Every finding on record at Twin City Trails of Journey LLC

Based on staff and resident interviews, record review, and review of the facility policy titled ABUSE, NEGELECT, [sic] AND EXPLOITATION, the facility failed to protect the resident's right to be free from physical abuse for one of 16 sampled residents (R) (R3). Specifically, R13 pushed R3, causing a fall. This deficient practice had the potential to place R3 at increased risk of injury related to being pushed. Findings include:Review of the facility's policy titled ABUSE, NEGELCT, [sic] AND EXPLOITATION, reviewed 03/05/2024, documented Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse. In addition, documented Definitions: 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. and .'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking.1. Review of the admission Record for R3 documented diagnoses including, but not limited to, schizoaffective disorder bipolar type, mixed obsessional thoughts and acts, other somatoform disorders, dementia unspecified, unspecified psychosis, and major depression.Review of the Minimum Data Set (MDS) assessment for R3, dated 03/25/2026, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. Section GG (Functional Abilities and Goals) documented that R3 was independent in activities of daily living, except for setup assistance with meals.Review of the care plan for R3, revised 04/07/2026, revealed a Focus that R3 had a behavior problem of attempting to restrict other residents from using the shared restroom.Review of the Progress Notes for R3 revealed an entry dated 06/02/2026 at 5:28 PM of, Writer was in room [ROOM NUMBER] assisting another resident. This resident (referring to R3) was in the bathroom when resident 10-3 (referring to R13) came in the bathroom. This resident told her she was washing her hands, but other resident refused to leave so this resident came out. A few minutes later this resident noticed the bathroom light was off so she opened the door to go in. Writer heard this resident holler out and looked to see this resident falling backwards to the floor. Writer went immediately to the bathroom and observed resident 10-3 standing in the other door way watching this resident. I asked resident what happened and she stated that resident 10-3 pushed her.2. Review of the admission Record for R13 revealed diagnoses including, but not limited to, paranoid schizophrenia and Alzheimer's disease.Review of the MDS assessment for R13, dated 03/25/2026, revealed that section C (Cognitive Patterns) documented a BIMS score of 13, indicating little to no cognitive impairment. Section E (Behaviors) documented no indicators of psychosis. Section GG (Functional Abilities and Goals) documented that R13 was independent with transfers and walking but needed setup or clean-up assistance with toileting. Review of the care plan for R13, revised 05/09/2026, revealed Focus areas for R13, including, but not limited to: R13 is alert. She verbalizes wants and needs. Ambulates to and from areas. Very poor decision-making skills. Loud and disruptive. Uncooperative. Takes belongings from others, rummaging through others' belongings. Easily agitated when things don't go her way. Does not respond to redirection most of the time. Very difficult to redirect.Review of the active Physician's Orders dated 06/10/2026, for R13 documented orders that included, but were not limited to:05/25/2026: Notify mental health provider that patients continue to refuse Haldol injection.05/04/2026: Refer to mental health provider for follow-up; recently released from behavioral unit.05/04/2026: Refer to mental health provider, patient appears t [sic] be non-compliant with medication regimen.Review of the Progress Notes for R13 revealed an entry dated 06/02/2026 of Writer was assisting resident 8-2 when resident 8-1 (R3) went to the bathroom to wash her hands. Resident 10-3 (R13) then went in the bathroom and resident 8-3 came out. After a few minutes, resident 8-1 opened the bathroom door. This resident (referring to R13) became aggressive and pushed her (referring to R3) out causing her to fall backwards to the floor. Resident {R13} using verbally abusive and aggressive language towards writer and resident {R3}. Other staff arrived and assisted with situation. Admin (Administrator), DON (Director of Nursing), MD (Medical Director), and police notified. 1013 Order (a legal document used to allow a licensed doctor, psychologist, or police officer to involuntarily hold someone for a mental health evaluation) received to send resident to ER (emergency room).Review of a facility-provided document title, FORM 1013-CERTIFICATE AUTHORIZING TRANSPORT TO EMERGENCY RECEIVING FACILITY & REPORT of TRANSPORTATION (Mental Health), and documented on the form, but not limited to, .This is to certify that I have personally examined (R13 name) on June 2, 2026 at 600pm, which was within the preceding 48 hours of the signing of this certificate. In my opinion this individual appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill AND: .presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to other persons; . This individual: Has committed/expressed recent overt acts/threats towards others. In addition, a handwritten note was entered on the line that read For example: Assaulted Peer. The document was dated and signed by the Medical Director (MD) on June 2, 2026, at 6:00 PM. Further review of this document revealed that the DON completed the form and signed on June 2, 2026, at 6:00 PM by filling in the blanks, including R13's name. Review of the facility-provided document titled #3706 Resident to Resident Altercation-Recipient dated 06/02/2026 at 5:15 PM revealed the Incident Description section included Nursing Description: Resident entered bathroom and was pushed down by resident room [ROOM NUMBER]-3. Resident Description: I entered the bathroom to wash my hands. The light was off, and she pushed me. Documented under Immediate Action Taken and Description: Staff intervened, and this resident was assessed for injury. Resident lying on her back on the floor in doorway of the bathroom. Resident alert and responsive, asking staff to help her up.Review of the facility-provided document titled #3707 Resident to Resident Altercation-Aggressor dated 06/02/2026 at 5:15 PM revealed the Incident Description section included, Nursing Description: (R13) was attempting to get into the shared bathroom, at this time another resident who shares the bathroom was attempting to get into the bathroom and was told to wait, which she did. When R13 went back into the bathroom, R3 was seen falling through the doorway to the floor. Resident Description: Resident unable to give description.In an interview on 06/09/2026 at 11:16 AM, R3 stated that at the time of the incident, she was in the bathroom washing off. R13 kept coming in, and I told her I was there. The fourth time she came in, I came out and let her in the bathroom. As soon as she went out and turned off the light, I went in there, and she came in and pushed me down. She stated she feels a lot safer at night since the woman in the other room is gone.In an interview on 06/11/2026 at 2:17 PM, Licensed Practical Nurse (LPN) EE stated at the time of the incident, she was assisting the lady in the middle bed of room [ROOM NUMBER], and R3 was in the bathroom. She heard R3 say I'm in here. R3 came out of the bathroom and waited a few minutes. LPN EE stated the light was off, so R3 went back to the bathroom, opened the door, and then she saw R3 fall backward. LPN EE stated she went to look and saw R13 in the other doorway, hollering something. She told R13 she needed to check R3, as she noticed a skin tear, and then the other staff came. LPN EE stated the light was off, so that is why R3 went back into the bathroom.In an interview on 06/11/2026 at 3:07 PM, Registered Nurse (RN) FF stated that at the time of the incident, she was in her office and heard screaming. She stated that when she entered R3's room, staff were assisting R3 to stand up and attempted to redirect R13 to her room, and R13 refused. RN FF stated that 911 and the police were called, as R13 refused to do anything. She stated that R13 was transported to the ER by Emergency Management Services (EMS).In a concurrent interview on 06/12/2026 at 12:07 PM, the Administrator and Director of Nursing (DON), the Administrator stated R13 had a diagnosis of schizophrenia, refused medications and care, and was not easily redirected. The DON stated that R13 had exhibited verbal aggression prior to the incident involving R3.

Based on staff interviews, record review, and review of the facility policy titled ABUSE, NEGELECT, [sic] AND EXPLOITATION, the facility failed to report a resident-to-resident physical altercation to the State Survey Agency (SSA) within the required timeframe for two of 16 sampled residents (R) (R3 and R13). Specifically, R3 fell as a result of being pushed by R13. This deficient practice had the potential to increase the risk of other potential abuse not being reported. Findings include:Review of the facility's policy titled ABUSE, NEGELCT, [sic] AND EXPLOITATION, reviewed 03/05/2024, documented Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse. In addition, documented Definitions: 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. and .'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking. In addition, documented in section VII. Reporting/Response, .A.1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes.B. The Administrator will follow up with government agencies.and to report the results of the investigation when final within 5 workings days of the incident, as required by state agencies.1. Review of the admission Record for R3 documented diagnoses including, but not limited to, schizoaffective disorder bipolar type, mixed obsessional thoughts and acts, other somatoform disorders, dementia unspecified, unspecified psychosis, and major depression.Review of the Minimum Data Set (MDS) assessment for R3, dated 03/25/2026, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. Section GG (Functional Abilities and Goals) documented that R3 was independent in activities of daily living, except for setup assistance with meals.Review of the Progress Notes for R3 revealed an entry dated 06/02/2026 at 5:28 PM of, Writer was in room [ROOM NUMBER] assisting another resident. This resident (referring to R3) was in the bathroom when resident 10-3 (referring to R13) came in the bathroom. This resident told her she was washing her hands, but other resident refused to leave so this resident came out. A few minutes later this resident noticed the bathroom light was off so she opened the door to go in. Writer heard this resident holler out and looked to see this resident falling backwards to the floor. Writer went immediately to the bathroom and observed resident 10-3 standing in the other door way watching this resident. I asked resident what happened and she stated that resident 10-3 pushed her.2. Review of the admission Record for R13 revealed diagnoses including, but not limited to, paranoid schizophrenia and Alzheimer's disease.Review of the MDS assessment for R13, dated 03/25/2026, revealed that section C (Cognitive Patterns) documented a BIMS score of 13, indicating little to no cognitive impairment. Section E (Behaviors) documented no indicators of psychosis. Section GG (Functional Abilities and Goals) documented that R13 was independent with transfers and walking but needed setup or clean-up assistance with toileting. Review of the Progress Notes for R13 revealed an entry dated 06/02/2026 of Writer was assisting resident 8-2 when resident 8-1 (R3) went to the bathroom to wash her hands. Resident 10-3 (R13) then went in the bathroom and resident 8-3 came out. After a few minutes, resident 8-1 opened the bathroom door. This resident (referring to R13) became aggressive and pushed her (referring to R3) out causing her to fall backwards to the floor. Resident {R13} using verbally abusive and aggressive language towards writer and resident (R3). Other staff arrived and assisted with situation. Admin (Administrator), DON (Director of Nursing), MD (Medical Director), and police notified. 1013 Order (a legal document used to allow a licensed doctor, psychologist, or police officer to involuntarily hold someone for a mental health evaluation) received to send resident to ER (emergency room).Review of the facility-provided document titled #3706 Resident to Resident Altercation-Recipient dated 06/02/2026 at 5:15 PM revealed the Incident Description section included Nursing Description: Resident entered bathroom and was pushed down by resident room [ROOM NUMBER]-3. Resident Description: I entered the bathroom to wash my hands. The light was off, and she pushed me. Documented under Immediate Action Taken and Description: Staff intervened, and this resident was assessed for injury. Resident lying on her back on the floor in doorway of the bathroom. Resident alert and responsive, asking staff to help her up.Review of the facility-provided document titled #3707 Resident to Resident Altercation-Aggressor dated 06/02/2026 at 5:15 PM revealed the Incident Description section included, Nursing Description: (R13) was attempting to get into the shared bathroom, at this time another resident who shares the bathroom was attempting to get into the bathroom and was told to wait, which she did. When R13 went back into the bathroom, R3 was seen falling through the doorway to the floor. Resident Description: Resident unable to give description.In an interview on 06/11/2026 at 9:49 AM, the Administrator stated that no incidents had been reported to the SSA since April 2026.In a concurrent interview with the Administrator and Director of Nursing (DON) on 06/12/2026 at 12:07 PM, the Administrator stated the incident was not reported to the SSA because he understood that it was witnessed that R13 was behaving erratically, and he was under the impression there was no assault. He further stated that staff asked if R13 could be transferred to the ER with a 10-13 status, and he felt that R13 should have been moved for the safety of the other residents. He further stated at the time that he did not see the incident as intentional, and it was unwitnessed, so it was not reported. The DON stated she was unable to determine if R13 intended to hurt R3. The DON stated she notified the Regional Nurse, and the Administrator stated he notified the Corporate [NAME] President. Cross-Reference F600

Based on staff interviews, record review, and review of the facility policy titled ABUSE, NEGELECT, [sic] AND EXPLOITATION, the facility failed to thoroughly investigate a physical altercation between two of 16 sampled residents (R) (R3 and R13). Specifically, R13 pushed R3, causing a fall. This deficient practice had the potential to increase the risk for abuse to continue. Findings include:Review of the facility's policy titled ABUSE, NEGELCT, [sic] AND EXPLOITATION, reviewed 03/05/2024, documented Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse. In addition, documented Definitions: 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. and .'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking. In addition, documented in section V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.1. Review of the admission Record for R3 documented diagnoses including, but not limited to, schizoaffective disorder bipolar type, mixed obsessional thoughts and acts, other somatoform disorders, dementia unspecified, unspecified psychosis, and major depression.Review of the Minimum Data Set (MDS) assessment for R3, dated 03/25/2026, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. Section GG (Functional Abilities and Goals) documented that R3 was independent in activities of daily living, except for setup assistance with meals.Review of the Progress Notes for R3 revealed an entry dated 06/02/2026 at 5:28 PM of, Writer was in room [ROOM NUMBER] assisting another resident. This resident (referring to R3) was in the bathroom when resident 10-3 (referring to R13) came in the bathroom. This resident told her she was washing her hands, but other resident refused to leave so this resident came out. A few minutes later this resident noticed the bathroom light was off so she opened the door to go in. Writer heard this resident holler out and looked to see this resident falling backwards to the floor. Writer went immediately to the bathroom and observed resident 10-3 standing in the other door way watching this resident. I asked resident what happened and she stated that resident 10-3 pushed her.2. Review of the admission Record for R13 revealed diagnoses including, but not limited to, paranoid schizophrenia and Alzheimer's disease.Review of the MDS assessment for R13, dated 03/25/2026, revealed that section C (Cognitive Patterns) documented a BIMS score of 13, indicating little to no cognitive impairment. Section E (Behaviors) documented no indicators of psychosis. Section GG (Functional Abilities and Goals) documented that R13 was independent with transfers and walking but needed setup or clean-up assistance with toileting. Review of the Progress Notes for R13 revealed an entry dated 06/02/2026 of Writer was assisting resident 8-2 when resident 8-1 (R3) went to the bathroom to wash her hands. Resident 10-3 (R13) then went in the bathroom and resident 8-3 came out. After a few minutes, resident 8-1 opened the bathroom door. This resident (referring to R13) became aggressive and pushed her (referring to R3) out causing her to fall backwards to the floor. Resident {R13} using verbally abusive and aggressive language towards writer and resident (R3). Other staff arrived and assisted with situation. Admin (Administrator), DON (Director of Nursing), MD (Medical Director), and police notified. 1013 Order (a legal document used to allow a licensed doctor, psychologist, or police officer to involuntarily hold someone for a mental health evaluation) received to send resident to ER (emergency room).Review of the facility-provided document titled #3706 Resident to Resident Altercation-Recipient dated 06/02/2026 at 5:15 PM revealed the Incident Description section included Nursing Description: Resident entered bathroom and was pushed down by resident room [ROOM NUMBER]-3. Resident Description: I entered the bathroom to wash my hands. The light was off, and she pushed me. Documented under Immediate Action Taken and Description: Staff intervened, and this resident was assessed for injury. Resident lying on her back on the floor in doorway of the bathroom. Resident alert and responsive, asking staff to help her up.Review of the facility-provided document titled #3707 Resident to Resident Altercation-Aggressor dated 06/02/2026 at 5:15 PM revealed the Incident Description section included, Nursing Description: (R13) was attempting to get into the shared bathroom, at this time another resident who shares the bathroom was attempting to get into the bathroom and was told to wait, which she did. When R13 went back into the bathroom, R3 was seen falling through the doorway to the floor. Resident Description: Resident unable to give description.In a concurrent interview with the Administrator and Director of Nursing (DON) on 06/12/2026 at 12:07 PM, the DON stated she interviewed R3 after the incident, and the resident stated she was not hurt. She stated she asked for psychological services to touch base with R3. The DON further stated she interviewed Licensed Practical Nurse (LPN) EE, who was in the room at the time of R3's fall. The DON confirmed that no other interviews were conducted with staff or other residents. The Administrator stated that he did not interview anyone regarding R3's fall or its circumstances. Cross-Reference F600

Based on observations, staff interviews, and review of the facility policies titled Food Preparation and Service F804 F812 and Refrigerators and Freezers F812, the facility failed to store foods in accordance with professional standards for food service safety. Additionally, the facility staff failed to record the daily temperatures of the refrigerator and freezer for two of two observed for temperature logs. The deficient practices had the potential to place 75 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: A review of the facility policy titled Food Preparation and Service F804 F812, last revised 10/23, revealed: Residents are provided with meals that are prepared by methods that conserve value, flavor, and appearance. Residents are provided with food and drink that is palatable, attractive, and at a safe and appetizing temperature. On 6/18/2024, at 9:30 am, during the initial tour of the kitchen with the Dietary Manager (DM), one pack of moldy sub sandwich rolls [six-count] was observed stored with ready-to-eat breads. The DM confirmed the bread was moldy and removed it from the bread rack. On 6/18/2024, at 9:44 am, observation of the temperature logs of the reach-in refrigerator revealed no documentation of the refrigerator temperature for 6/9/2024 and 6/10/2024 for the am shifts or for 6/1/2024, 6/5/2024, 6/10/2024, and 6/11/2024 for the pm shifts. On 6/18/2024, at 9:45 am, observation of the temperature logs of the reach-in freezer revealed no documentation of the freezer temperature for 6/9/2024 and 6/10/2024 for the am shifts or for 6/1/2024, 6/2/2024, 6/3/2024, and 6/5/2024 for the pm shifts. This observation was confirmed by the DM during an interview at the same time the observation occurred. On 6/19/2024 at 12:15 pm, observations of multiple eight-ounce (oz) glasses of juice, tea, and water were observed uncovered. The cups were to be transported to residents in the dining area and to residents who ate in their rooms. The DM stated, in an interview during the observation, that the glasses should have been covered after they were prepared. The DM further stated the dietary aides should not transport the drinks without a lid or cover.

Based on observations, staff interviews, and review of the facility policy titled Sanitation F812, the facility failed to ensure doors in the main kitchen remained in good repair to prevent pests from invading the main kitchen and one of two dining areas. This failure had the potential for pests to transfer harmful microorganisms to food leading to foodborne illness for the 75 residents receiving food from the kitchen. Findings include: A review of the facility's policy titled Sanitation F812, effective 10/23, revealed: 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Observation of the main kitchen on 6/18/2024 at 10:00 am, 6/19/2024 at 11:00 am, and 6/19/2024 at 12:15 pm revealed a substantial number of live flies in the kitchen area. This observation was confirmed in the presence of the Dietary Manager (DM), who was interviewed. On 6/18/2024 at 10:00 am, observation found the back door in the main kitchen was slightly open, with an opening at the top of the door. The DM revealed the door had been broken and had needed a repair for a while. Observation of the main dining hall between Unit 1 and Unit 2 on 6/18/2024 at 12:23 pm revealed multiple live flies around the area while residents were eating lunch. Several unidentified residents were observed swatting the flies away while eating lunch. On 6/19/2024 at 12:15 pm, observations found multiple eight-ounce (oz) glasses of juice, tea, and water were uncovered. Several insects were observed flying over the uncovered glasses. The DM acknowledged the insects during an interview conducted at the time of the observation. The DM further stated in an interview during the observation that the glasses should have been covered after they were prepared. On 6/20/2024 at 2:30 pm, the Maintenance Director (MD) revealed pest control treated the kitchen and dining area at least once a month. The MD stated the cause of the flies was a result of the back kitchen door not being replaced and further stated he was unaware the door needed to be replaced. The MD stated he could put a weather strip to cover the opening of the kitchen door until an order was placed for a new door. The MD revealed the back kitchen door had an air curtain (to prevent insects from coming into contact with the kitchen area and dining area), and he stated that, sometimes, the air curtain was turned off by staff.

Based on observations, staff interviews, and review of the facility policy titled Safe, Clean, Comfortable, Homelike Environment F584, the facility failed to ensure that maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment were provided. Specifically, 11 of 38 resident rooms were found in disrepair. These deficient practices had the potential to place residents at risk for the use of unsanitary and unsafe equipment and a potential for diminished quality of life. Findings include: A review of a facility policy titled Safe, Clean, Comfortable, Homelike Environment F584, dated effective 9/2023, revealed: Policy Statement: F 584 Residents have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports [sic] for daily living safely. Policy Interpretation and Implementation: 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 5. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order; b. Comfortable (minimum glare yet adequate (suitable to the task) lighting; c. Inviting colors and decor; d. Personalized furniture and room arrangements; e. Pleasant, neutral scents; f. Plants and flowers, were appropriate; g. Sufficient individual closet space; h. Comfortable temperatures; and i. Comfortable noise levels. During an observation of room [ROOM NUMBER] on 6/19/2024 at 9:47 am, a 6.5-inch-long by approximately 3-inch-wide hole was observed on the wall next to the left side of Bed 2. The wall near the head of the bed and behind the headboard had plaster missing and scrapes that were approximately 12 inches long and 3.5 inches wide and included multiple scrapes. During an observation of room [ROOM NUMBER] on 6/20/2024, at 11:52 am, observation revealed a white plaster patch was visibly covering most of the hole in the wall, and there were about two inches of wall not covered by plaster. Plaster was pulled up on the top left corner. During an interview on 6/21/2024 at 10:57 am, Certified Nurse Assistant (CNA) EE stated they also saw holes in the wall but were unsure of how long they were present. CNA EE stated they informed the nurse and maintenance verbally but were unsure when they told them. CNA EE then stated they did not use a computerized maintenance reporting system. During an interview on 6/21/2024 at 11:11 am, the Plant Operations Director stated they had fixed the wall in R70's room. When asked about the plaster not covering up the hole after the repair was made on 6/20/2024, the Plant Operations Director stated they would have to repair the wall again and use a board that would cover the entire hole. The Plant Operations Director further stated they were working on repairing walls, painting, patching up spots and tears on walls, repairing window seals and light fixtures, and replacing blinds. The Plant Operations Director stated they also had an assistant to help get some of the tasks completed in a timely manner. 27669 On 6/18/2024 at 10:00 am, during the initial tour of the facility, observation of room [ROOM NUMBER] revealed the walls were marred throughout the room. There was exposed sheetrock, peeled/cracked paint around the air vent in the ceiling, missing molding, and areas of unfinished wall repairs/painting. Observation on 6/18/2024 at 10:10 am revealed multiple areas in room [ROOM NUMBER] had unfinished wall repairs. There was exposed sheetrock, missing crown molding, chipped/peeled paint around the air vent in the ceiling surrounding the vent between beds B/C, and the wall was marred. In an interview on 6/19/2024 at 2:00 pm, the Assistant Director of Nursing (ADON) stated that the Maintenance staff was currently at another facility assisting with their facility repairs for an extended period. 16683 An observation on 6/18/2024 at 11:16 am of room [ROOM NUMBER] revealed the following: - Behind the headboard of Bed 2 were multiple, vertical scrapes of various depths across the width of the headboard (approximately 36 inches). In places, the scrapes abraded through only the paint. In other places, the scrapes went through the outer paper layer of the drywall, leaving behind shreds/curls of the outer paper. At their greatest depth, the scrapes dug into the gypsum. The largest area of abraded/exposed gypsum was estimated to be approximately 12 inches by 18 inches. - The headboard of Bed 2 had a length of gray, open-cell foam wrapped around the outer edge of the board. The appearance of the length of open-cell foam was consistent with that of pipe insulation. The foam was torn in places. - The wall behind Bed 1 (the bed by the door) was similarly damaged, with vertical scrapes of various depths across the width of the headboard, through the paint, the outer paper layer of the drywall, and/or the gypsum. - The wall behind the headboard of Bed 3 (the bed by the window) was also marred, not patched/repaired, and had been painted over where the scrapes had abraded the outer layer of the drywall paper and had dug into the gypsum. - Between Bed 2 and Bed 3 was a wall-mounted television (TV). The power cord to the TV was plugged into an electrical outlet. A coaxial cable was dangling loosely from the TV and was not long enough to reach a cable outlet. - An observation of the side wall next to Bed 1 found two (2) holes in a vertical line that completely penetrated through the drywall. Each hole was approximately 1 inch in diameter. In an interview on 6/19/2024 at 4:00 pm, the surveyor reported to the Administrator that the TV in room [ROOM NUMBER] room was not working, with the coaxial cable dangling from the TV and unable to be connected to a cable outlet. The Administrator stated that, if it were her, she would like to be able to watch TV in her room. Observations of Rooms 33 through 40 were made between 12:13 pm, and 12:35 pm on 6/20/2024. The observations were made in the company of Licensed Practical Nurse (LPN) CC, who confirmed the findings. The findings included: - Wall marring, including penetrations and scrapes of various depths through the paint, the outer paper layer of the drywall, and/or into the gypsum layer (all rooms observed) - Walls missing the outer paper layer of drywall, especially around wall-mounted soap dispensers and paper towel dispensers in bathrooms (multiple rooms) - Unsealed/unpainted oriented strand board sheathing covering tiled openings similar in size to that of single shower stalls (bathrooms of rooms [ROOM NUMBERS]) - Damage to bathroom doors through the outer layer of veneer, exposing the hardwood layer (multiple rooms, with the most extensively damaged surfaces on both sides of the bathroom door in room [ROOM NUMBER]) - Broken window blinds (multiple rooms) - Broken wooden windowsills (rooms [ROOM NUMBERS]) - Missing wooden baseboard (room [ROOM NUMBER]) - Missing paper towel dispenser (shared bathroom between rooms [ROOM NUMBERS]) - Rusted metal door frames to bathrooms (multiple rooms) - Rusted grab bar (shared bathroom between rooms [ROOM NUMBERS]) - Rusted and/or broken wall-mounted toilet paper holders (bathroom of room [ROOM NUMBER] and shared bathroom between rooms [ROOM NUMBERS]) - Rusted ceiling-mounted tracks for privacy curtains (room [ROOM NUMBER]) - The wall behind the toilet where the exposed, manual flush valve of the toilet was mounted was damaged, with the outer paper layer of the drywall hanging loosely from the wall (shared bathroom between rooms [ROOM NUMBERS]) - Broken nightstand (behind the door to room [ROOM NUMBER]) and a chest of drawers with missing drawer pulls (behind the door in room [ROOM NUMBER]) - Splatters of a beige-colored substance on the ceiling above Bed 2 (the middle bed of a three-bedroom in room [ROOM NUMBER]) - Broken electrical outlet (behind Bed 1 in room [ROOM NUMBER]) - Blue paper painter's tape on walls (room [ROOM NUMBER]) During an interview on 6/21/2024 at 1:35 pm, the Administrator stated she and the Plant Operations Director completed a walk-through on 6/10/2024 and identified rooms that needed to be repaired. The Administrator stated the facility's goal was to complete all repairs by October 2024.

Based on observations, staff interviews, review of facility-posted signage and temperature logs, and a review of the facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, the facility failed to store vaccines under proper temperature controls with twice daily monitoring and failed to remove from use medications, needles, and laboratory supplies that were kept past their expiration dates in one of one medication storage room and one of two medication carts reviewed. This deficient practice created the potential for residents to receive vaccinations with altered effectiveness and the potential for the use of expired medical and laboratory supplies. Findings include: The facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, revised [DATE], stated: APPLICABILITY: This Policy 5.3 sets forth the procedures related to the storage and expiration dates of medications, biologicals, syringes and needles. PROCEDURE: . 4. Facility should ensure that medications and biologicals that (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened [sic]. 5.1 Facility staff may record the calculated expiration date based on the date opened on the primary medication container [sic]. 5.2 Medications with a manufacturer's expiration date expressed in month and year (e.g. May, 2022) will expire on the last day of the month . 5.4 When an ophthalmic solution or suspension has a manufacturers [sic] shortened beyond use dated once opened, facility staff should record the date opened and the date to expire on the container . 10. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility Staff should monitor the temperature of vaccines twice daily . 10.3.2 Facility should monitor cold storage containing vaccines two times a day per CDC guidelines. An observation of the medication room for Unit 1 was conducted in the presence of the Director of Nursing (DON), beginning at 9:37 am on [DATE]. Observation found the following stock medications kept past their expiration dates and available for use: - Two 16-ounce bottles of Enulose 10 grams (GM) / 15 milliliters (ML) with expiration dates of ,d+[DATE]. - Two 16-ounce bottles of Biotene Dry Mouth Oral Rinse with expiration dates of [DATE]. The above were confirmed by the DON at the time of the observations. An observation of the medication refrigerator in the Unit 1 medication room, in the presence of the DON, at 10:01 am on [DATE], found four vials of pneumococcal vaccine polyvalent Pneumovax 23 vaccine, all with an expiration date of [DATE]. Posted on the cabinet door above the refrigerator was a sign that stated: FRIDGE TEMPS ARE TO BE RECORDED TWICE A DAY EVERY DAY. Review of the refrigerator's temperature logs for [DATE] found the following instructions: Completing the temperature long: Check the temperatures in both the freezer and the refrigerator compartments of your vaccine storage units and least twice each working day. Review of the information recorded on the [DATE] temperature logs found that twice daily recordings were not recorded for the following 10 dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The above observations were confirmed by the DON at the time of the observations. An observation of the medication cart for Unit 3 was conducted in the presence of Licensed Practical Nurse (LPN) CC, beginning at 10:25 am on [DATE]. Observation found the following prescription medications in the medication cart kept past their expiry or use by dates and which were available for use: - One (1) bottle of Systane Lubricant Eye Drops for Resident (R)38 with an expiration date of ,d+[DATE]. - One (1) bottle of Travatan Travoprost Ophthalmic Solution for R30 with an expiration date of 2024-APR. - One (1) bottle of latanoprost ophthalmic solution for R31 marked [DATE] and with a label stating: Discard after 42 days Exp. Date [DATE]. Additionally, the following supplies were found on Unit 3's medication cart and available for use: - One (1) Vacutainer tube with an expiration date of [DATE]. - One (1) filter needle with an expiration date of ,d+[DATE]. - One (1) safety needle with an expiration date of [DATE]. - One (1) Bluewing Safety Blood Collection Set w/ Luer Adapter with an expiration date of 240505 [[DATE]]. - One (1) Eclipse blood collection needle with an expiration date of [DATE]. All the above observations were confirmed by LPN CC at the time of the observations.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Answering the Call Light, the facility staff failed to ensure resident call lights were within reach for three of 18 sampled residents (R) (R5, R46, R70). This failure placed R5, R46, and R70 at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance. Findings include: A review of the facility policy titled Answering the Call Light, with a review date of 9/2023, revealed: General Guidelines 5. When a resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 1. A review of R5's quarterly Minimum Data Set (MDS), dated [DATE], revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 10 (indicating moderate cognitive impairment), and section GG (Functional Abilities and Goals) documented the resident required supervision with Activities of Daily Living (ADLs). During the initial tour of the facility, on 6/18/2024, at 9:40 am, R5 was observed lying in bed watching television (TV), and her call light was not within sight of the surveyor. During an interview conducted at the time of the observation, R5 stated she was not sure where her call light was. The resident's call light cord was observed draped over the headboard of her bed, with the call light pendant out of reach of the resident. 2. A review of R46's annual MDS, dated [DATE], revealed section GG (Functional Abilities and Goals) documented the resident was dependent on staff with Activities of Daily Living (ADLs). During the initial tour of the facility on 6/18/2024 at 10:10 am, and during an additional tour conducted on 6/19/2024 at 10:20 am, R46 was observed lying in bed resting with eyes closed, and the resident's call light pendant was observed laying on the floor beside the bed, out of sight and out of reach of the resident. 42991 3. A review of R70's admission MDS, dated [DATE], revealed section GG (Functional Abilities and Goals) documented the resident was dependent on staff with Activities of Daily Living (ADLs). During an observation on 6/19/2024 at 9:48 am, R70 was observed lying in bed with the call light hanging under the bed and not within reach of the resident. During an interview on 6/21/2024 at 10:57 am, Certified Nurse Assistant (CNA) EE stated they were to answer call lights immediately. When asked about the call light not being in reach for R70 on 6/19/2024 at 9:47 am, CNA EE stated they kept it in reach and did not know why it was not.

Based on observation, staff interview, record review, and review of the facility policy titled Handwashing/Hand Hygiene F 880, the facility failed to ensure staff administered medications via gastrostomy tube (G-Tube) (a tube surgically placed through the skin into the stomach to provide nutrition, hydration, and medication) to one resident (R) (R46) in a manner to prevent the development and transmission of infections. This deficient practice placed R46 at risk of contracting avoidable infections. Findings include: The facility policy titled Handwashing/Hand Hygiene F 880, effective date 9/2023, stated: Guidelines: . 2. Staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub [ABHR]. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves; c. Before performing any non-surgical invasive procedures; d. Before preparing or handling medications; e. Before handling clean or soiled dressings, gauze pads, etc.; f. Before moving from a contaminated body site to a clean body site during resident care. g. After contact with a resident's intact skin; h. After handling used dressings, contaminated equipment, etc.; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and j. After removing gloves . 8. The use of gloves does not replace handwashing/hand hygiene. Record review revealed R46 had active diagnoses that included dysphagia [difficulty swallowing], gastrostomy status [presence of a feeding tube], and overactive bladder. During an observation of medication administration to R46, beginning at 8:10 am on 6/19/2024, Licensed Practical Nurse (LPN) AA used alcohol-based hand rub (ABHR ) for hand hygiene and prepared R46's medications by expelling each oral tablet into separate 30 milliliters (ml) medication cups. She then placed each cup on top of the cart without first sanitizing or placing a barrier on the top of the cart. Observation of the top of the medication cart found dried, circular rings and light debris on the surface of the cart, which suggested the top of the cart was not clean. LPN AA crushed all tablets separately and placed each crushed tablet in its own 30 ml, graduated medication cup. LPN AA then donned a pair of disposable gloves without performing any hand hygiene, opened four capsules, and poured the contents of each capsule into a 30 ml graduated medication cup. LPN AA also poured two oral medications and liquid protein into separate 30 ml medication cups and measured and poured one capful of a powder medication into a water cup. After preparing all the medications, LPN AA stacked the graduated medication cups containing the medications such that the bottom of each stacked cup came into contact with the contents of the cup beneath it. LPN AA entered the resident's room, carrying in her still gloved hands, the stacked medicine cups, as well as a tongue depressor, and several additional cups, including those cups containing the oral solutions and the powder medication. As LPN AA approached the resident's bed, she picked up a folded towel that had been sitting on the seat of the resident's manual wheelchair, draped the towel across an empty portion of the resident's overbed table, and placed the cups of medication on the towel. LPN AA then walked back to the entrance of the room, doffed her gloves, donned a gown that she had previously hung on a hook by the entrance to the room, used ABHR from a wall-mounted dispenser in the hallway outside the door, re-entered the room, and donned a pair of disposable gloves that she pulled out of the pockets of her uniform. At 8:26 am on 6/19/2024, while wearing the new pair of gloves, LPN AA handled the overbed table to move it closer to the resident's bed and stated the need to obtain water for medication administration. LPN AA carried empty water cups to the closed bathroom door, knocked on the door, turned the doorknob to open the door, turned on the water faucet, filled two cups with water at the sink, turned off the water faucet, and carried the cups of water to the overbed table. Without changing gloves and performing hand hygiene after having touched multiple environmental surfaces (e.g., overbed table, bathroom doorknob, water faucet, etc.), LPN AA removed a piston syringe from an open wrapper that had been stored at the bedside and attached the tip of the syringe to a port on the resident's G-Tube. After verifying the placement of the G-Tube, LPN AA instilled a water flush and then proceeded to administer the medications with additional water flushes between each medication. At 8:36 am on 6/19/2024, after administering a final water flush after the last medication was given, LPN AA detached the syringe and capped the port of the G-Tube. LPN AA used the bed controller to lower the height of the resident's bed to its lowest position before carrying the piston syringe with the plunger to the bathroom. Wearing the same gloves, LPN AA knocked on the closed bathroom door, turned the doorknob to open the door, turned on the water faucet, rinsed the syringe and plunger, turned off the water faucet, and carried the piston syringe back to the resident's bedside. LPN AA placed the still wet syringe and plunger in an open wrapper and walked away from the bed. At 8:42 am on 6/19/2024, observation revealed the inside of the wrapper revealed multiple visible drops of a light, beige-colored liquid consistent with the appearance of an enteral nutritional product, and the tip of the syringe barrel contained a white substance consistent with the appearance of an incompletely dissolved tablet. LPN AA verified that the inside of the wrapper was wet and not clean. During an interview at 8:46 am on 6/19/2024, LPN AA confirmed stacking cups containing medications that had been placed on the top of the medication cart that had not been sanitized could contaminate the contents of the cups. LPN AA also confirmed her gloves should have been changed after contact with environmental surfaces, with hand hygiene performed between glove changes. During an interview with the Director of Nursing, Infection Preventionist, and Advanced Practice Registered Nurse at 9:03 am on 6/19/2024, all parties agreed the medication cups should not have been stacked, the piston syringe should not have been stored wet inside an unclean wrapper, and glove changes with hand hygiene should have occurred when gloves became contaminated from touching environmental surfaces.

Based on observations, staff interviews, and review of facility policy 'Food Service Staffing', the facility failed to ensure that the staff designated as director of food and nutrition services was a certified dietary or food service manager or had a similar food service management certification or degree. The deficient practice had the potential to affect 73 of 77 residents that received an oral diet. Findings include: Review of policy titled 'Food Service Staffing' last revised 10/2022 revealed '5. If the Dietician is not full time, then the community will employ another qualified nutritional professional to serve as the Dietary Manager. The person at a minimum must meet-one of the following qualifications: a. A certified dietary manager; b. A certified food service manager; c. Have similar certification in food service management and safety from a national certifying body; d. Has an associates or higher degree in food services management or in hospitality, if the course study includes food service or restaurant management from an accredited institution of higher learning.' During interview on 10/11/22 at 10:17 a.m. with Cook 'AA' revealed the facility did not have a dietary manager. States she has been filling in. Stated she was not a certified dietary or food service manager or similar food service management certification or degree. During interview on 10/11/22 at 11:03 a.m. with the Administrator confirmed the facility did not have a certified dietary or food service manager.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a sanitary environment free of standing water in the dishwasher room, watering leaking into a plastic bin in the refrigerator, standing water under the ice machine with brown colored substance pooled beneath the ice machine, and a vent in the dry storage room with a thick coat of black substance. The facility also failed to maintain the holding temperature of five foods on the steam table above 135 degrees, to prevent the potential for food-borne illnesses. This had potential to affect 73 of 77 residents receiving oral diets. Findings include: 1. During initial tour of kitchen on 10/13/22 at 10:17 a.m. revealed water running under the ice machine from a pipe. The floor under and surrounding the ice machine was wet. Beneath the ice machine had a black substance on the floor running into the floor drain. Refrigerator located in kitchen has water dripping from a vent inside of the refrigerator. The floor in the dishwasher room is unlevel and standing water is noted under a waterproof floor mat. Several floor tiles are missing. A board was noted on the floor beneath the dishwasher with brown and black staining and was wet. Cook 'AA' stated the floor is not level, so the board was placed under the dishwasher to level it out. Observation of the dry storage revealed a vent located above barrels of dry foods has a coat of black substance on it, and there is a hole noted on one side. During walk through of the kitchen on 10/11/22 at 11:03 a.m. with the Administrator, the findings above were confirmed. States her expectation is for the dietary staff to report any equipment or environmental issues promptly. During follow-up visit to kitchen on 10/12/22 at 12:12 p.m. revealed the same findings as observed on 10/11/22. 2. During observation of steam table temperatures on 10/13/22 at 11:47 a.m. obtained by Cook 'AA' with the facility's calibrated thermometer revealed temperatures were below 135 degrees Fahrenheit (F) for mixed vegetables, which was 120 degrees. Chopped chicken was 119 degrees. Puree chicken was 100 degrees, puree mixed vegetables was 90 degrees. The mashed potatoes were 110 degrees. During interview on 10/13/22 at 11:53 a.m. with Cook 'AA' revealed she was not sure what to do when temperatures were below 135 degrees. Stated the temperatures are not always checked before or during meal services. Further revealed a log of steam table temperatures for food is not kept. Cook 'AA' removed food from steam table and placed in the oven until food reached correct temperatures.

Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order, specifically the steam table, one of two refrigerators, and one ice machine. This had the potential to affect 73 of 77 residents receiving an oral diet. Findings include: During initial tour of kitchen on 10/11/22 at 10:17 a.m. with Cook 'AA' revealed water running under the ice machine from one of the pipes. Refrigerator located in kitchen had water dripping from a vent inside the refrigerator into a plastic pan. During walk through of kitchen on 10/11/22 at 11:03 a.m. with Administrator confirmed the findings. Stated her expectation is for the dietary staff to report any equipment or environmental issues promptly. During observation of steam table temperatures on 10/13/22 at 11:53 a.m. with Cook 'AA' noted the steam table was not functioning properly. Cook 'AA' stuck her hand into one of the water basin and stated the water was tepid to touch. During interview on 10/13/22 at 2:15 p.m. with Cook 'AA' she revealed the maintenance director was going to look at the steam table following dinner meal because 'something needed to be repaired'. Cross refer to F812.

Based on observation, staff interview, and record review, the facility failed to ensure that staff followed recipes for preparing pureed meals to avoid compromising the nutritive value of food items served to residents on a pureed diet when compared with items served to residents on a regular diet for 13 residents receiving a pureed diet. Findings include: Review of the lunch menu for 10/13/22 revealed items which included ranch baked chicken. During the preparation of pureed food items on 10/13/22 at 11:12 a.m. Cook 'BB' was observed placing approximately six slices of bread into the food processor. Cook 'BB' then placed an unmeasured amount of chicken into the food processor with liquid from the bottom of the pan holding the chicken. She turned the food processor on. After approximately 30 seconds, the cook checked the consistency of the bread/chicken mixture and scraped the sides of the food processor. Cook 'BB' then placed an additional six slices of bread into the food processor with an unmeasured amount of chicken and liquid from the pan holding the chicken. She then turned on the food processor for approximately one minute. Cook 'BB' then placed the mixture in a pan to be placed on the steam table. During interview on 10/13/22 at 11:12 a.m. with Cook 'BB' she revealed this is the way she was taught to make pureed meats. States she was unaware of a recipe to follow. During interview on 10/13/22 11:15 a.m. with Cook 'AA' revealed she has never seen a menu on how to make puree foods. States she was taught the same way. During phone interview on 10/13/22 at 12:33 p.m. with the Registered Dietician revealed blending chicken with bread is not an acceptable way to puree chicken. States there are recipes for puree foods that the facility has access to. Review of the recipe used by the facility for puree ranch chicken revealed for resident on a puree diet: 1. Measure the number of pureed portions required from the regular recipe. 2. Add to food processor and process to fine consistency. 3. Add hot broth and commercial thickener gradually to creamed chicken. All liquid may not be required. 4. Scare down sides of processor and process for 30 seconds.

Based on observations, interviews, record reviews, and review of Centers for Disease Control and Prevention (CDC) Guidelines, the facility failed to take steps to contain and prevent the transmission of COVID-19 by isolating a resident with known exposure to COVID-19. The facility failed to place one of five sampled residents (Resident (R) #1, who was COVID-negative) on transmission-based precautions (TBP) and/or isolation after his two roommates tested positive and were moved to the COVID-positive unit. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website titled, Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, revealed: Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit) . HCP (Healthcare personnel) should use all recommended COVID-19 PPE (personal protective equipment) for the care of all residents with exposures . regardless of symptoms . https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Review of the facility's policy titled Admission of/Care of Residents with Communicable Disease - COVID-19 F880 . last revised on 12/20, revealed .(residents) whose COVID-19 status is unknown or presumed negative .will be placed in isolation in a containment (yellow) area for 14 days . and .a. Community will follow CDC guidelines for the use of PPE (Personal Protective Equipment) with these residents and based upon community transmission rates . During an entrance conference with the Administrator and Director of Nursing (DON) on 2/25/21 at 8:55 a.m., the infection control survey logistics were discussed. The DON stated that there were currently six residents on the designated COVID unit, including three residents (R#3, R#4, and R#6) who tested positive that morning and were transferred into the COVID unit. The Administrator and DON said they had not had any large 'outbreaks' but have had a few cases consistently since the fall, and they .just can't get it completely out of here so we can open activities and ease restrictions. Review of the electronic medical record (EMR), including the undated Admission Record, revealed R#1 was a long-term resident. Review of the Point of Care (POC) COVID test results for R#1, dated 2/25/21, revealed the resident was negative for COVID 19. Observation on 2/25/21 at 11:20 a.m., on the facility's secure unit, revealed R#1 was in his room as Housekeeper (Hskpr) CC performed a deep clean of the room because R#1's two roommates (R#3 and R#4) tested positive for COVID 19 earlier that morning and were transferred to the COVID (+) unit. During the observation, Hskpr CC was observed to be wearing was an N-95 mask and gloves but was not wearing a gown or eye protection/face shield. When asked if the room was designated as a room on any type of isolation, Hskpr CC replied, No, because there was no cart outside the door. Certified Nursing Assistant (CNA) BB was observed working on the secure unit on 2/25/21 at 12:30 p.m. The CNA was passing meal trays and was asked if there were any isolation rooms on the hall. CNA BB responded, No, not back here. Licensed Practical Nurse (LPN) AA, who was working on the secure unit, was interviewed on 2/25/21 at 12:32 p.m. and was asked about the isolation status of the residents on the unit. She stated all of the residents on the secure unit had tested negative for the [MEDICAL CONDITION] except for the ones that transferred to the COVID unit earlier than morning. The LPN stated if they (facility) got a positive result, the policy was for positive residents to be moved to the COVID unit. When asked if residents with known exposure to COVID-19 should be isolated, the LPN stated yes, she thought they should be. When asked if R#1 was on isolation, she stated no. An interview with the DON and Infection Preventionist, in their shared office, on 2/25/21 at approximately 1:00 p.m. confirmed that three positive residents had been moved from the secure unit to the COVID unit when they tested residents and staff earlier that morning. When asked about R#1's isolation/quarantine status due to his known exposure to his COVID-positive roommates (R#3 and R#4), the DON stated .makes sense and we will .hadn't thought to do that before now .but he was exposed to both of them.

Based on observations, review of the facility policy titled, Food Receiving and Storage, and staff interviews, the facility failed to discard expired items in the walk-in cooler; and failed to ensure that stored food items were secured with date and label in the reach-in freezer. The deficient practice had the potential to affect 88 of 89 residents receiving an oral diet. Findings include: On [DATE] at 11:21 a.m., during the initial tour of the reach-in freezer with the Cook CC, the following items were revealed: Five clear plastic bags and two blue plastic bags with unidentified, unlabeled food items. On [DATE] at 7:35 a.m., during a tour of the walk-in cooler with the Dietary Manager (DM), there was a carton of thicken water with an open date of [DATE] and a use by date of [DATE]. During an interview with the DM, she stated they usually keep it for seven days after it is opened and then throw it out. She confirmed that the used by date on the carton was [DATE] and it should have been thrown out. Follow up observation on [DATE] at 7:45 a.m., of the reach-in freezer with the DM revealed one clear plastic bag of waffles that had been opened and folded over, not secured. During an interview on [DATE] at 8:50 a.m., the DM and Cook DD stated the process for receiving and storing food in the freezer is the responsibility of the person that works 9 a.m. - 3:00 p.m. She also stated that person is to label and date the food when it is open and label what it is. During an interview with the Administrator on [DATE] at 7:50 a.m. she stated the procedure for receiving and storage of foods is to mark when it came in, mark when it is opened and date it. She stated she was unaware of food items in the reach in freezer not labeled or dated. She stated that she expected that the dietary staff would ensure there would be no expired or undated or unlabeled foods in the reach-in freezer. Review of the policy titled, Food Receiving and Storage, under Policy Interpretation and Implementation: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on record review, staff interview and review of the facility policy titled Pre-Admission Screening and Resident Review (PASARR) the facility failed to ensure each resident received an assessment which accurately reflected the resident's status at the time of the assessment for five residents (R) (R#26, R#27, R#54, R#3, and R#9) of 41 residents reviewed for accuracy of assessments related to PASARR. Findings include: Review of the facility policy titled Pre-Admission Screening and Resident Review (PASARR), effective 1/2020, indicated: 8. The Interdisciplinary Assessment Team must use the MDS (Minimum Data Set) form currently mandated by Federal and State regulations to conduct the resident assessment. 9. The assessment process will include: a. Incorporating the recommendations from the PASARR level 2 determination and the PASARR evaluation report into the assessment, care planning and transition of care. 1. Review of the MDS Annual Assessment Section A1500 for R#26, dated 9/21/19, revealed it was not coded for PASARR level 2. R#26 had [DIAGNOSES REDACTED]. She had a PASARR level 2 dated 3/7/14 and received tele-psych services. She had a care plan for mood and behaviors and the use of antipsychotic medications. 2. Review of the MDS Annual Assessment Section A1500 for R#27, dated 3/21/19, revealed it was not coded for PASARR level 2. R#27 had [DIAGNOSES REDACTED]. He had a PASARR level 2 dated 4/3/15 and received tele-psych services. He had a care plan for medication complications and antidepressant use. 3. Review of the MDS Annual Assessment Section A1500 for R#54, dated 7/4/19, revealed it was not coded for PASARR level 2. R#54 had [DIAGNOSES REDACTED]. He had a PASARR level 2 dated 6/14/04 and received tele-psych services. He had a care plan for drug related complications. 4. Review of the MDS Annual Assessment Section A1500 for R#3 , dated 11/1/19, revealed it was not coded for PASARR level 2. R#3 had [DIAGNOSES REDACTED]. She had a PASARR level 2 dated 1/14/14 and received tele-psych services. She had a care plan for behaviors and medications. 5. Review of the MDS Annual Assessment Section A1500 for R#9, dated 9/23/19, revealed it was not coded for PASARR level 2. R#9 had [DIAGNOSES REDACTED]. He had a PASARR level 2 dated 1/14/14 and received tele-psych services. He had a care plan for medication effects and behaviors. An interview held on 2/05/20 at 10:00 a.m. with the Director of Nursing (DON) and the MDS Coordinator BB revealed when a resident is receiving PASARR services it should be coded on the MDS under Section A1500. The DON verified R#26, R#27, R#54, R#3, and R#9 were not coded on the Annual MDS Assessments for receiving PASARR services.

Based on observations, policy review entitled Storage of Medications, and staff interview the facility failed to ensure proper storage of insulin for one of two medication carts. Findings include: Observation of medication cart on station three on 2/04/2020 at 10:00 a.m. revealed the following unopened [MEDICATION NAME] 100ml vial. The medication was verified as unopened and improperly stored by Unit Manager EE. Interview with the Unit Manager EE on 2/4/2020 at 11:34 a.m. in reference to expectations for storage of unopened insulin revealed that nurses are expected to store insulin in the refrigerator in the drug room until needed and not on the medication carts. Interview with Administrator on 2/05/2020 at 8:49 a.m. in reference to expectations for storage of insulins revealed that the insulins should be stored according to manufacturing directions if the package instructs to refrigerate, the expectation is for staff to follow those instructions and refrigerate the medication; not store them on the medication cart. Review of the facility policy titled Storage of Medication with an effective date of 1/2020 revealed under Policy Interpretation and Implementation: 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly.

Based on observation, staff interview and review of the facility policy Refrigerators and Freezers (revised (MONTH) (YEAR)) and the facility Admission Packet, the facility failed to maintain two refrigerators in two of two pantries (Unit I/Unit II and Unit III) in a manner to prevent food-borne illnesses. The census was 98 residents. Findings include: Review of the facility policy Refrigerators and Freezers (revised (MONTH) (YEAR)) revealed that the facilty will ensure safe refrigerator and freezer maintenance, temperatures and sanitation Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures all food should be appropriately dated with received dates (dates of delivery) to ensure proper rotation. Review of the facility Admission Packet provided by the Administrator regarding residents' foods brought from the outside revealed that perishable foods must be stored in a re-sealable container with a tight-fitting lid. The food must be stored in the refrigerator with a name and date on the container. Food that is found outdated will be discarded. On 8/9/18 at 2:15 p.m., the following food items were observed in the refrigerator in the Unit I/Unit II pantry with Licensed Practical Nurse (LPN) JJ: a. One jar of Clover Valley Mayonnaise without an open date or name. b. One container of OUI coconut yogurt without a delivery date or name. c. One styrofoam container that had a staff person's name but, did not have a date. d. One Stouffer's dinner carton that had a staff person's name but, did not have a date. The dinner was frozen to the bottom of the freezer compartment and not easily removed. The temperature of the refrigerator was at a safe temperature of 40 degrees Farenheit (F). However, there was not a Temperature Log in the pantry to indicate that the refrigerator temperatures were monitored. LPN JJ stated at that time that she did not know the location of the Temperature Log. Continued interview with LPN JJ revealed that the jar of mayonnaise belonged to a resident. On 8/9/18 at 2:25 p.m., the following food items were observed in the refrigerator in the Unit III pantry: a. One Styrofoam container that had a staff person's name but, did not have a date. b. One Styrofoam container of an unrecognizable food that did not have a name or delivery date. c. Two (2) plastic jars of mustard without an open date or name. d. One plastic container of salad without an open date or name. e. One bottle of French salad dressing without an open date or name. f. One bottle of Bar-B-Que sauce without an open date or name. g. One unopened package of Party Pizza Rolls and two (2) individual frozen sausage biscuits wrapped in cellophane were observed in the freezer compartment. The food items did not have a delivery date or name. The temperature of the refrigerator in the Unit III pantry at that time was at a safe temperature of 41 degrees (F). However, there was not a Temperature Log in the pantry to indicate that the refrigerator temperatures were monitored. On 8/9/18 at 2:40 p.m. LPN II, who was the Supervisor for Unit III, and the Dietary Manager confirmed the above observations for the pantry refrigerator on Unit III. Interview with LPN II at that time revealed that she did not know to whom the food items belonged nor did she know the location of the Temperature Log. Interview with the Dietary Manager at that time revealed that the refrigerators in the pantries were used to store residents' food and that staff were not supposed to store their food in the pantry refrigerators. The Dietary Manager stated that all food items in the refrigerators should be labeled with the resident's name and date of delivery. Further interview with the Dietary Manager revealed that the nurses were responsible for monitoring the refrigerator temperatures daily and ensuring that food items were dated and labeled with the residents' names. On 8/9/18 at 3:10 p.m., the Dietary Manager provided the (MONTH) (YEAR) Temperature Log for the pantry refrigerator for Unit I/Unit II and the temperatures were safe. However, the Dietary Manager stated at that time that the last Temperature Log she was able to find for the pantry refrigerator for Unit III was from (MONTH) (YEAR). Interview with LPN II (Unit III) on 8/9/18 at 3:40 p.m. revealed that she thought dietary staff were responsible for monitoring the pantry refrigerator temperatures and ensuring food items were labeled and dated. Interview with LPN KK (Unit II) on 8/9/18 at 3:44 p.m. revealed that she checked the pantry refrigerator for Unit I/II when she obtained supplements for her residents and ensured at those times that all food items were labeled and dated. Interview with LPN JJ (Unit I) on 8/9/18 at 3:48 p.m. revealed that she rarely went into the pantry for Unit I/Unit II and that she did not know who was responsible for ensuring that food items were labeled and dated. Interview with the Assistant Director of Nursing (ADON) on 8/09/18 at 4:02 p.m. revealed that the pantry refrigerators were reserved for the residents' food items and that staff should not store their personal food items in those refrigerators. Interview with the Administrator on 8/09/18 at 4:25 p.m. revealed that nursing was responsible for monitoring the pantry refrigerator temperatures daily and ensuring that food items were labeled and dated. Continued interview revealed that nursing was responsible for cleaning the refrigerators weekly and as needed. Interview with Registered Nurse (RN) LL, who was responsible for Infection Control, on 8/09/18 at 4:37 p.m. revealed that none of the residents had been diagnosed with [REDACTED].

Based on observations, interviews, and review of the hand hygiene policy, the facility failed to ensure staff used proper hand hygiene, at two of two meals, served in the dining room on the secured unit. Findings include: Observation on 8/06/18 from 12:20 p.m. to 12:45 p.m. on unit three dining room revealed certified nursing assistant (CNA) HH did not use hand sanitizer or wash hands with soap and water when serving lunch trays. Observation on 8/06/18 from 12:20 p.m. to 12:45 p.m. on unit three dining room revealed CNA HH touched the meal cart door and did not use hand sanitizer, or soap and water, before removing the tray from the kitchen meal cart and setting it up for the resident. Observation on 8/06/18 from 12:20 p.m. to 12:45 p.m. on unit three dining room revealed CNA HH touched the left armrest of Resident # 22's wheelchair and did not use hand sanitizer, or wash hands with soap and water, before setting up the meal tray for the resident. Observation on 8/06/18 from 12:20 p.m.to 12:45 p.m. on unit three dining room revealed CNA HH touched the top of the meal cart and did not use hand sanitizer, or soap and water, before removing the meal tray from the cart and setting it up for the resident. Observation on 8/06/18 from 12:20 p.m. to 12:45 p.m. on unit three dining room revealed CNA CC set up tea, lemonade and water on a small rolling cart, distributed the drinks to residents and did not use hand sanitizer, or soap and water, between residents or after touching the small rolling cart. 22 residents were served this meal, sitting at seven tables. Interview on 8/09/18 02:25 p.m. with CNA GG revealed because unit three was a secure unit, it did not have mounted hand sanitizer, staff carry hand sanitizer in their pocket or borrow from nurses on the unit. The facility had Epi-clenz instant hand sanitizer in stock for staff to use, or they could bring their own. CNA GG also revealed hand sanitizer should be used between residents when serving meal trays. Interview on 8/09/18 at 2:00 p.m. with the infection control nurse revealed she had only worked here two weeks and part of her duties would be education of staff, she planned to do a review of hand hygiene as one of the first in-services. Her expectation of hand hygiene when serving meals were that staff would wash hands with soap & water before they begin and use hand sanitizer in between residents and meal trays. Interview on 8/09/18 at 2:10 p.m. with the ADON also revealed staff should wash hands with soap & water before they start passing out meal trays, and hand sanitizer between residents and trays. Interview on 8/09/18 at 3:25 p.m. with the Administrator revealed the facilities policy for hand hygiene. Her expectation was that staff wash hands with soap and water before they begin serving trays and use hand sanitizer between residents. She revealed hand sanitizer was available in stock and staff could keep sanitizer in their pocket, or use sanitizer mounted on the wall. The locked/secure unit didn't have mounted sanitizer, but it was available at the nurse's desk. The Administrator also revealed hand sanitizer was readily available and in stock for all staff to use but if none were available she expected them to wash with soap & water between residents. Review of the policy titled Handwashing/Hand Hygiene F 880, Policy Interpretation and Implementation revealed employees must wash hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water before and after handling food; and before and after assisting a resident with meals.

Based on observations, record review and interviews the facility failed to ensure that Activities of Daily Living (ADL) Care was provided related to shaving facial hair for one resident (R) #28. The sample size was 44 residents. Findings include: Record review revealed that R#28 has a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident (R) R# 28's Brief Interview for Mental Status (BIMS) score was 9. R#28 was assessed as requiring extensive assistance of 2 plus persons for her ADL care. Documentation specified that R# 28 required extensive assistance of 2 plus persons for physical assistance with her personal hygiene. Review of one of R#28's Care Plans related to activities of daily living (ADL's) with initial date 5/22/14 and revision date of 5/23/18 stated that R#28 required extensive assistance with ADL's. The goal for the resident was that she will remain well-groomed through review date. Review of R#28's Flow Sheet for ADL's dated 7/27/18 through 8/09/2018 revealed documentation of R#28's refusal on only one date on 7/27/18. There was no documentation of R# 28's refusal of ADL's care on 8/6/18 through 8/9/18. Observation on 8/06/18 at 10:07 a.m. revealed R#28 with long, gray hairs growing from her chin area. R# 28 was observed on 8/07/18 at 8:30 a.m. and 8/08/18 at 10:10 a.m. with long gray hair on her chin observed. Interview on 8/06/18 at 10:10 a.m. with R# 28 stated she wants the long hairs on her chin shaved and has informed staff but it has not been done. An interview with the Certified Nursing Assistant (CNA) AA on 8/09/18 at 10:00 a.m. revealed that resident's facial hair is long and resident has not been shaved today. CNA AA continued to reveal that residents are shaved at bath times but R#28 refuses care often. She stated when residents refuse baths or care it is documented on resident's flow sheet. An interview conducted on 8/9/18 at 11:00 a.m. with Licensed Practical Nurse BB, Nurse Manager, stated that R#28 does refuse care and the documentation should be on the flow sheets. She stated that residents are groomed during their bath and as needed and R#28 requires assistance from staff for bathing and grooming. She confirmed R#28 facial hair is long and needs shaving. She continued to state that her expectation is for residents to be shaved at bath times and as needed and documentation should be done on the resident's flow sheet for refusal of care.

Based on record review and staff interview, the facility failed to revise the care plan to include the determination of the frequency the resident should be monitored and to designate the staff person that would be responsible for the monitoring of three (3) residents (# 114, 81 and 85) from twenty-six (26) sampled residents. A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to exist from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: 1. Record review for resident # 114 revealed that a care plan had been developed on 4/19/2010 which identified the resident as having elopement behaviors. As identified in the care plan, the resident had the potential for elopement due to frequent threats to leave the facility unescorted. Interventions were added at this time for placing and checking the WanderGuard bracelet and encourage the resident to ventilate her feelings regarding placement in the Facility. On 6/4/2010, 6/11/2010 and on 6/19/2010, the care plan was updated after the resident had eloped from the facility over the back fence on these dates. Two additional interventions that were added after these dates were to perform visual checks of the resident and to monitor the resident when she was on the back porch, but failed to include the frequency of monitoring and to designate the staff person responsible for conducting the monitoring. 2. Record review for resident # 85 revealed a care plan dated 3/19/2009 and on 3/09/2010 had identified the resident as having the potential for elopement due to a history of leaving the facility unescorted and having a history of climbing the fence. This care plan had also been updated on 9/08/2009 and 02/27/2010 after the resident eloped from the facility. An intervention to monitor the resident and a determination of the frequency and assignment of staff to conduct the monitoring was not added as an intervention of the plan even after the two elopements. In an interview with the Care Plan Coordinator on 6/26/2010 at 9:30 a.m. she stated that visual monitoring had been done on this resident but had not been added to the care plan as an intervention and should have been. 3. Record review revealed resident #81 had eloped from the facility on 6/09/2009 and 2/28/2010. Review of the care plan dated 6/10/2010 for the potential for elopement revealed that the staff were to encourage resident #81 to let staff know when he wanted to go outside, to explain the dangers of leaving the facility unattended, to attempt to determine where the resident wanted to go, monitor for increased pacing and check the WanderGuard bracelet every shift. Resident #81 was assessed a being confused and independent with ambulation. There were no interventions that address threat the resident removed their WanderGuard bracelet, or that the resident elopes under and over the back yard fence. Interview with Licensed Practical Nurse (LPN "BB") and Licensed Practical Nurse (LPN "DD") on 6/24/2010 at 2:30 p.m. revealed that resident #81 was assessed for wandering but the interventions were not relevant to his wandering behavior or mental status. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 26, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identified as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a "K" level to an "E" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion Date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuard had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position hire: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservices were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with the Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010. Cross refer to F323

Based on observations, review of facility's policy and procedure: Wandering Resident Monitoring, review of facility's Accident/Incident Report, record review and staff and responsible party interviews, the facility failed to provide adequate supervision to residents that had been identified as being at risk for elopement; failed to implement effective interventions by securing a fenced area; and failed to develop effective safety measures to prevent residents from eloping for four (4) residents (#114, 85, 81 and "E") from twenty-six (26) sampled residents and one (1) randomly observed resident. It was determined that the facility's failure to prevent resident elopement, and a lack of a working WanderGuard system, which they relied almost exclusively on to prevent elopement, resulted in a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident existed from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: 1) Record review for resident #114 revealed the resident was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED]. An admission Minimum Data Set, dated dated [DATE] assessed the resident as having short and long term memory problems, moderately impaired cognitive skills and was exhibiting periods of altered perception or awareness of surroundings. The resident was also assessed as exhibiting verbal, physical abusive behaviors, as being socially inappropriate and resistive to care. Review of a Nurses Note dated 6/03/2010 revealed that at 10:50 p.m., the resident received medication for an increase in agitation and stated that she was going to sleep outside on the bench (in the back yard). When staff went to check on the resident 20 minutes later, at 11:10 p.m., 911 was called when the resident was not found on the porch. The resident was located at a nearby business and returned to the facility by the police. A Nurses Note dated 6/11/2010 at 12:00 a.m. indicated that the resident walked out on the porch, was staying out there and would not come back in the building. When the nurse checked on her at 12:05 a.m., the resident was not on the porch. The resident was located down the road near the police station and was returned to the facility. On 6/19/2010, another Nurses Note revealed that the resident escaped over the back fence. Police had called the facility to inform them that they had picked up a lady (resident #114) walking down the road. A care plan developed 4/19/2010 identified the resident as having the potential for elopement due to threats of leaving the facility unescorted. Initial interventions that were initiated included adding a WanderGuard bracelet to the resident, check the placement of the bracelet every shift, conduct a WanderGuard system check every morning and to encourage the resident to ventilate her feelings of placement into the nursing home. Additional interventions added to the care plan after the first elopement, 6/03/2010, was to monitor the resident for an increase in agitation and medicate if appropriate. After the second elopement, 6/11/2010, interventions were added to redirect the resident when agitated, provide visual checks and monitor the resident when she was out on the porch. When the resident eloped the third time, 6/19/2010, interventions were added to encourage the resident to talk to the doctor about her placement in the nursing home, refer the resident for psychological services and encourage medication compliance. A review of the Weekly Checklist for WanderGuard Monitoring completed by the Maintenance Supervisor revealed that he was checking the system on a weekly basis and not daily. Review of the PAR (Patients at Risk) Tracking Form detailed the elopement of the resident from the facility on 6/04/2010. Documentation of the action that was taken by the PAR team was to inservice staff on the WanderGuard alarm system, the resident would be redirected when agitated, visual checks would be conducted every 30 minutes and the resident would be supervised when on the back porch. For the 6/11/2010 elopement, the response written on the PAR note was to continue with visual checks every 30 minutes, have staff 1:1 with resident when she is on the porch. On 6/19/2010 after describing the third elopement for the resident, the interventions that were added to the PAR note were to interview the resident, staff and nurses to determine the resident's behavior prior to elopement, interview the resident to discover how she eloped and to administer medications for agitation. Observation of the resident on 6/22/2010 at 3:10 p.m. revealed that the resident was outside on the smoking porch (same area where resident has eloped three previous times) unsupervised by staff. The Assistant Director of Nursing was at the Nurses Station at the time of the observation but left the area with another resident. As the resident entered the building from the porch, the WanderGuard alarm sounded. Without any visible staff in the area, the resident was observed to reach under the alarm sensor on the side of the door and turn it off. An interview with the Director of Nursing on 6/26/2010 at 11:30 a.m. revealed that a resident is placed in the monitoring program if they attempt to/or leave the facility. The frequency of monitoring is determined based on if the resident is displaying a pattern of behaviors, has made multiple attempts to leave the facility or has a history of elopement and would stay on this schedule for the next quarter if we suspect they might attempt to elope again. The residents should be reassessed to determine if the frequency (of monitoring) needed to be changed if there were any changes or additional attempts to elope. The Elopement/Wandering Risk Assessment was completed on this resident on 6/04/2010 and again on 6/23/2010, twelve (12) days after the second elopement of 6/11/2010 . An assessment after the elopement on 6/11/2010 had not been completed per the facility policy and interview with the Director of Nursing. Included in the facility's Policy and Procedure for Wandering Resident Monitoring: The PAR Committee will review the resident's wandering behavior and determine if the resident requires visual monitoring and establish a monitoring schedule based on the resident's behavior pattern. Residents requiring monitoring will be reviewed weekly. An interview with the Medical Director on 6/25/2010 at 12:00 p.m. revealed that it is difficult to get a psychological evaluation done on the residents and he thought that PASSR was no longer available. He also stated that the criteria that has to be met before a resident is sent out for evaluation has become more involved. Review of the clinical record for resident #114 revealed PASSR Level I and Level II Screenings had been conducted. An interview with the Administrator on 6/23/2010 at 8:30 a.m., revealed that the facility had put interventions in place to monitor the resident but they had not been consistently carried out. There was a pattern that the resident usually attempted to leave at change of shift (from evening to night shift). No evaluations or changes were made to the areas of the fence where the resident was believed to have eloped. The staff relied heavily on hearing the door alarm to let them know if someone is leaving the facility. 2) Record review for resident # 85 revealed an admission date of [DATE] with an admission [DIAGNOSES REDACTED]. The resident was assessed on the 6/07/2010 Minimum Data Set as having long and short term memory problems and moderately impaired cognitive skills for daily decision making. The resident was also identified with being verbally abusive, exhibiting socially inappropriate and disruptive behaviors as well as resisting care. A care plan developed on 3/19/2009, identified the resident as having the potential for elopement related to a history of leaving the facility unescorted and a history of climbing the (back yard) fence. Updates added to the care plan on 9/08/2009 revealed the resident had left the facility by jumping over the fence and the intervention added to address this behavior was to discuss the dangers of jumping over the fence with the resident. According to the care plan on 02/27/2010, the resident left the facility and was found across the street from the facility property. A Nurses Note dated the same day indicated that the resident had again left the facility. It was documented that he opened the front door by leaning on the handle until it opened. An intervention added to the care plan in response to this elopement was to assist the resident to the DRPH (day room program) room, monitor the resident while in the program and allow the resident time to express his feelings. Review of an Accident/Incident Report dated 10/07/2009 at 1:30 p.m. revealed the resident was noted climbing the gate at the back fence and refused to come down. He ran to the dollar store across the street. Staff escorted the resident back to the facility. The facility disposition for this incident was to counsel the resident 1:1 and continue with the WanderGuard and visual checks (no frequency specified). Review of the facility's policy and procedure for Wandering or a Missing Resident revealed the following: Wandering exhibited by residents who are cognitively impaired can put the resident at risk for harm. Whenever a resident leaves facility property, unaccompanied by staff or without notifying staff, an elopement has occurred. The potential for harm to the resident who wanders or elopes increases with the extent of cognitive impairment. If a resident repeatedly wanders off the unit, the Resident Care Plan should reflect a monitoring schedule to ensure resident safety. Included in the facility's Policy and Procedure for Wandering Resident Monitoring: The PAR Committee will review the resident's wandering behavior and determine if the resident requires monitoring and establish a monitoring schedule based on the resident's behavior pattern. Residents requiring monitoring will be reviewed weekly Review of the Wandering Resident Monitor form revealed that the resident was being monitored every hour with documentation of his location at the time of the observation before and after the days of elopement that was entered on the care plan; however, adding the intervention to conduct visual checks on the resident had not been added to the care plan on 3/19/2009 and on 3/09/2010. And based on the facility's policy, the resident was not assessed for more frequent monitoring following the most recent elopements from the facility. In an interview with the Care Plan Coordinator on 6/26/2010 at 9:30 a.m. revealed that visual monitoring had been done on this resident but had not been added to the care plan as an intervention. An interview with the Director of Nursing on 6/26/2010 at 11:30 a.m. revealed that a resident is placed on the monitoring program if they attempt to/or leave the facility. The frequency of monitoring is determined based on if the resident is displaying a pattern of behaviors, has made multiple attempts to leave the facility or has a history of elopement. A random observation of the back door leading to the fenced area on 6/22/2010 at 4:05 p.m. revealed that the WanderGuard system did not alarm as another resident wearing a WanderGuard bracelet walked out of the door accompanied by staff. Facility staff checked the door alarm by having another resident wearing a WanderGuard bracelet approach the door. It was determined that the alarm was not functioning properly. 3. Record review for resident #81 revealed an annual MDS, dated [DATE] assessed the resident as having short and long term memory problems, persistent anger with self and others, repetitive movements, verbally abusive and resists care. [DIAGNOSES REDACTED]. He was assessed on the Elopement/Wandering Risk Assessment as being ambulatory, wandering with a pre-determined destination and as being confused. Review of the incident/accident form dated 6/09/2009 revealed that resident #81 had removed his WanderGuard bracelet and after a smoke break at 11:45 p.m. on the back porch, he climbed the fence and left the facility. He was seen by a passerby and the police were notified. The passerby directed the police to where the resident was on the road. Resident #81 told the police he had just gotten off the bus and he was returned to the facility. The nursing staff had not seen him since giving him medication at 9:45 p.m. and at the time he was returned by the police were not aware that resident #81 was not in the building. Review of the Nurses' Notes dated 2/28/2010 at 5:30 p.m. revealed that the resident could not be found for the supper meal. The resident was found on Highway 80 trying to thumb a ride to the Interstate. The police returned resident to the facility. The resident had again removed the WanderGuard bracelet and gone out the back porch and on this occasion, under the fence. Interview with LPN "DD" on 6/24/2010 at 1:00 p.m. revealed that they just try to watch the residents the best they can and redirect them to activities. There were no interventions developed to prevent this resident from leaving the building again. 4. Resident "E" was admitted to facility on 8/03/2009 from another facility and had a history of [REDACTED]. The resident had severe speech limitations (only one (1) or two (2) words) and was assessed as rarely understands what is being said. The resident was observed to be ambulatory with an unsteady gait. Resident "E" had a current physician order [REDACTED]. The resident was assessed as having the potential for elopement due to past history and a WanderGuard was place on the resident on Admission to the facility. Resident "E"s care plan was updated on 4/20/2010 to include visual checks, WanderGuard and potential for elopement due to attempts to climb the (back yard) fence. The resident was assessed as resisting care on 1/18/2010 and 4/20/2010 on the Minimum Data Sets (MDS). Record review of the Social Worker notes dated 10/01/2009 revealed the resident was frequently going out the smoke room door, going thru other resident's rooms, climbed through other resident's windows. SW Notes included behaviors of hiding in closets, wandering into other's rooms and getting into their beds. The resident was to wear a WanderGuard bracelet. An interview with the resident's responsible party on 6/24/2010 at 11:00 a.m. revealed that he/she had been notified by the facility that the resident had climbed out of a window to the outside and was attempting to get under the (back yard) fence. The responsible party could not remember exactly when this occurred. An interview with the Administrator on 6/24/2010 at 10:30 a.m. revealed she was not aware of the resident climbing through windows. An interview with the Social Worker on 6/24/2010 at 12:55 p.m. revealed that she thought the note was an error and should have documented that the resident had not climbed through a window to the outside, but rather would attempt to enter the building from outside windows. She agreed that the documentation indicated something different. 5. An observation on 6/22/2010 at 8:30 a.m. revealed a male resident was sitting in the area, at the Nurses Station, near the door to the smoking porch when a resident wearing a WanderGuard exited to the smoking porch setting off the door alarm. No staff were in the area, and the male resident yelled to staff at the end of the hall, "I'll get it", then walked over to the WanderGuard system at the door, reached under the box and turned off the alarm. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 26, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identified as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a "K" level to an "E" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion Date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuard had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position hire: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservices were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with the Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010.

Based on observation, record review and staff interview the facility failed to be administered in a manner that ensured the safety of residents with wandering and elopement behaviors. The failure to implement effective interventions to address residents leaving the facility with staff being aware and to maintain a safe environment, specifically, the back yard fenced area effected seventeen (17) residents identified by the facility as having a high risk for their safety based on elopement behaviors. Therefore, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to exist from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: During interview with the Administrator on 6/25/2010 at 10:00 a.m. revealed she was aware of problems with elopement and that this had been an on-going problem. The residents in this facility were described as unique and do not have the same issues as in other facilities. "If these residents decide to leave you can not prevent it". Interventions that were put into place for (named) resident (#114) were not consistently followed. The resident was difficult to keep track of. She indicated that they placed one-to-one supervision on the resident after the second elopement but they stopped after a couple of days and the supervision should have been on going. Interview with the DON and the Administrator on 6/25/2010 at 2:00 p.m. and 4:00 p.m. revealed neither was aware that residents knew how to and were turning off the WanderGuard system when an alarm would sound. Nor were they aware that staff were in visual site of the area when this was occurring. An interview on 6/25/2010 at 2:15 p.m. with the Administrator revealed that when they looked back at the whole year of occurrences, the number of elopements was more than they realized. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 25, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identified as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a "K" level to an "E" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion Date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuards had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservice were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010. Cross refer to F323

Based on record review and staff interview the facility failed to have an effective Quality Assurance process that identified elopement as an issue for residents needing supervision and or monitoring to ensure their safety, that developed effective interventions and determined the effectiveness of any interventions that were developed. The facility failed to identified a significant number of residents with wandering behaviors or to identify commonalities in how residents were leaving the facility with staff awareness. This effected seventeen (17) residents currently residing in the facility with elopement behaviors. A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to exist from June 3, 2010 until June 26, 2010 when the facility submitted an acceptable plan of correction. Findings include: An interview on 6/25/2010 at 2:15 p.m. with the Administrator revealed she did not remember if elopement was addressed in the most recent Quality Assurance (QA) meeting that took place on 6/16/2010. Interview at that time revealed she was not aware of the number of, or the frequency of residents leaving the facility without staff being aware. She further commented that when you look back at the year, there had been more elopements than she realized. Record review of the summary documentation of the QA meetings conducted in the past year revealed wandering or elopement was listed as a topic twice but no trending, new interventions or factors contributing to elopement from the facility were discussed. Although the back yard fence was a frequent source of elopement by residents, no solutions were developed. A lack of sufficient outside sources for psychiatric referrals was listed but no solutions developed. The Administrator was aware that the back yard fence, gate and roof sections have been problematic with residents going over and under the fence and that the fence needed repairs. Interview with the Medical Director on 6/25/2010 at 2:30 p.m. revealed he attended the QA meetings. The situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident was determined to have been removed on June 26, 2010 but, the associated noncompliance continues in order to ensure the following are maintained by the facility: all residents identifies as having wandering and elopement behaviors have an effective plan of care that ensures ongoing safety; that all direct care staff are inserviced on the revised policy and procedures related to resident elopement; new staff position of Safety Tech is filled and implemented; all WanderGuard systems are functional and monitored on a daily basis and back yard fencing and gate repairs are conducted. Therefore, the scope and severity of the deficiency was reduced from a "K" level to an "E" level when the facility implemented the following plan of correction: 1. All residents identified as having wandering and elopement behaviors were reassessed and care plans were revised to include individualized interventions based on the assessment. All remaining residents were assessed to ensure accuracy of previous determinations. Completion date: June 23, 2010. 2. A development of an Elopement Alert Notice book with resident photographs was placed at each nursing station. Completion date: June 24, 2010 3. Repair of the malfunctioning WanderGuard system on Station II. Completed: June 23, 2010. 4. All residents wearing WanderGuard had them tested to be sure they were working consistently. Completed: June 22, 2010. 5. Daily monitoring of the doors for WanderGuard and key pad functioning to be conducted by the Maintenance or Housekeeping Supervisors. A tool was developed to document the results of the monitoring. Completed: June 23, 2010. 6. 24 hour monitor (staff person) in place until permanent repairs to areas of back yard fence, gate, and resident windows. (Authorization of repairs was obtained with a completion date of 7/15/2010) Completed date for monitor position hire: June 23, 2010. 7. Revision to policy: Elopement Prevention Interventions for Residents Deemed at Risk. An inservice was conducted that included risk factors, elopement behaviors, monitoring of residents, new tool for documenting monitoring and the revised policy. Five inservices were conducted from June 22-25, 2010. The remaining 21 staff not available for inservice will have training on new policy prior to returning to work. 8. A Quality Assurance meeting was held with Administrator, all department heads and the facility's Medical Director to develop long term interventions, review policy changes and new documentation tools. Completed: June 25, 2010. Cross refer to F323.