Every finding on record at Wellsville Manor

Based on observation, interview, and record review, the facility failed to provide the services of a full-time Certified Dietary Manager (CDM) for the residents who resided in the facility and received their meals from the kitchen. Findings included: - On 05/20/26 at 11:00 AM, Dietary Staff BB verified she was the Certified Dietary Manager (CDM) for the two facility kitchens but continued to work at another facility as well.During an interview on 05/21/26 at 09:35 AM, Administrative Staff A stated there should be a full-time CDM on site, and this was the expected transition for Dietary Staff BB. Administrative Staff A verified there should be a qualified dietician or other clinically qualified nutrition professional working full-time in the facility, to oversee the kitchen staff and dietary needs of the residents.During an interview on 05/21/26 at 11:05 AM, Consultant GG verified she was overseeing seven facilities kitchens and currently visits this facility on Fridays, then verified that neither she nor the CDM are working over 35 hours a week at the current facility.

Based on observation, interview, and record review, the facility failed to ensure effective sanitizing of dishes when the sanitizer did not reach 120 degrees Fahrenheit, in one of the facility's two kitchens. Findings included:- During an observation on 05/20/26 at 12:15 PM, Dietary Staff EE ran a cycle of glassware through the sanitizer, in the secondary kitchen, and verified the temperature was 111 degrees Fahrenheit (F). During an interview on 05/20/26 at 12:30 PM, Maintenance Staff U confirmed the temperature on the sanitizer should be 120 degrees F. On 05/20/26 at 03:00 PM, Maintenance Staff U stated the temperature on the sanitizer was adjusted to 120 degrees Fahrenheit. The facility's undated Dietary Services Leadership & Shared CDM Policy stated residents are to receive safe, sanitary, and nutritionally adequate meals in accordance with physician orders, resident preferences and regulatory requirements.

Based on observation, interview, and record review, the facility failed to implement adequate infection control practices when staff failed to perform hand hygiene and failed to sanitize shared equipment. Findings included:- On 05/20/2026 at 01:25 PM, an observation revealed Certified Nurse Aide (CNA) P and CNA N used a Hoyer lift (full body mechanical lift) for Resident (R) 35 who was on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and transferred the resident from the wheelchair to the bed to change the resident's soiled brief. CNA P and CNA N washed their hands and applied personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses before transferring and changing resident). CNA P and CNA N removed the soiled brief and applied a clean brief without changing gloves and performing hand hygiene. The two CNA staff then removed their PPE and placed it in the trash.On 05/20/2026 at 01:35 PM, an observation revealed CNA P and CNA N removed the Hoyer lift from R35's room and took it to R29's room across the hall without cleaning the lift. CNA P and CNA N used the unsanitary Hoyer lift to transfer R29 to the bed from the resident's wheelchair. On 05/20/2026 at 01:50 PM, an observation revealed CNA N removed the Hoyer lift from R29's room and placed it in the clean storage area with the other Hoyer lift without cleaning it. During an interview on 05/20/2026 at 02:04 PM, CNA P stated that dayshift does not clean the Hoyer lifts after resident use and only night shift was responsible for cleaning the equipment. CNA P indicated the Hoyer would be cleaned later that night.During an interview on 05/20/2026 at 02:10 PM, Licensed Nurse (LN) G stated that staff was supposed to clean the Hoyer lift after each resident use, and the night shift staff was responsible for deep cleaning the Hoyer lift. LN G went down to the clean storage area and cleaned the Hoyer lifts.During an interview on 05/20/2026 at 02:17 PM, Administrative Nurse E stated that the Hoyer lift was to be cleaned after each resident use and was to be deep cleaned by the night shift staff. Administrative Nurse E said the day shift staff had been educated on cleaning the Hoyer lift after each resident use.The facility's undated policy Equipment Cleaning Disinfection Policy documented that resident care equipment shall be cleaned and disinfected between resident use and whenever visibly soiled, contaminated, or as indicated by manufacturer instructions, facility infection prevention protocols, or applicable regulatory requirements.The facility's undated policy Enhanced Barrier Precautions documented the facility followed recommendations and guidance from the Centers for Disease Control to keep all residents safe from Healthcare Acquired Infections (infections that residents acquire while receiving medical treatment in a healthcare facility).

Based on observation, interview, and record review, the facility failed to inform Resident (R) 5 or her representative about the risk and benefits of taking an antidepressant (a class of medications used to treat mood disorders).Findings included:- R5's Electronic Medical Record (EMR) revealed the following diagnoses: major depressive disorder (major mood disorder that causes persistent feelings of sadness).R5's 06/10/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS recorded R5 took a diuretic (a medication to promote the formation and excretion of urine), opioid (a class of controlled drugs used to treat pain), hypoglycemic (a type of medication to treat high blood glucose levels), and an anticonvulsant.R5's Falls Care Area Assessment (CAA) documented R5 received pain medications and diabetic medications.R5's Psychotropic Drug Use CAA was not triggered.R5's Care Plan documented R5 took an antidepressant for a diagnosis of major depressive disorder to improve functioning and reduce symptoms on 03/16/26.R5's Physician's Orders documented an order for sertraline 50 milligrams mg every evening, ordered on 05/29/25.R5's EMR had a Consent for Use of Psychotropic Medication dated 03/16/26. The uncompleted assessment documented R5 took sertraline 50mg for depression. The consent was unsigned.R5's EMR showed no indication that R5 or the representative was notified of the medication including the risk verses benefits or potential side effects of the medication.On 05/21/26 at 08:26 AM, R5 sat in her recliner watching television. R5 appeared relaxed and comfortable.On 05/21/26 at 10:14 AM, Administrative Nurse F stated Administrative Nuse D did the consents for medication.On 05/21/26 at 10:28 AM, Administrative Nurse D stated that they realized in March that they had not done the consents on any psychotropic medications. They began to do them at that time. Administrative Nurse D verified that the resident or representative did not consent to the medication. It must have been skipped over.The facility policy for Medication Management, Consents, and Monitoring, undated, documented prior to initiating psychotropic medications, the facility shall inform the resident and/or legal representative of medication name and purpose, risk and benefits, potential side effects, alternative treatment options, and the right to refuse treatment. The facility will maintain a signed consent in the medical record.

Based on observation, interview, and record review, the facility failed to accurately assess and monitor a psychotropic medication for Resident (R) 27, who received Ambien (a psychotropic medication used to induce sleep) nightly.Findings included:- R27's Electronic Medical Record (EMR) revealed the following diagnoses: insomnia (inability to sleep) and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R27's 09/08/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS recorded R27 took an antidepressant (a class of medications used to treat mood disorders), anticoagulant (a class of medications used to prevent the blood from clotting), and opioid (a class of controlled drugs used to treat pain). The MDS did not accurately document that R27 took a hypnotic (a class of medications used to induce sleep).R27's 09/08/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R27 took pain medication which managed her pain well but lacked documentation of the hypnotic or diagnosis of insomnia.R27's Care Plan documented R27 took Ambien, which had a Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). It directed staff to monitor pain, sleep patterns, and respirations. Do not give more than seven to ten days consecutively on 03/14/26.R27's Physician's Orders documented an order for zolpidem (Ambien) 5mg for insomnia every night, start dated 04/29/26.R27's EMR lacked evidence of monitoring for side effects and effectiveness for the ongoing use of the Ambien.On 05/19/26 10:06 AM, R27 reclined in her recliner with her feet up. R27 requested that the facility switch out her bed for the recliner. R27 stated all she does all day was just lay here. R27 reported that she liked staying in her room.On 05/21/26 8:59 AM Licensed Nurse (LN) G stated that how the staff monitored the effectiveness of a psychotropic medication is a reminder to document the behaviors and adverse reactions originating on the care plan and it goes to the orders, where the nurse saw it and documented on the medications in a nurse's note. Different medications have different frequencies for documentation. R5 had a reminder to document on the sertraline every six weeks. R27 did not have a reminder to monitor the zolpidem, and the nurses had not been monitoring this hypnotic medication for sleep.On 05/21/26 at 10:14 AM, Administrative Nurse F noted R27's Ambien should have been added to the care plan should have been documented on the care plan at admission so staff could document on the effectiveness of the medication.On 05/21/26 at 10:28 AM, Administrative Nurse D stated she fixed it so the zolpidem was now showing up on the care plan so the nurse would document it.The facility policy Medication Management, Consents, and Monitoring, undated, documented residents have the right to be free from unnecessary medications. The facility will ensure medications are used only when clinically indicated, monitored for effectiveness and adverse consequences, and supported by appropriate documentation.

Based on interview and record review, the facility failed to provide Resident (R) 2, and R54 a written notification of transfer to the resident and/or his representative as soon as practicable and failed to send a copy of that notification to the ombudsman. The facility also failed to provide R2 or the representative with the bed-hold upon discharge to the hospital.Findings included: 1. R2's Electronic Medical Record (EMR) revealed a diagnosis of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) and urinary tract infection (UTI-an infection in any part of the urinary system).R2's Minimum Data Set (MDS) tab documented a Discharge MDS on 11/20/25, 01/23/26, 03/14/26, and 04/26/26.R2's Nurse's Note, dated 11/21/25 at 01:50 AM, documented R2 returned to the facility after having the nephrostomy tubes changed, at 09:10 PM, R2 had a temperature of 102 Fahrenheit (F), and was sweating and had low back pain. The doctor was notified and advised staff that R2 likely required evaluation at the hospital due to similarities to previous UTI/sepsis episode. R2 was sent out to the hospital. R2's Nurse's Note, dated 01/23/26 at 05:10 PM, documented R2 had red colored urine and a fever. The doctor was notified and gave the order to send R2 to the emergency room for evaluation. R2's Nurse's Note, dated 03/14/26 at 04:56 PM, documented R2 had lower back pain and reported that one of her nephrostomy tubes felt like it was being pulled. Assessment of the right nephrostomy tube site revealed the nephrostomy dressing was soiled with what appeared to be dried mucus. The opening where the tube enters the skin also appeared larger than expected. Sutures were present and intact. A small amount of blood and sediment was observed in the right outermost tube and bag. The dressings were changed, and the doctor was notified and recommended applying mupirocin ointment to insertion site and monitoring closely.R2's Nurse's Note, dated 03/14/26 at 05:57 PM, documented R2 had a fever of 101.3 F and pain to her right outermost nephrostomy tube. The doctor was notified and provided an order to send R2 to the hospital.R2's Nurse's Note, dated 04/26/26 at 08:54 PM, documented R2 continued to have a temperature of 101.2 F an hour after she received Tylenol. The doctor was notified and gave the order to send R2 to the hospital if R2 worsened.R2's Nurse's Note, dated 04/26/26 at 09:55 PM, documented R2's temperature was now 102.9 and the nurse sent her to the hospital.R2's EMR lacked documentation that the bed hold was provided to the resident or the representative. The EMR also lacked documentation of a written notification to the residents and/or the representative, which explained the reason for the transfer to the hospital, or that the ombudsman was notified of the transfer. The facility was unable to provide the evidence upon request.2. R54's Nurse's Note, dated 03/26/26 at 01:39 PM, documented R54 had complaints of chest pain that radiated to his jaw and arms. The doctor was notified and gave the order to have him evaluated at the emergency room. R54 was transported by ambulance.R54's EMR lacked documentation of a written notification to the residents and/or the representative, which explained the reason for the transfer to the hospital, or that the ombudsman was notified of the transfer. The facility was unable to provide the evidence upon request.During an interview on 05/19/26 at 01:50 PM, Administrative Nurse E stated that, to her knowledge, the ombudsman was not notified of the discharges or transfers of the LTC residents.During an interview on 05/20/2026 11:30 AM, Social Service X stated she was unaware of the regulation to provide a bed hold to the resident or representative at the time of transfer. Social Service X was also unaware of the regulation to notify the residents and/or the representative in writing of the reason for the transfer and appeal policy and notify the ombudsman of transfers.During an interview on 05/20/26 at 08:54 AM, Administrative Staff A said the SS X had been responsible for providing bed holds and transfer/discharge notification. She also said that the ombudsman had not been notified in writing of transfers and discharges, but the facility contacted the ombudsman on 05/19/26 and have implemented a policy to contact the ombudsman in writing of all transfers and discharges.The facility's policy Ombudsman Notification and Transfer/Discharge Policy documented the facility shall comply with all applicable federal and Kansas requirements regarding resident transfer and discharge notification, including to the Kansas Long-Term Care Ombudsman Program.

Based on observation, interview, and record review, the facility failed to accurately assess Resident (R) 5 and R27.Findings included:1. R5's Electronic Medical Record (EMR) revealed the following diagnoses: major depressive disorder (major mood disorder that causes persistent feelings of sadness).R5's 06/10/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS recorded R5 took a diuretic (a medication to promote the formation and excretion of urine), opioid (a class of controlled drugs used to treat pain), hypoglycemic (a type of medication to treat high blood glucose levels), and an anticonvulsant. The MDS did not accurately document that R5 took an antidepressant (a class of medications used to treat mood disorders).R5's 06/10/25 Falls Care Area Assessment (CAA) documented R5 received pain medications and diabetic medications.R5's 06/10/25 Psychotropic Drug Use CAA was not triggered due to not being accurately assessed on the MDS.R5's Care Plan documented R5 took an antidepressant for a diagnosis of major depressive disorder to improve functioning and reduce symptoms on 03/16/26.R5's June 2025 Electronic Medication Administration Record (EMAR) documented R5 took sertraline 50 milligrams (mg) on 06/04/25, 06/05/25, 06/06/25, 06/07/25, 06/08/25, 06/09/25, and 06/10/25.R5's Physician's Orders documented an order for sertraline 50 milligrams mg every evening, ordered on 05/29/25.R5's June 2025 Electronic Medication Administration Record (EMAR) documented R5 took sertraline 50 milligrams(mg) on 06/04/25, 06/05/25, 06/06/25, 06/07/25, 06/08/25, 06/09/25, and 06/10/25.On 05/21/26 at 08:26 AM, R5 sat in her recliner watching television. R5 appeared relaxed and comfortable.2. R27's Electronic Medical Record (EMR) revealed the following diagnoses: insomnia (inability to sleep) and major depressive disorder (major mood disorder that causes persistent feelings of sadness).R27's 09/08/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS recorded R27 took an antidepressant (a class of medications used to treat mood disorders), anticoagulant (a class of medications used to prevent the blood from clotting), and opioid (a class of controlled drugs used to treat pain). The MDS did not accurately document that R27 took a hypnotic (a class of medications used to induce sleep).R27's 09/08/25 Psychotropic Drug Use Care Area Assessment (CAA) documented R27 took pain medication that managed her pain well but lacked documentation of the hypnotic or diagnosis of insomnia.R27's Care Plan documented R27 took Ambien, which had a Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). It directed staff to monitor pain, sleep patterns, and respirations. Do not give more than seven to ten days consecutively on 03/14/26.R27's Care Plan was not updated with the Psychotropic Use care plan for the nurse to document behaviors and side effects. R27's Physician's Orders documented an order for zolpidem 10 mg every night, ordered on 09/02/25.R27's September 2025 Electronic Medication Administration Record (EMAR) documented R5 took zolpidem 10 mg on 09/02/25, 09/03/25, 09/04/25, 09/05/25, 09/06/25, 09/07/25, and 09/08/25On 05/19/26 at 10:06 AM, R27 reclined in her recliner with her feet up. R27 requested that the facility switch out her bed for the recliner. R27 stated all she does all day is lay here. R27 reported that she liked staying in her room.On 05/21/26 at 10:14 AM, Administrative Nurse F stated that, according to the EMAR, R5 had taken the antidepressant during the lookback period and should have been documented on the MDS. Administrative Nurse F verified understanding that since it was not documented on the MDS, it was not documented on the CAA, and on the care plan at admission. Administrative Nurse F verified that, according to the EMAR, R27 had taken the hypnotic medication during the lookback period and it should have been documented on the MDS.On 05/21/26 at 10:28 AM, Administrative Nurse D stated that she expected the MDS to accurately represent the residents.The facility policy for MDS Accuracy Policy, undated, documented the purpose of the policy was to ensure MDS assessments are completed accurately, in a timely manner, and in accordance with regulations.

Based on observation, interview, and record review the facility failed to identify and implement resident-centered interventions and monitor effectiveness of interventions to prevent falls for Resident (R) 3 who was at high risk for falls. Findings included:- R3's Electronic Health Record (EHR) documented diagnoses of pneumonitis (an infection in the lungs due to inhalation of food and vomit), sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), polyosteoarthritis (degenerative changes to many joints characterized by swelling and pain), encephalopathy (a broad term for any brain disease that alters brain function or structure), dementia (a progressive mental disorder characterized by failing memory and confusion), atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure), urinary tract infection (UTI-an infection in any part of the urinary system), overactive bladder (a sudden, uncontrollable urge to urinate that is difficult to postpone), and diarrhea.R3's Annual Minimum Data Set (MDS), dated 03/19/2026, documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. R3 required a wheelchair for mobility. The MDS documented that R3 was set up for clean-up assistance for eating and was dependent on transfers and substantial to maximal assistance for most of her other activities of daily living (ADL).R3's Care Plan, dated 03/17/25 documented she was at risk for falls due to weakness, impaired balance, incontinence and disease conditions. The care plan directed staff to place the bed in the lowest position as a fall intervention for a fall on 05/03/25. R3's Care Plan, directed staff to ensure bedside commode is in the bathroom with the curtain pulled as a 05/18/26 fall intervention.R3's Care Plan, documented frequent visual checks between 09:00 PM and 12:00 AM for the fall date of 12/15/25.R3's re-admission Fall Risk Evaluation, dated 02/20/26, documented that she had a history of one or more falls within the previous 6 months and documented she is not a low fall risk.R3's Annual Fall Risk Evaluation, dated 03/14/26, documented a history of one or more falls within the previous 6 months and documented she is not a low fall risk.R3's Safety Event-Copy of Fall Assessment and Root Cause Analysis, dated 05/18/26, documented an unwitnessed fall with injury, and that R3 was reaching for something and slid or fell from her wheelchair. R3's EHR Progress Note, dated 03/07/26 and timed at 03:38 PM, documented by a note by Licensed Nurse (LN) H, which listed the root cause of the fall was R3 attempted to transfer to the commode and did not use her call light. LN H further documented that Certified Nursing Aide (CNA) N had discovered R3 sitting on the floor in front of her wheelchair with one hand on the grab bar right outside of her bathroom and that R3 stated she was trying to use the commode. LN H documented that R3 did not use her call light and that neurological assessments were initiated because R3 had a BIMs score of five that indicated severe cognitive impairment.Observed on 05/13/26 at 02:36 PM, R27 sat in her wheelchair in the common area television room and played dominoes with staff and another resident.Observed on 05/20/26 at 08:05 AM, R3 lay in bed with her eyes closed on a scoop mattress. The bed was raised approximately three to four feet from the floor and was not in the lowest position.Observed on 05/21/26 at 08:22 AM, R3 lay in bed. Her bed was in a low position, approximately six inches from the floor, with a fall mat at the bedside.On 05/20/26 at 03:08 PM, Administrative Nurse D said that she could not define or explain what frequent checks were because there was no way to quantify that time frame. Administrative Nurse D stated it was a task and was not something staff can put an exact time frame on.On 05/21/26 at 09:45 AM, CNA N said staff would leave the door to the bathroom propped open with a trash can. CNA N said they pull the privacy curtain if R3 is not using the bedside commode. CNA N said R3 is to have her bed in the lowest position with a fall mat next to her bed and said these are the only fall interventions she is aware of.On 05/21/26 at 11:45 AM, CNA M said that R3's Care Plan documents that her bed is to be in the lowest position with a fall mat on the floor next to the bed. CNA M said that the plan documented the bedside commode was to be kept in the bathroom blocking the doorway. CNA M further stated that there was nothing in the bathroom that R3 was required to use and the door to the bathroom was propped open with a trash can per R3's request.The facility fall prevention protocol policy is undated and documents that each elder residing at this facility will be provided care that ensures the elder's environment remains as free from accident hazards as possible. The protocol further documents that an elder is considered to need high fall risk prevention protocols if the elder has had a fall while living at the facility.

Based on interview and record review, the facility failed to ensure that Resident (R) 2 received appropriate treatment and services to prevent urinary tract infections to the extent possible by failing to keep the urine collection bag attached to the nephrostomy(an artificial opening created between the kidney and the skin which allows for the urinary diversion) tubes below the level of the kidney.Findings included:- R2's Electronic Medical Record (EMR) revealed a diagnosis of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body) urinary tract infection (UTI-an infection in any part of the urinary system), and a kidney infection.R2's 07/06/25 admission Minimum Data Set (MDS) documented R2 had an indwelling catheter and took antibiotics.R2's 07/06/25 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R2 was in isolation for a UTI and had nephrostomy tubes in both kidneys, which staff are managing.R2's EMR contained Discharge Instructions for Nephrostomy Tube Care, dated 05/15/26, which documented the nephrostomy tube drains urine from the kidney around the blockage to a bag outside the body. It instructed that the bag should always remain below the bladder. It should never be higher than the bladder.On 05/20/26 at 2:42 PM, R2 sat in the recliner in a reclined position. R2 had an apron with pockets on the chest for her urostomy bags. The bags were positioned in the pockets on her chest as she relaxed and watched television.On 05/20/26 at 2:58 PM, Certified Nurse Aide (CNA) P stated the staff transferred R2 with a Hoyer lift (total body mechanical lift). R2 was dependent on staff for all transfers. CNA P stated the staff knows R2 had nephrostomy tubes, and they were careful not to pull or tug on them. They always had the nurse present when they provided cares for R2. R2 had bags on the side of her bed to place the urine collection bags in while she was in bed.On 05/20/26 at 3:02 PM, Licensed Nurse (LN) G Stated the urine collection bags were to be in the bags on the sides of the recliner. They were never to be above the level of R2's bladder. LN G went in at that time and moved the bags.During an interview on 05/21/26 at 10:28 AM, Administrative Nurse D stated it was her expectation that staff always keep the urine collection bags below the level of the bladder to prevent back flow and infection.The facility's policy Catheter and Nephrostomy Tube Care Policy documented drainage bags are to remain below the level of the bladder or kidney insertion site.

The facility reported a census of 43 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included: - During an initial tour of the kitchen on 08/20/24 at 07:41 AM, the following areas of concern were noted: 1. The trash can in the dish washing area contained dried-on food and liquid substances on all sides and the lid. 2. The trash can by the hand washing sink contained dried-on food and liquid substances on all sides and the lid. 3. The shelf underneath a preparation table which held plastic pitchers, cutting boards and clean eating utensils, contained food debris. 4. The inside of the microwave contained dried-on food on all sides and the top. 5. Four colored cutting boards contained deep grooves and were discolored. 6. An oscillating fan had a build-up of dust in the slats of the fan. 7. One side of the stove had dried-on food substances. 8. One of two reach-in freezers had a build-up of food substances on the bottom. 9. One of two reach-in freezers had a build-up of food substances on the bottom and a build-up of a black substance in the rubber door seals. 10. Three plastic tubs, beneath a prep table, which held clean cooking utensils, contained a sticky substance on the bottom of the tubs. 11. Five plastic containers on a wire rack which contained clean kitchen utensils, had a heavy build-up of food debris and a sticky substance on the container latches. 12. The table holding the large stand mixer, had a build-up of food substance on the bottom shelf, holding the two large mixing bowls. On 08/21/24 at 10:50 AM, Dietary staff BB confirmed the areas of concern and stated the areas would need to be included on a cleaning schedule. The facility lacked a policy for kitchen cleanliness. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility appropriately to prevent the potential for food borne bacterial.

The facility reported a census of 43 residents with 14 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate assessment/Minimum Data Set (MDS for four residents (R)23, R 37, R 2, and R 13 related to siderails used as restraints. Findings included: - Review of Resident (R)23's undated Physician Orders documented diagnoses which included hypertension (high blood pressure), chronic kidney disease, and heart failure. The Admission Minimum Data Set (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The MDS indicated bedrails not used as restraints (physical restraint are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). The Quarterly MDS dated [DATE], documented BIMS score of 15, indicating cognitively intact. The bedrails used as restraint daily. The Quarterly MDS dated [DATE], documented a BIMS score of 15, indicating cognitively intact. The bedrails used as restraint daily. Observation on 08/20/24 at 10:21 AM, revealed the resident as alert and oriented. She sat in her wheelchair and self-propelled her wheelchair about the room. There were bedrails at the head of the resident's bed. On 08/19/24 at 12:10 PM, R 23 reported she requested the bedrails at the head of her bed. The bedrails did not restrict her movement in any way. She reported she used the bedrails to reposition herself in the bed and she would object to their removal. On 08/20/24 at 01:53 PM, Certified Nurse Aide (CNA) N stated the facility did not have any residents that used bedrails as restraints. Residents used bedrails to increase their independence. R 23 preferred to lay in the bed with her legs positioned on a pillow. She used her bedrails to turn side to side. On 08/21/24 at 10:29 AM, Licensed Nurse (LN) G confirmed the resident used the bedrails to position herself in the bed, turn from side to side, and enter and exit the bed. She had full access to her body. The bedrails did not restrict her movements but increased her independence. He stated the facility did not use restraints in the facility. On 08/21/24 01:33 PM, Administrative Nurse D confirmed the above findings. She reported the facility did not use bedrails to restrain residents. She stated the MDS Coordinator had inaccurately coded bedrails used daily as a restraint She stated, upon review, inaccurate assessment affected 31 resident's assessments. Administrative Nurse D verified the bedrail use by the resident did not meet the definition of restraints as given in the Resident Assessment Instrument Manual (RAI), which the facility used for guidance to accurately compete the residents MDS. The undated facility policy Bedrails documentation included each resident has the right to be free from any physical restraints. It is the policy of the facility to be restraint-free environment. The facility failed to complete an accurate assessment/Minimum Data Set (MDS for (R)23, related to bedrails used as restraint. - Review of Resident (R)37's undated Physician Orders documented diagnoses which included pain, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) with current pathological fracture (broken bone caused by disease). The Admission Minimum Data Set (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS indicated bedrails not used as restraints (physical restraint are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body). The Quarterly MDS dated [DATE], documented BIMS score of one, indicating severe cognitive impairment. The bedrails used as restraint daily. The Quarterly MDS dated [DATE], documented BIMS score of one, indicating severe cognitive impairment. The bedrails used as restraint daily. Observation on 08/19/24 at 12:36 PM, revealed the resident's bed with bedrails at the head of the bed. On 08/19/24 at 12:10 PM, upon inquiry 37 reported she could move around without limitation. The bedrails helped her to move around. On 08/20/24 at 01:53 PM, Certified Nurse Aide (CNA) N stated the facility did not have any residents that used bedrails as restraints. Residents used bedrails to increase their independence and self-position when in the bed. R 37 used her bedrails to enter and exit the bed independently. The resident is impulsive but the bedrails help her with her balance when she gets in and out of bed independently. On 08/21/24 at 10:29 AM, Licensed Nurse (LN) G confirmed the resident used the bedrails to position herself in the bed, turn from side to side, and enter and exit the bed. She had full access to her body. The bedrails did not restrict her movements but increased her independence. He stated the facility did not use restraints in the facility. LN G reported the resident was impulsive and moved around the room getting in and out of bed independently. On 08/21/24 01:33 PM, Administrative Nurse D confirmed the above findings. She reported the facility did not use bedrails to restrain residents. She stated the MDS Coordinator had inaccurately coded bedrails used daily as a restraint. She stated, upon review, inaccurate assessment affected 31 resident's assessments. Administrative Nurse D verified the bedrail use by the resident did not meet the definition of restraints as given in the Resident Assessment Instrument Manual (RAI), which the facility used for guidance to accurately compete the residents MDS. The undated facility policy Bedrails documentation included each resident has the right to be free from any physical restraints. It is the policy of the facility to be restraint-free environment. The facility failed to complete an accurate assessment/Minimum Data Set (MDS for (R)37 related to bedrails used as restraint. 28560 - Review of Resident (R) 2's medical record revealed diagnoses that included femur (long bone in the thigh) fracture and chronic obstructive pulmonary disease (COPD progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive status. The resident had no devices used as a restraint. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/08/24, assessed the resident with no weight bearing of the right extremity and on a turning and repositioning program with a pressure reducing mattress on her bed. The Quarterly MDS, dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13 which indicated normal cognitive status. The resident used a restraint of bed rails daily. The Care Plan reviewed 08/01/24, instructed staff the resident use side rails for mobility and independence. The Siderail Use and Risk Assessment, dated 04/04/24, assessed the resident used two bed rails for the promotion of resident mobility, positioning, and independence. The device assisted to maintain proper body alignment. Observation, on 08/19/24 at 1:11 PM, revealed the resident seated in her recliner in her room. The bed contained two quarter rails. Interview with the resident at that time revealed she had been bed bound for a while due to femur fracture, but now received therapy. The resident stated she used the rails to help turn and reposition when in bed, but now slept in her recliner. Interview, on 08/19/24 at 1:30 PM, with Administrative Nurse D and Administrative Staff A, revealed the facility was restraint free, and confirmed the MDS inaccurately coded the bed rail as a restraint. The facility policy Bed Rails undated, instructed staff the facility was to provide a restraint free environment. If a bed rail is used the facility will ensure individual bed rail assessments and evaluations are performed on a regular basis. The facility follows the RAI (Resident Assessment Instrument) Manual for the completion of the MDS. The facility inaccurately assessed this resident's use of side rails as a restraint on the MDS dated [DATE]. - Review of Resident (R) 13's medical record, revealed diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognitive status. The resident utilized two bed rails as a physical restraint daily. The Cognitive Loss Care Area Assessment (CAA) dated 01/11/24, assessed the resident utilized bed rails for positioning assistance. The Quarterly MDS dated [DATE],assessed the resident daily use of bed rail as a restraint. The Quarterly MDS dated [DATE], assessed the resident daily use of bed rail as a restraint. The Care Plan reviewed 06/25/24, instructed staff the resident used side rails for independence and mobility. The Siderail Use and Risk Assessment, dated 04/06/24 and 07/09/24, assessed the resident utilized bed rails to maintain proper body alignment. Observation, on 08/20/24 at 09:13 AM, revealed the resident positioned in bed with two quarter bed rails in the down position. Certified Nurse Aide (CNA) O and P used a draw sheet to turn and reposition the resident to prepare for transfer with a mechanical lift. CNA P stated the resident did not usually assist staff to turn with the use of side rails. Interview, on 08/21/24 at 01:00 PM, with Administrative Nurse D, confirmed the MDS coding of the bed rail as a restraint was inaccurate. Administrative Nurse D stated the facility was restraint free. The facility policy Bed Rails undated, instructed staff the facility was to provide a restraint free environment. If a bed rail is used, the facility will ensure individual bed rail assessments and evaluations are performed on a regular basis. The facility follows the RAI (Resident Assessment Instrument) Manual for the completion of the MDS. The facility inaccurately assessed this resident's use of side rails as a restraint on the MDS, dated 01/11/24, 04/11/24 and 07/11/24.

The facility reported a census of 43 residents with 14 sampled for review. Based on observation, interview, and record review, the facility failed to complete a Significant Change Minimum Data Set (MDS), within 14-days, as required, for two Residents (R)19 and R 44, regarding admission onto hospice care. Findings included: - Review of Resident (R)19 electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score to be four, indicating severe cognitive impairment. The resident did not have a condition or chronic disease which would result in a life expectancy of less than six months, and she did not receive hospice care during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/26/24, documented the resident had a diagnosis of dementia. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. The resident had a condition or chronic disease that could result in a life expectancy of less than six months, and she received hospice care during the assessment period. The care plan, revised 08/13/24, lacked staff instruction regarding hospice care. Review of the resident's EMR revealed the following physician's order: Admit to hospice care for the diagnosis of cerebrovascular disease (the death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), ordered 08/06/24. On 08/20/24 at 01:51 PM, Administrative Nurse D stated the facility was not aware of the need to complete a significant change MDS when a resident admitted to hospice. The facility utilized the Resident Assessment Instrument (RAI) in the completion of MDS's. The facility failed to complete a significant change MDS, within the 14 -days, as required, for this resident who admitted to hospice care. - Review of Resident (R)44's electronic medical record (EMR), revealed a diagnosis of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderate impairment. The resident did not have a condition or chronic disease that could result in a life expectancy of less than six months. He did not receive hospice care during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/24/24, documented the resident had impaired cognition related to a past CVA. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed moderate impairment. The resident did not have a condition or chronic disease which would result in a life expectancy of less than six months, and she did not receive hospice care during the assessment period. The care plan, revised 07/25/24, instructed staff the resident received hospice care for end-of-life care and support. Review of the resident's EMR revealed the following physician's order: Admit to hospice care for the diagnosis of cerebrovascular accident (CVA-the death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), ordered 07/02/24. On 08/20/24 at 01:51 PM, Administrative Nurse D stated the facility was not aware of the need to complete a significant change MDS when a resident admitted to hospice. The facility utilized the Resident Assessment Instrument (RAI) in the completion of MDS's. The facility failed to complete a significant change MDS, as required, for this resident who admitted to hospice care.

The facility reported a census of 43 residents with 14 sampled for review. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one Resident (R)19, regarding admission onto hospice care. Findings included: - Review of Resident (R)19 electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) score to be four, indicating severe cognitive impairment. The resident did not have a condition or chronic disease which would result in a life expectancy of less than six months, and she did not receive hospice care during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/26/24, documented the resident had a diagnosis of dementia. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. The resident had a condition or chronic disease that could result in a life expectancy of less than six months, and she received hospice care during the assessment period. The care plan, revised 08/13/24, lacked staff instruction regarding hospice care. Review of the resident's EMR revealed the following physician's order: Admit to hospice care for the diagnosis of cerebrovascular disease (the death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), ordered 08/06/24. On 08/20/24 at 01:51 PM, Administrative Nurse D stated a resident's care plan should include hospice care instructions for the staff. The facility policy for Care Plan Revisions, undated, included: When changes in a resident's condition occurs, the plan of care will be updated timely. The care plan will be revised when a resident or their family makes the decision to accept hospice services. The care plan shall include detailed and comprehensive instructions to staff on which staff from which specific organization provides services and equipment for the care of the resident and support to the family. The facility failed to complete a comprehensive care plan for this resident who admitted to hospice care.

The facility reported a census of 43 resident with 14 residents selected for review, which included two residents reviewed for respiratory needs. Based on observation, interview, and record review, the facility failed to provide appropriate nebulizer equipment for one of the two Residents (R)2. Findings included: - Review of Resident (R) 2's medical record revealed diagnoses that included femur (long bone in the thigh) fracture and chronic obstructive pulmonary disease (COPD progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive status. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/08/24, assessed the resident with COPD and slept with the head of the bed elevated due to shortness of breath when lying flat. The Care Plan reviewed 08/01/24, instructed staff the resident received oxygen therapy and to observe for signs and symptoms of oxygen deprivation and assess lung sounds as needed. The resident may receive inhalers and breathing treatments in dining area/public areas if she chose. A Physician Order dated 08/18/24, instructed staff to administer ipratropium-albuterol (medications used to dilate airways) breathing solution for nebulization (a technique that require a machine and mask or handheld mouthpiece that turns liquid medication into a mist to inhale into the lungs), 0.5 milligrams (mg)-3 mg (2.5 mg base)/3 ml, every six hours, through 08/20/24. Review of the Medication/Treatment Administration Record dated August 2024, revealed the resident received administration of the ipratropium-albuterol medication on 08/18/24 at 12:00 PM and 06:00 PM, and on 08/19/24 at 06:00 AM (12:00 PM not administered due to wrong size mask) and 09:26 PM (15 and a half hours later). A Nurse Note dated 08/19/24 at 02:31 PM, notified the physician of a delay in providing the breathing treatment due to unavailable supplies. A Physician Order dated 08/20/24, instructed staff to administer the above order through 08/23/24. Observation, on 08/19/24 at 12:47 AM, revealed Certified Medication Aide (CMA) M, prepared to administer the ipratropium-albuterol medication for nebulization. CMA M noted the mask used to place over the resident's nose and mouth was a pediatric (child) size and did not fit the resident appropriately to ensure R2 received the full benefit of the medication. CMA M searched the facility for an appropriately sized mask or handheld inhalation device and was unable to locate one. Interview, on 08/19/24 at 02:18 PM with Licensed Nurse G, confirmed the facility received pediatric masks instead of the ordered adult masks. Interview, on 08/19/24 at 04:30 PM, with Administrative Nurse D, revealed staff obtained the appropriate nebulizer supplies through a local retailer. The facility policy Nebulizer Treatment undated, instructed staff to provide safe and effective delivery of medication to the trachea (windpipe the connection from the voice box (larynx) to the lungs, bronchi (two tubes that connect the lungs to the trachea) and or lungs using proper technique and universal precautions. The facility failed to provide proper nebulizer equipment for R2 to ensure optimal effectiveness of ipratropium-albuterol.

The facility reported a census of 48 residents. Based on observation, interview and record review, the facility failed to store, prepare, and serve food in a sanitary manner for the residents of the facility. Findings included: - Observation, on 11/28/22 at 08:44 AM, revealed the following areas of concern in the refrigerators in the main kitchen: 1) Five condiment squeeze bottles without caps over the open tips. 2) Three sausage patties in a baggie dated 11/21/22. 3) Biscuit gravy in a plastic container dated 11/23/22. 4) An opened bag of bacon bits dated 11/12/22. 5) Sliced black olives in a plastic bag dated 11/15/22. 6) Two ice packs for resident treatments. 7) A resident's personal bowl of turkey and mashed potatoes covered with plastic wrap dated 11/25/22. The pantry contained the following areas of concern: 1) No open date or expiration date on a bag of crushed cornflakes. 2) An opened and unsealed bag of flour. 3) A box of bread dated 11/18/22, with no date on the individual loaves of bread. 4) Raisin Bran in a plastic cereal container dated 07/22. 5) Rice crisp cereal in a plastic cereal container dated 07/22. Interview, on 11/28/22 at 08:45 AM, with Dietary Staff BB, revealed all refrigerated items must be dated when opened and confirmed the identified items above noted were past their safe use by timeframe. Dietary Staff BB stated the resident family brought in the turkey and mashed potatoes and explained that it should contain the name and date. The ice pack for resident treatments should not be kept in the kitchen refrigerator with resident foods. The Country View kitchen refrigerator contained the following areas of concern: 1) Five slices of sausage pizza in a plastic bag dated 11/23/22. 2) An open package of cheddar cheese with an open date of 10/14/22. 3) A plastic bag containing lunchmeat with a noted white slime contained no open date. 4) No date on sliced turkey lunchmeat in a baggie. 5) Five boiled eggs in a baggie with no date. 6) One half of a tomato in a baggie with no date. 7) Three large tortillas in a bag with no expiration date or open date. 8) A resident's personal, opened strawberry jam dated 08/15/22. 9) A plastic squeeze bottle of ranch dressing dated 11/08/22 with no cover over the open tip. 10) A plastic squeeze bottle of French dressing undated and with no cover over the open tip. 11) Two plastic squeeze bottles with an unknown white and yellow substance with no date or cover over the open tips. 12) BBQ sauce in a plastic squeeze bottle with no cover over the open tip. 13) Salsa in a plastic squeeze bottle dated 10/18/22 and no cover over the tip. 14) Two plastic bags of ham and turkey both with no dates. 15) An open plastic bag of bacon bits dated 10/12/22. 16) A jar of salsa dated 08/2/22 with expiration dated 11/23/22. 17) A staff member's personal lunch bag. Interview, on 11/28/22 at 09:30 AM, with Dietary Staff EE, confirmed the above areas of concern, and stated the staff member should not keep their personal lunch bag in the kitchen refrigerator. Observation, on 11/29/22 at 02:00 PM, during the environmental tour of the main kitchen revealed the following areas of concern: 1) The entire surface of the back of the prep table contained multiple splashes and drips of an unknown substance. 2) Two air vents above the prep table contained dust build up and the two air vents above the stove also contained dust build up. 3) Eight vents above the stove contained grime and dust. 4) The lids and interior surfaces of eight plastic boxes containing cooking utensils contained dust, dirt crumbs and grime. 5) Three small skillets contained scratches and chipping of the nonstick surface. 6) One large skillet contained unknown substances in areas of the interior surface. 7) Five of the six burners of the stove contained an accumulation of grime and burnt on substances. 8) The left oven of the stove contained burnt on substance and brown discolorations across all of the interior surfaces. 9) The right oven contained a large amount of brown greasy substance down the door and on the floor of the oven. Interview, on 11/29/22 at 02:30 PM, with Dietary Staff BB, confirmed the above and stated she did have a cleaning schedule, but staff did not keep up with the cleaning. Dietary Staff BB stated she thought the spillage in the right oven occurred with the noon meal. Observation, on 11/29/22 at 02:00PM, revealed the dishwasher in the Country View unit, contained an empty bottle of sanitizer as staff ran it for the dishware from the noon meal. Interview at that time with dietary staff CC revealed he did not check the dishwasher sanitation level and did not know if the dishwasher provided high temperature or chemical sanitation. Interview, on 11/29/22 at 03:30 PM, with Administrative Staff A, revealed the dishwashers utilized a low temperature water with a chemical sanitizing agent and staff should ensure the sanitizer feeds into the machine. The facility policy Food brought in by Family and Visitors: undated, instructed staff that food must be kept in resealable containers with tightly fitting lids and labeled with resident name and use by date. The Food Storage Policy, undated, instructed staff to monitor the refrigerator daily and discard the food when it has been in the refrigerator for 72 hours or when food is past the printed expiration date, which ever comes first. The facility failed to store, prepare, and serve food in a sanitary manner for the residents of the facility.

The facility reported a census of 48 residents and identified four residents on physician ordered pureed diets. Based on observation, interview and record review, the facility failed to ensure staff prepared the pureed (a process to render foods to a consistency of pudding or mashed potatoes) foods in a manner to provide nutritional support as planned in the recipes and menus. Findings included: - Interview, on 11/28/22 at 08:44 AM, with Dietary Staff BB, revealed four residents received pureed foods. Review of the Diet Spreadsheet for Wednesday (11/29/22) for pureed diet lunch, revealed the following for the planned pureed consistency meal: grilled chicken, oven roasted rosemary potatoes, California blend vegetables, chef's choice of dessert, and buttered dinner roll. Review of the recipe for pureed foods for five servings of the pureed oven roasted rosemary potatoes, instructed staff to measure 2.5 cups of potatoes and add 0.5 cup of hot milk gradually to blend until smooth consistency. The recipe indicated that the liquid specified in the recipe was a suggested amount. Review of the recipe for the planned pureed biscuit, for five servings, instructed staff to place five biscuits in the food processor and add 1.5 cups of milk. Interview, on 11/29/22 at 11:15 AM, with Dietary Staff BB, revealed she did not have the recipe to puree the oven roasted rosemary potatoes and used chicken broth to obtain the desired pudding/mashed potato consistency. At that time Dietary Staff BB proceeded to place the potatoes in the food processor and added an unmeasured amount of chicken broth. Dietary staff BB proceeded to puree the California vegetables grilled chicken and placed them in the oven to reheat to ensure they were reheated to 165 degrees Fahrenheit. At approximately 12:00PM, Dietary Staff BB sent the pureed hot foods and pureed pineapple upside down cake to the nursing unit to serve to the four residents with pureed diets. Interview on 11/29/22 at 12:10 PM, Dietary Staff BB, confirmed she did not provide the four pureed diet residents the buttered dinner roll per the menu. Dietary Staff BB stated the facility did not have dinner rolls and so she obtained four slices of unbuttered bread and placed them in the food processor. Dietary Staff BB confirmed she did not have a recipe for pureed bread but would use chicken broth to obtain the correct texture. The facility policy Diet and Nutrition Care Manual dated 2021, instructed staff that standardize pureed recipes are the first step to assure a product that is consistent in taste, appearance, consistency, and nutrient content. The facility failed to ensure these four residents receiving pureed foods, received the full nutritional support as planned in the menus and recipes to prevent weight loss.

The facility reported a census of 48 residents and identified three as confused and self-mobile. The facility failed to keep hazardous chemicals out of the reach of the identified three confused self- mobile residents to prevent incidental ingestion and accidents. Findings included: - Observation on 11/30/22 at 07:50 AM, revealed an unlocked whirlpool/shower room door on the Meadowlark area. An unlocked cabinet next to the whirlpool contained a gallon bottle of 12% bleach. The bottle label documented, Keep out of the reach of children. On 11/30/22 at 07:55 AM, Licensed Nurse G verified the door to the whirlpool/shower room was to be locked at all times. Observation on 11/30/22 at 08:00 AM, revealed an unlocked whirlpool/shower room door on the Countryview area. A spray bottle containing Pro-con turquoise 3 cleaner disinfectant sat out directly available on a sink countertop. The bottle had a label that documented, Keep out of the reach of children. On 11/30/22 at 08:15 AM, housekeeping employee U verified the doors to the whirlpool/shower door in the Meadowlark area were to always remain locked. They can be unlocked by either key, or a code being entered into a keypad on the lock. She did not know how long the door had been unlocked or who had unlocked it. Housekeeping employee U also verified that the Meadowlark whirlpool/shower room door was unlocked. Additionally, housekeeping employee U confirmed the 12% bleach bottle was in an unlocked cabinet. On 11/30/22 at 08:20 AM, housekeeping employee U verified the doors to the whirlpool/shower door in the Countryview area were to always remain locked. They can be unlocked by either key, or a code entered a keypad on the lock. She did not know how long the door had been unlocked or who had unlocked it. Housekeeping employee U also verified that the Countryview area whirlpool/shower room door was unlocked. Additionally, housekeeping employee U confirmed the bottle of Pro-con turquoise 3 cleaner disinfectant was on a sink countertop. There was a lock on a cabinet under the sink that was unlocked. Housekeeper U did not know where the key was. On 11/30/22 at 09:40 AM, Administrative Staff A reported staff should keep hazardous chemicals locked up. The facility's policy for Control of Hazardous Chemicals, with no date, documented all substances with warning labels, including but not exclusive to Keep out of reach of children, would be locked and inaccessible at all times. All hazardous chemicals are to be locked at all times to avoid accessibility of any elder in the facility. The facility failed to keep these hazardous chemicals out of the reach for the three confused, self-mobile residents to prevent accidental ingestion and accidents.

The facility reported a census of 48 residents with 13 residents sampled, including two residents reviewed for respiratory. Based on interview, record review and observation, the facility failed to ensure sanitary use of respiratory equipment to prevent respiratory infections for one of the two sampled residents, Resident (R)4, regarding storage of distilled water for the oxygen (O2) concentrator. Findings included: - Review of Resident (R)4's electronic medical record (EMR) included the following diagnoses: Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), lung cancer (cancer of the lung) and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She had a diagnoses of cancer, Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and respiratory failure. The resident received oxygen (O2) therapy while a resident at the facility. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/07/22, documented the resident admitted to the facility on hospice services and required continuous supplemental oxygen. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She had a diagnoses of cancer, Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and respiratory failure. The resident received oxygen therapy while a resident at the facility. The care plan for respiratory, updated 10/04/22, instructed staff the resident used supplemental oxygen continuously due to diagnoses of COPD and lung cancer. Review of the resident's EMR, included a physician's order, dated 07/09/22, which included: instructions for the staff to administer oxygen at two to five liters (L) per nasal cannula (NC), to maintain oxygen saturations above 90%. On 11/28/22 at 02:14 PM, the resident rested in bed with her eyes closed. The resident received oxygen via NC at 2L, as ordered. The oxygen concentrator had a humidifier bottle attached with the water bubbling, indicating the resident's oxygen had humidification. A gallon jug of distilled water sat directly on the floor next to the oxygen concentrator, lacking a barrier. On 11/29/22 at 07:53 AM, the resident rested in bed with her eyes closed. The resident received oxygen via NC at 2L, as ordered. The oxygen concentrator had a humidifier bottle attached with the water bubbling, indicating the resident's oxygen had humidification. A gallon jug of distilled water sat on the floor next to the oxygen concentrator, lacking a barrier. On 11/28/22 at 08:30 AM, Certified Nurse Aide (CNA) M stated the resident used oxygen at all times. On 11/29/22 at 01:45 PM, CNA N stated the resident used oxygen at all times. CNA N was unsure of the care required by the resident's oxygen concentrator. On 11/29/22 at 02:36 PM, Licensed Nurse (LN) G stated the distilled water container should not be stored on the floor. On 11/30/22 at 09:52 AM, Administrative Nurse D stated the gallon jug of distilled water should not be stored on the floor without a barrier. The facility policy for Administration of Oxygen, undated, included: Oxygen concentrators will be kept and maintained in such a way as to be compliant with all relevant health and safety guidelines. The facility failed to ensure proper care of oxygen equipment for this dependent resident with respiratory issues, to prevent respiratory infections.

The facility reported a census of 42 residents with 16 residents sampled, including one resident reviewed for an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on interview, record review, and observation, the facility failed to ensure staff provided care of the catheter tubing in a sanitary manner to prevent urinary tract infections for the one Resident (R) 39, sampled. Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. She required extensive assistance of one staff for toileting and used a walker and wheelchair for locomotion. She had an indwelling urinary catheter and was frequently incontinent of bowel. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 01/18/21, documented the resident had an indwelling urinary catheter due to permanent urinary retention (lack of ability to urinate and empty the bladder). The quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. She required extensive assistance of one staff for toileting and used a walker and wheelchair for locomotion. She had an indwelling urinary catheter and was frequently incontinent of bowel. The Urinary Incontinence Care Plan, updated 03/23/21, instructed staff to complete catheter care twice daily and as needed (PRN). Staff were to ensure the catheter bag was secure and suspended appropriately from the wheelchair. Review of the resident's electronic medical record EMR, revealed the resident readmitted to the facility from a local hospital with an indwelling urinary catheter on 05/06/19, due to urinary retention following a back surgery. On 05/18/21 at 10:39 AM, Activity staff Z, propelled the resident from an activity back to her room. The resident's catheter tubing noted to drag on the floor underneath the wheelchair during the transport. On 05/18/21 at 11:47 AM, the resident sat at the dining room table in her wheelchair. The catheter tubing was in direct contact with the floor underneath her wheelchair. On 05/19/21 at 12:04 PM, the resident sat at the dining room table in her wheelchair awaiting lunch. The catheter tubing was in direct contact with the floor underneath her wheelchair. On 05/19/21 at 01:10 PM, Certified Nurse Aides (CNA) O and N toileted the resident in the resident's bathroom. The catheter tubing was in direct contact with the bathroom floor as the resident sat on the toilet. On 05/24/21 at 11:27 AM, CNA P was visiting with the resident in the commons area. The resident's catheter tubing rested directly on the floor underneath her wheelchair. On 05/18/21 at 10:39 AM, Activity staff Z stated, she did not do cares with the resident's catheter. She was only bringing the resident back to her room following an activity. On 05/19/21 at 01:10 PM, CNA O stated, he was unsure if the catheter tubing should be on the floor or not. CNA O stated the resident's catheter tubing was always on the floor. On 05/19/21 at 01:10 PM CNA P stated, the resident's catheter tubing would normally drag on the floor beneath her wheelchair. On 05/20/21 at 10:14 AM, CNA M stated, the resident's tubing should not come in contact with the floor. On 05/20/21 at 10:14 AM, CNA, P stated, the resident's catheter tubing was usually on the floor due to it not staying in the dignity bag beneath the wheelchair. On 05/20/21 at 11:47 AM, Licensed Nurse (LN) G stated, the catheter tubing should not be on the floor. On 05/20/21 at 02:10 PM, Administrative Nurse, D stated, the catheter tubing should not rest directly on the floor. The facility policy for Foley Catheter Care, undated, included: Catheter tubing should be arranged so it does not hang in a dependent loop. The facility failed to ensure staff handled this dependent resident's urinary catheter tubing in a sanitary manner to prevent urinary tract infections.

The facility reported a census of 54 residents, with three identified as an elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff) risk and reviewed for elopement. Based on record review, observation, and interview, the facility failed to provide adequate supervision and assistive devices to prevent one of the three residents, Resident (R) 1 from exiting through an unlocked kitchen door, through the kitchen into the back service hallway, through an outside, unsecured exit door, down a cement sidewalk, down 2 cement steps, down a cement curbing, and the resident fell on to the cement parking lot near the facility dumpster, without staff knowledge. The resident experienced a laceration to the head which required a staple in the emergency room to close placing the resident in immediately jeopardy at the time of the incident. Findings included: - The signed Physician order [REDACTED]. The Significant Change Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severely impaired cognition. He had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and wandering behaviors in the facility. He required limited assist with activities of daily living (ADLs) and required a mobility device when ambulating. The resident had a history of [REDACTED]. The resident did not have alarms or a previous elopement. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/06/20, revealed the resident had a history of [REDACTED]. He had history of looking out of the facility exit doors. The Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of one, indicating he had severely impaired cognition. The resident required limited assist with ADLs and needed a mobility device for ambulating. The resident had delusions and exhibited wandering behaviors. The resident had history of falls, wandering, and exiting seeking. The resident did not have personal alarms or a previous elopement. The Care Plan dated, 05/18/18, identified the resident was a risk for elopement due to poor decision making, wandering, and had exit seeking behaviors. He had delusions. The resident was a fall risk due to impaired safety awareness, weakness, and lack of coordination. Staff should walk with the resident throughout the facility, one-on-one, and provide validation therapy for redirection when he wandered and was exit seeking. Staff should complete monitoring of his behaviors that included wandering and exiting seeking, or a significant change in his behavior. The Elopement Assessment, dated 08/13/20, revealed the resident experienced hallucinations, cursing, and exit seeking. The Elopement Assessment, dated 08/26/20, revealed the resident exited the building without staff knowledge. Staff found the resident outside on the ground. The summary of both assessments revealed the resident was a Definite Risk for Elopement, due to his ambulation, [DIAGNOSES REDACTED]. Both assessments scored the resident at 24, which was a high risk for elopement. The resident had unsteady gait, altered awareness of his physical environment, impulsive behaviors, and impaired cognition. The facility's Investigative Report, dated 08/26/20 at 04:45 AM, rev sealed Certified Nurse Aide (CNA) N observed the resident without his walker in the hall outside his room prior to the elopement and his fall. CNA N stated she redirected the resident to his chair in his room and placed his walker in front of him. CNA N stated she notified the Licensed Nurse (LN) G and then assisted CNA M with another resident. CNA M and CNA N noticed that R 1 was not in his room, however she was unsure of what time she noticed the opened sliding door into the kitchen. CNA M and CNA N entered the kitchen, down the service hall, through the unsecured exit door to the outside, where staff observed the resident's walker at the top of two stairs. The staff found the resident lying on the concrete at the bottom of two steps and off the curb. CNA M notified LN G. LN G assessed the resident and then transferred him via wheelchair into the facility. After LN G assessed the resident, and the resident transferred to the emergency room for further evaluation . The Nurse's Notes dated, 08/26/20 at 05:33 AM, revealed the resident was found unsupervised outside of the facility. The resident was found lying on the ground with a 2.1 centimeter (cm) laceration to his head and a 0.5 cm abrasion to his right knee. Staff completed a neurological assessment and transported the resident to the emergency room for an evaluation. According to www.Wunderground.com, on 08/26/20 at 04:53 AM, when the resident eloped, the outside temperature was 69 degrees Fahrenheit with calm wind, no precipitation, and 90% humidity. At 5:53 AM, the outside temperature was 68 degrees Fahrenheit with calm wind, no precipitation, and 93% humidity. On 09/23/20 at 03:33 PM, the resident sat at the nurses' nook in a straight back chair, appropriately dressed. The resident's walker sat in front of him. On 09/23/20 at 03:49 PM, the resident remained in the straight back chair at the nurses' desk, with three staff members present. The resident's front wheel walker satin locked position, within reach of the resident. On 09/23/20 at 05:21 PM, the resident sat on the side on his bed eating dinner on a bedside table. His front wheeled walker was in a locked position within reach and the call light was securely attached to the grab bar on the resident's bed. On 09/24/20 at 02:19 PM, The resident sat in a straight back chair across from the nurse's nook. The resident was wearing blue jeans, red long sleeve button shirt, and rubber soled laced shoes. The resident's front wheel walker was in locked position in front of him. The resident was alert, people watching . On 09/23/20 at 05:36 PM, CNA M stated she and CNA N assisted (R6) another resident, both staff heard the resident's door open. She observed the resident was not in his room and the sliding door to the kitchen was unsecured and open. CNA M stated she entered the kitchen, through the service hall, through the exit door of the building, and observed the resident lying on the concrete by the dumpster. She then advised LN G the resident was outside of the facility without supervision. On 09/24/20 at 12:47 PM, CNA O stated the resident recently had a doctor's appointment outside of the facility prior to the elopement and the resident's exit seeking behaviors increased. The resident slept during the night prior to the incident. He wandered to the nurses' nook looking for his wife and car during the day. The CNA O stated that she was the Certified Medication Aide (CMA) passing medications the evening of 8/25/20 and secured the sliding kitchen door at 09:00 PM. On 09/24/20 at 01:01 PM, CNA P stated the resident had exiting seeking behaviors. The resident's exiting seeking was not daily. The resident does not wear a wanderguard and ambulated well with staff supervision, with a front wheel walker. On 09/24/20 at 01:08 PM, CNA Q stated the resident had been exiting seeking on 08/25/20 (the day prior to the elopement) during the day. He was alert with confusion. His care plan included one on one with his exiting seeking behaviors. On 09/23/20 at 03:21 PM, LN G stated that CNA M and CNA N advised her the resident entered the unsecured, sliding door of the kitchen, entered the service hall, exited the building through the unsecured locked door, and staff found him lying on the ground outside of the facility. LN G stated that she was sitting at the nurses' nook and did not see the resident ambulating in the hall prior to exiting through the unsecured kitchen door, however, LN G stated she did not recall CNA M and CNA N advised her the resident entered the hall prior to the incident. After the resident fell , staff transferred him into the facility via a wheelchair. She stated the resident always wore jeans, long-sleeves, and rubber soled, laced shoes. The resident should be supervised with wandering/exiting seeking behaviors. The resident received a laceration to the right side of his head and an abrasion to his right knee. Staff sent the resident to the emergency room for evaluation. The resident did have a history of four falls in the previous three months. On 09/23/20 at 02:38 PM, Administrative Staff A stated the facility system failure occurred when the staff failed to secure the sliding door to the kitchen, failed to have a secure lock on the exit door of the service hall, and failed to have a functioning camera in the dining room to view the unsecured, sliding door in the kitchen. The resident had a history of [REDACTED]. She stated the resident had a history of [REDACTED]. She stated when reviewing the facility cameras, the resident exited the unlocked exit door of the building at 05:03 AM and the visibility was still dark. The facility's undated Elopement Policy, lacked guidance of regarding supervision of residents that wander and secured exit doors, for the safety of the residents of the facility . The facility failed to provide adequate supervision and assistive device to prevent R1 from exiting the unsecured facility exit door. The resident experienced a laceration to the head which required a staple in the emergency room to close and placed the resident in immediate jeopardy. This deficient practice was cited as past non-compliance when the facility completed the following on 08/27/20 at 08:00 PM; 1. The door entering the kitchen was shut and locked by LN G on 08/26/20 at 5:15 AM. 2. The facility staff provided one-on-one with R1 until he was transported to the local emergency room by staff. 3. The facility installed a secure lock with a code on the unsecured exit door of the service hall, on 08/26/20 at 4:00 PM. 4. All staff were reeducated starting on 08/26/20 and completed on 08/27/20 at 08:00 PM. This education included elopement, elopement risks, report and investigate missing residents of unauthorized leave, assessment of resident upon return to the facility, and new security locks and codes to the facility. 5. The facility notified the medical director and conducted a quality assurance/performance improvement (QAPI) plan.

The facility reported a census of 56 residents. The sample included 17 residents with 3 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide planned interventions to keep 1 (#54) of the 3 residents reviewed as safe as possible, to prevent a fall, which resulted in a laceration with staples to the back of the head. Findings included: - The electronically signed physician orders, of resident # 54, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 11/10/16, revealed the resident had a BIMS (brief interview for mental status) score of 1, indicating severely impaired cognition. The resident required extensive assistance of 1 staff for bed mobility, transfer, ambulation, toileting, and personal hygiene. His/her balance was not steady, and he/she required a walker/wheelchair for mobility. The resident had one non-injury fall during the assessment period. The quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00. Changes from the previous MDS, revealed the resident used a wheelchair for mobility, and had 2 or more no injury falls during the assessment period. The quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 1, and the resident did not ambulate. The resident had 2 or more non-injury falls, and 1 injury (except major) fall. Review of the Fall Assessment, dated 5/11/17, evidenced a score of 24, that placed the resident at risk for falls. The CAA (care area assessment) for falls, dated 11/22/16, revealed the resident at risk for falls due to poor safety awareness, impaired decision making, and ataxia. The fall care plan, dated 5/16/17, included the following: On 7/29/15, staff assessment of the environment for safety issues, and intervene as needed. On 7/29/15, place the resident's bed in the lowest position, with a fall mat beside the bed. On 9/18/15, staff added a side rail to the bed for the resident to use when he/she sat on the side of the bed. On 10/31/16, staff should place the resident's wheelchair in the bathroom when the resident was in the bed. Staff encouraged the resident to call for transfer assistance, however, the resident had severely impaired decision making ability. On 11/6/16, the resident's wheelchair to be kept in the bathroom when the wheelchair not in use, however,staff placed the same intervention to prevent a fall 6 days earlier. On 2/7/17, staff educated the resident to use his/her call light for assistance, however, the resident continued to have severely impaired cognition. Review of the nurse's notes on 4/25/17 at 6:48 am, noted the resident called for assistance. The resident was on the floor, and had a 1.7 centimeter laceration (wound to the skin) on the back of his/her right side of the head. The resident's fall mat was not at the side of the bed, and the folded fall mat was behind the door. The resident's bed was in a high position, and the resident's electric bed controls were next to his/her pillow. Facility staff transferred the resident to the hospital emergency room . On 4/25/17 at 7:18 pm, the resident returned to the facility with four staples to the head laceration sustained from the fall. Observation, on 6/13/17 at 9:30 am, the resident rested on the low bed with his/her eyes closed. The fall mat was on the floor by the bed with the transfer rail raised, and the wheelchair placed in the bathroom. Observation, on 6/13/17 at 4:09 pm, the resident rested on the low bed with the fall mat next to the bed. The call light was not visible next to the resident, and the wheelchair was in the bathroom. On 6/13/17 at 3:32 pm, direct care staff L, reported the staff should place a fall mat next to the resident's bed when the resident was in the bed. The resident was impulsive and anxious when he/she wanted to get out of the bed. On 6/14/17 at 8:18 am, direct care staff H, reported on 4/25/17, at approximately 6:45 am, the resident fell . The bed was in the high position, the folded fall mat was in the closet, and the wheelchair was not in the bathroom as care planned. He/she verified the resident was unable to fold the fall mat. On 6/14/17 at 9:49 am, licensed nursing staff I, reported the resident had an injury fall on 4/25/17 and the resident went to the hospital. The resident returned to the facility with staples to the back of his/her head. Staff I verified the fall mat was not at the bedside, and the bed was not in the lowest position. On 6/14/17 at 3:42 pm, administrative nursing staff C, reported the staff were to place the fall mat by the resident's bed, and the bed should have been in the lowest position. On 6/14/17 at 4:25 pm, physician J, reported the resident had dementia, and he/she expected the staff to follow the care plan to keep the resident as safe as possible. On 6/14/17 at 4:37 pm, licensed nursing staff K, stated the resident fell , and struck the back of his/her head, and required staples to close the laceration to the back of his/her head. When the resident was in the bed, it was expected that staff keep the bed in the lowest position, the fall mat placed on the floor by the bed, and the wheelchair in the bathroom. Licensed nursing staff K reported as long as the bed was in a low bed, the resident could still climb out of the bed, but the fall mat would keep the resident safe from injury. On 6/19/17 at 9:05 am, administrative nursing staff B, reported the staff failed to have the fall mat next to the bed, and the resident must have reached the electric bed control, and raised the bed up. He/she was not certain if the resident raised the bed. He/she verified staff failed to follow the care plan, and the resident received a laceration/ staples to the right upper back of the scalp as a result from the injury fall. The facility's policy for falls and fall risk managing, dated December 2007, documented staff and the attending physician would identify appropriate interventions to reduce the risk of falls. Staff should implement interventions to minimize serious consequences of falling. The facility failed to provide planned interventions to prevent repeated falls for this severely cognitively impaired resident. The resident sustained [REDACTED].

The facility reported a census of 52 residents, and identified 3 as elopement risk. The sample included these 3 residents. Based on observation, interview and record review, the facility failed to provide adequate supervision and failed to have a functioning door alarm to ensure one (#01) of the 3 sampled residents, did not exit the facility at night in 28 degree weather, without staff knowledge. The resident remained outside (from 6:50 PM until 7:07 PM) for approximately 17 minutes, when staff found the resident and returned him/her into the facility. The resident was hypothermic with a temperature at 93.7 degrees. (Hypothermia is body temperatures below 95 degrees and below.) This deficient practice placed the resident in immediate jeopardy. Findings included: - On [DATE] the physician order [REDACTED].#01. The primary care physician listed a [DIAGNOSES REDACTED]. A [DATE] annual MDS (minimum data set) assessment identified the resident with severely impaired cognition, in need of limited assistance for transfers and walking. It also documented a history of 2 or more falls, for the resident since admit without injury. The MDS identified the resident wandered daily. The cognition CAA (care area assessment), dated [DATE] included: The resident has a [DIAGNOSES REDACTED]. There were times the resident walked and stated that he/she was looking for his/her parents or his/her family because he/she believes they were here to pick the resident up and were waiting for him/her. The resident's parents have been deceased for years. The resident does not present a danger to himself/herself or others. The care plan, dated [DATE], included, the resident had cognitive impairment related to dementia; hearing loss may contribute to confusion and impaired ability to understand his/her surroundings. He/she may wander, and often does not recall what he/she was looking for or where he/she was going. The care plan failed to include a plan to address the resident's wandering behavior to direct staff as to which specific interventions or redirection staff should use related to this resident's elopement potential An elopement assessment, dated [DATE] included: The resident was A&O (alert and oriented) to himself/herself. At times believed himself/herself to be young and seeks out his/her parents. The resident wandered frequently through the day, and was very difficult to redirect for any period of time. The resident was hard of hearing and ambulated with a RW (roller walker) and SB (stand by) assistance of 1. The assessment further documented the staff had no concerns at the time of the assessment completion. Review of the exit door video surveillance, for [DATE] at 6:50 P.M., revealed the resident exited through the facility east exit door without staff knowledge. The key pad failed to function correctly, the door opened without any code input. Further review of the video door surveillance, for [DATE] at 7:07 P.M., (17 minutes later) revealed that certified nursing staff C brought the resident back into the facility through the south door. The staff member noticed the resident outside walking across the staff parking lot on the east side of the building, as he/she was leaving work. The resident had left his/her walker on the sidewalk and his/her glasses were on the ground by the walker. A written statement, by administrative nursing staff E, dated [DATE], documented, the facility (prior to the resident's elopement at 6:50 PM), had the resident on 1:1 care with a staff member, due to behaviors, until 6:09 P.M. Nurses notes, dated [DATE] at 12:53 A.M., revealed a late entry from [DATE] at 7:07 P.M., which documented; upon return to the facility, the resident's hands were red and cold. The resident wore a light jacket, long sleeved shirt, pants, shoes, and socks. Nursing staff placed the resident by the facility fireplace and wrapped him/her in blankets. Vitals taken at 7:07 P.M. included, temperature 93.7 degrees farenheit (F) (normal range 97.8 - 99.1), oxygen saturation level at 86 % on room air (normal range 95 - 100%), B/P (blood pressure) ,[DATE] (normal range ,[DATE] - ,[DATE]), pulse 68 (normal range 60 to 100), respirations of 16 (normal range . At 7:30 P.M., staff repeated the vital signs and documented temperature 97.1 degrees, oxygen saturation at 92% on room air, B/P ,[DATE], and pulse 77. The facility documented the resident's temperature on [DATE] as 98.3 degrees. The outside temperature for the facility's geographical area, on [DATE] at 7:00 P.M., tested at 28 degrees, with a wind at 18 miles per hour, per weather information from Wunderground.com. On [DATE] at 10:00 A.M., interview with administrative staff A, revealed following the elopement incident on [DATE], the facility immediately started an investigation, watched the video surveillance, and called maintenance staff D into the building. Staff A further explained per the video observation of [DATE] at XX, revealed an unidentified resident who came to the exit door key pad and punched in multiple numbers on the key pad. Staff A felt at that time, the unidentified resident accidentally punched in the deactivation code, which turned off the exit door alarm system. The maintenance staff member reactivated the exit door key pad code upon entrance to the facility following the elopement incident on [DATE]. On [DATE] the facility consulted the door company and the company removed the deactivation code for the facility exit doors, from the key pad system. The facility failed to ensure a functional exit door alarm system, to keep this confused wandering resident from exiting the facility without staff knowledge. The resident wandered around the building, approximately 100 yards, through a parking lot, and onto the graveled section of the lot. The resident experienced hypothermic condition, with a body temperature which dropped to 93.7 degrees, before staff noted the resident outside unattended for 17 minutes, and in 28 degree weather. The investigation revealed the facility was in past-noncompliance as of [DATE] as the facility: 1. Reactivated exit door and checked all doors to ensure proper working order by the maintenance department at 8:15 P.M. on [DATE]. 2. Implemented daily door checks to ensure proper working order on [DATE] at 8:15 P.M 3. Verbally educated staff regarding elopement procedures and keypad door alarm function on [DATE] at 7:30 P.M., and on-going. 4. Resident received 1:1 care for remainder of night and over the weekend. 5. Consulted with Montgomery Doors to remove the deactivation codes. Doors were not able to be deactivated as of [DATE] at 9:15 A.M

The facility reported a census of 58 residents. Based on observation, record review, and interview, the facility failed to adequately monitor the hot water temperature of the lavatory in the therapy room that placed 26 ambulatory residents with access in immediate jeopardy. Findings included: - On 8/11/14, during the initial tour of the facility, at 9:00 AM, the hot water in the therapy room sink tested , and immediately revealed a temperature of 163.8 degree Fahrenheit. A resident in the therapy room used one of the stationary bikes, with therapy staff L at a desk in the therapy office, around the corner. At 9:10 AM, the hot water was retested , with a different thermometer, and the temperature recorded 158 degrees Fahrenheit. A resident was in the therapy room, at that time. On 8/11/14 at 9:20 AM, surveyor requested if maintenance staff K wanted to check the water temperature with his/her thermometer and the staff member stated "no", as he/she was able to see the steam rising from the sink when the hot water was turned on. Staff K immediately turned the hot water valve off under the sink. Staff K stated he/she was not sure if the sink hot water temperatures had been checked since being installed in this room, about a month ago. On 8/11/14 at 9:40 AM, administrative staff B, after being informed of the hot water in the therapy. On 8/11/14 at 9:41 AM, staff S stated he/she did not know when the therapy sink had been checked last and also reported he/she not sure if the sink is on the check list. On 8/11/14 at 9:48 AM, therapy staff L stated the doors to the therapy room are always open because the residents will come in and do exercises on their own without staff present. At 9:50 AM, observation revealed that resident #65 used the exercise bike in the therapy room without staff present. During this time, therapy staff sat in the therapist office, out of view and around the corner in another room from the resident. On 8/11/14 at 12:28 PM, maintenance staff K, stated he/she installed a mixer valve on the hot water line to the therapy sink, and the water temperatures were now scheduled to be taken weekly. At that time the hot water temperature rechecked at 104 degrees Fahrenheit. On 8/11/14 at 3:05 PM, therapy staff L stated he/she previously noticed the water was hot, but staff L turned the cold water on with the hot water. Staff L reported the facility had approximately 4 to 7 residents, who came into the room and independently used the therapy equipment in the room. On 8/11/14 at 5:10 PM, administrative staff B was informed of the immediate jeopardy situation related to the excessive hot water temperature of 163.8 degrees in the therapy room sink. This created the potential for residents or anyone who turned on the hot water in this sink, to immediately experience burns to the skin. On 8/13/14 at 2:10 PM, maintenance staff K, provided the facility monitoring water temperature logs. Review of the last 12 months of water temperatures monitored, revealed the sink in the physical therapy room was not included in the water temperature log. The undated facility policy for testing water temperatures documented, all sinks, showers, and water faucets will be tested on a weekly basis. Water temperatures in public areas and resident rooms will be maintained at 120 degrees or below for resident safety. In the event a public area or resident room water temperature is higher than 120 degrees the maintenance department will be notified of the issue and the sink will be disabled and/or shut off until repair can be made. The Maintenance Department and/or Administrator will maintain a water temperature testing log. The facility staff failed to check the hot water temperature in this therapy room sink, since installed approximately 1 month prior, and until found during the resurvey. The facility failed to ensure the residents environment remained as free from accident hazards as possible, and placed these 26 residents in immediate jeopardy for injury or harm related to excessive hot water temperatures. The facility abated the immediate jeopardy when the facility turned the hot water off, installed a mixer valve, and completed in-services of all staff on August 17, 2014 at 9:00 PM. The in-service directed staff to notify maintenance if they felt the water was too hot at any sink that was accessible to residents. This immediate jeopardy was abated on August 17, 2014 at 9:00 PM, however, the deficiency remained at a scope and severity of a E.

The facility reported a census of 35, with twenty one residents selected for review. Based on record review and interview, the facility failed to adequately assess and provide timely interventions for resident # 46, when the resident began exhibiting signs of post operative distress and chest pain. Findings included: - On 8/27/10, staff admitted resident #46 to the facility, under skilled medicare part A services, with [DIAGNOSES REDACTED]. On 8/27/10, the admission nursing assessment revealed the resident awake, alert and oriented to person, place and time. The assessment further identified the resident as ambulatory, requiring only supervision for toileting and personal hygiene, with an abdominal dressing, with staples and rubber bands intact. Nurses notes, dated 8/28/10 at 12:00 p.m. recorded "Complaining of abdominal pain at incision. Gave as needed [MEDICATION NAME] 7.5/325 two by mouth as ordered. Incision dressing intact. Pain intensity of 10." The clinical record failed to evidence follow up of pain relief of this pain medication administration. Nurses notes, dated 8/28/10 at 1500 p.m. recorded "Resident complaining of chest pain. Vital signs within normal limits.....Will notify oncoming nurse." physician's orders [REDACTED]. Nurses noted dated 8/28/10 at 1900 p.m. revealed "Given order for complaints of chest pain. [MEDICATION NAME] 0.4 milligrams sublingually, one for complaints of chest pain, repeat every 5 minutes up to 3 times, if no relief call 911. The resident's wife informed of order given doctor." physician's orders [REDACTED]. Nurses notes dated 8/29/10 at 0200 a.m. revealed, "Pain intensity 10." The clinical record lacked any documentaion of any administration of pain medication and/or location of the pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the clinical record lacked any additional assessment of the residentuntil, on 8/29/10 at 8:30 a.m., when staff assessed the resident. At that time, staff recorded the resident with a temperature of 101 degrees Farenheit. Dressing soaked with drainage. Removed dressing. Incision red and inflamed. Abdomen distended. [MEDICAL CONDITION] of lower extremities. Short of breath and wheezing. Spoke with the doctor and received an order to send the resident to the emergency room to be evaluated. The resident's family took the resident to the emergency room ". On 11/8/10 at 5:05 p.m. interview with licensed staff B revealed "I wasn't here when that resident was here. I know there were several problems." On 11/8/10 at 4;45 pm interview with licensed staff D revealed "I would have sent him/her out immediately when he/she started complaining of chest pain, and his/her oxygen saturation required supplemental oxygen. He/she should definitely have been given the [MEDICATION NAME] immediately. I can't see that he/she ever got it. The nurse was wrong in not getting help if he/she didn't feel comfortable with the resident. He/she should have been sent to the emergency room immediately." On 11/8/10 at 5:10 p.m.,an interview with licensed staff C revealed, "He/she was good when he/she came in. He/She was alert and oriented. He/She had the surgery and was physically in pretty good shape. I would have sent the resident to the hospital immediately when he/she first complained of chest pain. The weekend nurse should have called the director of nursing The resident should have gone out with his/her first complaints." The facility failed to adequately monitor, assess and provide treatment for [REDACTED].

The facility reported a census of 32 residents, with 7 selected for review. Based on observation, interviews, and record review, the facility failed to provide necessary care and services for 1 resident #135, with constipation, who experienced severe pain with rectal bleeding, when staff manually removed a large hardened stool from the resident's rectum. Findings included: - The most recent comprehensive assessment for resident #135, dated 9/24/10, indicated cognitive impairment, required limited assistance of 1 staff for activities of daily living needs, incontinent of bowel/bladder, no laxatives used, and without any diarrhea, constipation, or fecal impaction. The care plan, dated 10/30/10, instructed staff, "If I have not had a bowel movement within 3 days assess me for constipation. Administer medications as ordered by the physician." Addition, dated 12/2/10, "Enema as directed PRN." The resident's medical record documented admission to the hospital from 11/15/10, with return to the facility on [DATE]. The resident experienced a decline in ability and returned on 11/19/10, with hospice services. The resident's [DIAGNOSES REDACTED]. The hospital nurse assessment on the transfer record to the facility, dated 11/19/10, documented the resident with new hospice services for declined ability, required 1 person to assist with transfers, and used a wheelchair for mobility. The assessment further documented, "Drugs: [MEDICATION NAME] 0.25-0.5 ml (milliliter) every 2 hours PRN (as needed) and [MEDICATION NAME] Internasal 0.25-0.5 ml every 2 hours PRN. Bowel Habits: Not continent, Not constipated. No laxatives used. Last bowel movement on 11/19/10..." The resident's medical record in the facility, included a physician's telephone order, dated 12/2/10, "Enema as directed PRN." However, the nurses notes lacked any documentation as to why the nurse called the physician for this order, or any constipation problems the resident experienced. The nurses notes, dated 12/2/10 at 2:00 PM, documented, " New orders see MAR and POS. " Furthermore, the following nurses notes failed to identify any further constipation problems, or if the staff provided the newly ordered enema for the resident. Observation on 12/15/10 at 2:00 PM, the resident sat in the bedside recliner with feet elevated and half way off the the footrest. The resident voiced anxiety and repeated, "Need to go, can't go, need to go, can't go, need to go, can't go..." The surveyor reported the resident's anxiety to certified nurse aide B, and the aide explained staff recently repositioned the resident in the bedside recliner but now would assist the resident to the bathroom. Nurse aide B and certified medication aide D entered the resident's room and assisted the resident from the recliner, into a wheelchair, into the bathroom, and onto the toilet. While on the toilet, the resident continued with, "I need to go, help me, I need to go, help me, I need to go, help me..." certified medication aide D explained if the resident's went the 3 days without a bowel movement, the staff followed their policy and gave the resident a laxative on the third day. The medication aide left the room to report the resident's constipation to the charge nurse. The medication aide returned with a suppository and the two staff lifted the resident above the toilet enough for the certified medication aide to insert the suppository rectally into the resident. The medication aide reported feeling hard stool in the rectal vault when inserting the suppository. The staff replaced the resident into the wheelchair and redirected the resident to the front lobby area for activity. The staff explained they would wait awhile and then assist the resident back onto the toilet. On 12/15/10 at 2:45 PM, certified nurse aides A and F, assisted the resident to the large shower/bathroom to toilet. The staff waited with the resident who passed gas without any bowel movement. The resident continued to indicate she needed to have a bowel movement. At 3:00 PM, licensed nurse C entered the bathroom to check on the resident's progress. The nurse applied 2 gloves to her right hand, applied lubricant to the right index finger and went behind the resident who sat on the toilet. The two certified nurse aides assisted the resident to lean forward, and the nurse leaned over the back of the resident. The resident was calling out in pain, "...it hurts, it hurts..." and the staff kept telling the resident, "push, push, push..." After approximately 3 minutes, the nurse stopped and removed the gloves, instructing the nurse aides to, "Let (him/her) rest for a few minutes." The nurse washed hands and applied new gloves. The surveyor asked the nurse to explain exactly how she "helped" the resident to start the bowel movement. Licensed nurse C explained they applied gloves, applied lubricant to the finger, inserted the finger into the resident's rectal area, and went around on the inside. Approximately 5 minutes later, the nurse repeated the process and the nurse aides assisted the resident to lean forward on the toilet. While the nurse inserted the gloved finger into the resident's rectum, the resident continued to state, "Stop, Stop, It hurts, It hurts..." After approximately 3 minutes, the nurse stopped and removed the gloves. The nurse reported to the resident and the nurse aides that the resident expelled a large bowel movement and the nurse felt nothing else in the resident's rectum. The surveyor asked licensed nurse C, and nurse aides A and F, if the resident's history included constipation such as this. The nurse explained, "About a week ago (he/she) was constipated like this." The staff flushed the toilet with the resident still on the toilet. Nurse aide A, explained to the resident, "You should feel better it is all out." The resident looked at the aide and stated, "Please, don't make it hurt anymore." Nurse aide F provided perineal hygiene to the resident from the backside, while the resident remained on the toilet. Then nurse aides A and F lifted the resident from the toilet and pulled up the incontinent brief. The surveyor noted 2 drops of red blood fall into the water of the toilet. The toilet contained pink water. The staff lifted the resident into the wheelchair and assisted the resident to the television area to sit. The resident held tightly onto the hand of nurse aide A as the aide talked with the resident and attempted to calm the anxious resident. On 12/15/10 at 3:25 PM, administrative licensed staff G explained, "The staff should follow the physician standing orders for what to do with constipation. (His/Her) orders do not include manual bowel movement removal." The nurse stated, "This should never have come to this manual removing." The undated, Policy and Procedure for Bowel Management, included, "...5.) The charge nurses on a standard practice shall implement a laxative for any resident who has not had a bowel movement for 3 consecutive days. 6.) The charge nurse reserves the right to consult with the Director of Nurses regarding "normal" bowel movement patterns for a particular resident who may extend past the 3 day standard." The undated and unsigned, Standing Orders, included, "Constipation: Assess bowel sounds. Milk of Magnesia 30 cc (cubic centimeters) PO (by mouth) daily PRN (as needed) or [MEDICATION NAME] 17 G (grams) daily PRN. [MEDICATION NAME] 10 mg (milligrams) suppository rectally daily if Milk of Magnesia does not produce the desired effects. Fleets enema if no results from Milk of Magnesia or suppository. Notify physician if no results within 48 hours..." On 12/15/10 at 4:55 PM, the resident's medical record lacked any documentation related to the incident of hardened stool, with manual removal, which caused the resident extreme pain and rectal bleeding. Licensed nurse G verified the nurse should have notified the physician following the incident but failed to do so. On 12/15/10 at 5:00 PM, licensed nurse C verified the failure to notify the physician following the incident when the resident experienced pain and rectal bleeding, during and following removal of the hard stool. The facility failed to consult the physician when the resident exhibited signs of constipation. Facility staff failed to notify the physician of the resident's pain with hardened stool in the rectum prior to manual removal of the stool, which caused the resident severe pain and rectal bleeding.