skin assessment completed without any abnormal findings. Elopement assessment completed. Patient placed on 1:1 monitoring will continue. Review of admission records showed Resident #1 was admitted to the facility on [DATE] with diagnoses to include unspecified sequelae of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, and syncope and collapse. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], Cognitive Patterns, showed a Brief interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Functional Abilities showed he could walk 150 feet with supervision or touching assistance. Restraints and Alarms showed a wander/elopement alarm was used less than daily. Review of Resident #1's Physician orders showed:-Device: Wander management bracelet-check placement every shift. Started: 11/14/25 Ended: 11/20/25. Review of Resident #1's care plan showed a focus area of [Resident #1] at risk for elopement as evidenced by Exhibit exit-seeking behavior-ambulating without assist in hallways, etc. Initiated on 11/10/25. Interventions included: Use diversional activities when exit-seeking behavior is occurring . initiated 11/10/25; - continue frequent visual checks as indicated initiated 1/7/26; and Use audible monitoring system to alert staff of exit seeking behaviors {electronic monitoring device} initiated 11/10/25 resolved on 12/11/25. Review of Resident #1's Elopement Risk Evaluations identified he was an elopement risk on 9/17/25, 11/3/25, and 12/23/25. Review of Resident #1's Progress notes showed:-9/24/25 Palliative care Note: . spoke with [resident representative] who states that patient lives in an apartment just down the road from her. She does admit that she works during the day. She states that patient's dementia has progressively slowly gone worse. She also states that she is concerned with patient's wandering during the day and his overall safety . -11/10/25 Nursing Note: Patient exhibited escalating behavioral concerns. Patient refused to sit down and refused redirection or instruction from nurse and cna. Patient repeatedly attempted to leave the unit through exit door. -12/10/25 Psychology Provider Note: The patient is an [AGE] year-old-male with recent episodes of agitation and combativeness secondary to confusion. He has presented with agitation, not following safety instructions, and exit seeking. He continues to present with cognitive decline. The patient was unbale to provide information about his diagnosis and treatment. Symptoms are reported to have been present for more than two weeks. The patient's current health issues present a barrier to symptom improvement. -12/15/25 Nursing Note: noted periods of agitation and exit seeking, after multiple redirection attempts NSG [nursing] staff was able to comfortably transfer him back to his room without incident, Psych notified, awaiting for further instructions. -1/6/25 Nursing Note: PT [patient] is resting on bed, alert with confusion, up and moving around the hall way [sic] period for a few minutes then back to bed, . -1/10/25 Nursing Note: Pt is up and walking around the hall way [sic] for a short time, then back to bed, meds [medications] take [sic] with supervision, fluid encourage, continue to monitor. The weather on 1/11/26 was 66 degrees Fahrenheit cloudy with brief precipitation and 84% humidity. (https://world-weather.info/forecast/usa/trinity_west/11-january/). During an interview on 2/10/26 at 9:30 a.m. with Staff A, Receptionist, he stated he received elopement training about a week ago and has not had any residents leave on his shift. He stated he updates the elopement book daily with direction from Human Resources (HR) and the Nursing Home Administrator (NHA) when they get a new admit. He stated he confirms the residents who are in the book and checks to see the electronic monitoring devices are working daily. During an interview on 2/10/26 at 10:15 a.m., with Staff C, Licensed Practical Nurse (LPN), she stated she has had elopement training. She stated they did have an elopement recently. She stated Resident #1 asked her to leave multiple times throughout her shift. She stated she redirected him and she let the nurse know. She stated he was found after going missing for about an hour. During an interview on 2/10/26 at 1:10 p.m. with Staff D, Certified Nursing Assistant (CNA), she stated she is unsure how to identify who is an elopement risk or who is supposed to be wearing an electronic monitoring device. She stated she is not sure of the process or know if there are any residents at risk for elopement in the facility. During an interview on 2/10/26 at 1:17 p.m. with Staff E, LPN, she stated they have orders in the Medication Administration Record (MAR) for the electronic monitoring devices. She stated they do a daily huddle [meeting] to notify staff if they have a new resident with exit seeking behaviors and check it daily, and every shift they document they have seen and checked the electronic monitoring device. She stated someone else comes in with a device to check that the electronic monitoring device is working every day. During an interview on 2/10/26 at 1:52 p.m. with Resident #1's primary care physician he stated, Resident #1 was a sneaky guy and had cognitive decline. He stated his mental state varied. He stated if the facility decided to take off the electronic monitoring device, they should have communicated this with him. He stated they were trying to cover the fact that his mentation would vary, and that Resident #1 could not understand the time of day sometimes. He stated he does not have any awareness of Resident #1 having exit seeking behaviors and that was not communicated to him from the facility. He stated he was notified of Resident #1's elopement by the NHA and understands he was found miles away. During an interview on 2/10/26 at 2:38 p.m. with the Nursing Home Administrator (NHA), Regional Nurse and the Regional Director of Operations, the NHA stated, Resident #1 went out the exit door on the second floor and down the stairs. She stated he went by the maintenance office on the second floor, saw the stairs, held the door handle for 30 seconds which opened the door, went down the stairs and when he got downstairs, he opened the exit door and went outside of the facility. She stated the door leading to the outside did not have an alarm at time of the incident. She stated the door locks from the outside, but you can open it from the inside. The NHA stated Resident #1 did not exhibit wandering and exiting behaviors prior to the incident. The NHA stated when interviewing staff nobody noticed the resident trying to leave and nobody heard any door alarms. The NHA stated Resident #1 had an elopement assessment upon admission and was identified as being at risk. The NHA stated Resident #1 left somewhere between 2:00 p.m. and 2:15 p.m. The NHA stated the temperature outside was 70 degrees and was not raining at that time. The NHA stated at one point [in previous months] Resident #1 had an electronic monitoring device but did not have one on at the time of him leaving. The Regional Nurse stated that the electronic monitoring device only works for the front door on the first floor, so it wouldn't have mattered in this situation anyway because it does not alert at any of the other doors. The NHA stated the exit door on the second floor with the delayed press, an alarm normally stays on once it is opened, but this one time it did not work. The NHA stated they tested the door and it was working. During an interview on 2/10/26 at 3:17 p.m. with Staff G, CNA, she stated we had a code Dr. [NAME] (missing resident) called, and everyone went downstairs and got assigned an area to search for the missing resident. She stated she had just gotten back from break and went to the assigned area. Earlier she heard someone, (she thinks it was a visitor) say they had seen someone with a matching description on the road. She stated a couple of staff members left the facility to go look for him. She stated she got in her car and left the facility; she made a left and then a right and saw his clothing description and found the Resident #1. Resident #1 was on the road in front of the plaza with a coffee shop and other stores. She stated she told Resident #1 to get in her car and brought him back to the facility. She stated she asked Resident #1 if he was ok and he stated he did it on purpose and that no one saw him leave. She stated Resident #1 did not remember where he was going. She stated it was raining and the resident was damp from the rain. She stated she did not hear any door alarms. During an interview on 2/10/26 at 3:31 p.m. Staff B, Registered Nurse (RN) stated Resident #1 was assigned to her on the day of the elopement. Staff B, RN stated Resident #1 did not have any exit seeking behaviors. She stated he would walk back and forth from nursing station and his room. She stated she was doing her med pass around 2:00 p.m., saw the resident walking to and from the nursing station and his room. She stated she went to another residents' room to give medication. The CNA came back from break and notified her of not seeing Resident #1 in his room. They both initiated the code Dr. [NAME] (missing resident) and started the search. She stated the search started around 2:15 p.m. She stated she does not know how the resident was found. She stated she saw a team member bring Resident #1 back and assessed resident. She does not remember if it was raining and stated the residents' clothes were a little damp. She stated Resident #1 did not say a word to her when he was back, was just smiling. She stated she does not remember hearing any door alarms. During an interview on 2/10/26 at 3:39 p.m. with Staff F, CNA stated being assigned to Resident #1 on the day of the elopement. Staff F, CNA stated that day she had left the resident at nurse's station around 1:45 p.m. so she could go on her lunch break. When she came back around 2:15 p.m., she went to check on the resident, and he was not in his room. She stated she looked around the building and could not find him. She told the nurse she could not find him and that's when the code Dr. [NAME] was called. She stated the resident was found down towards a plaza about a half mile away. She stated Resident #1 would walk around the facility all the time. She stated she did not hear any alarms. During an interview on 2/11/26 at 9:20 a.m., with the Maintenance and Housekeeping Director. She stated the electronic monitoring devices are checked every day. She stated the main lobby door is the only door that is protected by electronic monitoring devices. She stated the other doors do not use electronic monitoring devices. She stated she checked them every day, to ensure they beeped and locked and the lock is working properly and if it opened it would beep and alarm. She stated they have never had problems with the doors and have never had to have the manufacturers come out and check the doors due to any issues. During an interview on 2/12/26 at 9:28 a.m. Staff H, CNA stated a Dr. [NAME] code (missing resident) was initiated on 1/11/26 around 2:17 p.m. Staff H stated Resident #1 arrived back to the facility around 2:25 p.m. and was a little damp from the rain. Staff H stated Resident #1 has shown behaviors of exit-seeking in November and December. Staff H stated if the staff knew more maybe we could have been more aware of continuing to look out for Resident #1.A review of the facility policy titled Missing Resident/Elopement, with no revision date, revealed the following: POLICYIt is the policy of the facility to provide a safe and secure environment for all residents. In the event of a resident elopement it is the policy of [NAME] Rehab to implement its police/procedures immediately to locate the resident in a timely manner. If an at risk of elopement resident is seen attempting to leave the premises the situation will be immediately reported to the DON/designee, documented, and reviewed as part of the facility QA&A [Quality Assessment and Assurance].For a Resident attempting to leave the facility:Redirect the resident in a courteous manner.Get help from other staff in the immediate vicinity if necessaryInstruct staff member to inform the Charge Nurse or Director of Nursing Services/designee and review the need for the need to the individual plan of care. The facility's immediate actions to remove the Immediate Jeopardy included:-1/11/26 1:1 enhanced monitoring implemented upon Resident #1 return to the facility until discharge 1/12/26- care plan updated-Post Traumatic Stress Disorder (PTSD) evaluation completed 1/11/26 with no concerns.-1/11/26 Review of identified Resident #1 for elopement risk. An updated Elopement evaluation was completed and plan of care update as indicated-1/11/26 Resident #1 was interviewed upon return to the facility and was able to describe to NHA/DON the path that he had taken and what occurred. The Identified door that was used to exit the unit was evaluated at that time for proper function and alarm and no issues were identified-All facility internal exit doors were then evaluated for proper function 1/11/26 and no issues identified. Education on doors and alarms completed on 100% of staff on 1/12/26.-1/11/26 Temporary auditory sensor alarms were placed at identified secondary doors that exit the facility 1/11/26-Ad Hoc [unplanned] Committee meeting 1/11/26 5:45 p.m. with review of the concern and potential corrective interventions and approval of PIP [Performance Improvement Plan]. -Mock elopement drills initiated 1/11/26 at 4:06 p.m. and completed q shift [every shift] x 1 week then q day [every day] x 1 week then every other day ongoing per QAPI [Quality Assurance Performance Improvement] recommendations.-1/11/26 initiated education regarding Missing Resident/Elopement Policy/Procedure, including elopement books, Abuse/Neglect/Exploitation. As of 1/12/26 - 114 of 114 facility staff members and 26 of 26 contract therapy staff have been educated.-1/11/26 - record of previous daily exit door checks were reviewed for past 90 days to validate completion and no concerns identified. Door checks are to continue daily at the direction of the QAPI committee-1/11/26 Elopement books reviewed to ensure proper information is in place and books are easily accessible.-1/11/26 Verification of functioning of current [electronic monitoring device] device check machine-1/11/26 Current residents were evaluated for elopement risk and new Elopement Evaluations were completed with plan of care reviews and updates as indicated-1/11/26 Review of current residents with [electronic monitoring devices] - verified evaluation for accuracy and appropriateness. Verified proper order and documentation for placement. Update evaluation, order, and plan of care as indicated. [Electronic monitoring device] system checked at front door and found to be functioning.-Follow up Ad Hoc Committee meeting 1/11/26 at 10:30 p.m. with members in attendance to review the days' actions, interventions and outcomes. Follow up review and approval of PIP items. The Medical Director participated in the QAPI meeting in facility. -1/12/26 25 of 25 direct care Licensed Nursing staff educated on completion of Elopement Evaluations-1/12/26 Verification of proper functioning of exit doors and alarms by the regional maintenance consultant-1/12/26 Locked exit doors were converted to remove the delayed egress. Exit doors function using key fob/keypad for exiting the facility with Education to staff. 114 of 114 staff members. 26 of 26 contract therapy staff have completed.-1/12/26 Education for 25 of 25 direct care Licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device. -1/12/26 Verification of resident Photos and resident room name door tags completed for identification/verification. Updated as indicated-Ad Hoc Committee meeting 1/12/26 at 2:00 p.m. with members in attendance to review the steps taken above. Follow up review and approval of PIP item completion.-1/15/26 - Ad Hoc committee meeting held. Elopement drill tracking form and process reviewed and updated to promote better organization of the search. Location form updated to ensure all areas of the facility are assigned.-On 1/11/26 Initiated ongoing competency testing in support of continued education related to Resident Elopement Awareness and Prevention with an emphasis on signs and symptoms of exit seeking behavior and including related potential interventions and including notification. Currently 129 of 131 staff have completed. 26 or 26 contract therapy staff members have completed. 2 staff members have not been scheduled to work.2/12/26- Education to licensed staff on Identifying Elopement Risk and locating [electronic monitoring device] status. Verification of the facility's removal plan was conducted by the survey team on 2/12/26.Reviewed the updated care plan for Resident #1. Reviewed sign in sheets for education to staff completed 1/11/26 on doors and alarms with 100% completion. Observed permanent alarms on secondary exit doors. Reviewed sign-in sheet for 1/11/26 Ad Hoc QAPI meeting. Reviewed audits for mock elopement drills. Reviewed sign-in sheets for education to staff on 1/12/26 on abuse and neglect with 100% completion. Reviewed the door checks provided by the Maintenance Director. Reviewed elopement books were updated with the correct information as it pertains to the policy. Observed the Maintenance Director verifying the electronic monitoring device check machine to ensure it is functioning. Reviewed current residents who were identified as elopement risks with updated elopement evaluations and care plans updated. Reviewed education sign-in sheets completed 1/12/26 on elopement evaluations with 100% completion to direct care Licensed Nursing staff. Observed and verified exit doors functioning with a keypad or key fob to exit. Reviewed education sign-in sheets to staff completed 1/12/26 related to the exit doors and use of keypad or key fob to exit with 100% completion. Reviewed Ad Hoc meeting sign-in sheets for 1/12/26 and 1/15/26. Reviewed competency testing related to elopement awareness and exit seeking behavior for all staff. On 2/12/26 interviews were conducted over two shifts, regarding elopement reeducation with 26 staff, 17 Certified Nursing Assistants, 4 Licensed Practical Nurses, 4 Registered Nurses and 1 Physical Therapy staff. The staff members were able to state that they had been trained related to identifying residents at risk for elopement and were knowledgeable about the new policies.On 2/12/26 at 4:10 p.m., the facility was asked to conduct an elopement (Dr. Walker) drill. Staff on both the first and second floors responded promptly after a code was announced via portable radio. Staff were observed saying Dr. [NAME] to their peers. Clinical, non-clinical, and administrative staff that responded checked on residents, and searched inside the facility. A debriefing was conducted, following the drill, to discuss opportunities for improvement.Based on verification of the facility's immediate jeopardy removal plan the immediate jeopardy was determined to be removed on 2/12/26 and the non-compliance was reduced to a scope and severity of D.

Based on interview and record review, the facility failed to honor a resident's right to a safe, orderly, and planned discharge for one (#1) of one resident discharged while an appeal was pending. Findings Included: During a telephone interview on 05/01/2025 at 2:32 p.m., Resident #1 stated she was discharged from the facility on 04/29/2025 while awaiting a hearing discharge. She stated she called to file the appeal on what she thought was the 10th day, but the facility told her she filed the appeal on the 11th day and would still be discharged home. The resident stated she was not ready to come home and could not afford to pay her portion of the bill. She stated she could not go home without a sit- to stand lift which she required for transfers. Resident #1 stated she was still waiting for an upright walker because she cannot really stand. She stated she was incontinent and could not access her bathroom at her house due to it being too small. Resident #1 stated she had been forced to wear adult briefs and was dependent on her [male family member] to change her. Resident #1 stated she never wanted her [male family member] to have to bathe and change her. She said, It is uncomfortable to have my [male family member] bathe me and provide incontinence care. It is not dignified. The resident stated the previous Wednesday she sat in a soiled brief all day because, I was embarrassed. Resident #1 stated waiting to be assisted has caused her some redness in her private area. She stated a nurse was supposed to come came out and help get her change into a clean brief. She stated she was approved for 28 hours of nursing care a week and was still working on setting up a schedule with the provider to be able to provide her with incontinence care at least twice a day. She said, I want to spread out the nursing hours, so I don't have to have my [male family member] provide my incontinence care or my showers. Resident #1 stated her discharge appeal hearing was scheduled on 05/06/2025. Review of Resident #1's admission record revealed an admission date of 10/22/2024 and a discharge date of 04/29/2025. Resident #1 was admitted to the facility with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, chronic hepatic failure without coma, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure with hypoxia, acute on chronic diastolic (congestive) heart failure, lymphedema, not elsewhere classified, morbid (severe) obesity due to excess calories, dysphagia, unspecified, depression, unspecified, and anxiety disorder, unspecified. Review of a quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental status (BIMS) score of 15/15 indicating intact mental cognition. Review of a care plan for Resident #1 initiated on 10/22/2024 showed the resident wishes to return home with her [family member] upon improvement of her condition. Interventions included to discuss with resident/family representative discharge planning process. Investigate needs for returning home such as cooking, cleaning, shopping, medical equipment, financial resources, meals, pharmaceutical needs, physician follow- up, respite care, Home healthcare, Lifeline, adult protective service, live- in care provider transportation etcetera. Review of a Physical Therapy (PT) discharge summary evaluation dates of service 1/20/2025 - 4/11/2025 showed a goal for transfers, patient will safely perform functional transfers with Min [minimal] A [assist] with reduced risk for falls in order to decrease level of assistance from caregivers. Under comments it showed, transfers continue to vary from Mod A [moderate assistance] x1 (person) to assist x2 (persons]. Therapy recommended use of sit to stand at home for safety. For ambulation: it showed, patient will ambulate up to 60 ft (feet) with upright RW [Rollator walker], CGA [Contact Guard Assist], in order to safely enter/exit her bathroom at home. The evaluation showed at discharge on [DATE] the resident was ambulating 35 ft with upright FWW [Front Wheeled Walker], CGA, WC [Wheelchair] to follow. For standing, the goal showed patient will increase dynamic standing balance to fair- spontaneously righting self when needed in order to reduce the risk for falls and prepare for transfers. At discharge on [DATE], the assessment showed Resident #1's performance was fair, Min (A) [minimal assist or UE [upper extremity] support to stand w/o [without] LOB [Loss of Balance] and to reach ipsilaterally [on the same side of the body], unable to weight shift. The evaluation revealed the resident could stand- supported for a duration of 1-3 minutes. Discharge recommendations showed wheelchair as primary mode of mobility, sit to stand lift, lift chair, upright walker for ambulation as tolerated, home health services. Review of an Occupational Therapy (OT) progress note for Resident #1 dated 04/16/2025 revealed, discussed recommended equipment for home which includes bedside commode, toileting aide, female urinal, reacher, sock aid, hospital bed, 2ww [wheeled walker], upright walker, [NAME] [sit-stand] lift. Review of a social services progress note for Resident #1 dated 04/22/2025 showed, in home medical provider has delivered a hospital bed, 3:1 commode and wheelchair for Resident #1 . Social Services is having difficulty locating a sit to stand lift. Social services was told by multiple DME (Durable Medical Equipment) organizations that the product is on back order and or items are being leased. This writer reached out to Medicaid case worker to see if transitional funds could purchase the lift for Resident #1. Social services awaiting response from Medicaid. Review of a social services progress note for Resident #1 dated 05/01/2025 showed this writer spoke with Resident #1 upon returning home. She was approved for 28 hours of caregiver services . a schedule has not been established as of yet . Resident #1 inquired about when she would be receiving the upright walker and reclining lift chair. This writer states she will reach out to Medicaid case worker to follow up. Resident #1 also asked about bathroom modifications and furniture removal. An e-mail was sent to Medicaid case worker for follow - up. Review of a psychology progress note for Resident #1 dated 04/08/2025 revealed Resident #1 reported feeling sadness and worry. She reported that she is going home this week and feels overwhelmed with setting her home to be ready for her arrival. She reported worry, thoughts rumination and anxiety. She reported that she has an outpatient psychiatric provider. She will continue treatment with. Feelings explored and validated. Short term goal explored with the patient, who engaged in therapy and intervention. Psychologist collaborated with the patient to explore coping strategies to manage negative mood symptoms using psychoeducation. Review of a psychology progress note for Resident #1 dated 04/02/2025 revealed Resident #1 reports some increased anxiety this week due to personal stressors and uncertainty about her future. She has been given 30-days' notice due to financial issues and is expected to move home with her [male family member]. She worries about her independence and being able to care for herself. She admits her [male family member] can help some but is looking into home health. Review of a social services progress note for Resident #1 dated 03/18/2025 revealed, 30-day nursing home transfer and discharge notice issued to residents. Copy of notice provided to residents. Pt (patient) verbalizes that she is aware of reason for discharge -states She is not paying her portion of what is due. Copy of discharge notice to be sent to ombudsman office. Review of a social services progress note for Resident #1 dated 04/01/2025 revealed, this writer spoke with the Ombudsman Office who confirms Resident #1 has filed a fair- hearing appeal. The appeal was filed on 3/31/2025. Due to not meeting the 10-day deadline, discharge may move forward. Should the resident win the appeal it is understood that she will re-admit to the facility. Review of the Nursing home transfer and discharge notice revealed a notice was given on 3/18/2025. Reason for discharge or transfer: Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay. The notice was presented by the Nursing Home Administrator (NHA) and signed on 3/18/2025. Resident or resident representative signed on 3/18/2025. Review of the State of Florida Department of children and family's office of appeals hearings order revealed a request for a hearing was filed by the petitioner on 3/28/2025. The request is based on an action by the respondent to discharge the petitioner. Review of a social services progress note for Resident #1 dated 04/04/2025 revealed, facility received letter from office of appeal hearings. Resident #1 filed her appeal on 3/28/2025. The ombudsman office was notified on 3/31/2025. Requested documents have been sent to the appeals officer. Review of the order scheduling hearing for Resident #1 revealed a hearing was scheduled for Tuesday, May 6, 2025, time 1:00 PM, place: by telephone. Review of resident #1's Discharge summary dated [DATE] showed, patient discharged at 11:45 am with all medications and narcotics except OTC [Over The Counter] meds. Patient understood medication regime and ileostomy teaching done weeks prior to discharge, and she is fluent with ostomy changing and care. All belongings packed up and sent with pt. All discharge instructions are sent with patient. During an interview on 05/01/2025 at 12:49 p.m., the Social Services Director (SSD) stated Resident #1 was issued a discharge notice in March for nonpayment. She stated the ombudsman had notified the facility Resident #1 had filed an appeal. The SSD stated since the resident filed the appeal on the 11th day, they could continue with the discharge. During an interview 05/01/25 at 2:28 p.m. the Department of Children and Families, office of Appeals Hearings office administrator confirmed Resident #1 had appealed the discharge from the facility and had an upcoming hearing scheduled on May 6, 2025, at 1 p.m. The office administrator confirmed the facility, and the resident had been furnished copies of the hearing notice. During an interview on 05/01/2025 at 3:34 p.m., the NHA stated Resident #1 was discharged prior to her appeal date because she filed the appeal on the 11th day. The NHA confirmed knowing the resident had a pending appeal prior to her discharge. The NHA confirmed the facility had received the hearing notice for the upcoming hearing on May 6, 2025. Review of a facility policy titled Transfer or Discharge notice dated December 2016 showed a policy statement, our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Policy interpretation and implementation showed: 3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. A statement of the resident's rights to appeal the transfer or discharge, including: (1). The name, address, email and telephone number of the entity which receives such requests. (2). information about how to obtain, complete and submit an appeal form; and (3). how to get assistance completing the appeal process. 11. In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident.

Based on observation, record review and interviews the facility failed to ensure four kitchen staff members (Certified Dietary Manager, A, B, and C) wore hairnets, beard guards and gloves in accordance with professional standards for food service safety, in one of one kitchen observed. Findings included: During the initial tour of the kitchen on 11/18/24 at 9:05 a.m., Staff A, [NAME] was observed with uncovered facial hair, standing over a pot on the stove stirring the contents with no beard guard in place. An additional observation at this time revealed the Certified Dietary Manager (CDM) standing at a prep table with no hairnet in place. During an interview on 11/18/24 at 9:05 a.m. the CDM stated she was just at morning meeting and she came straight to the kitchen and began working. The CDM stated she just forgot to put a hairnet on after the morning meeting. The CDM stated Staff A, [NAME] should have a beard guard on. An observation on 11/18/24 at 4:15 p.m. showed Staff B, Dietary Aide (DA) with facial hair standing over a large metal bowl with no beard guard in place. During an interview on 11/18/24 at 4:15 p.m. the CDM stated that all employees with facial hair should be wearing a beard guard. The CDM turned to Staff B, DA and told him to put a beard guard on. Staff B, DA responded and said he didn't know where the beard guards were, and the other male kitchen staff showed him where the beard guards were located. An observation on 11/20/24 at 11:26 a.m. showed Staff C, DA walked over to a kitchen table and opened a loaf of bread with her bare hands. Staff C, DA was observed taking out slices of bread and laying the bread on the covered table without washing her hands and without gloves. Staff C, DA took out a total of eight slices of bread without gloves. The Regional Dietitian (RD) was observed informing Staff C, DA that the bread needed to be discarded, hands washed and to put gloves on prior to proceeding in making sandwiches. During an interview on 11/20/24 at 11:26 a.m. Staff C, DA stated that she knew she was supposed to be wearing gloves when working with food, but got so busy today, and that sometimes she wears gloves and sometimes she does not. During an interview on 11/20/24 at 12:43 p.m. the CDM stated Staff C, DA had been educated in the past regarding wearing gloves. Review of the facility's policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated October 2017, showed, Policy Statement: Food and nutritional services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 8. Contact between food and bare (ungloved) hands is prohibited. 12. Hair nets or caps and/or beard restraints must be worn from contacting exposed food, clean equipment, utensils and linens.

Based on observation, interview and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for four months (June, July, October and November 2024) of six months reviewed. Findings included: Review of the Resident Council Meeting Minutes, dated June 4, 2024 revealed: Old Business a concern relating to CNAs (Certified Nursing Assistant) wanting more aides on the floor during mealtimes, especially weekends. Under the section New Business, the following was documented: CNA - weekends aids [sic] need to be on the floor more - call light takes more time during the lunch time. Review of the Resident Council Meeting Minutes, dated July 2, 2024, revealed: Old Business a concern relating to call lights take more time during the lunch time. Under the section New Business, the following was documented: CNAs are busy. Sometimes they say Just a minute, but it takes much longer. Review of the Resident Council Meeting Minutes, dated October 11, 2024, revealed under the section New Business the following: Call lights not being answered, mostly after meal time. Review of the Resident Council Meeting Minutes, dated November 4, 2024, revealed under the section New Business the following: Takes longer to answer call lights. A review of the Grievance Logs from June 2024 to November 11, 2024 revealed no grievances, issues, or concerns documented for the Resident Council. During an interview on 11/21/2024 at 1:50 p.m. the Activities Director (AD) stated she was completing grievances from the Resident Council meeting if more than one resident has the issue. If just one resident, then she completes one independently. The AD recalled completing grievance forms for the group on call lights regularly. She stated call lights come up during each Resident Council Meeting, especially regarding the 3 p.m.-11 p.m. shift and during mealtime. The AD stated she was not keeping a photocopy of the grievance turned in. During an interview on 11/21/2024 at 1:36 p.m. with the Social Service Director (SSD), a review of the grievance process was conducted. The SSD stated once the grievance is received, it is logged in by social services. The SSD stated, I take the grievance to our morning meeting for discussion, at which all managers are in attendance. We decide who is responsible for investigating the grievance and that manager takes the grievance to complete the investigation, determine resolution and follow up with the resident/responsible party. Once completed, the grievance form is returned to social services. The SSD stated, we like to get them back in three to five days. The SSD stated most of the grievances get resolved, some are repeating. The SSD stated call light concerns seem to repeat, although she was not sure as tracking of grievances is by department, not by issue. During an interview on 11/18/24 at 12:55 p.m. the Nursing Home Administrator (NHA) stated the follow through on grievances should be to have them wrapped up in approximately 72 hours. The NHA stated she did not have any information regarding the grievances. The NHA stated the SSD does complete a trending of grievances and that she does not. During an interview on 11/19/2024 at 10:30 a.m. with the Resident Council President. The Resident Council President stated the concerns regarding call lights continue to be an ongoing issue without resolution. Review of the facility's policy and procedure titled, Grievance/Complaint, Filing, with a revision date of August 2022, revealed: Policy: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy interpretation and implementation: 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, staff to property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues but will be responded to in writing, including a rationale for the response. 10. The grievance officer, administrator and staff will take immediate action to prevent further potential violation of resident rights while the alleged violation is being investigated. 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct and identify problems. a. The administrator, or his/her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation can be provided to the resident upon request and a copy will be filed in the grievance binder.

Based on observation, interview, and record review, the facility failed to ensure four residents (#413, #42, #263, and #264) of four residents reviewed for wound care concerns received wound care treatment in accordance with professional standards of practice. Findings included: 1. An observation and interview was conducted with Resident #413 on 11/20/24 at 1:30 p.m. Resident #413 was observed sitting in a chair dressed in day clothes next to her bed. A gauze dressing was observed on her left lower leg with a date of 11/16. The resident stated, The dressing hasn't been changed in four days and it is supposed to be changed every other day. Every time I ask about it, the nurse tells me the next shift will do it. Review of Resident #413's Admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses of congestive heart failure, and non-pressure chronic ulcer of left calf. Review of Resident #413's progress note - Brief Interview for Mental Status (BIMS) evaluation, dated 11/11/24, revealed a BIMS score of 15 indicating she is cognitively intact. Review of Resident #413's November 2024 active physician orders revealed an order with a start date of 11/09/24 for cleanse LT [left] lower posterior leg open area with nss [normal saline]; apply silver Alg [alginate], Abd [abdominal dressing] and wrap with a gauze change QOD [every other day] every night shift every other day for wound. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 11/20/24 at 3:10 p.m. She said the wound care practitioner comes to the facility on ce a week and usually rounds with the unit managers. If an order is changed or updated, sometimes the wound care practitioner will put it in that day. An interview with the Wound Care Nurse Practitioner was conducted on 11/21/24 at 11:02 a.m. She stated she would not expect to see dressings not changed as ordered. She also stated she didn't see a date on Resident #413's dressing and would not expect a dressing that is supposed to be changed every other day to not be changed for five days. She went on to state since Resident #413's dressing was not changed, it was hard to get off and she had to moisten it. She said if the order needs to be changed in the system, she will put the order in, and sometimes she does have an issue with the dressings not being changed as ordered. 46234 2. An observation was conducted on 11/18/24 at 2:52 p.m. of Resident #42 in bed. The resident had a dressing on each foot that was not dated. Review of the Admission Record showed Resident #42 was admitted on [DATE] with diagnoses including non-pressure chronic ulcer of right heel and midfoot with unspecified severity, non-pressure chronic ulcer of other part of right foot with unspecified severity, peripheral vascular disease (PVD), and acquired absence of other left toes. Review of Resident #42's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/24, revealed under Section C - Cognitive Patterns, showed the resident had a BIMS score of 14, indicating he was cognitively intact. Review of Resident #42's Skin Only Evaluation, dated 11/18/24, showed he had current skin issues on the right toe, right dorsal foot, left heel, and right heel. Review of Resident #42's care plan showed a focus area of skin disruption related to a left heel PVD ulcer and right heel PVD ulcer (with gangrene). Interventions included treatment per orders and avoid friction and shearing when doing care by lifting resident utilizing draw/turn sheets. Review of Resident #42's November 2024 physician orders showed the following: - Cleanse wound to left heel with wound cleanser, pat dry. Apply silver alginate, cover with abd (abdominal) and wrap with kerlix. Every night shift and PRN (as needed). Dated 9/25/24. - Cleanse wound to right heel with wound cleanser, pat dry. Apply silver alginate, cover with abd and wrap with kerlix. Every night shift and PRN. Dated 11/7/24. Review of Resident #42's Treatment Administration Record (TAR) showed the wound orders were signed off as completed on 11/18 and 11/19/24. An observation was conducted on 11/19/24 at 3:00 p.m. of Resident #42. The dressings on each heal were observed unchanged with no date. The right heel dressing was soiled with a quarter sized area of serosanguineous drainage. An additional observation of Resident #42 conducted on 11/20/24 at 9:54 a.m. revealed the two dressings remained in place unchanged and undated. The area of serosanguineous draining soiling the right heel dressing had increased to half-dollar sized. An interview was conducted on 11/20/24 at 2:05 p.m. with Staff D, LPN. She stated wound care was provided daily by the resident's assigned nurse on the night shift and weekly the wound nurse practitioner does a wound evaluation. When asked about Resident #42's dressing not being dated for the past 3 days, she stated it was done by the night nurse. She then added that she noticed another one of her residents also had an undated dressing. An observation on 11/20/24 at 3:07 p.m. revealed Resident #42's dressing remained unchanged and undated. An interview was conducted on 11/21/24 at 9:30 a.m. with Resident #42. He said at 1:30 a.m. on 11/21/24 his dressing was changed. He was not happy it was done in the middle of the night. He said his dressing is not changed daily. 48223 3. During an interview on 11/18/24 at 11:31 a.m. Resident #263 stated concern regarding the treatment of her wounds not being completed. Resident #263 continued to state on Friday 11/15/24 her left heel started to bleed, and all the nurse did was wrap a towel around the heel and nothing has been done since. Resident #263 was observed lying in bed. The resident's left foot was observed in a Podus type boot with a towel under the heel and a bandage covering the ankle and heel, dated 11/14/24. The resident's toes were exposed. The big toe had what appeared to be dried blood on the outer tip of the toe and nail. On 11/19/24 at 10:00 a.m., Resident #263 was observed and interviewed while lying in bed. The resident's left foot was observed in a Podus type boot with towel under the heel and a bandage covering the ankle and heel, dated 11/14/24. The resident stated no one had changed the bandages. Review of the Admission Record revealed Resident #263 was admitted to the facility on [DATE], with diagnoses to include osteomyelitis to left ankle and foot, type 2 diabetes mellitus with foot ulcer, pressure ulcer of left buttock, and other co-morbidities. Review of Resident #263's MDS, Section C - Cognitive Pattern, dated 11/20/2024, revealed a BIMS score of 15/15, which meant the resident was cognitively intact. Review of Resident #263's November 2024 active Order Summary Report showed the following orders: - Cleanse left heel with normal saline, apply Santyl ointment, cover with ABD pad, and wrap in kerlix, change Monday, Wednesday, and Friday evening shift for wound care - dated to start 11/15/24 and discontinued 11/17/24. - Cleanse left heel with normal saline apply Santyl ointment cover with ABD pad and wrap in kerlix, change Monday, Wednesday, and Friday night shift for wound care - dated to start 11/18/24 and discontinued 11/21/24. A review of the TAR for November 2024 for Resident #263 showed treatment for the left heel provided was on 11/15/24 and 11/18/24. 4. On 11/18/24 at 12:02 p.m. and 11/20/24 at 1:25 p.m., Resident #264 was observed in the resident's room. Resident #264's left arm had a dressing (4x4 gauze with transparent dressing covering) with no date. During an interview on 11/18/24 at 12:05 p.m. Resident #264 and a family member noted the dressing on resident's left forearm. The resident and family were unaware of what happened to require a dressing. The family representative stated, Since the bandage is not dated, I'm not sure when it happened. During an interview on 11/20/24 at 1:40 p.m., Staff D, LPN confirmed routinely caring for Resident #264. Staff D, LPN stated, she was not aware of the dressing on Resident #264's arm. Staff D, LPN reviewed the electronic record for Resident #264, including current orders, and no orders for treatment were found. Staff D, LPN entered the resident room and asked Resident #264 what happened and Resident #264 stated no recollection. Staff D, LPN confirmed the dressing was on the resident's left forearm and was not dated and should have been. During an interview on 11/21/24 at 2:09 p.m. the Director of Nursing (DON) stated the dressing should be dated and the expectation is for the nurses to follow the physician orders. Review of the facility's policy and procedure titled, Wound Care, with a revised date of October 2010, showed: Purpose: the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify there is a physicians order for this procedure. 2. Review the residence care plan to assess for any special needs of the resident. a. Themselves for example, the resident may have PRN (as needed) orders for pain medication to be administered prior to wound care. 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etcetera., with alcohol pledge it before opening, as necessary. (Note: this may be performed at the treatment cart.) .Steps in the Procedure: .13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, date and apply to dressing. Be certain all clean items are on clean field Documentation: The following information should be recorded in the resident's medical record: 1. Wound care provided. 2. The date and shift the wound care was provided. 3. The name and the title of the individual performing the wound care. (Photographic Evidence Obtained)

Based on observations, interviews, and policy review, the facility failed to ensure medication was stored appropriately in four resident rooms out of thirty-six resident rooms sampled, in three medication carts out of five facility medication carts, and one medication storage room out of two facility medication storage rooms. Findings included: 1. An observation and interview was conducted on 11/20/24 at 9:09 a.m. with Staff E, Licensed Practical Nurse (LPN). Upon approaching the medication cart in the 100 hall the nurse opened the top drawer. One medication cup that had medication crushed in apple sauce with a spoon in it and two medication cups with medication were observed in the top drawer. The nurse was observed removing a fourth medication cup filled with medication from the drawer. When asked what the cups of medication were for she said she was going to administer them to residents. She said she pulled them and did both residents in the room. She had no response when asked if it was ok to have medications pulled and sitting in the medication cups in the drawer. An audit of a first-floor medication cart was conducted on 11/20/24 at 10:48 a.m. with Staff E, LPN. The medication cart had six loose pills in the drawers of the cart. The top drawer contained an insulin pen with no resident label. The medication cart drawers were observed to contain tape, scissors, thermometer, blood pressure cuff, stethoscope, pulse oximeter, and pudding in the same compartments containing medication. The top drawer was observed to have dirt/debris in the corners and rust spots on the metal. The narcotic drawer contained 3 vaping cartridges, hearing aids, and an unlabeled, open bottle of nasal spray. The bottom of the medication cart, behind the drawer, contained several loose pills, debris, and a bubble pack of resident medication. Staff E, LPN said the insulin pen probably fell out of the bag it was in, and the prescription label came off. Staff E, LPN said she did not know other items could not be stored in the cart with medication. She said there had not been education on the medication carts with the exception possibly of orientation. She said loose pills were not supposed to be in the cart and if she saw them, she would have removed them. As for cleaning the carts, she said she didn't know if there was a process in place for cleaning carts regularly or deep cleaning carts. An audit of a second-floor medication cart was conducted on 11/20/24 at 11:20 a.m. with Staff D, LPN. The cart contained three loose pills in the drawers of the cart. The nurse said she didn't know those were back there. The top drawer was observed to have a set of keys in the compartment with medication bottles. The narcotic drawer was observed to have two lighters, a resident wallet, and batteries. Staff D confirmed loose pills should not have been in the cart and said she wasn't aware the additional items could not be in with the medications. She said each nurse took care of their own medication cart. 41015 2. An observation of Resident #59's room on 11/18/24 at 11:11 a.m., revealed 11 packets of peri-care ointment, 5 grams each, laid on top of a nightstand. An interview was conducted following the observation with Resident #59. Resident #59 stated he was unaware the ointments were left on the nightstand. Review of the Admission Record showed Resident #59 was readmitted to the facility on [DATE]. There were no medication self-administration assessments found in Resident #59's medical record. The Order Summary Report showed no orders for Resident #59 to self-administer his own medications. 48223 3. During an interview on 11/21/24 at 12:25 p.m. the Director of Nursing (DON) stated skin protectants were usually kept in the treatment cart unless a resident had a self-administration completed. On 11/18/24 at 11:21 a.m. and 11/20/2024 at 3:05 p.m., in resident room [ROOM NUMBER] on the window side, a bottle of wound cleanser was observed on the night stand next to the bed. On 11/18/24 at 11:30 a.m. and 11/19/2024 at 4:07 p.m., in resident room [ROOM NUMBER] on the door side, a bottle of ketoconazole shampoo 2% was observed on the night stand next to the bed. On 11/18/24 at 11:33 a.m. and 11/19/2024 at 4:10 p.m., in resident room [ROOM NUMBER] on the door side, 3 packets of [brand name] skin protectant were observed on the night stand next to the bed. On 11/18/24 at 11:24 a.m. and 11/19/2024 at 4:11 p.m., in resident room [ROOM NUMBER] on the window side, a bottle of tolnaftate antifungal powder and packets of [brand name] skin protectant were observed on the night stand next to the bed. On 11/20/24 at 3:18 p.m., in resident room [ROOM NUMBER] (one occupant), an observation of the following: Nicorette gum was in a box on the over bed table. The box was open revealing several packets of the Nicorette gum. A box was on the bed with antiseptic skin cleanser and Triamcinolone Acetonide cream. 48441 4. On 11/20/24 at 11:05 a.m., an observation was conducted of the first hallway medication storage room with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM). The refrigerator for narcotics had a large padlock lock unlocked. Inside the refrigerator, the narcotic black box was secured to the floor of the refrigerator but also unlocked. In the narcotic box was a syringe of Lorazepam injectable. Staff L, LPN/UM stated she was unaware the narcotic box needed to be locked. On 11/20/24 at 11:15 a.m., an observation was made of Med Cart 1 high with Staff L, LPN/UM An observation was made of loose pills throughout the cart. Staff L, LPN/UM stated the medication cart was cleaned Monday. A review of the facility's policy titled, Storage of Medications, showed the following policy statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. The policy interpretation and implementation showed the following: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . 7. Antiseptics, disinfectants, and germicide used in any aspect of resident care have legible, distinctive labels that identify the contents and the directions for use and are stored separately from regular medications . 10. Resident medications are stored separately from each other to prevent the possibility of mixing medications between residents. 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses 'station or other secured location. Medications are stored separately from food and are labeled accordingly . 13. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. (Photographic Evidence Obtained)

Based on observation, interview, and record review the facility failed to implement safety precautions for smoking supplies for one resident (#52) of one sampled resident for smoking. Findings included: On 11/18/2024 at 11:47 a.m. Resident #52 was observed in her room sitting in her wheelchair, with an electronic monitoring device on her right ankle and her purse next to her with cigarettes and a lighter. Resident #52 stated she was a smoker and is able to go smoke with the activity department at specific times of day. On 11/18/2024 at 4:12 p.m. Resident #52 was observed sitting in a wheelchair being escorted to the second-floor elevator. The resident had cigarettes and a lighter in her purse next to her in the wheelchair. Review of the Admission Record revealed Resident #52 was admitted to the facility on [DATE]. Review of Resident #52's Minimum Data Set (MDS) assessment, dated 10/9/2024, Section C- Cognitive Pattern, revealed a Brief Interview for Mental Status (BIMS) score of 11/15, which meant the resident was moderately cognitively impaired. Review of Resident #52's smoking assessment, dated 9/29/2024, showed Resident #52 is not a smoker. Review of Resident #52's smoking assessment, dated 10/15/2024, showed Resident #52 has cognitive loss, smokes 1-2 cigarettes per day, not able to light own cigarette, resident needs supervision, resident needs facility to store lighter and cigarettes. Under the section of the IDTC (Inter Disciplinary Team Conference) Decision showed: Resident have [sic] fluctuations in her cognition throughout the day, safe to smoke with supervision and Smoking policy reviewed. Review of Resident #52's smoking assessment, dated 10/23/2024, showed Resident #52 does not have cognitive loss, smokes 1-2 cigarettes per day, is able to light own cigarette, resident needs supervision, resident needs facility to store lighter and cigarettes. Under the section of the IDTC (Inter Disciplinary Team Conference) Decision shows: Needs supervision, safe to smoke with supervision and Resident follows other residents outside to smoke. She needs supervision to get in and out of building safely. Review of Resident #52's care plan, dated 10/3/2024, showed a Focus Area: [Resident #52] has impaired cognition with memory problems related to BIMS = 11/15. - Smoking dated 10/14/2024 showed the resident is a smoker. The goal for Resident #52 showed, will smoke safely at designated area(s) through next review. The interventions included: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. The resident requires SUPERVISION while smoking per facility practice. An interview was conducted with Staff H, Licensed Practical Nurse (LPN) on 11/20/2024 at 1:38 p.m. Staff H, LPN confirmed caring for Resident #52 and stated Resident #52 is a smoker and goes out with supervision. Staff H, LPN continued to state usually if a resident is marked needing supervision, we (the staff) would hold the supplies (cigarettes and lighters) although Resident #52 holds all of her supplies. An interview was conducted with the Nursing Home Administrator (NHA) on 11/20/2024 at 4:22 p.m. The NHA reviewed Resident #52's smoking assessments from 9/29/2024, 10/15/2024 and 10/23/2024. The NHA confirmed the assessments showed the resident was in need of supervision. Review of the facility's policy titled, Smoking Policy - Residents, revised July 2017, showed: Policy Statement- This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation . 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: (a). Current level of tobacco consumption; (b). Method of tobacco consumption (traditional cigarettes; Electronic cigarettes; Pipe, etc.); (c). Desire to quit smoking, if a current smoker; and (d). Ability to smoke safely with or without supervision (per a completed safe smoking evaluation). 7. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident smoking privileges based on the safe smoking evaluation. 8. A residents ability to smoke safely will be reevaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, E cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited.14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etcetera, except when they are under direct supervision.

Based on observations, interviews, and record review, the facility failed to ensure a central line dressing was changed as ordered for one resident (#33) out of four residents sampled. Findings included: On 11/19/24 at 10:46 a.m., an observation was made of Resident #33's peripherally inserted central catheter (PICC) dressing, dated 10/27/24. Resident #33 stated he was getting an intravenous antibiotic for an infection but could not state where the infection was. On 11/20/24 at 8:40 a.m. an observation was made of Resident #33's PICC dressing with a remnant of a sticker on the clear dressing. Resident #33 stated he did not know what happened to the dressing. On 11/20/24 at 10:45 a.m. an observation was made of Resident #33's PICC dressing with the same remnant of a sticker on the clear dressing, but a date of 11/20 written in a green marker with identified initials. A review of Resident #33's Admission Record showed an initial admitted [DATE], with a readmitted [DATE]. A review of the Admission Record showed Resident #33 diagnoses not limited to encounter for orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis, other sites, and atherosclerosis of native arteries of extremities with gangrene right leg. A review of Resident #33's current physician orders showed orders for the following: - Vancomycin Hydrochloride (HCL) Intravenous solution reconstituted 1.25 grams, use 1.25 grams intravenously two times a day for osteomyelitis with a start date of 11/12/2024. - Change PICC line dressing on right upper arm (RUA) weekly on Sunday every day shift every Sunday with a start date of 10/20/2024. - Monitor PICC line site on RUA for s/s (signs and symptoms) of infection every shift with a start date of 10/13/2024. A review of Resident #33's Minimum Date Set, dated 10/29/24, Section O - Special Treatments, Procedures and Programs showed a check mark for Other H1. IV medications while a resident. On 11/20/24 at 11:05 a.m. an interview was conducted with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff L, LPN/UM stated she was the nurse wrote today's date in green onto Resident #33's PICC line dressing. Staff L, LPN/UM stated she saw the remnants of the sticker on the dressing, which prompted her to ask the resident if anyone had changed the dressing. Staff L, LPN/UM stated she asked the resident if his dressing was changed and she stated the resident stated to her something was done yesterday. Staff L, LPN/UM marked the dressing with the green marker for today's date. Staff L, LPN/UM stated PICC line dressings are changed within 24 hours of a new resident's arrival to the facility and then every seven days per physician orders and as needed for soiling or if the dressing should be loose. A review of the facility's policy and procedures titled, Central Venous Catheter Dressing Changes, revised January 2020, showed a purpose statement: The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Further review of the policy showed the following general guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change dressing if any suspicion of contamination is suspected. 3. Catheter site care shall allow for the observation and evaluation of the catheter skin junction and surrounding tissue. 4. After original insertion the dressing will consist of gauze and semi permeable membrane dressing. This must be changed within 24 hours 5. Change transparent semi permeable membrane dressing at least every five to seven days and PRN (as needed) when wet soiled or not intact. (Photographic Evidence Obtained)

Based on observation, record review, and interview, the facility failed to accommodate food preferences for two residents (#90 and #263) of six sampled residents. Findings included: 1. On 11/18/2024 at 11:51 a.m. Resident #90 was observed sitting in front of the lunch meal. Resident #90's meal ticket showed, NO RICE, No POTATO, NO PACAKES [sic] NO WAFFLES NO FRENCH TOAST DOUBLE VEGGIES!!! Resident #90 had rice on the plate. Resident #90 refused to eat the rice, and no other options were provided. During an interview on 11/18/2024 at 11:51 a.m. Resident #90 stated, I never get what I am supposed to get. Resident #90 continued to state, It doesn't matter how many times I tell people, they just send what they want. I have lost weight while I am here, I have protein shakes brought in to ensure I receive the protein I need for my diagnosis. On 11/20/2024 at 1:50 p.m. Resident #90 was observed sitting in front of the lunch meal. Resident #90's meal ticket showed, NO RICE, No POTATO, NO PACAKES [sic] NO WAFFLES NO FRENCH TOAST DOUBLE VEGGIES!!! Grilled Cheese, Baby Carrots, Savory Chicken Noodle Soup, Pudding and choice of beverage. Resident #90 had carrots on her plate, a grilled cheese, pudding and juice, but no chicken noodle soup. (Photographic Evidence Obtained) Review of Resident #90's Admission Record revealed the resident was admitted on [DATE]. Diagnoses included end stage hypertensive heart and chronic kidney disease without heart failure, with end stage renal disease, dependence on renal dialysis, and type 1 diabetes. Review of the Minimum Data Set (MDS) assessment, dated 11/8/2024, revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15/15, which meant the resident was fully cognitively intact. Review of the Order Summary Report of active physician orders, dated 11/21/24, revealed: - controlled carbohydrate diet, Regular texture, thin consistency, order and start date 10/15/2024 - Pro Stat one time a day for end stage renal disease, give 30 ML (milliliter) may mix with beverage of choice, order dated to start 10/23/2024. The care plan for Resident #90 revealed the following focus areas: - Potential for complications related to hemodialysis for diagnosis of ESRD (end stage renal disease), dated 10/16/2024. Interventions included: Consult with dietitian PRN (as needed) for nutritional support r/t (related to) renal disease . ,dated 10/16/2024. - [Resident #90] has nutritional problem or potential nutritional problem r/t post BKA (below the knee amputation), skin integrity, THERAPEUTIC DIET, AND DIAGNOSIS OF PVD (peripheral vascular disease), DM TYPE 1 (diabetes mellitus), ESRD ON HD (hemodialysis), dated 10/21/2024. Interventions included: The resident will maintain adequate nutritional status as evidenced by no s/s of malnutrition, and consuming at least 50% of meals thru next review; Monitor/record/report to MD (Medical Doctor) PRN s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months; Provide and serve supplements as ordered: liquid protein x 30 days; Provide, serve diet as ordered. Monitor intake and record q (every) meal, dated 10/21/2024. 2. During an interview on 11/18/2024 at 11:21 a.m. Resident #263 stated she requested several times for no gravy on the food served and continues to receive it. On 11/19/2024 at 11:55 a.m. Resident #263 was observed with a lunch tray. Resident #263's meal had chopped meat smothered in a brown gravy. Resident #263 stated, I am not going to eat that, I have told them, no gravy. No other option was provided for the resident. During an interview on 11/20/2024 at 2:55 p.m. the Certified Dietary Manager (CDM) stated a therapy aide completes resident choices daily including likes and dislikes. The CDM continued to state meetings are held with all residents upon admission and upon request. The CDM said, I try to speak with them daily in the morning to see if there is anything the resident would like. Upon discussion of the observation of the gravy served to Resident #263 and Resident #90's preferences not being followed, the CDM stated they were not surprised and would need to educate the dietary staff, again. The CDM stated the tray tickets should be followed. Review of the facility's policy and procedure titled, Resident Food Preferences, undated, showed: Policy Statement: individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diets will only be ordered with the resident or representative's consent. Policy interpretation and implementation: 1. Upon residence admission (or within 24 hours after his/her admission) the dietician or CDM will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and meal times. 7. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. 10. The facilities quality assessment and performance improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc.

Based on observation, interview, and policy review, the facility did not ensure appropriate infection control practices on two of two units related to respiratory equipment being left uncovered for one (#103) of one resident sampled for respiratory concerns, an ice scoop left uncovered in a hall, handling of clean linens, cleaning of glucometers, and contact precautions for one (#263) of two residents sampled for transmission-based precautions. Findings included: 1. An observation and interview was conducted on 11/19/24 at 10:05 a.m. in the room of Resident #103. There was a respiratory mask sitting on the bedside table uncovered. The resident said she does not routinely get breathing treatments, only when needed. She said staff leave the respiratory mask on the table uncovered just like it is. Review of Admission Record showed Resident #103 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of Resident #103's Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns, showed she had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of Resident #103's November 2024 physician orders showed an order for Ipratopium-Albuterol Solution 0.5-2.5mg (milligrams)/3ml (milliliters). Give 3 ml inhaler every 6 hours as needed for shortness of breath or wheezing, dated 10/22/24. An observation was conducted on 11/20/24 at 9:09 a.m. during medication administration with Staff E, Licensed Practical Nurse (LPN). The nurse was observed getting a glucometer and a bottle of glucose test strips, entering a resident room, donning gloves, and pricking a resident's finger for a blood glucose check. She wiped the resident's finger then squeezed the finger to get a drop of blood out. She then put her finger with the same gloves in the container containing glucose test strips. When the nurse exited the resident room, Staff E placed the glucometer on the medication cart prior to cleaning it. The glucometer and bottle of test strips were not labeled with a resident name. The nurse said they tried each resident having their own glucometer, but now she just used one for all residents. An observation was conducted on 11/19/24 at 9:38 a.m. of an ice scoop sitting uncovered on a cart with an ice chest in the 200 hall. The ice scoop remained uncovered at 11:47 a.m. An interview was conducted on 10/21/24 at 3:00 p.m. with the Director of Nursing (DON). She confirmed the nurse should not put her hands with soiled gloves in the bottle with the glucose test strips unless it specifically belongs to that resident. She said glucometers should be cleaned between residents and not be placed on the medication cart prior to being cleaned. The DON said the facility had enough glucometers for each resident to have their own and she didn't know why the nurse was using one for all residents. The DON said the ice scoops in the hall should be placed in the container that is on the cart, they should not be left uncovered. The DON also stated respiratory masks should be placed in a bag/box in the resident room and should not be left uncovered on the bedside table. 48223 2. On 11/18/24 at 11:31 a.m., Resident #263 was observed lying in bed. The resident's left foot was observed in a Podus type boot with a towel under the heel and a bandage covering the ankle and heel, dated 11/14/24. The residents' toes were exposed. The big toe had what appeared to be dried blood on the outer tip of the toe and nail. The resident room door did not indicate any type of precautions. On 11/20/24 at 9:45 a.m. Resident #263 was observed lying in bed and the resident room door did not indicate any type of precautions. Review of Resident #263's progress notes dated 11/19/24 at 2:36 p.m. showed the resident complained of loose stools. The nurse practitioner (NP) was notified and ordered a stool culture to check for c-diff (Clostridium Difficile). Review of Resident #263's November 2024 Order Summary Report showed an order dated 11/19/2024: collect stool for c-diff. During an interview on 11/20/24 at 11:48 a.m. Staff H, Licensed Practical Nurse (LPN) confirmed Resident #263 had complained of loose stools and the NP ordered a culture for C-Diff. Staff H, LPN confirmed no precautions were taken at this time. Staff H, LPN stated resident's only go on precautions if when the test results are back and positive for the infection, No precautions are needed yet. If a resident were to need precautions, signs are placed on the door to inform staff of resident needs. Staff H, LPN confirmed Resident #263 is sharing an IV (intravenous) medication pole with another resident who is in need of IV medication. During an interview on 11/21/24 at 12:25 p.m. with the DON and acting Infection Preventionist (IP) stated, Residents who have an order for C-diff are not isolated right away, there is limited space for isolated residents, and it doesn't always come back positive. As soon as we get the result we isolate if positive. If a resident were sharing equipment, bleach wipes would need to be used to clean the equipment. Staff would know this based on the isolation sign on the door. The DON/IP continued to state respiratory equipment should be stored in a plastic bag, that is dated when not in use. During an interview on 11/21/24 at 3:30 p.m. the Nursing Home Administrator (NHA) stated the facility follows CDC (Centers for Disease Control and Prevention) guidelines. Review of the facility policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, undated showed the following: - Policy Statement: transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; Arrives for admission with symptoms of an infection; Or has a laboratory confirmed infection; and is at risk of transmitting infection to other residents. - Policy Interpretation and Implementation: . 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 3. The Centers for Disease control and prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that the personnel and visitors are aware of the need for any and the type of precaution. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE (Personal Protective Equipment), and/or instructions to see a nurse before entering the room. Signs and notifications comply with the resident's rights to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident care equipment items such as stethoscopes, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. - Contact Precautions: 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the residents environment. 3. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with low-risk roommate). 4. Staff and visitors wear gloves (clean non sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves will be removed and hand hygiene performed before leaving the room. Staff will avoid touching potentially contaminated environmental surfaces or items in the residence room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Review of the facility policy and procedure titled, Clostridium Difficile, undated, showed the following: - Policy Statement: Measures are taken to prevent the occurrence of Clostridium Difficile Infection (CDI) among residents. Precautions are taken while caring for residents with C difficile to prevent transmission to other residents. - Policy Interpretation and Implementation: . 3. The primary reservoirs for C difficile are infected people and surfaces. Spores can persist on resident care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. 4. C difficile is transmitted via the fecal oral route. Therefore, any resident care activity that involves contact with the residents mouth when hands or instruments are contaminated may provide an opportunity for transmission, for example: oral care/suctioning; . administration of oral medications; . 5. Steps toward prevention and early intervention include; ongoing surveillance of CDI; increasing awareness of symptoms and risk factors among staff, residents and visitors; considering C difficile and differential diagnosis, especially in residents with symptoms or risk factors; frequent hand washing with soap and water by staff and residents; wearing gloves when handling feces or articles contaminated with feces; disinfection of items with potential fecal soiling (e.g., bed pans, commode chairs, bed rails, etcetera.) Using disinfecting agent recommended for C difficile (e.g., household bleach and water solution or an EPA registered germicidal agent effective against C difficile spores); and removal of environmental sources of C difficile (ie., replacement of electronic thermometers with disposables). 9. Residents with diarrhea associated with C difficile (i.e., residents who are colonized and symptomatic) are placed on contact precautions. Review of the facility policy and procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, with a revision date of November 2011, showed the following: - Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. - Steps in the Procedure: Infection Control Considerations Related Oxygen Administration . 3. [NAME] bottle with date and initials upon opening and discard after 24 hours. 7. Change the oxygen cannula and tubing every seven (7) days or as needed. 8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: . 7. Store the circuit [mask/pipe/tubing, etc] in plastic bag, marked with date and resident's name, between uses. 9. Discard the administration set up every seven (7) days. (Photographic Evidence Obtained)

Based on observations, record reviews, and interviews, the facility failed to ensure one (Resident #7) of two residents sampled for the self-administration of medications was assessed and determined to be clinically appropriate and safe to administer medications. Findings included: An observation was conducted at 10:04 a.m. on 5/4/23 of two medication cups on the over-bed table of Resident #7. There were no residents in the room during the observation. Staff C, Licensed Practical Nurse/LPN observed and confirmed on 5/4/23 at 10:18 a.m., the presence of the two medication cups on Resident #7's over-bed table. Staff C stated the resident was competent and able to take meds by self. Staff C identified one of the tablets as Labetalol, a beta-blocker, and the other was a vitamin. Staff C declined to disclose the name of vitamin. Staff C stated the medications were given at breakfast. He said the resident was at Dialysis and had been on Dialysis for so long, they knew which medications could be taken before Dialysis and which ones should not be taken. A review of the facesheet for Resident #7 revealed the resident was admitted on [DATE] with diagnoses not limited to end stage renal disease, unspecified tremor and atherosclerotic heard disease of native coronary artery with unspecified angina pectoris. The 5-day Minimum Data Set (MDS), identified the resident's Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. The review of Resident #7's physician orders did not reveal an order that would allow the resident to self-administer medications. The physician order list included an order, dated 4/21/23 that instructed staff to Do not hold medications for dialysis. A review of progress notes and documents did not include an assessment for Resident #7's ability to self-administer medications. Resident #7's Medication Administration Record (MAR) was requested but not received. On 5/4/23 at 3:37 p.m., the Director of Nursing (DON) stated the doctors sign off on the self-administration forms and it was not included in the physician orders but uploaded in the documents tab under progress notes. The DON stated Resident #7 could probably self-administer but did not know about an evaluation. She reviewed the uploaded progress notes, (physician notes) and confirmed neither note included a self-administration evaluation. The DON stated staff were to stay with the residents to ensure the residents took their medications. The policy - Self-Administration of Medications, identified Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The interpretation and implementation included: - 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. - 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: -- b. Comprehension of the purpose an proper dosage and administration time for his or her medications; - 5. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. - 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe store is not possible in the resident's room, the medication of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them.

Based on observations, record reviews, and interviews, the facility failed to ensure the controlled substances of one (Resident #8) of three residents sampled was accurately reconciled after the administration of the medication. Findings included: On 5/4/23 at 10:22 a.m., Staff C, Licensed Practical Nurse (LPN) reported being unaware of any discrepancy regarding the accounting of controlled substances. The staff member stated if there was a discrepancy in the accounting, if someone did not add or subtract correctly, and if unable to rectify it, the supervisor was notified. A review of Resident #8's controlled substances on 5/4/23 at 12:40 p.m. was conducted with Staff C. The Individual Resident's Controlled Substance Record identified 30 tablets of 0.5 milligram (mg) of Lorazepam was delivered on 4/30/23. The record indicated 24 tablets should be remaining. The observation with Staff C revealed 25 tablets remained on the blister card. Staff C pointed to the count above and said, doesn't that look like a 5?, this is what we talked about earlier. Staff C confirmed the count on the form should match the amount of tablets that remained on the card. A review of Resident #8's facesheet indicated the resident was admitted on [DATE] and the diagnoses included generalized anxiety disorder. The residents' May Medication Administration Record (MAR) indicated a physician order for Lorazepam 0.5 mg - Give 1 tab by mouth every 2 hours as needed for anxiety. The review of Resident #8's Controlled Substance Record for Lorazepam indicated that the resident received one tablet on 5/1/23 at 10:00 p.m., one tablet at 2:30 p.m on 5/2/23, one tablet at 9:00 p.m. on 5/2/2023, one tablet at 7:00 p.m. on 5/3/2023, and one tablet at 9:00 a.m. on 5/4/23, a total of 5 tablets which at the time of the observation with Staff C left the remaining tablets, 25 (30-5 = 25). A review of Resident #8's MAR indicated that the resident was not administered Lorazepam at anytime on 5/1/23. The policy - Controlled Substances, identified that The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. The interpretation and implementation indicated that the record should contain #4 , L: signature of nurse administering medication and 8: Licensed Nurses are to count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty count together. They must document and report any discrepancies to the Director of Nursing Services/designee at the time observed.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-one medication administration opportunities were observed and three errors were identified for one (Resident #6) of one residents observed. These errors constituted a 14.28% medication error rate. Findings included: On 5/4/23 at 9:44 a.m., an observation of medication administration with Staff C, Licensed Practical Nurse (LPN) was conducted with Resident #6. The staff member dispensed the following medications: - Aspirin Enteric-coated 81 milligram (mg) tablet - Magnesium Oxide 400 mg tablet (staff member dispensed one tablet from a bottle in another medication cart) - Vitamin C 250 mg - 2 tablets - Vitamin B12 100 microgram (mcg) tablet The staff member confirmed that 5 tablets had been dispensed at this time. - Topiramate 100 mg tablet - Pantoprazole 40 mg tablet - Metolazone 2.5 mg tablet - Multi-Vitamin tablet - Vitamin E 90 mg (200 international unit (iu)) tablet - Lidocaine 4% topical patch - Carbamazepine 200 mg - 1.5 tablets - Potassium Extended Release (ER) 20 milliequivalent - 2 tablets - Cranberry 450 mg tablet - Docusate Sodium 100 mg softgel - Atarax 50 mg tablet - Tamsulosin 0.4 mg capsule - Zonisamide 100 mg - 2 capsules - Losartan 50 mg tablet - Furosemide 40 mg tablet - Methocarbamol 500 mg tablet - Carvedilol 12.5 mg tablet Staff C said Resident #6's aspirin tablet was due at 8:00 a.m. He reviewed the dispensed medications to ensure all were noted. He entered the resident's room and placed the medication cup on the over-the-bed table. Staff C applied the Lidocaine patch to the resident's left shoulder. The resident asked for applesauce to take medications. Staff C left the room, leaving the medications on the table. The observation continued after returning to the room. The resident had dumped the tablets/capsules onto a blanket. Staff C watched the resident take the medications. A review of Resident #6's Medication Administration Record (MAR) revealed the following physician orders that were not followed during the observation: - Magnesium Oxide 500 mg - Give 2 tablets (1000 mg) by mouth daily, diagnosis (dx) age-related deficiency. - Vitamin E 180 mg softgel - Give 1 capsule by mouth by daily, dx: age-related deficiency. - Aspirin 81 mg chewable tablet - oral once daily (1) time a day. On 5/4/23 at 3:37 p.m., the Director of Nursing (DON) stated the expectation was to follow physician orders. A policy regarding the Administration of Medications was requested but not received.

Based on observations, review of the facility policy, and interviews, the facility failed to ensure medications were not accessible to residents, visitors, and/or unauthorized staff on one (Cart 2) of two medications carts on the second floor. Findings included: On 5/4/23 at 9:40 a.m., an observation was made of a nurse leaving a medication cart parked outside of room [ROOM NUMBER] and entering a nearby resident room. A continued observation indicated that the medication cart was unlocked while unattended, a medication cup with medications in it and 2 bottles of over-the-counter (OTC) medications were sitting on top of the cart. At the same time of the observation, another staff member, Staff Member B (Registered Nurse/RN), walked to cart and locked it. Staff B confirmed that the medication was unlocked and unattended. Staff Member C (Licensed Practical Nurse/LPN) confirmed the presence of the bottles of Ibuprofen and Docusate Sodium on top of the medication cart. Staff C confirmed that bottles did contain medications. The staff member stated, if you want to call them meds, their stool softener and Ibuprofen. During the task of medication administration, Staff C dispensed a tablet of low-dose aspirin into a medication cup then placed the med cup behind the carts' laptop, don't touch that and walked to another medication cart parked further away from the nursing station. The staff member returned with a tablet and continued to dispense Resident #6's medications. The policy - Storage of Medications, indicated that The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The interpretation and implementation of the policy identified that: 1. Drugs and biologicals used in the facilty are stored in locked compartments under proper temperature, light, and humidity controls. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs an d biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended.

Based on observations, interviews, and policy review, the facility failed to ensure air conditioning (A/C) units were maintained in a sanitary manner for one of four hallways, during four of four days of survey. Findings included: During a facility tour on 09/18/22 at 10:04 a.m., A/C units on the first-floor hallway (rooms 116-129) were noted with bio growth around the grills, dust on surfaces, filters clogged with dirt, lint build-up, and debris. On 09/19/22 at 12:43 p.m., A/C units were noted with on-going concerns related to bio-growth on units, and filters with dirt and debris. On 09/21/22 at 2:23 p.m., on- going concerns with A/C units as previously observed, noted not cleaned. On 09/21/22 at 9:02 a.m., an interview was conducted with Staff A, housekeeping aide. Staff A stated she did not clean A/C units. Staff A stated she wiped the surfaces down during general cleaning. Staff A looked at one of the filters in room [ROOM NUMBER] and said, Yes they need to be cleaned. Staff A stated maintenance was responsible for cleaning the filters. Staff A stated she would notify her supervisor of the concern. On 09/21/22 at 09:10 a.m., an interview was conducted with the Housekeeping Manager (HM). The HM stated the housekeeping department was not responsible for the maintenance of the A/C units. The HM stated it was the maintenance department's responsibility. The HM stated she had not seen them clean the units this month. The HM stated she thought they followed a schedule, but she was not sure. An interview was conducted on 09/21/22 at 09:16 a.m. with the director of maintenance (DOM). The DOM stated the A/C units were cleaned every other month or as needed. The DOM stated they cleaned the units when the filters were visibly clogged. The DOM stated he did not remember the last time they cleaned this hall, but he would check. He stated they did not keep a schedule but maybe they should. The DOM toured the hall with the surveyor and looked at room [ROOM NUMBER] as a sample . The DOM observed filters in this room and stated they were clogged with dirt and debris. The DOM said, We will take care of this now, they should not look like that. I know it is unsanitary. The DOM stated they would use bleach and water to clean the bio-growth substance. The DOM stated they normally kept the units clean. A follow-up was conducted on 09/21/22 at 09:30 a.m. with the nursing home administrator (NHA). The NHA stated she thought the A/C units were recently cleaned. She stated they had records showing the filters were cleaned recently. Her expectation was to maintain clean units. Review of an undated facility policy titled, clean air filters, showed instructions to: 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace. 3. Re-install access cover. 4. Clean grill on cover. 5. Close and make sure it is secure. 6. At a minimum, air filters are to be replaced or thoroughly cleaned . 7. Clean evaporate coils if lint build up. 8. Inspect electric motor.

Based on staff interviews and record review the facility failed to provide three (#33, #43, and #114) of three residents sampled for hospitalization s with written notification and completed notification of transfers and failed to notify the State Long-Term Care Ombudsman Council (LTCOC) office of transfers. Findings included: An interview was conducted on 4/22/21 at 2:15 p.m. with the Social Service Director (SSD). The SSD reported that it was her responsibility to notify the State Office of the Long-Term Care Ombudsman of residents transfer or discharge and if she was being honest, up until you guys came I didn't know I was supposed to. She admitted to beginning her tenure with the facility in July 2020. At 1:58 p.m. on 4/22/21, the SSD stated the Nursing Home Transfer and Discharge Notices were her responsibility to complete if the resident discharges to home and nursing was responsible for them if the resident was being transferred to the hospital. On 4/20/21 at 3:47 PM, Staff Member A, Registered Nurse (RN), explained the procedure to sending a resident to the hospital. She stated she wrote an order to send to the hospital and sent a Situation, Background, Assessment, and Review (SBAR). Staff Member C, Licensed Practical Nurse (LPN), interjected physician notes. Staff A did not answer when asked if she completed a Nursing Home Transfer and Discharge Notice. On 4/20/21 at 3:54 p.m., Staff Member B, RN was interviewed immediately following the transfer of one of her assigned residents to the hospital. She stated they, used to do the form for Nursing Home Transfer and Discharge Notice. On 4/22/21 at 12:42 PM, the Director of Nursing (DON) stated if a resident was being transferred to the hospital the nurse was responsible for completing the Nursing Home Transfer and Discharge Notices. 1. Record review for Resident #33 revealed a SBAR dated 12/2/20 indicated Resident #33 began vomiting and to feel weak and an order was received by the provider to send the resident to the emergency room (ER). An admission observation, dated 12/5/20, identified Resident #33 returned to the facility at 12:04 a.m. by an ambulance stretcher. A SBAR dated 12/31/20 indicated the facility received an order to send the resident to the ER due to fever and being non-responsive. On 1/3/21 at 10:54 p.m., an Admission observation was documented to indicate the resident returned to the facility. A request was made on 4/21/21 at 4:49 p.m. to provide the Nursing Home Transfer and Discharge Notices for the resident. The facility provided one notice dated 12/2/20. The notice did not include the name of the resident's representative, a reason for his discharge or transfer, the date that the notice was given to the resident/legal guardian/representative, or the date the notice was given to the Local Long-Term Care Ombudsman Council. The facility did not provide the notice for the transfer on 12/31/20. 2. A review of Resident #43's Resident Census revealed an original admitted [DATE] and multiple discharges/hospitalization s. The facility provided Resident #43's Nursing Home Transfer and Discharge Notices which revealed: - 1/12/20 - the form did not include the location to which the resident was transferred or discharged to, the effective date, the reason for discharge or transfer, the date that the resident, physician, and Nursing Home Administrator/Designee signed the form, and the date the notice was provided to the LTCOC. - 4/27/20 - the form did not include the location to which the resident was transferred or discharged to, the date the notice was given, the effective date, the reason for discharge or transfer, and the date the notice was provided to the LTCOC. - 5/20/20 - the form did not include the complete information for the location to which the resident was transferred or discharged to, the effective date, the reason for discharge or transfer, the date that the resident (documented as refused to sign), physician, and Nursing Home Administrator/Designee signed the form, and the date the notice was provided to the LTCOC. - 6/3/20 - the form did not include the complete location to which the resident was transferred or discharged to, the reason for discharge or transfer, the date that the resident and physician signed the form, and the date the notice was provided to the LTCOC. - 8/17/20 - the form did not include the effective date, the reason for discharge or transfer, the date that the physician signed the form, and the date the notice was provided to the LTCOC. - 10/2/20 - the form did not include the reason for discharge or transfer, the date that the physician, and Nursing Home Administrator/Designee signed the form, the date the notice was provided to the LTCOC, and the notice was signed by Staff Member E, Licensed Practical Nurse (LPN) as the resident/ resident representative. - 12/18/20 - the form did not include the date the notice was given, the effective date, the reason for discharge or transfer, and the date the notice was provided to the LTCOC. 3. A review of Resident #114's closed medical record revealed a discharge date of [DATE]. A review of SBAR communication form dated 3/4/21 revealed Resident # 114 was sent to the emergency room for evaluation due to extreme weakness and altered mental status. A review of the Nursing Home Transfer and Discharge Notice dated 3/4/2021 revealed the following areas were not completed: resident representative, reason for discharge or transfer, the date the notice was given to resident, legal guardian or representative and LTCOC. During an interview with Staff D, Unit Manager (UM), on 4/22/21 at 2:15 p.m. the UM confirmed that she filled out the form, but may have been in a hurry to complete it. She stated that the resident's son was notified of the transfer, and it was documented on the SBAR. On 4/22/2021 at 4:40p.m, the DON stated that she will have to get the Nursing Home Administrator (NHA) to provide the answer of why the Nursing Home Transfer and Discharge Notice information was not completed. Neither the DON nor the NHA returned to provide answers. Record review of the facility policy and procedure titled, Transfer or Discharge Notice, last revised December 2016 revealed: 2. Under the following circumstances, the notice will be given as soon as it is practical but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. f. An immediate transfer or discharge is required by the resident's urgent medical needs 3. The resident/ or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. Effective date of the transfer or discharge c. The location of which the resident is being transferred or discharged

Based on interviews, record reviews and observations, the facility failed to ensure four Residents (#26, #49, #64, #84) of four residents sampled received restorative nursing services in order to maintain their ability to perform activities of daily living. Findings Included: 1) During an interview on [DATE] at 2:22 p.m. Resident #26 stated he had not had a shower in 10 days and feels like he gets restorative nursing when he is in the shower but has not received the restorative nursing program he was told he would get. The resident stated he is not progressing forward and wants to go home but is not sure if that will be possible. Review of the care plan problem area dated [DATE] revealed the resident's ADL/restorative nursing program required active range of motion to bilateral upper extremity 6 days per week. Long term goal to increase strength for transfers and wheel chair mobility created on [DATE]. Approach date of [DATE] for bilateral upper extremity using 3 to 4 pound weight and green theraband, all planes as tolerated, once a day from 7 a.m. to 3 p.m. Problem area revealed the resident ADL/restorative nursing program for limited ability to complete sit to stand created on [DATE]. Long term goal to maintain lower extremity strength to reduce risk of decline to perform sit to stand. Approach using grab bar with max assist x 2 or sit to stand transfers using parallel bars with moderate assist x 1, gait belt for safety, once a day from 7 a.m. to 3. p.m. dated [DATE]. Problem area requires active range of motion to bilateral lower extremity 6 days per week dated [DATE]. Long term goal to maintain lower extremity strength to reduce risk of decline to perform sit to stand dated [DATE]. Approach for bilateral lower extremity using 2 to 3 pound cuff weights for 10 to 15 reps x 2 to 3 sets once a day during 7 a.m. to 3 p.m. dated [DATE]. Review of the minimum data set (MDS) dated [DATE] section C revealed the resident had a brief interview for mental status score (BIMS) of 15 meaning intact cognition. Review of the restorative nursing nursing category report from [DATE] to [DATE] revealed Resident #26 received one therapy session on [DATE] for range of motion and none for transfers. For the dates of [DATE] to [DATE] the resident received two therapy sessions, one on [DATE] for range of motion and transfer. One session on [DATE] for range of motion. During an interview with the Director of Rehabilitation (DOR) on [DATE] at 9:41 a.m. she stated the resident was on the restorative program for a few things and that they started using the care plans in the computer. Therapy adds the restorative nursing program to residents and the restorative nursing aide prints it out and completes the tasks as required. 2) During an interview with Resident #49 on [DATE] 9:20 a.m. she stated she is not getting restorative therapy on her back, shoulders and walking. Review of Resident #49's admission documentation revealed the resident was admitted on [DATE] with a readmitted on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the resident was discontinued from the occupational therapy services to restorative nursing program. Review of the MDS dated [DATE] revealed in section C. a BIMS score of 14 meaning cognitively intact. Review of the care plan dated [DATE] for problem area ADL/Restorative Nursing program required resident do active range of motion to back and bilateral shoulders 6 days per week. Long term goal to maintain current level of function. Approach date [DATE] the resident will complete back and shoulder stretches for pain management x 20 reps once a day from 7 a.m. to 3 p.m. Problem start date of [DATE] for limited ability to dress/undress self. Long term goal to maintain ability to complete all ADL's and functional mobility with wheel chair at current level of function. Approach date of [DATE] to complete all ADL's with minimal assist, including transfers. Review of Resident #49's restorative nursing program dated [DATE] to [DATE] revealed the resident received therapy on [DATE] for range of motion. Review of Resident #49's restorative nursing program dated [DATE] to [DATE] revealed the resident received therapy on [DATE] and [DATE] for range of motion. During an interview on [DATE] at 9:40 a.m. with the Director of Rehab she stated the resident doesn't like to participate in therapy. She starts and stops and says its pointless but she has restorative nursing program for her ADL's, transfers and shoulders. 3) During an interview with Resident #64 on [DATE] at 11:26 a.m. she stated she is declining in her walking abilities and used to walk 325 feet but has not been getting restorative nursing and is wanting to get restorative nursing again since she can not walk like she used too. Resident #64 stated she is going to the bathroom on her own since staff take so long to assist her. During an interview on [DATE] at 9:00 a.m. Resident #64 stated she has not had restorative care due to the aide being pulled to work on the floor as a CNA. During an interview on [DATE] at 11:00 a.m. the resident stated she had not been to restorative but maybe 3 times and used to walk up to 325 feet and feels like she is loosing her abilities without therapy. During an interview on [DATE] at 11:25 a.m. Resident #64 stated she is hoping to regain therapy so she won't lose her abilities. Resident #64 confirmed she had restorative therapy maybe 3 times in a month. During an interview on [DATE] at 9:11 a.m. with the DOR, she stated therapy has been tasked with entering the restorative program in the computer and there will be no order for restorative just the order to discontinue therapy and move to restorative nursing program. The DOR stated Resident #64 is currently on active range of motion for upper body and was on lower body but that expired. Review of the medical record revealed Resident #64 was admitted on [DATE] with a readmit on [DATE] and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], revealed in section C a BIMS score of 15, cognitively intact. Review of the care plan dated [DATE] revealed a problem area for active range of motion to bilateral upper extremities 6 days per week. Goal to increase strength for mobility an transfers. Approach date of [DATE] for bilateral upper extremity (bue) using one pound dowel and yellow theraband, all planes 3 sets of 10 reps as tolerated. [DATE] ADL resident requires active range of motion bilateral upper 6 days per week. resident will increase strength for mobility and transfers. bue using 1 lb dowel and yellow theraband, all planes 3 sets of 10 reps. Review of the restorative nursing report dated [DATE] to [DATE] revealed Resident #64 received restorative nursing on [DATE] for walking. Review of restorative nursing from [DATE] to [DATE] revealed Resident #64 received restorative nursing on [DATE] for range of motion. 4) During an interview with Resident #84 on [DATE] at 9:30 a.m. she stated she has not received restorative therapy and she needs help with all her extremities. During an interview with the DOR on [DATE] at 9:33 a.m. she stated the resident was on a functional maintenance program from January through March then she moved to the restorative nursing program through [DATE]th for bilateral upper extremities. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed a BIMS score of 15 for cognitively intact. Review of the care plan revealed a problem area on [DATE] for range of motion to bilateral upper extremity. Long term goal to decrease contracture to bilateral upper extremity. Approach date of [DATE] for bilateral upper passive range of motion, all planes as tolerated. Wear bilateral elbow splints daily, 4 to 6 hours as tolerated with skin check pre and post wear, once a day from 7 a.m. to 3 p.m. Problem start date of [DATE] for limited range of motion to bilateral elbows. Long term goal to maintain passive range of motion bilateral upper extremities, all planes to be able to assist with ADL's and use of joystick when in chair. Approach dated [DATE] to wear bilateral elbow splints daily as tolerated. Once a day from 7 a.m. to 3 p.m. Problem area dated [DATE] for limited range of motion to bilateral upper extremity. Long term goal to receive passive range of motion to bilateral upper extremity, daily to maintain range of motion to be able to assist with ADL's and use of joystick when in chair. Approach date of [DATE] for passive range of motion to bilateral upper extremities, all planes as tolerated. Once a day from 7 a.m. to 3 p.m. Review of the restorative nursing report dated [DATE] to [DATE] revealed the resident received therapy on [DATE] and [DATE] for range of motion and splint or brace assistance. Review of Resident #84's restorative nursing program dated [DATE] to [DATE] revealed the resident received therapy on [DATE] and [DATE] for range of motion. During an interview on [DATE] at 2:30 p.m. with Staff member O, CNA she stated she gets the census daily for restorative therapy and has 26 residents that need restorative therapy daily. She stated in the last month she has worked at least six days on the floor as a CNA. She stated, I can not keep up with restorative when I am working on the floor. Staff member O, stated she completes morning daily weights on residents that takes until around 10:30 a.m. then she will get a few residents to do restorative nursing and around 11 a.m. she gets residents ready for lunch then charts. Staff member O, stated, On a day when I work restorative I work 40 minutes before noon and after lunch about 3 hours a day as restorative aide. We used to have another restorative aide but now I am the only one and I work the floor as a CNA and next week I start monthly weights. I do not have enough help to do the restorative position. Staff member O, confirmed she did not have an effective restorative program after looking at the amount of therapy the residents have received since [DATE]st. Staff member O confirmed the unit manager is over the restorative program. During an interview with Staff member D, UM on [DATE] at 4:44 p.m. she confirmed the restorative nursing Residents #26, #49, #64 and #84 should be getting restorative nursing five to six days a week and they are not at this time. Staff member D stated she just acquired this position recently and was not aware the residents were not getting restorative therapy. During an interview with the Director of Nursing (DON) on [DATE] at 4:34 p.m. she confirmed that residents scheduled for restorative therapy should be getting therapy as directed. Review of the policy restorative nursing services revised [DATE], one page revealed: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. 2. residents may be started on restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the residents plan of care.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and four errors were identified for three (#75, #81, and #28) of five residents observed. These errors constituted a 16% medication error rate. Findings included: The policy titled Administering Medications, 2001 Med-Pass Inc. (Revised April 2019), acknowledged that Medications are administered in a safe and timely manner, and as prescribed. The policy identified the following Interpretation and Implementations: - 3. Medications are administered in accordance with prescriber orders, including any required time frame.; - 6. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - 8. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. On 4/20/21 at 8:25 a.m., an observation of medication administration with Staff Member A, Registered Nurse (RN), was conducted with Resident #75. Staff Member A was observed administering the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -- Pure Aide 0.4/0.3% Lubricant Eye drops - Biofreeze topical gel - [MEDICATION(S)] (Guiafenesin) 400 milligram (mg) tablet - Multi Vitamin with minerals tablet - [MEDICATION(S)] 5 mg tablet - [MEDICATION(S)] 0.25 mg tablet - [MEDICATION(S)] 50 mg tablet A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (Guaifenesin) Extended Relief 12 hour (hr) 600 mg tablet orally every 12 hours. - Calcium with Vitamin D (calcium [MEDICATION(S)] - vitamin D3) 600 mg orally daily. During the observation, Staff A notified Resident #75 that she did not have the Calcium with Vitamin D but would hunt it down. The MAR for the resident indicated on 4/20/21 at 8:43 a.m., Staff A noted that the Calcium with Vitamin D was unavailable for administration. 2. On 4/20/21 at 8:55 a.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #81. Staff Member I was observed administering the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 200 milligram (mg) tablet - Vitamin B-12 1000 microgram (mcg) tablet - Senna Plus 8.6/50 mg tablet - Topamaz 50 mg tablet - 2 Vitamin C 250 mg tablets - [MEDICATION(S)] spray A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Geri-kot (sennosides - Over the Counter (OTC)) 8.6 mg tablet: Give one tablet by mouth twice daily. Dx: Constipation. 3. On 4/20/21 at 8:48 a.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN) was conducted with Resident #28. The staff member administered oral medications without any concerns. After an observation of another resident's (#81) administration the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what the red meant, Staff I asked this writer if they knew anything about the system, acknowledged that the resident had a late medication, and stated I must have missed it. The following medication administration was observed at 9:00 a.m. for Resident #28: - [MEDICATION(S)] KwikPen U-100 Insulin glargine) Insulin pen; 100 units/milliliter (mL); 34 units subcutaneous. The observation identified that Staff I dialed the KwikPen to 34 units, entered the resident room, donned gloves, stood next to the resident. The staff member complied with stepping outside the resident room with this writer prior to injecting 34 units of insulin. While standing next to the medication cart, Staff I was asked if she had primed the KwikPen, she admitted that she had not and that she did usually prime the pen. The staff member wasted 34 units of [MEDICATION(S)] insulin, retrieved another fine needle from another floor nurse, primed the pen with 2 units, dialed 34 units of insulin, and then administered it to the resident. A review of Resident #28's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Comment: 0. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the manufacturer literature, [MEDICATION(S)] KwikPen should be prime before each injection. The literature identified, priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly and if you do not prime before each injection, you may get too much or too little insulin. The instructions for the [MEDICATION(S)] KwikPen indicated to prime you pen, turn the dose knob to select 2 units, hold pen with needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, and while holding you pen with needle up, push the dose knob until it stops, the user should see insulin at the tip of the needle. This information was located at: https://uspl.lilly.com/[MEDICATION(S)]/[MEDICATION(S)].html#ug0. At 4/22/21 at 11:26 am., an interview was conducted with the Consultant Pharmacist. She confirmed that medications should be available to be administered including over the counters and that that staff should verify that the correct medication is dispensed and administered. She confirmed that the [MEDICATION(S)] Kwikpen should be primed prior to each use and that [MEDICATION(S)] can be given anytime of the day as long as staff reached out to the physician. At 12:33 p.m. on 4/22/21, the Director of Nursing was interviewed regarding the Medication Administration observations. When asked if insulin pens should be primed prior to use, she stated she believed so but would like a chance to confirm. The Director of Nursing did not offer any further information regarding this concern.

Based on interview and record review the facility failed to complete a through investigation of a grievance and failed to provide a resolution to the grievance for 1 of 41(#213) sampled residents. Findings included: Review of the facility's documents revealed that a grievance was filed on 1/6/21 which revealed that the family member to resident #213 complained that the resident was told that she could urinate and make bowel movements in her incontinence brief. Further review of the grievance revealed that the facility provided an In-service dated 1/9/21 to Certified Nursing Assistants (CNA) related to not telling residents to have incontinent episodes in the incontinent briefs. Review of the grievance form revealed that there was no documentation that would indicate that an investigation was completed related to the family member's complaint. Closer review of the document revealed that the area that identified resolution and date of follow-up was left blank. Interview on 4/22/21 at 2:36 PM with the Director of Social Services revealed that she did not complete the investigation for this grievance. She reported that the Administrator In Training at the time was assisting with grievances and completed this grievance investigation, resolution and follow up. She was not aware at this time if a complete investigation was conducted. She confirmed that she was the Grievance Coordinator and is responsible for ensuring that grievances are investigated and a resolution provided. She also said that the CNAs were in-serviced on not telling the residents that they should urinate or have bowel movements in their incontinent briefs, and that the in-service would be considered the resolution. She was unable to verbalize if the complainant was apprised of the resolution. Review of the Facility policy titled Filing Grievances/Complaints with a revised date of November 2010 revealed the following 5. Upon receipt of a grievance and/or complaint, Social Service Director will investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. 7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems