Bremond Nursing and Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices that are complete, accurately documented, readily accessible, systematically organized and protected from unauthorized release for 3 (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for maintenance of clinical records. 1. The facility failed to ensure staff documented accurately after Resident #1 was found on the floor and sent out for evaluation on 10/12/25 and returned to the facility on [DATE].2. The facility failed to ensure staff updated the care plan for Resident #2 after she reported she had a fall on 09/15/25.3. The facility failed to ensure staff accurately documented a progress note after Resident #3 had an apparent unwitnessed fall on 10/13/25. These deficient practices could place residents at risk of injuries related to falls or not receiving necessary treatment.Findings included:1. Review of Resident #1's admission record, printed 10/15/25, reflected a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified intellectual disabilities, unsteadiness on feet, unspecified lack of coordination, dementia with agitation, and Alzheimer's disease with late onset. Review of Resident #1's MDS assessment dated [DATE] reflected he was rarely/never understood so a BIMS assessment was not completed. The MDS assessment reflected he needed set up assistance for transfers and ambulation and had no falls since the prior MDS assessment. Review of Resident #1's comprehensive care plan initiated 08/07/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment. Goal: I will remain free from injury due to falls. Interventions/Tasks: I will be given non-skid socks or footwear to help me move safely. I will be assisted with walking, transfers, or toileting as needed, based on my current ability. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #1 had an unwitnessed fall on 10/12/25 at 8:30 PM. Review of Resident #1's progress note dated 10/13/25 at 5:48 AM., and written by LVN A, reflected EMS was notified and Resident #1 was sent to the acute hospital after being found on the floor. Review of Resident #1's progress notes from 09/14/25 to 10/15/25 reflected there were no notes to address: The date and time the resident was found on the floor and sent out to the hospital or the date and time the resident had returned to the facility. During an interview on 10/14/25 at 2:25 PM., LVN B stated Resident #1 had gone out to the hospital sometime on the night shift on 10/12/14. She stated when she was coming in for her shift on the morning of 10/13/25, Resident #1 was just returning to the facility. LVN B stated if there was an unwitnessed fall, they were expected to get vital signs, complete a head-to-toe assessment, write a progress note and incident report, and notify the NP/MD, RP, and DON. She stated thorough documentation was important to ensure the residents received the proper care. During an interview on 10/15/25 at 10:57 AM, the VPCO stated the DON had told her Resident #1 had been sent out to the hospital on [DATE] because of a fall. She stated with any fall; she expected the event to be reported. That report triggered the required assessments. She expected the DON to complete an assessment and to reassess the resident before closing out the event at 72 hours as some bruises took time to develop. She stated if the documentation was missing or not accurate, there was no way to assess the outcome, and the facility may have missed something. During an interview on 10/15/25 at 11:42 AM, the DON stated she expected documentation to be accurate and timely. She expected after a fall the nurse completed a fall assessment, a progress note, an incident report, notification of the NP/MD, RP, and DON. She stated she and the ADON were responsible for monitoring the documentation and train/in-service staff, but since the ADON was out, she was responsible. The DON stated the ADON was also the MDS nurse who was responsible for care plans. She stated while the ADON was out, she was responsible for ensuring care plans were updated. During an interview on 10/15/25 at 12:18 PM, the ADM stated it was important that documentation was thorough and timely. She expected staff to take care of the resident first then complete the documentation. She stated it was her expectation that the documentation painted a picture of the resident's status so anyone would know what happened. She expected all documentation was completed before the staff left at the end of their shift. The ADM stated the new ADON was responsible for monitoring documentation, but she was out on leave, so the monitoring was done by the DON. During an observation and attempted interview on 10/15/25 at 1:28 PM, Resident #1 was sitting in a wheelchair in the dayroom. His posture was relaxed, no indicators of pain or distress observed. He made eye contact and smiled. He responded to questions with a giggle but did not respond verbally. A telephone interview with LVN A was attempted on 10/15/25 at 10:43 AM. A telephone interview with LVN A was attempted on 10/15/25 at 2:03 PM. No return call was received prior to the exit. 2.Review of Resident #2's admission record, printed 10/15/25, reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), abnormalities of gait and mobility, muscle weakness, and repeated falls. Review of Resident #2's quarterly admission assessment, dated 09/08/25, reflected a BIMS score of 12 which indicated moderately impaired cognition. The assessment reflected Resident #2 needed set up assistance for transfers and ambulation. The assessment reflected no falls since the prior assessment. Review of Resident #2's comprehensive care plan, initiated 08/11/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness. Goal: I will remain free from injury. Interventions/Tasks: I will be reminded to use my call light. Staff will ensure my bed is in the lowest position, wheels are locked, and the call light is always within reach. My care plan will be updated after any fall or change in condition. Further review revealed the fall care plan did not reflect any revisions after the 09/15/25 fall. Review of Resident #2's progress note dated 09/15/25 at 5:05 AM, and written by LVN C, reflected in part, Resident reported that she fell. she stated she hit her left arm. Upon assessment, a laceration was noted. When asked if she would like to be sent out for further evaluation, resident declined. Wound cleansed. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #2 had an unwitnessed fall on 09/14/25 at 8:46 PM. Review of Resident #2's Fall Risk Evaluation, dated 09/15/25, reflected that she was at high risk of falls. During an interview on 10/15/25 at 1:20 PM, Resident #2 stated she had a fall at the facility but did not remember when it happened. She stated nothing was hurt besides her pride and she declined to be sent out to the hospital. She stated staff were attentive and checked on her frequently. 3.Review of Resident #3's admission record, printed 10/15/25, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis list reflected schizoaffective disorder, bipolar type. Review of Resident #3's medical record reflected her MDS assessment was not yet due nor completed. Review of Resident #3's baseline care plan, initiated 10/13/25, reflected in part, Focus: I am at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment. Goal: I will remain free from injury. Interventions/Tasks: I will be given non-skid socks or footwear to help me move safely. I will be reminded to use my call light. Staff will ensure my bed is in the lowest position. Review of the incident log from 09/01/25 through 10/14/25, reflected Resident #3 had an unwitnessed fall on 10/13/25 at 7:30 PM. Review of Resident #3's progress notes from 10/13/25 through 10/15/25 at 1:03 PM, reflected no progress note regarding a fall. Review of Resident #3's Fall Risk Evaluation dated 10/13/25 at 11:28 PM, reflected a score of 14 which indicated she was at risk for falls. During an interview on 10/15/25 at 11:42 AM, the DON stated she witnessed Resident #3 on the floor on the evening of 10/13/25. She stated she treated it as an unwitnessed fall and initiated the incident report and assessments. She stated she did not document a progress note but should have. During an observation and interview on 10/25/25 at 1:45 PM, Resident #3 was observed sitting up in a wheelchair in her room dressed in clean clothes. No bruises or injuries were observed on her exposed skin. Resident #3 stated she felt good because she just had a shower. When asked if she had a fall at the facility, she stated, About 25 times. She repeated that she had about 25 falls. She denied pain, and she denied any injuries. She stated she felt safe at the facility and wanted to stay there forever. Review of the facility's Incidents and Accidents policy, reviewed/revised 04/11/25, reflected in part, It is the policy of this facility for staff to utilize (Title) to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve a resident. Compliance Guidelines: 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained for follow-up interventions. Review of the facility's Fall Prevention Program policy, Reviewed/Revised 10/14/25, reflected in part, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Compliance Guidelines: When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the resident's Ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 4 residents (Resident #1) reviewed for Discharge Rights.<BR/>The facility failed to notify Resident #1's Ombudsman in writing of the transfer/discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. <BR/>This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.<BR/>Findings included:<BR/>Review of Resident #1's undated Face Sheet reflected she was a [AGE] year-old female with an initial admission date of 08/06/2024. Resident #1 was discharged to a behavioral hospital on [DATE] with a warrant for emergency detention. Resident #1's diagnoses was Unspecified Dementia, (mental decline without a specific underlying diagnosis) unspecified severity, with psychosis disturbance (group of mental health disturbances characterized by a loss of touch with reality, leading to abnormal thoughts, perceptions and behaviors), Major Depressive Disorder (serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and Generalized Anxiety Disorder (severe ongoing anxiety that interferes with daily activities). <BR/>Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 5 indicating severe cognitive impairment. <BR/>Review of an Application for Emergency Apprehension and Detention dated 01/25/2025 and signed by the ADM reflected Resident #1 has been having very poor and combative behavior. She has been disturbing the peace of the community in the nursing facility.<BR/>Review of a Notice of Discharge or Transfer dated 02/24/2025 for Resident #1 and e-mailed to her Guardian on 02/24/2025 reflected she was being discharged from the facility. The document did not include the correct name of the Ombudsman and no address was provided. <BR/>Review of the Warrant for Emergency Detention for Resident #1 dated 3/25/2025 reflected there was reasonable cause to believe that the person evidences mental illness; that the person evidences substantial risk of serious harm to the person or others; that the risk of harm is imminent unless the person is immediately restrained; and that necessary restraint cannot be accomplished without emergency detention. <BR/>In a telephone interview on 04/01/2025 at 10:53 AM, the Ombudsman stated she did not receive a copy of the discharge notification for Resident #1 of the facility's intent to discharge. <BR/>In an interview on 04/02/2025 at 11:53 AM, the ADM stated I didn't send a written notice to the Ombudsman of the discharge for Resident #1. I sent one to the guardian. I should have sent a written notice to the Ombudsman, but I tried to reach her by phone twice.<BR/>In an interview on 04/02/2025 at 12:37 PM, the DON stated the facility follows CMS policy, and it was a learning process. She provided a copy of the admission, transfer and discharge rights that she said the facility was supposed to follow. She stated she had started a training for employees.<BR/>Review of a document dated 3/31/2025 and provided by the DON on 04/02/2025 revealed Title 42-Public Health, Chapter IV- Centers for Medicare and Medicaid Services, Department of Health and Human Services, Subchapter G- Standards and Certifications, part 483- requirements for States and Long-Term care Facilities. Transfer and Discharge- Facility requirements- (3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must (1) Notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.<BR/>No documentation was provided by the ADM at the time of exit from the facility of a written notice of discharge to Resident #1's Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to provide the necessary care and services for 1 of 11 (Resident #8) residents reviewed for transfer status. The facility failed to ensure that Resident #8, who was a 2 person assist in May 2025 and was changed to a mechanical transfer on 8/14/2025, did not suffer a decline in mobility. An Immediate Jeopardy (IJ) was identified on 8/15/2025. The IJ template was provided to the facility on 8/15/2025 at 4:45PM. While the IJ was removed on 8/16/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure put residents at risk for decline in activities of daily living, decreased mobility, and serious harm. Findings included: Review of Resident # 8's Face sheet on 8/12/2025 reflected an [AGE] year-old, female admitted to the facility 12/13/2023 with a diagnosis of vascular dementia (dementia caused by problems with the blood vessels in the brain), unspecified abnormalities of gait and mobility (difficulties with walking), and hypertension (high blood pressure). Review of Reentry MDS for Resident #8 dated 2/17/2025 reflected a BIMS score of 15 (indicating no cognitive impairment). Resident #8's ability to move from Lying to Sitting, ability to move from sit to stand, and Toilet transfer is listed as partial/moderate assist. There are no categories of mobility for which Resident #8 had refused to be assessed. Speech Therapy, Physical Therapy, and Occupational Therapy sections reflected 0 minutes for each category for the period prior to last MDS. Restorative Program reflected 0 minutes of restorative therapy for the period prior to last MDS. Review of Reentry MDS for Resident #8 dated 05/22/2025 reflected a BIMS score of 15 (indicating no cognitive impairment). Resident #8's ability to move from Lying to Sitting, ability to move from sit to stand, and Toilet transfer is listed as partial/moderate assist. There are no categories of mobility for which Resident #8 had refused to be assessed. Speech Therapy, Physical Therapy, and Occupational Therapy sections reflected 0 minutes for each category for the period prior to last MDS. Restorative Program reflected 0 minutes of restorative therapy for the period prior to last MDS. Review of Orders for Resident #8 reviewed on 8/13/2025 reflected no order for mechanical lift transfer. Review of Care plan for Resident #8 in EMR (electronic medical record) reflected no problems or interventions related to mobility risks or transfers. Review of Paper Care Plan for Resident #8 reflected a Problem Area, Problem Start Date: 09/20/2024, Category: ADLs Functional Status/Rehabilitation Potential, [Resident #8's] ability to (ADL: e.g., transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene) has deteriorated R/T disease process Edited: 05/22/2025 Edited By: [ADON]. Approach section listed, Follow PT/OT/ST recommendations. Edited: 05/22/2025 Edited By: [ADON], Provide assistance for ADL as needed. Edited: 05/22/2025 Edited By: [ADON], Transfer extensive assist 1-2 Edited: 05/22/2025 Edited By: [ADON], and Report any further deterioration in status to physician. Edited: 05/22/2025 Edited By: [ADON]. Problem Area started on 04/29/2024, revised by ADON on 05/22/2025 reflected: [Resident #8] is at risk for skin impairment, age related, impaired mobility. The Approaches listed for the problem area reflected, PT/OT to evaluate for rehab potential. Edited: 05/22/2025 Edited by: ADON. Problem area dated 02/20/2024, Revised 07/25/2025 and Edited by Activity Director, reflected: [Resident #8] also enjoys going outside to feed the cat. In the related Approach area, it reflected, Staff will encourage, assist, or plan out of door activities for fresh air weather permitting. Edited: 05/22/2025 Edited by: ADON and Staff will encourage or assist involvement in social groups of interest such as bible study, current events, trivia. Problem area dated 2/26/2024, edited by ADON on 5/22/2025, reflected Category: Cognitive Loss/Dementia [Resident #8] appears to have recall deficit as evidenced by: Periods of paranoia, making false accusations then denies making them, lack of acceptance or understanding of safety issue related to her living environment, Poor decision making. Goal for this problem area reflected a long-term goal target date of 8/22/2025, reflected [Resident #8] will understand helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. As evidenced by documentation in the medical record. Edited: 5/22/2025 Edited By: ADON. Related approaches dated 5/22/2025 reflected, Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Review of Resident #8's Progress Notes in Paper Chart since 5/9/2025 -8/4/2025, reflected there were no notes indicating the resident was out of bed, nor are there any notes indicating refusals to get out of bed. There are no notes indicating a refusal of Physical or Occupational therapy during this time frame. Review of Physician Assessment for Resident #8 dated 7/12/2025 signed by Medical Director reflected fatigue, WC mobility, and weakness were chosen to describe Resident #8's general condition and extremities. There were handwritten notes reflecting, Pt. refuses BP meds and noncompliance with medications. There were no further notes regarding mobility or refusals of care. Review of Resident #8's most recent Occupational Therapy Discharge Summary prior to start of survey, for dates of service from 11/15/2024 to 11/18/2024, reflected, Discharge Recommendations: DC to this LTC facility under care of nursing. Restorative Program Established/Trained= Not indicated at this time Functional Maintenance Program Established/Trained=Not indicated at this time. Document was signed by OT F. Review of Resident #8's Summary of Occupational Therapy Daily skilled services signed by OT F dated 11/18/24 reflected, Pt (patient) declined to get out of bed, but finally agreed to work in the bed with therapy. Therapist went to pt's room x3 (three times) in order to get pt to participate. Once pt finally did agree to do therapy she was actually very cooperative and did everything requested of her. Pt education on the importance of movement/getting out of bed due to having pneumonia. Review of Physical Therapy Summary of Daily Skilled Services dated 11/18/2024 and signed by PT H, reflected, Patient requiring encouragement in order to participate proceeding to perform LE/UE (Lower Extremity/Upper Extremity) therex (therapeutic exercise) in all tolerable planes working on str (strength), endurance/ROM (range of motion) w cuing and breaks taken throughout session PRN (as needed).Review of Resident #8's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2025 and signed by OT G reflected, Personal Hygiene= Substantial/maximal assistance and Transfers section reflected, Recommended use of [mechanical] lift for all transfers. In the section labelled Reason for Therapy there is a note reflecting the following: Reason for Skilled Services: Patient requires skilled OT (occupational therapy) services to assess safety and Independence with ADLs (activities of daily living), develop and instruct on compensatory strategies, develop and instruct in exercise program, increase safety awareness, facilitate sitting tolerance and postural control, provision of pain management techniques, provision of modalities and strengthening, increase functional activity tolerance, and develop and instruct on adaptation techniques in order to enhance patient's quality of life by improving ability to return to prior level of skill performance. Review of Summary of Daily Skilled Services dated 8/14/2025 signed by OT G, the Response to Tx (treatment) section reflected Response to Session Interventions: actively participates with skilled interventions. Interview with Resident #8 on 8/12/25 at 9:41AM she stated I don't know when the last time I got up. Last time there were two people. Maybe seven days ago. She stated that she could not remember doing any therapy in the facility. She stated that she walked in the facility using a cane and now could no longer get out of bed. Observation of two person transfer on 8/13/2025 at 2:30PM with CNA A and CNA B revealed Resident #8 was lying in bed attempting to sit up. CNA A and CNA B watched Resident #8 attempt to sit up and did not offer assistance. Resident #8 stated that she was not able to sit up or stand on her own. She stated that she needed help. CNA A and CNA B did not assist after requests from resident. After 15 minutes of attempting to sit from a lying position, she refused to attempt any longer and requested to go stay in bed. She stated, I used to be able to sit and stand, but I can't anymore. No gait belt was observed in the room or in possession of the CNAs for the transfer and they were later found to be unable to properly apply a gait belt. In an interview with LVN D on 8/13/2025 at 2:47PM reflected that Resident #8 was known to be a two-person transfer. He stated that for a normal two-person transfer, if a person was struggling to sit up, the staff would assist the resident to a sitting position. In an interview with LVN C on 8/14/25 at 6:10AM she stated she had worked at the facility full time since September or October of 2024. She stated that she currently worked primarily night shifts but worked days and nights previously. She stated that Resident #8 was almost a mechanical lift now. She stated she knows Resident #8 was able to stand in May, but now she cannot. She stated she was transferring mostly by herself from the bed to the wheelchair and back at the beginning of the year with little assistance from staff. She stated that she could recall last seeing her transfer in March with little assistance from staff. She stated the last time she saw her transfer was around May with assist of two staff, where they had to physically assist her to sit up, which was not normal previously. She stated that she told dayshift at that time that the resident had shown a decline. She could not recall the date. She stated the resident refuses to get up at times. She stated that Resident #8 used to get up to feed the cats. She stated that refusals should be documented in the chart. She stated that residents have the right to refuse, but that staff should be building a relationship with the resident and try to find out the source of the refusals. She stated that residents should receive ongoing education and encouragement from staff with refusals of care. She stated that not getting out of bed can result in a decline in mobility. She stated that improper transfers can result in injuries.In an interview with CNA A on 8/14/25 at 8:45AM, she stated in the transfer with Resident #8 on 8/13/25 she should have assisted her to sit up. She denied having a gait belt for the transfer. She stated she does not use a gait belt on anyone in the facility during transfers. She stated she did not assist the resident with the transfer on 8/13/2025 because she was nervous. She stated it has been more than 3 months and less than 6 months since she's seen Resident #8 up out of bed. She stated the resident refuses to get out of bed a lot. She stated she does inform the nurse. She stated that the level of struggle she saw on 8/13/2025 from Resident #8 attempting to sit up for a transfer was new. She stated in the past, Resident #8 could help more. She stated the resident refuses a lot to get out of bed. She stated she does inform the nurse when the resident refuses. She stated that not providing assistance with transfers for residents that require assistance, can lead to residents feeling discouraged. She stated that if residents do not get out of bed they can lose their strength and ability to get out of bed. In an interview with CNA B on 8/14/2025 at 9:28AM, she said she worked at the facility for about a month. She said she had assisted Resident #8 out of bed with two people approximately two weeks ago. She stated she has seen the resident up, probably twice since she started working at the facility. She stated that she let her take her time to do some and then assisted when her when she needed it. She stated at that time she was not able to stand for the transfer. She stated they did get her in the wheelchair with two people. She stated each person stood on one side of the resident. She stated they then put their arm under her arm, and with the other hand, held on to the resident's pants. She stated that Resident #8 was able to sit up on her own two weeks prior during the transfer. She stated the resident refuses at times. She stated that not providing assistance with transfers for those residents that need it, can lead to resident' potentially giving up and possibly not wanting to try to get up. She stated that if residents do not get out of bed when they are able, they might lose their ability to get out of bed. In an interview with ADON on 8/14/2025 at 7:07AM, she stated that Resident #8 was a two-person transfer. She stated that she frequently refuses therapy. She stated there are no therapy notes for 2025. She stated she would print the last three therapy assessments for review by surveyor. She stated that there was no documentation of refusals of therapy in resident records for nursing in the last 3 months or therapy services documentation in 2025. She stated the Care Plan for the resident included being resistive to care at times, but did not include refusals of therapy. She stated she was not sure if the physical or occupational therapist spoke directly to the resident regarding her therapy opportunities and the risks of not participating in rehabilitative services. She stated that the Resident #8 refused therapy to her after her most recent hospitalization at the end of May, but that she did not document the refusal. In an interview with OT G on 8/14/2025 at 11:40AM, she stated that she worked with a different company than the previous therapists at the facility. She stated she started in the facility as a PRN (As needed) Occupational Therapist when the new company took over at the beginning of the month. She stated that she met Resident #8 on the morning of 8/14/2025. She stated that she reviewed her records. She stated that after speaking with Resident #8, she is going to recommend a mechanical lift for her transfers. She stated she has never seen it documented who has a gait belt in the facility, but if you are standing and moving them, they should have a gait belt on unless they are independent transfers or a mechanical lift is used for transfer. She stated that during transfers staff can hurt the resident's shoulders, cause shearing, or staff could drop them without a gait belt or with improper use of gait belt. She was not sure if Resident #8 was a mechanical lift prior to this assessment but stated that if a resident was screened previously as partial assist and then they are later screened as requiring a mechanical lift, that it would be considered a change in condition for the resident. In an interview with RNC on 8/14/2025 at 12:04 PM, she stated that she had been in the facility for 8 days, since the change of ownership. She stated that she was functioning as the Director of Nursing prior to the DON taking on her role at the facility. She stated that there was not a DON prior to the change of ownership, which would make the ADON responsible for supplies and resident care prior to 8/5/2025. She stated that the current owners use a different therapy company than was used previously by the facility. She stated that all residents who were not independent or mechanical lift transfers should have a gait belt on for transfers. She stated that if a resident was reaching and trying to sit up during a transfer that she would assist them with sitting position. She stated that if a resident made an effort to transfer, she would assist them with the rest of the transfer. She stated that Resident #8 should be assessed quarterly by therapy services. She stated that if there are any signs of decline, residents should be evaluated by therapy and treated per their recommendations. She stated that their responsibility as a facility is to maintain or improve status of residents, unless the situation can be helped. She stated that if a resident screens as needing a mechanical lift, when their previous recommendation was for partial assistance with transfers, that it would indicate a change in condition. She stated that if we are not assisting a resident to get out of bed, they can decline. She stated that residents do have the right to refuse care. She stated that she expected staff to encourage residents to get out of bed, to educate them regarding the consequences of not getting out of bed, to get family involved if applicable, and to perform passive range of motion if they continue to refuse to help prevent a decline in mobility. She stated that staff should try to find the source of why the resident is refusing care and address their underlying concerns. In an interview with Resident #8 on 8/14/2025 at 1:05PM she stated that she feels unhopeful when she attempts to transfer. She stated that she trusts one male staff member to transfer her. Resident observed lying in bed during the interview. In a phone interview with facility NP on 8/15/2025 at 12:04PM, she stated that she does not know of any degenerative conditions for Resident #8 that would make a decline in mobility unavoidable. She stated that the resident has some conditions which could cause pain, but that the resident nor the facility has reported an increase in pain. She stated that Resident #8 cannot transfer or stand without assistance from staff. She stated that to her knowledge, the resident could stand briefly to be assisted to the wheelchair. She stated that a new order for a mechanical lift would constitute a change in condition regarding the mobility status for Resident #8. She stated that she knows the resident to refuse care and transfers at times. She stated that she last observed the resident get up with staff assistance of 3-4 staff, gait belt, and walker on 5/23/25 when she ordered a urine culture for the resident. She stated that the extra staff present during the transfer where there to assist with collecting the urine sample. She stated that she knows Resident #8 to be a 2-person transfer. She stated that she saw a note from the morning stating that Resident #8 is now a mechanical lift transfer. She stated that when a resident is refusing to get out of bed, they should be evaluated to see if there is a change in condition. She stated that when a resident is refusing, the facility needs to ensure they are doing what they can and that it isn't just easier for staff not to get her up. She stated that not getting out of bed could contribute to a decline in mobility. She stated that not using a gait belt or using gait belts in properly could result in a fall or injuries to the resident. She stated it was a fundamental skill for a CNA and anyone who transfers residents to know how to use a gait belt. She stated she could not recall any injuries with transfers that would have warranted a gait belt. In an interview with ADON on 8/15/2025 at 1:50PM, she stated she could not believe she did not notice that Resident #8 had not been out of bed. She stated she was not aware that Resident had a change in mobility prior to the OT assessment on 8/14/2025. She stated that she could not recall seeing Resident #8 out of bed in the last few weeks. She stated that she was responsible for monitoring resident care and ensuring appropriate care was provided to Resident #8 at the time of the decline. She stated she was responsible for updating care plans at this time also. She stated that gait belt should be included in the care plan for residents that require a gait belt with transfers. She stated that she informed the physician and psychiatry about Resident #8's refusals of care in the past. She stated that she doesn't know exactly why the resident would refuse to get up recently. She stated that in the past she has given reasons like that she does not want to be forced to do things and that she does not want to put on a show for anyone. She did not recall when she stated this, but stated it was not directly related to a recent occurrence. She stated that Resident #8 does not have any family to her knowledge. She stated that Resident #8 is her own responsible party. She stated that staff try to encourage her to get out of bed with things that she likes. She stated that the facility tried to put her on skilled services when she got back from a hospital stay on 6/29/2025, but the resident refused at that time. She stated she does not have any documentation in the resident records to state that she was evaluated and subsequently refused offer of therapy. Observation of Resident #8 on 8/15/2025 at 1:56PM revealed the resident sleeping in her bed. In a follow up interview with RNC on 8/15/2025 at 2:54PM she stated that there was no evidence that an IDT meet was done related to her refusals of care. In a follow up interview with ADON on 8/15/2025 at 2:54PM she stated that there was no QAPI meeting in which Resident #8's refusals of care were discussed. In an interview with the ADMIN on 8/15/25 at 3:43 PM, he stated that he wanted everyone in the building to thrive. He stated everyone who wants to be up out of bed, should be allowed or assisted as needed to get up. He stated that therapy has a role in assisting with mobility needs of the residents. He stated all refusals should be documented. He stated the impact of not getting a resident out of bed could result in weakness. He stated that he would defer to nursing for specifics in the causes of a decline in mobility. He stated refusals for care and therapy should be care planned. He stated that after a few times of refusing, staff should notify the doctor or the NP. He stated that the facility does have to honor a resident's right to refuse. He stated it is the facility's obligation to talk to them and try to find out why they are refusing. He stated they usually have multiple staff attempt to talk to a resident about refusals of care. He stated that psychiatry services can occasionally assist with refusals of care. He stated that he was responsible for ordering the supplies for this facility. He stated there is a supply list at the nurses' station where staff can add needed supplies. He stated he made orders every Tuesday based on the list. He stated he was not aware there was a lack of gait belts available for resident use. He stated he was not aware that gait belts were not being used with residents. He stated that not using a gait belt could cause a fall or injuries, including discomfort to the residents. He stated his expectation was that residents who need gait belts should have them. Review of facility policy on Safe Resident Handling/Transfers (no date) reflected, All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them.Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur.Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment.Review of Facility ADL policy (no date) stated: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care; Transfer and ambulation; Toileting; Eating to include meals and snacks; and Using speech, language or other functional communication systems.Policy Explanation and Compliance Guidelines: Conditions which may demonstrate unavoidable decline in ADLs include: Natural progression of the resident's disease state with known functional decline. Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment; counsel and/or offer alternatives to the resident or representative.The facility will maintain individual objectives of the care plan and periodic review and evaluation. The ADMIN was notified of Immediate Jeopardy on 08/15/2025 at 4:35 PM and the need for a Plan of Removal. The Plan of Removal was accepted on 08/16/2025 at 11:18 AM and was as follows: On 8/12/2025 a recertification survey was initiated at facility. On 08/15/2025 the surveyor provided an Immediate Jeopardy (IJ) Template for SNF notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Notification of the Immediate Jeopardy states as follows: F-676 - Activities of Daily Living (F676 The facility failed to ensure provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: S483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living to include mobility and transfers. Mobility Decline) 1. Immediate Actions Taken for Those Residents IdentifiedAction: Resident #8 immediately evaluated by nursing staff. Care plan updated to reflect current mobility status, interventions to maintain or improve function, and therapy recommendations. Resident requires a mechanical lift. Order placed in Point Click Care (PCC) for mechanical lift transfers. Physical Therapy referral placed in PCC for evaluation and treatment. Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 by noon Action: Facility-wide audit of all residents with transfer needs conducted to ensure correct transfer methods are documented, appropriate equipment is available at point of care, and no additional residents have experienced an undocumented decline. If equipment is not available, the DON/Designee will initiate an urgent order through the facility's contracted vendor, provide interim safe transfer methods, and ensure staff are trained on the temporary intervention until the equipment is in place. Any identified changes were addressed immediately through therapy referral and care plan updates. No changes identified.Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 by noon Action: All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy, proper gait belt use, and immediate reporting of mobility declines to the DON and/or ADON. Competency validation with return demonstration completed prior to resident care. Staff members will be educated prior to working their next shift. Staff who are not present will receive education via the telephone and complete the competency with return demonstration prior to working their next shift. All new hires and agency staff will receive education and competency evaluation with return demonstration prior to providing resident care. Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or Designee Date: 08/17/2025 by noon 2. How the Facility Identified Other Possibly Affected Residents: Action: 100% audit of all residents requiring assistance with transfers conducted to ensure accuracy of transfer status, care plans, and availability of required equipment. No other residents identified.Person(s) Responsible: Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or Designee Date: 08/15/2025 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Policy on Safe Resident Handling/Transfers reviewed with no changes made. Staff members will be educated on policy prior to working their next shift. Staff who are not present will receive education via the telephone and will sign the in-service sheet prior to working their next shift. All new hires and agency staff will receive education prior to providing resident care.Person(s) Responsible: VP of Clinical Operations, Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 policy reviewed08/17/2025 by noon for education of all staffAction: Change in Condition Protocol reviewed with no changes made. Staff members will be educated on policy prior to working their next shift. Staff who are not present will receive education via the telephone and will sign the in-service sheet prior to working their next shift. All new hires and agency staff will receive education prior to providing resident care.Person(s) Responsible: VP of Clinical Operations, Director of Nursing (DON), Assistant Director of Nursing, and Regional Nurse Consultant, and/or DesigneeDate: 08/15/2025 policy reviewed08/17/2025 by noon for education of all staff 4. How the Corrective Actions Will be Monitored/Ensure Comprehension, by whom and for how long: Action: All licensed nurses, CNAs, and therapy staff received immediate education on Safe Resident Handling/Transfers policy, including proper use of gait belts and mechanical lifts, and the requirement to report any resident mobility changes to nursing leadership. Staff completed a competency validation with return demonstration prior to providing further resident care. Staff not on-site were educated via telephone and completed competency validation prior to their next scheduled shift. All agency and new hire staff will receive the same education and competency validation prior to resident care assignment. Person(s) Responsible: DON, ADON, and/or DesigneeDate: 08/17/2025 by noon for education of all staffAction: DON/designee will conduct a minimum of 5 random transfer observations per shift for 4 weeks to ensure: proper transfer method is being used per care plan and gait belts/mechanical lifts are available and used appropriately. Results documented on Transfer Audit Log; noncompliance addressed immediately with re-education.Person(s) Responsible: DON, ADON, and/or DesigneeDate: Ongoing x 60 days Action: Interdisciplinary team will review all audit results in QAPI weekly for 8 weeks, then monthly for 4 months. Any identified trends will result in additional training.Person(s) Responsible: Administrator, DON, Rehab DirectorDate: Ongoing QAPI-Action: Medical Director notified of the deficient practice/IJ and Plan of Removal.Person(s) Responsible: DON, Administrator, and/or DesigneeDate: 08/14/2025 Monitoring facility's plan of removal was completed on 8/16/2025 as follows: Review of Resident #8's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2025 and signed by OT G, reflected that Resident #8 was evaluated on 8/14/2025 by nursing staff and occupational therapist. Resident #8's Care plan was updated on 8/14/2025 to reflect mechanical lift transfer and related care. Resident #8's Physician orders updated on 8/15/2025 to reflect mechanical lift transfer. There is a physician order for PT/OT (physical therapy/occupational therapy) to Evaluate and Treat dated 8/15/2025. In an interview with RNC on 08/16/2025 at 1:00PM, she stated that Resident #8 was transferred to hospital on 8/15/2025 at 8:08AM for sore throat and cough. She was not available for interview at that time. In an interview with ADON on 8/16/2025 at 1:53PM, she stated that the Facility-wide 100% audit of all residents with transfer [

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of six residents (Resident # 15 and Resident #18).<BR/>1. The facility failed to ensure Resident # 15's nails were cleaned and did not have any rough edges. <BR/>2. The facility failed to ensure Resident # 18's facial hair was removed and nails were cleaned.<BR/>These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of Resident #15's Face Sheet dated, 06/27/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of rheumatoid arthritis unspecified site (a chronic inflammatory disorder that can affect more than just your joints), unspecified lack of coordination ( uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), age- related physical debility ( generalized weakness, exhaustion, poor balance, and decreased physical activity), muscle weakness ( lack of muscle strength), and chronic pain syndrome ( long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition, such as arthritis. It may affect people to the point that they can't work, eat properly, and/ or take part in physical activity).<BR/>Record review of Resident #15's Annual MDS Assessment, dated 05/02/2024, reflected the resident had a BIMS score of 12 reflected his cognition was moderately impaired. Resident # 15 did not reject care. Resident #18 was assessed to require assistance with personal hygiene, toileting, dressing, bathing, and transfers. Resident #15 had diagnosis of arthritis (joint inflammation) and muscle weakness (lack of muscle strength).<BR/>Record review of Resident #15's Comprehensive Care Plan, dated 05/15/2024, reflected Resident #15 preferred bed baths. Intervention: Staff will offer shower/ bed bath three times weekly. Staff will educate Resident #15 about proper hygiene. Resident #15 had rheumatoid arthritis and was at risk for decreased in ADLs and increased joint pain. Intervention: monitor for increased joint pain- give meds/ treatment per order - assess for signs of relief of pain. Resident #15 required assistance with ADLs. Interventions: Resident #15 required assistance with bathing, dressing, toileting, transfers, and eating.<BR/>Record review of Resident #15's Treatment Administration Record (TAR) dated 06/01/2024 - 06/31/2024 reflected Resident #15 did not refuse nail care. <BR/>Record review of Resident #15's nurses notes from 05/01/2024 thru 06/26/2024 Resident #15 did not refuse nail care. <BR/>Observation on 06/25/2024 at 10:21 AM Resident # 15 was in his room sitting in wheelchair watching television. Resident #15 had blackish hard substance underneath the forefinger and middle fingernails on his right hand. His middle and ring fingernails was rough around the edges. There was an odor of bowels on his right hand. <BR/>In an interview on 06/25/2024 at 10: 24 AM Resident #15 stated he tried to clean his nails but he was not physically able to clean his own nails or trim his nails. He stated some of his nails was rough and needed to be smoothed but he was not able to do this and he would try but he was afraid he would get his nails infected if he tried. Resident #15 also stated he needed assistance with his nails and all his care. He stated someone came in yesterday (06/24/2024) to trim his nails and they said his nails did not need to be trimmed. He asked the staff to file his nails and the staff stated they did not file nails all they did was trim nails. He stated his nails were dirty yesterday afternoon after the staff left the room. He stated the person never returned to his room and he did not ask anyone else to assist him. He stated if she stated it was not their job to file the nails he was not going to ask anyone else. Resident #15 did not recall the person's name. Resident #15 stated he has not refused any nail care from staff. <BR/>2. Record review of Resident #18's Face Sheet dated, 06/26/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia (affects memory, thinking and social abilities), contracture of muscles, unspecified upper arm (occurs when your muscles, tendons, joints, or other tissues or shorten causing a deformity and can cause loss of movement in the joint), muscle weakness (lack of muscle strength).<BR/>Record review of Resident #18's Quarterly MDS Assessment, dated 04/01/2024, reflected the resident had a BIMS score of 0 indicated her cognition was severely impaired. Resident #18 did not reject care. She was assessed to be dependent on staff for ADLs such as: eating, oral hygiene, toileting hygiene, personal hygiene, showers, lower body dressing and all transfers except sit to lying and lying to sitting on side of bed. <BR/>Record review of Resident #18's Comprehensive Care Plan, dated 03/07/2024, reflected Resident #18 had a diagnosis of dementia (affects memory, thinking and social abilities) with expected decline in cognitive impairment over a period of time as a natural progression of the disease. Intervention: document decline in cognitive status. Resident #18 was identified needed assistance with ADLs (the type of ADLs was not specified). <BR/>Record review of Resident #18's Treatment Administration Record (TAR) dated 06/01/2024 - 06/31/2024 reflected Resident #18 did not refuse nail care. <BR/>Record review of Resident #18's nurses notes from 05/01/2024 thru 06/26/2024 Resident #18 did not refuse nail care. <BR/>Observation on 06/25/2024 at 10:36 AM Resident #18 was sitting in her Geri chair listening to music. She had slightly curled facial hair approximately 2-3 inches long on the left side of her face near her mouth. Resident #18 had blackish hard substance underneath her nails on her middle and ring finger on the right hand. She also had hard blackish and her ring and fore finger on her left hand. <BR/>In an interview on 06/25/2024 at 10:39 AM Resident #18 was not interview able. She did not respond verbally or with gestures to any questions. <BR/>In an interview on 06/27/2024 at 11:00 AM the DON stated it was a joint effort between the CNAs and the nurses to complete nail care on the residents. She stated the nurses was responsible for residents with diagnosis of diabetes ( a disease in which the body's ability to produce or respond to the hormone insulin was impaired). The Director of Nurses stated nail care was scheduled by the TAR and when residents received showers. She also stated nail care was also expected to be completed as needed. She stated if a resident had blackish substance underneath their nails the substance may be dirt and not bacteria. She stated no one knows if it was bacteria underneath the residents' fingernails. The DON stated if the scent was feces was noticed underneath residents' fingernails there was a potential this may be bacteria. She stated it was a possibility a resident may become physically ill such as vomiting or diarrhea if they ingested bacteria from feces. She also stated if a resident had rough fingernails there was a possibility the resident may scratch themselves and develop a skin tear. The DON stated she did not believe women having facial hair was a dignity issue or any type of issue. She stated if a resident was not able to communicate verbally if they wanted facial hair she did not believe this was an issue for the female resident to have facial hair. She stated if there was any refusal of nail care it would be documented in the nurses notes or on the TAR. <BR/>In an interview on 06/27/2024 at 11:20 AM LVN A stated the nurses and CNAs were responsible for nail care. She stated the nurses was responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN A stated it was the CNAs responsibility to clean and trim all other residents' nails. She stated the nurses checked the diabetic nails weekly and the CNAs reported to the nurses if any diabetic nails needed to be cleaned or trimmed. LVN also stated the nurse would document on the TAR (Treatment Administrator Record) and/ or nurses notes if any resident refused nail care. She stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance may had bacteria underneath the residents' nails. She also stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea. She stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear. LVN A stated she was not aware of anyone refusing nail care; however, she would need to refer to the TAR to know for certain if Resident # 15 or Resident #18 refused nail care. <BR/>In an interview on 06/27/2024 at 11:30 AM CNA E stated the nurses completed all diabetic fingernails and the CNAs was responsible for all other residents' nails. She stated the CNAs was responsible to complete nail care such as trimming, filing, and cleaning the nails. She stated the staff was very busy and it was difficult to complete nail care on residents except when the resident was in the shower. CNA E also stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day there were times the staff was not able to clean, trim or file the residents' nails. CNA E stated there were also times the nursing staff may have time to do one of the nail tasks but not all three tasks such as filing, cleaning, and trimming. She stated if a resident had blackish substance underneath their nails it was usually from their bowels. She stated if a resident swallowed some of their bowels the resident may become ill with sores in their mouth, yeast infections in their mouth, get E. coli (a bacteria that is commonly found in the lower intestine of warm-blooded organisms) and may develop major stomach problems such as diarrhea. She stated she worked with Resident #15 and Resident #18 and she was not aware of them refusing nail care. She stated if a resident's nails were rough there was a possibility the resident may scratch themselves and develop a skin tear or possibly scratch their eye and cause a tear on their eyeball. <BR/>Record review of the Facility Policy on ADLs dated, 05/05/2023, reflected Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. POLICY: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.<BR/>*

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of five residents ( Resident # 3) reviewed for activities. The facility failed to provide Resident #3 in room activities on the dates of 07/03/2025 thru 08/11/2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life. Findings included: Record review of Resident# 3's face sheet, dated 08/14/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included depression, unspecified ( a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder ( a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ( a condition where individuals experience cognitive decline consistent memory loss, impaired thinking, etc. without behaviors). Record review of Resident#3's Annual MDS Assessment, dated 10/02/2024, reflected Resident #3 had a BIMS score of 0, which indicated her cognition was severely impaired. Resident #3 was not capable of responding to questions of her activity preferences. Record review of Resident #3's Quarterly MDS Assessment, dated 05/31/2025, reflected Resident #3 was rarely/never understood. The staff completed Resident #3 cognitive assessment. Resident #3 decision making ability was severely impaired (never/rarely make decisions). She had poor short- and long-term memory recall. Record review of Resident #3's Comprehensive Care Plan reflected (problem created on 08/15/2022) Resident #3 was dependent on staff for meeting emotional, intellectual, physical, and social needed related to Alzheimer's (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). Resident #3 care plan (revised on 08/13/2025) reflected Resident required personalized engagement to support psychosocial wellbeing. Resident #3 will participate in at least one 1:1 activity of choice a minimum of two times per week to enhance social interaction and emotional wellness. Monitor for changes in engagement levels and adjust the type of timing of 1:1 activities as needed. Record Review of the Activity In Room Participation record for the months of July 2025 and August 2025 reflected Resident #3 did not receive in room visits from 07/03/2025 thru 08/11/2025. Observation and interview on 08/12/2025 at 10:05 AM Resident was in her room lying in bed. Resident # 3's television was not on and there was not any stimulation in resident's room. Resident #3 was not interviewable. Interview on 08/14/2025 at 8:30 AM, the Activity Director stated Resident #3 did not receive in room activities from 07/03/2025 thru 08/11/2025. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if residents were not coming out of their room, the residents were to be provided in room activities. The Activity Director stated she provided in room activities at least twice a week. She stated there was not an excuse why Resident #3 did not receive in room visits. The Activity Director stated if a resident was not receiving activities on a consistent basis there was a potential a resident may become bored, depressed, or have a decline in their quality of life. Interview on 08/14/2025 at 10:45 AM, the Administrator stated he expected in room activities be provided to the residents needing these types of activities. He stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored and isolated. He stated the Activity Director was responsible for all activities in the facility. He stated the Administrator would be responsible for monitoring the Activity Director. Record review of the facility's Activity Policy, dated not dated, reflected It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Activities may be conducted in different ways: one-to-one programs, person appropriate- activities relevant to the specific needs, interests, culture, background, etc. for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure Resident #1 eloped from the facility on 2/28//2023 and fractured his right hip, that required surgery to treat. Resident #1 was found 2 &frac12; blocks away from the facility on the ground, he had fallen and was unable to get up. <BR/>This failure resulted in an identification of an (IJ) Immediate Jeopardy on 3/1/2023 at 6:06 p.m. The (IJ) Immediate Jeopardy template was provided to the ADM on 3/1/2023 at 6:06pm. While the (IJ) Immediate Jeopardy was removed on 3/3/2023 at 4:40 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal.<BR/>This failure could place all residents that are elopement risk and refuse to wear a wander guard at risk for accidents, harm, and/or death.<BR/>Findings included: <BR/>Review of Resident #1's face sheet dated 3/2/2023, reflected a 64- year- old man, admitted to the facility on [DATE]. Resident #1 was diagnosed with Parkinson's disease (a disease of the central nervous system that affects movements), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder) not due to a substance or known physiological condition, Insomnia ( a common sleep disorder that can make it hard to fall asleep), Paranoid schizophrenia ( a psychological disorder where the lines are blurred between what is real and what isn't), delusional disorder(a belief or altered reality that is persistently held despite evidence or agreement to the contrary) and heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). <BR/>Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 5 (indicates the resident does not have the cognitive ability to understand). The MDS also reflected Resident # 1 is ambulatory with no assistance. <BR/>Review of MAR dated 2/1/2023-2/282023, reflected the following orders: <BR/>Resident to reside on secure unit for personal safety - start 12/29/2020 open ended <BR/>9/1/2022- Resident may have trial integration off unit into general population- open ended <BR/>9/1/2022- May have wander guard -open ended<BR/>Record review of Resident #1's care plan dated 2/28/2023, reflected the following: Problem: Resident has been observed to leave the grounds within the past week without notifying staff despite reminders. Interventions: Explain to resident the policy and procedure for leaving the facility and review periodically for continued need for secure placement. The care plan did not reflect any updates of interventions in place for Resident #1 for the period of 9/1/2022 when Resident #1 came off the secure unit through 2/28/2023.<BR/>Record review of Risk elopement assessments for Resident #1 reflected the following:<BR/>-12/19/2017 Resident #1 was identified as risk for elopement, <BR/>-9/19/2021 was not an elopement risk, with no interventions,<BR/>-11/15/2022 Resident #1 was not an elopement risk, with no interventions, <BR/>-5/21/2022 reflected it was unknown if Resident # 1 was an elopement risk and to remain on secure unit for safety, and. <BR/>-2/23/2023 reflected Resident #1 was not a risk for elopement with the following interventions: Frequent monitoring how often not noted, keep behavior logs, review medications, utilizations of sign in/sign out logs, recreational activities, and music. <BR/>Record review of facility progress notes dated 6/2/2022- 2/28/2023 for Resident #1 reflected, no monitoring notes, no behavioral log, no sign in or out sheets used by Resident #1, or any notes regarding activities or music. There was one progress note dated 2/28/2023 regarding Resident #1's refusal to wear the wander guard. <BR/>In an interview on 3/1/2023 at 11:10 a.m., the hospital staff reported Resident #1 was brought into the hospital by EMS. She stated it was reported Resident #1 was found on the street trying to get up. The hospital staff stated Resident # 1 had a fractured right hip and was scheduled for surgery later in the day. She stated Resident # 1 was hallucinating and having delusional thoughts since he was admitted . <BR/>In an interview on 3/1/2023 with concerned citizen stated approximately 5:25am he and his son noticed Resident # 1 had fallen and was trying to get up. He stated they called 911 for assistance, he stated Resident #1 reported that he tripped over the curb and hurt his hip.<BR/>In an interview on 3/1/2023 at 12:29 p.m., LE stated EMS contacted them to come to the scene on 3/1/2023 around 5:45 a.m., LE stated they spoke with Resident #1 he was able to tell them the facility he came from, that he had fallen and was unable to get up. LE reported, Resident #1 was transported to the hospital due to his injury he sustained from falling. LE stated they went to facility and asked if anyone was missing? LE reported the staff they spoke to was not aware that anyone was missing at the time, LE stated they informed the facility of Resident #1 name and advised that he was transported to the hospital for further medical treatment. <BR/>Review of Police call for service report dated 2/28/2023, reflected the facility was notified at approximately 5:50am asking if they were missing anyone from the facility. LVN A, reported that she was not aware that anyone was missing at the time. LVN A was advised that Resident # 1 had been injured and was transported to the hospital.<BR/>In an interview on 3/1/2023 at 10:02 a.m., LVN A stated she was the nurse on duty last night, she stated they work 12 hours shifts 6pm to 6am. She stated Resident #1 has insomnia and walked all night looking for cigarettes. She stated she last saw Resident #1 at approximately 5:10 a.m. walking down the hall, when she was going to check on another resident who had pushed their call light. She stated she was contacted by the local police department at about 5:45 a.m. asking if they were missing anyone. She stated she was not aware that Resident #1 was missing and stated he must have gone out one of the back doors that does not have alarms. She stated Resident #1 had never attempted to elope from the facility. LVN A stated Resident #1 was found 2 &frac12; blocks from the facility, stated he was headed to the post office to return some counterfeit money. LVN A stated when she looked, it appeared that she had some money missing from her purse she had behind the nurse's station. LVN A stated she immediately contacted the hospital so that she could provide any information they needed for Resident #1, she stated she then made all other notifications to the ADM, DON, and Resident #1's guardian. <BR/>In an interview on 3/1/2023 at 11:19 a.m., Resident #1's Guardian stated he was admitted to the facility on [DATE] on the secure unit due to being an elopement risk. She stated he had previous elopements at previous placements and had attempted from this facility. Resident #1's Guardian stated she was notified by the facility that the secure unit would be shut down. She stated the facility completed another risk assessment for elopement and indicated Resident #1 was no longer at risk for elopement. Resident #1's Guardian stated Resident #1 was very familiar with the back doors at facility, she stated he often would go out the door when she visited as he was able to go in and out the doors as he pleased. Resident #1's Guardian stated she believed the facility shut down the secure unit due to staffing and census issues. Resident #1's Guardian stated Resident #1 refused to wear the wander guard bracelet and was unaware of any other interventions in place. She stated she was not aware of Resident #1 trying to elope since he initially admitted . Resident #1's Guardian stated she was also concerned that the incident happened at 5:45 a.m., but she did not get contacted about the incident until sometime after 7:00 a.m. <BR/>In an interview on 3/1/2023 at 1:30 p.m. the DON stated LVN A who was on duty that night, contacted her around 6:39 a.m. She stated LVN A reported that the police were just at the facility asking if they had a resident missing. The DON stated LVN A was not aware Resident #1 was missing at the time when she was contacted by the police. The DON stated she advised LVN A to make all notifications, she also stated that LVN A stated Resident #1 must have gone out one of the back doors because they do not lock or alarm. The DON stated none of the doors at the facility alarm when opened unless the resident has on a wander guard bracelet. The DON stated the other residents who are an elopement risk have on a wander guard bracelet and if they get within 10 feet of any of the doors the alarms will sound. The DON stated when she started at the facility in October 2022, Resident #1 was already off the secure unit, she stated he had never tried to elope before this time. The DON was asked about previous care plans and interventions for Resident #1 because he refused to wear the wander guard bracelet, she was not able to locate any documents. The DON was not able to locate any documentation regarding Resident #1's behaviors, monitoring of Resident #1, or any sign-in/or out sheets. <BR/>In an interview on 3/1/2023 at 4:30 p.m., the ADM stated all residents who have been identified as elopement risk wear a wander guard bracelet, he stated Resident #1 refused to wear his wander guard. The ADM stated he was not aware that Resident #1 tried to elope from the facility in the past he stated it must have been before he started at the facility. The ADM stated all residents have the right to be safe and it is his expectation that all residents are safe in the facility. The ADM stated the alarms on the doors alarm if the resident was wearing a wander guard and they come within 10 feet of any of the doors. The ADM stated they opened back up the secure unit on 2/28/2023. <BR/>Observation and test on 3/1/2023 of all doors in facility, reflected all doors are able to be opened without any alarms going off coming in or going out the doors. The door where staff believe Resident #1 went out leads out to the side parking lot on the south end of the building. The facility is located 2 blocks from an active railroad and busy street with blinking yellow light for traffic going through. <BR/>Observation on 3/1/2023 at 3:30pm of secure unit with code required secured doors. Observed two residents residing on the secure unit and staff working on the unit. <BR/>Reviewed facility Abuse/Neglect policy undated reflected: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. <BR/>Reviewed facility Elopement Risk Assessment policy dated 11/01/2017 reflected the following: All residents are assessed on admission for elopement risk utilizing an elopement risk form. All residents are re-assessed for elopement potential by the MDS nurse /social worker or designee periodically throughout a resident's stay and with a significant change. Interventions will be added to the resident's care plan after analyzing the information obtained. The baseline care plan will identify if a resident is admitted as an elopement risk on admission. <BR/>Reviewed QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. <BR/>An (IJ) Immediate Jeopardy was identified on 3/1/2023 at 6:06 p.m., due to the above failures. The ADM was notified on 3/1/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 3/1/2023 at 6:06pm, and a Plan of Removal (POR) was requested.<BR/>A Plan of Removal was accepted on 3/3/2023 at 1:56 p.m. and reads as follows:<BR/>Plan of Removal <BR/>Immediate Plan of Removal <BR/>Identified resident is not currently in the facility:<BR/>Residents at risk of elopement have the potential to be affected. <BR/>Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy on 2/28/23. Any not completed in past 90 days or found to be inaccurate were completed by the Director of Nursing on 3/1/23. Identified residents at risk reviewed using the Elopement Risk Assessment for interventions on 2/28/23, by the Director of Nursing and any issues identified were corrected appropriately at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 2/28/23. <BR/>Licensed nurses will be re-educated on Abuse/Neglect, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This includes intervening if the resident verbalizes the desire to leave the facility or threatens to leave the facility or refuses to wear a wander guard. Licensed nurses will also be re-educated on documenting in progress notes, adding to the 24-hour report and updating care plans with changes of condition This education will be initiated on 2/28/23 by the Director of Nursing and completed by 3/2/23. The Director of Nursing will monitor for compliance.<BR/>Any member of target audience not receiving by 3/2/23 will receive prior to next scheduled shift. This education will be presented in the new hire orientation and for any agency staff by the Director of Nursing/charge nurse. <BR/>New admissions, readmissions and quarterly assessments will be reviewed in morning meeting beginning 3/2/23 Monday thru Friday as part of the clinical morning meeting process to review Elopement risks assessments for accuracy and interventions validated if indicated. The 24-hour report will be reviewed by the Director of Nursing/Assistant Director of Nursing for any documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. <BR/>The Medical Director was notified of the Immediate Jeopardy on 3/1/23. <BR/>Ad Hoc QAPI was held by the administrator on 3/1/23 to discuss the contents of this plan. <BR/>The administrator will oversee the compliance of this plan.<BR/>Monitoring of Plan or Removal on 3/2/2023 was as follows: <BR/>Interview on 3/2/2023 at 3:00 p.m., with hospital staff reported Resident #1 remains in the hospital in recovery from surgery. Hospital staff reported that Resident #1 has refused care by pulling out his picc line and still had delusional thoughts. Resident # 1 is scheduled to return to the facility once released from the hospital.<BR/> Reviewed elopement risk assessments dated 3/1/2023 completed and updated for Resident #2 and Resident #3, reflected both are at risk for wandering, elopement risk, and will reside on secure unit for their safety and wear a wander guard bracelet.<BR/>Observation conducted on 3/2/2023 at 3:30 p.m., of Resident #2 and Resident #3, on the secure unit. Resident #2 and Resident #3 appeared to be resting, they did not appear to be in any pain or distress. Resident # 2 and Resident # 3 was observed wearing their wander guard bracelets. <BR/>In an interview on 3/2/2023 at 2:10 p.m., LVN B stated she completed the elopement drill and has been in-serviced on the policy, procedures and steps to take when there is a missing resident. LVN B stated she had also been in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM is the abuse/neglect coordinator. <BR/>In an interview on 3/2/2023 at 2:20 p.m., LVN C stated she participated in the elopement drill today. She reported being in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacts the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. <BR/>In an interview on 3/2/2023 at 2:30 p.m., LVN D stated she worked the morning of the incident. She stated she worked on 3/1/2023 from 6am to 6pm she was coming on shift when LE came to facility and asked LVN A if they had a resident missing. LVN D stated LVN A was not aware that Resident #1 was missing. She stated whenever, she worked the 6pm to 6am shift she knows she have to walk all night and check on Resident #1 because he walks all through the night. She stated when she worked, she would have to know where all her residents are at all times for safety of the residents. LVN D stated she had participated in the elopement drill at facility and knows that steps to take when they have a resident missing. She stated she had also been in-serviced on abuse/neglect and documentation. <BR/>In an interview on 3/2/2023 at 2:40 p.m., CNA B stated she participated in the elopement drill today. CNA B stated they learned the code to call code white if they have a missing resident and they step to take to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed to report immediately when they see or suspect abuse/neglect. <BR/>In an interview on 3/2/2023 at 2:50 p.m. CNA C stated she participated in the elopement drill today. CNA C stated they learned the code to call code white if they have a missing resident and to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed report immediately. <BR/>In an interview on 3/2/2023 at 3:10 p.m., DON stated she and most of the staff have been trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained are either PRN (as needed) staff or staff that only worked in the summer. DON stated the rest of the staff even agency staff as they come to work have been trained over the elopement process, abuse/neglect, and documentation. <BR/>In an interview on 3/2/2023 at 3:20 p.m., the ADM stated all staff have been trained on the elopement process. He stated all staff participated in the elopement drill skills test on what to do if they have a missing resident. He stated it is his responsibility to ensure that all the residents in the facility are safe. ADM stated they are also looking at other ways to ensure the safety of the residents while maintain their independence. <BR/>In an interview on 3/3/2023 at 3:40p.m., the ADM, stated on 3/1/2023 he verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. <BR/>Record review of the AdHoc (for particular reason) QAPI(Quality assurance performance improvement) dated 3/1/2023 to address IJ(Immediate Jeopardy). <BR/>Monitoring completed on 3/3/2023 as follows: <BR/>Resident # 1 remains in hospital, Resident # 1 is scheduled to return to the facility once released from the hospital<BR/>Observation made on 3/3/2023 at 4:10 p.m., of Resident # 2 and Resident # 3 on secure unit, no concerns noted during observation.<BR/>Review of elopement assessments dated 2/28/2023, reflected all residents in facility were re-assessed for elopement risk. Two residents identified for secure unit /wander guard. These residents are currently on secure unit. <BR/>Review of care plan dated 2/28/2023 for Resident #1 and Resident # 2 with current interventions: <BR/>1. <BR/>Monitor for placement Q shift <BR/>2. <BR/>Monitor for proper functioning 24 hours a day <BR/>3. <BR/>Monitor resident in facility and document attempts to elope out of facility<BR/>4. <BR/>Assess quarterly for continued use of wander guard <BR/>5. <BR/>Explain to resident the policy and procedures for leaving the facility<BR/>6. <BR/>Resident will reside on the secure unit for safety <BR/>7. <BR/>Offer daily activities to address resident's interest <BR/>8. <BR/>Review periodically for continued need for secure placement <BR/>3/3/2023 Review of in-services completed: all nursing staff verified completion except one PRN staff.<BR/>3/2/2023- Documentation Expectations <BR/>3/2/2023- Resident refusal of wander guard / immediate reporting to charge nurse <BR/>2/28/2023- Safety <BR/>2/28/2023- Elopement Drill / Policy and procedure <BR/>2/28/2023- Abuse/Neglect <BR/>2/28/2023- Elopement, Care plans, New admissions, elopement risk assessment and Quarterly assessments<BR/> Record review of in-service sheet dated 2/28/2023 reflected 2 CNA's who work PRN had not completed the training. One nursing staff who only works in the summer had not received the training.<BR/> In an interview on 3/3/2023 at 4:15pm with BOM (business office manager), stated they have not had any new admissions, readmissions. <BR/>On 3/3/2023 at 4:40 p.m., the ADM was informed the (IJ)immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage, preparation, and service.<BR/>1. The facility dishwasher was out of sanitizer and still being used to wash dishes.<BR/>2. The CK/DM failed to sanitize the puree bowl between puree dishes and used unsanitized tongs to handle sausage during the puree process.<BR/>3. There was no system in place to accurately monitor holding temperatures for the pureed foods.<BR/>These failures placed residents at risk of food-borne illness.<BR/>Findings included:<BR/>1.<BR/>Observation on 04/26/23 at 12:26 PM revealed an Autochlor A5 Water Saver dishwasher (chemically sanitizing dishwasher) in the facility kitchen. When a wash/rinse cycle of the machine was conducted with a plastic coffee cup, the available chemical test strips did not indicate any presence of chlorine or other disinfecting fluid. DA D ran the dishwasher again and tried detecting chemical in the water on the surface of the coffee cup again, and no presence of chemical resulted. <BR/>During an interview on 04/26/23 at 12:30 PM, DA A stated he tested the chemical content of the dishwasher daily and had done so earlier that morning before breakfast. DA A stated he logged the results of his tests on a paper form hanging on the wall behind the dishwasher. DA A stated the chemical must have run out on the dishwasher. He stated the chemical content should have registered at 50 ppm. <BR/>During an interview on 04/26/23 at 12:40 PM, the ADM stated the chemical sanitizer had run out in the dishwasher, and he had just ensured an order was put in for more. He stated the facility would revert to disposable dishes until the chemical sanitizer was restored to the dishes. The ADM stated the residents had already been served lunch and were eating, and there was no way to guarantee they did not eat on dishes that had not been properly sanitized. <BR/>Review of the log hanging behind the dishwasher reflected an entry for 04/26/23 with a checkmark next to it and no further information. <BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>4-204.117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. The presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment. The automatic dispensing of these chemical agents, plus a method such as a flow indicator, flashing light, buzzer, or visible open air delivery system that alerts the operator that the chemicals are no longer being dispensed, ensures that utensils are subjected to an efficacious cleaning and sanitizing regimen.<BR/>2.<BR/>Observation on 04/25/23 at 11:04 AM revealed the CK/DM pureed one scoopful of broccoli in a food processor, rinsed the processor bowl under running water in a sink next to the preparation area without using any soap or sanitizing solution, poured the pureed broccoli into a small chafing dish, and pureed rice with milk in the food processor bowl. She then rinsed the food processor bowl in the nearby sink without using soap or sanitizer, poured the pureed rice into a small chafing dish, and pureed whole pinto beans. The CK/DM then poured the pinto beans into a small chafing dish and rinsed the food processor bowl in the same sink. There were still beans visible on the inside of the food processor. She then retrieved a chafing dish filled with Polish sausage from the cook area and pulled a pair of metal tongs out of the bottom of the sink where she had been pouring and rinsing the food processor bowl and retrieved a sausage link with the tongs. She proceeded to puree the sausage in the food processor bowl. <BR/>During an interview on 04/25/23 at 11:10 AM, CK/DM stated her last supervisor said she did not even have to rinse the food processor bowl in between pureeing different food items, but she did not like to leave food in there, so she rinsed some of it out. The CK/DM stated she was not a certified dietary manager and had been going to school to become certified, but she had to take over the dietary manager position when the last one quit, and she had not been able to attend her classes, because she was working so hard as the CK and DM. The CK/DM stated the town the facility was in was very small, and there were no options for dietary manager or cook applying for the jobs.<BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>The 3 compartment requirement allows for proper execution of the 3-step manual warewashing procedure. If properly used, the 3 compartments reduce the chance of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual warewashing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same 3 steps: 1. Application of cleaners and the removal of soil; 2. Removal of any abrasive and removal or dilution of cleaning chemicals; and 3. Sanitization. Refer also to the public health reason for &sect; 4-603.16.<BR/>3.<BR/>Observation on 04/25/23 at 11:48 AM revealed the CK/DM attempted to take the temperature of the pureed sausage, but there was too little food depth to measure with only one serving of each dish in each chafing dish. The CK/DM stated she did not have a way to measure the temperature of the pureed food and did not know she needed to do so. When asked if she did not regularly or daily take the holding temperature of the pureed foods, she stated she normally did that later on but did not clarify what that meant. <BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>Hot Holding In a January 2001 report, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) recommended that the minimum hot holding temperature specified in the Food Code: FDA believes that maintaining food at a temperature of 57&deg;C (135&deg;F) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness.<BR/>During an interview and record review on 04/27/23 at 08:44 AM, the LD stated she came to the facility in person once a month, and all her other duties were remote. The LD stated the company that owns the facility placed the responsibility for most of the kitchen inspections/sanitation reports with the dietary manager and administrator positions, but she did conduct her own kitchen inspection when she came to the building from a brief checklist. The LD stated the ADM did a weekly kitchen inspection, and the CK/DM was in there daily, so they were primarily responsible for any issues with kitchen sanitation. The LD stated some of the checklist items were marked N/A because the facility was so small and old they did not have the items. The checklist she worked from had the following items listed that were applicable to the facility:<BR/> -pot washing and dishwashing<BR/>-food temperature log<BR/>-no cross contamination during cooking<BR/>-clean dishes air drying with no wet items in racks.<BR/>The LD stated she did not routinely check the chemical dishwasher but left that up to the CK/DM, who needed to be ensuring it was done daily. The LD stated she would usually watch the CK/DM make the puree to make sure she was using the right thinner, but she had not noticed anything [NAME] with sanitation during purees. The LD stated the facility just had one small food processor and only one resident on a puree diet, so they did not cook food in big batches. The LD stated this made it difficult to measure the temperatures on the steam table. The LD stated she did not really know how to solve that problem, because the pureed foods did have to be maintained at the same 135 degrees as the other foods. The LD stated the food processor bowl should have been washed and sanitized in between dishes. The LD stated, since they prepared these foods in such small batches, they could not send the bowl through the dishwasher, but needed to wash it in soapy water by hands and sanitize in the approved sanitizing sink with a chlorine bleach component. The LD stated she did not know the protocol they had developed, but the food processor bowl needed to be washed and sanitized. The LD stated when the previous dietary manager left, the facility promoted the CK/DM while she was still working on her dietary manager certificate. The LD stated some of the instances of noncompliance in the kitchen were probably due to the CK/DM not having her full education as a food and nutrition services manager. The LD stated the CK/DM was not a certified dietary manager and had not worked more than two years as a food and nutrition services manager. The dietitian stated the potential result for all the identified failures in the kitchen could have been an outbreak of food-borne illness among the resident population. A copy of the most recent kitchen sanitation checklist was requested from the LD but not received prior to the end of survey. <BR/>During an interview on 04/27/23 at 02:15 PM, the ADM stated he monitored the kitchen by conducting weekly kitchen inspections and documented them on a checklist. The ADM stated he had not observed any of the issues noted during his inspections. The ADM stated the CK/DM was not a certified dietary manager. He stated she had started the class to become certified, and prior to the ADM taking his position, the previous administrator had cut staff in the kitchen. The ADM stated that resulted in the CK/DM having to take over the kitchen. The ADM stated he had the CK/DM call the certification school the day prior, and she learned she would have to start the classes over again. The ADM stated the failures identified in the kitchen could result in food borne illness for the residents. The ADM stated he would provide his completed kitchen inspection sheets but had not provided them prior to exit. <BR/>Review of facility's policy, titled Food Safety, and dated 08/01/20 did not include any policy related to holding temperatures, dishwasher operation, or cookware sanitization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical and nursing needs for one (Resident #1) of four residents reviewed for care plans, in that:<BR/>The facility failed to develop a care plan for Resident #1's sacrum (a shield shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) stage four pressure ulcer and the care plan did not address his non-compliance with treatment. <BR/>This failure could place residents at risk for not having their individual care needs met, errors in providing care, poor wound healing/worsening wound condition.<BR/>Findings included: <BR/>Review of Resident #1's Face Sheet dated 1/4/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Adult failure to thrive (older adult has a loss of appetite, eats and drinks less than usual, and is less active than normal), Osteomyelitis of vertebrae (painful bone infection that develops from bacteria or fungi, is itself rare), Chronic Obstructive Pulmonary Disease (chronic condition in which a patient's lungs are susceptible to infections and moreover, the infections show exaggerated symptoms in the patients. Hence there is higher risk of morbidity and mortality in the patients suffering from COPD (as compared to normal people), and chronic respiratory failure (when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).<BR/>Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 13 indicating cognition was intact. Resident #1 was assessed to be dependent on staff for ADL assistance. Resident #1 was assessed to have unhealed pressure ulcer and a wound infection. Resident #1 was on routine pain medications. <BR/>Review of Resident #1's Comprehensive Care Plan dated from 12/04/2023 to 01/04/2024 reflected a focus area revised on 12/21/2023 Resident #1 had pain. Resident #1 had COPD. Resident #1 was assessed for intolerance related to imbalance between supply oxygenation needs. Resident #1 pressure ulcer to the sacrum was not assessed on the current care plan dated 12/21/2023. <BR/>Review of Resident #1's Consolidated Physician orders dated from 12/04/2023 to 01/04/2024 reflected an order dated 09/26/2023 reflected daily wound treatment: Stage 3; clean with NS/NC; pat dry: apply skin prep to wound edges; apply honey alginate calcium to wound bed; cover with foam silicone bordered dressing QD (every day) and PRN (as needed). Order was d/c (discharged ) on 12/07/2023.<BR/>Review of Resident #1's Consolidated Physician Orders dated from 12/04/2023 to 01/04/2024 reflected an order dated 11/08/2023 with an end date of 11/23/2023 reflected daily wound treatment: special instructions: alginate calcium apply once daily for 15 days. Foam silicone bdr (do not know acronym for bdr) and faced apply once daily for 15 days once a day. <BR/>Review of Resident #1's Consolidated Physician Orders dated from 12/04/2023 to 01/04/2024 reflected an order dated 12/07/2023 reflected daily wound treatment to sacrum. Superabsorbent gelling fiber pad apply once daily for 16 days; Sodium hypochlorite gel (anasept) apply once daily for 30 days. Order was d/c on 01/05/2024. <BR/>Review of Resident #1's Consolidated Physician Orders dated from 12/04/2023 to 01/04/2024 reflected an order dated 12/29/2023. Daily wound treatment: sacrum; negative pressure wound therapy apply three times per week for 30 days: 125 mm hg, black or green foam in wound bed, bridge to either hip. Change TIW the bone in the wound bed just slightly larger than the wound cavity. End date 01/30/2024. <BR/>*Review on 01/19/2023 of Resident #1's Care Plan Conference Summary reflected the issue of non-compliance with repositioning was discussed with family and family offered support for encouraging the resident. <BR/>Review on 01/19/2024 of Resident #1's Care Plan reflected no interventions to address resident's non-compliant with treatment. <BR/>In an interview on 01/04/2023 at 3:30 PM the ADON stated the facility was trying to update all the documents into the new electronic medical records. She stated all the documents related to Resident #1 were reviewed by her and she thought the pressure ulcer was on the care plan. She stated it was her responsibility to complete care plans and she did not know why the wound for Resident #1 was not on the care plan. She stated all medical, emotional, behavior issues with a resident were expected to be on the care plan. The ADON stated the care plan was how all staff knew what type of care a resident has been identified by the interdisciplinary team. She stated there was a possibility a resident may not receive the appropriate care during their stay at the facility. <BR/>In an interview on 01/04/2024 at 4:00 PM the Administrator stated the ADON was responsible for care plans and he did not understand why Resident #1's wound was not on the care plan. He stated he did not know what to say about the care plans. He stated all residents' medical needs were expected to be on the care plan. He stated the resident may not get the care needed. <BR/>In an interview on 01/04/2024 at 4:10 PM requested a care plan policy from the Administrator and it was not provided at the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of six residents (Resident # 15 and Resident #18).<BR/>1. The facility failed to ensure Resident # 15's nails were cleaned and did not have any rough edges. <BR/>2. The facility failed to ensure Resident # 18's facial hair was removed and nails were cleaned.<BR/>These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of Resident #15's Face Sheet dated, 06/27/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of rheumatoid arthritis unspecified site (a chronic inflammatory disorder that can affect more than just your joints), unspecified lack of coordination ( uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), age- related physical debility ( generalized weakness, exhaustion, poor balance, and decreased physical activity), muscle weakness ( lack of muscle strength), and chronic pain syndrome ( long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition, such as arthritis. It may affect people to the point that they can't work, eat properly, and/ or take part in physical activity).<BR/>Record review of Resident #15's Annual MDS Assessment, dated 05/02/2024, reflected the resident had a BIMS score of 12 reflected his cognition was moderately impaired. Resident # 15 did not reject care. Resident #18 was assessed to require assistance with personal hygiene, toileting, dressing, bathing, and transfers. Resident #15 had diagnosis of arthritis (joint inflammation) and muscle weakness (lack of muscle strength).<BR/>Record review of Resident #15's Comprehensive Care Plan, dated 05/15/2024, reflected Resident #15 preferred bed baths. Intervention: Staff will offer shower/ bed bath three times weekly. Staff will educate Resident #15 about proper hygiene. Resident #15 had rheumatoid arthritis and was at risk for decreased in ADLs and increased joint pain. Intervention: monitor for increased joint pain- give meds/ treatment per order - assess for signs of relief of pain. Resident #15 required assistance with ADLs. Interventions: Resident #15 required assistance with bathing, dressing, toileting, transfers, and eating.<BR/>Record review of Resident #15's Treatment Administration Record (TAR) dated 06/01/2024 - 06/31/2024 reflected Resident #15 did not refuse nail care. <BR/>Record review of Resident #15's nurses notes from 05/01/2024 thru 06/26/2024 Resident #15 did not refuse nail care. <BR/>Observation on 06/25/2024 at 10:21 AM Resident # 15 was in his room sitting in wheelchair watching television. Resident #15 had blackish hard substance underneath the forefinger and middle fingernails on his right hand. His middle and ring fingernails was rough around the edges. There was an odor of bowels on his right hand. <BR/>In an interview on 06/25/2024 at 10: 24 AM Resident #15 stated he tried to clean his nails but he was not physically able to clean his own nails or trim his nails. He stated some of his nails was rough and needed to be smoothed but he was not able to do this and he would try but he was afraid he would get his nails infected if he tried. Resident #15 also stated he needed assistance with his nails and all his care. He stated someone came in yesterday (06/24/2024) to trim his nails and they said his nails did not need to be trimmed. He asked the staff to file his nails and the staff stated they did not file nails all they did was trim nails. He stated his nails were dirty yesterday afternoon after the staff left the room. He stated the person never returned to his room and he did not ask anyone else to assist him. He stated if she stated it was not their job to file the nails he was not going to ask anyone else. Resident #15 did not recall the person's name. Resident #15 stated he has not refused any nail care from staff. <BR/>2. Record review of Resident #18's Face Sheet dated, 06/26/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia (affects memory, thinking and social abilities), contracture of muscles, unspecified upper arm (occurs when your muscles, tendons, joints, or other tissues or shorten causing a deformity and can cause loss of movement in the joint), muscle weakness (lack of muscle strength).<BR/>Record review of Resident #18's Quarterly MDS Assessment, dated 04/01/2024, reflected the resident had a BIMS score of 0 indicated her cognition was severely impaired. Resident #18 did not reject care. She was assessed to be dependent on staff for ADLs such as: eating, oral hygiene, toileting hygiene, personal hygiene, showers, lower body dressing and all transfers except sit to lying and lying to sitting on side of bed. <BR/>Record review of Resident #18's Comprehensive Care Plan, dated 03/07/2024, reflected Resident #18 had a diagnosis of dementia (affects memory, thinking and social abilities) with expected decline in cognitive impairment over a period of time as a natural progression of the disease. Intervention: document decline in cognitive status. Resident #18 was identified needed assistance with ADLs (the type of ADLs was not specified). <BR/>Record review of Resident #18's Treatment Administration Record (TAR) dated 06/01/2024 - 06/31/2024 reflected Resident #18 did not refuse nail care. <BR/>Record review of Resident #18's nurses notes from 05/01/2024 thru 06/26/2024 Resident #18 did not refuse nail care. <BR/>Observation on 06/25/2024 at 10:36 AM Resident #18 was sitting in her Geri chair listening to music. She had slightly curled facial hair approximately 2-3 inches long on the left side of her face near her mouth. Resident #18 had blackish hard substance underneath her nails on her middle and ring finger on the right hand. She also had hard blackish and her ring and fore finger on her left hand. <BR/>In an interview on 06/25/2024 at 10:39 AM Resident #18 was not interview able. She did not respond verbally or with gestures to any questions. <BR/>In an interview on 06/27/2024 at 11:00 AM the DON stated it was a joint effort between the CNAs and the nurses to complete nail care on the residents. She stated the nurses was responsible for residents with diagnosis of diabetes ( a disease in which the body's ability to produce or respond to the hormone insulin was impaired). The Director of Nurses stated nail care was scheduled by the TAR and when residents received showers. She also stated nail care was also expected to be completed as needed. She stated if a resident had blackish substance underneath their nails the substance may be dirt and not bacteria. She stated no one knows if it was bacteria underneath the residents' fingernails. The DON stated if the scent was feces was noticed underneath residents' fingernails there was a potential this may be bacteria. She stated it was a possibility a resident may become physically ill such as vomiting or diarrhea if they ingested bacteria from feces. She also stated if a resident had rough fingernails there was a possibility the resident may scratch themselves and develop a skin tear. The DON stated she did not believe women having facial hair was a dignity issue or any type of issue. She stated if a resident was not able to communicate verbally if they wanted facial hair she did not believe this was an issue for the female resident to have facial hair. She stated if there was any refusal of nail care it would be documented in the nurses notes or on the TAR. <BR/>In an interview on 06/27/2024 at 11:20 AM LVN A stated the nurses and CNAs were responsible for nail care. She stated the nurses was responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN A stated it was the CNAs responsibility to clean and trim all other residents' nails. She stated the nurses checked the diabetic nails weekly and the CNAs reported to the nurses if any diabetic nails needed to be cleaned or trimmed. LVN also stated the nurse would document on the TAR (Treatment Administrator Record) and/ or nurses notes if any resident refused nail care. She stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance may had bacteria underneath the residents' nails. She also stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea. She stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear. LVN A stated she was not aware of anyone refusing nail care; however, she would need to refer to the TAR to know for certain if Resident # 15 or Resident #18 refused nail care. <BR/>In an interview on 06/27/2024 at 11:30 AM CNA E stated the nurses completed all diabetic fingernails and the CNAs was responsible for all other residents' nails. She stated the CNAs was responsible to complete nail care such as trimming, filing, and cleaning the nails. She stated the staff was very busy and it was difficult to complete nail care on residents except when the resident was in the shower. CNA E also stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day there were times the staff was not able to clean, trim or file the residents' nails. CNA E stated there were also times the nursing staff may have time to do one of the nail tasks but not all three tasks such as filing, cleaning, and trimming. She stated if a resident had blackish substance underneath their nails it was usually from their bowels. She stated if a resident swallowed some of their bowels the resident may become ill with sores in their mouth, yeast infections in their mouth, get E. coli (a bacteria that is commonly found in the lower intestine of warm-blooded organisms) and may develop major stomach problems such as diarrhea. She stated she worked with Resident #15 and Resident #18 and she was not aware of them refusing nail care. She stated if a resident's nails were rough there was a possibility the resident may scratch themselves and develop a skin tear or possibly scratch their eye and cause a tear on their eyeball. <BR/>Record review of the Facility Policy on ADLs dated, 05/05/2023, reflected Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. POLICY: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.<BR/>*

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure Resident #1 eloped from the facility on 2/28//2023 and fractured his right hip, that required surgery to treat. Resident #1 was found 2 &frac12; blocks away from the facility on the ground, he had fallen and was unable to get up. <BR/>This failure resulted in an identification of an (IJ) Immediate Jeopardy on 3/1/2023 at 6:06 p.m. The (IJ) Immediate Jeopardy template was provided to the ADM on 3/1/2023 at 6:06pm. While the (IJ) Immediate Jeopardy was removed on 3/3/2023 at 4:40 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal.<BR/>This failure could place all residents that are elopement risk and refuse to wear a wander guard at risk for accidents, harm, and/or death.<BR/>Findings included: <BR/>Review of Resident #1's face sheet dated 3/2/2023, reflected a 64- year- old man, admitted to the facility on [DATE]. Resident #1 was diagnosed with Parkinson's disease (a disease of the central nervous system that affects movements), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder) not due to a substance or known physiological condition, Insomnia ( a common sleep disorder that can make it hard to fall asleep), Paranoid schizophrenia ( a psychological disorder where the lines are blurred between what is real and what isn't), delusional disorder(a belief or altered reality that is persistently held despite evidence or agreement to the contrary) and heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). <BR/>Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 5 (indicates the resident does not have the cognitive ability to understand). The MDS also reflected Resident # 1 is ambulatory with no assistance. <BR/>Review of MAR dated 2/1/2023-2/282023, reflected the following orders: <BR/>Resident to reside on secure unit for personal safety - start 12/29/2020 open ended <BR/>9/1/2022- Resident may have trial integration off unit into general population- open ended <BR/>9/1/2022- May have wander guard -open ended<BR/>Record review of Resident #1's care plan dated 2/28/2023, reflected the following: Problem: Resident has been observed to leave the grounds within the past week without notifying staff despite reminders. Interventions: Explain to resident the policy and procedure for leaving the facility and review periodically for continued need for secure placement. The care plan did not reflect any updates of interventions in place for Resident #1 for the period of 9/1/2022 when Resident #1 came off the secure unit through 2/28/2023.<BR/>Record review of Risk elopement assessments for Resident #1 reflected the following:<BR/>-12/19/2017 Resident #1 was identified as risk for elopement, <BR/>-9/19/2021 was not an elopement risk, with no interventions,<BR/>-11/15/2022 Resident #1 was not an elopement risk, with no interventions, <BR/>-5/21/2022 reflected it was unknown if Resident # 1 was an elopement risk and to remain on secure unit for safety, and. <BR/>-2/23/2023 reflected Resident #1 was not a risk for elopement with the following interventions: Frequent monitoring how often not noted, keep behavior logs, review medications, utilizations of sign in/sign out logs, recreational activities, and music. <BR/>Record review of facility progress notes dated 6/2/2022- 2/28/2023 for Resident #1 reflected, no monitoring notes, no behavioral log, no sign in or out sheets used by Resident #1, or any notes regarding activities or music. There was one progress note dated 2/28/2023 regarding Resident #1's refusal to wear the wander guard. <BR/>In an interview on 3/1/2023 at 11:10 a.m., the hospital staff reported Resident #1 was brought into the hospital by EMS. She stated it was reported Resident #1 was found on the street trying to get up. The hospital staff stated Resident # 1 had a fractured right hip and was scheduled for surgery later in the day. She stated Resident # 1 was hallucinating and having delusional thoughts since he was admitted . <BR/>In an interview on 3/1/2023 with concerned citizen stated approximately 5:25am he and his son noticed Resident # 1 had fallen and was trying to get up. He stated they called 911 for assistance, he stated Resident #1 reported that he tripped over the curb and hurt his hip.<BR/>In an interview on 3/1/2023 at 12:29 p.m., LE stated EMS contacted them to come to the scene on 3/1/2023 around 5:45 a.m., LE stated they spoke with Resident #1 he was able to tell them the facility he came from, that he had fallen and was unable to get up. LE reported, Resident #1 was transported to the hospital due to his injury he sustained from falling. LE stated they went to facility and asked if anyone was missing? LE reported the staff they spoke to was not aware that anyone was missing at the time, LE stated they informed the facility of Resident #1 name and advised that he was transported to the hospital for further medical treatment. <BR/>Review of Police call for service report dated 2/28/2023, reflected the facility was notified at approximately 5:50am asking if they were missing anyone from the facility. LVN A, reported that she was not aware that anyone was missing at the time. LVN A was advised that Resident # 1 had been injured and was transported to the hospital.<BR/>In an interview on 3/1/2023 at 10:02 a.m., LVN A stated she was the nurse on duty last night, she stated they work 12 hours shifts 6pm to 6am. She stated Resident #1 has insomnia and walked all night looking for cigarettes. She stated she last saw Resident #1 at approximately 5:10 a.m. walking down the hall, when she was going to check on another resident who had pushed their call light. She stated she was contacted by the local police department at about 5:45 a.m. asking if they were missing anyone. She stated she was not aware that Resident #1 was missing and stated he must have gone out one of the back doors that does not have alarms. She stated Resident #1 had never attempted to elope from the facility. LVN A stated Resident #1 was found 2 &frac12; blocks from the facility, stated he was headed to the post office to return some counterfeit money. LVN A stated when she looked, it appeared that she had some money missing from her purse she had behind the nurse's station. LVN A stated she immediately contacted the hospital so that she could provide any information they needed for Resident #1, she stated she then made all other notifications to the ADM, DON, and Resident #1's guardian. <BR/>In an interview on 3/1/2023 at 11:19 a.m., Resident #1's Guardian stated he was admitted to the facility on [DATE] on the secure unit due to being an elopement risk. She stated he had previous elopements at previous placements and had attempted from this facility. Resident #1's Guardian stated she was notified by the facility that the secure unit would be shut down. She stated the facility completed another risk assessment for elopement and indicated Resident #1 was no longer at risk for elopement. Resident #1's Guardian stated Resident #1 was very familiar with the back doors at facility, she stated he often would go out the door when she visited as he was able to go in and out the doors as he pleased. Resident #1's Guardian stated she believed the facility shut down the secure unit due to staffing and census issues. Resident #1's Guardian stated Resident #1 refused to wear the wander guard bracelet and was unaware of any other interventions in place. She stated she was not aware of Resident #1 trying to elope since he initially admitted . Resident #1's Guardian stated she was also concerned that the incident happened at 5:45 a.m., but she did not get contacted about the incident until sometime after 7:00 a.m. <BR/>In an interview on 3/1/2023 at 1:30 p.m. the DON stated LVN A who was on duty that night, contacted her around 6:39 a.m. She stated LVN A reported that the police were just at the facility asking if they had a resident missing. The DON stated LVN A was not aware Resident #1 was missing at the time when she was contacted by the police. The DON stated she advised LVN A to make all notifications, she also stated that LVN A stated Resident #1 must have gone out one of the back doors because they do not lock or alarm. The DON stated none of the doors at the facility alarm when opened unless the resident has on a wander guard bracelet. The DON stated the other residents who are an elopement risk have on a wander guard bracelet and if they get within 10 feet of any of the doors the alarms will sound. The DON stated when she started at the facility in October 2022, Resident #1 was already off the secure unit, she stated he had never tried to elope before this time. The DON was asked about previous care plans and interventions for Resident #1 because he refused to wear the wander guard bracelet, she was not able to locate any documents. The DON was not able to locate any documentation regarding Resident #1's behaviors, monitoring of Resident #1, or any sign-in/or out sheets. <BR/>In an interview on 3/1/2023 at 4:30 p.m., the ADM stated all residents who have been identified as elopement risk wear a wander guard bracelet, he stated Resident #1 refused to wear his wander guard. The ADM stated he was not aware that Resident #1 tried to elope from the facility in the past he stated it must have been before he started at the facility. The ADM stated all residents have the right to be safe and it is his expectation that all residents are safe in the facility. The ADM stated the alarms on the doors alarm if the resident was wearing a wander guard and they come within 10 feet of any of the doors. The ADM stated they opened back up the secure unit on 2/28/2023. <BR/>Observation and test on 3/1/2023 of all doors in facility, reflected all doors are able to be opened without any alarms going off coming in or going out the doors. The door where staff believe Resident #1 went out leads out to the side parking lot on the south end of the building. The facility is located 2 blocks from an active railroad and busy street with blinking yellow light for traffic going through. <BR/>Observation on 3/1/2023 at 3:30pm of secure unit with code required secured doors. Observed two residents residing on the secure unit and staff working on the unit. <BR/>Reviewed facility Abuse/Neglect policy undated reflected: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. <BR/>Reviewed facility Elopement Risk Assessment policy dated 11/01/2017 reflected the following: All residents are assessed on admission for elopement risk utilizing an elopement risk form. All residents are re-assessed for elopement potential by the MDS nurse /social worker or designee periodically throughout a resident's stay and with a significant change. Interventions will be added to the resident's care plan after analyzing the information obtained. The baseline care plan will identify if a resident is admitted as an elopement risk on admission. <BR/>Reviewed QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. <BR/>An (IJ) Immediate Jeopardy was identified on 3/1/2023 at 6:06 p.m., due to the above failures. The ADM was notified on 3/1/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 3/1/2023 at 6:06pm, and a Plan of Removal (POR) was requested.<BR/>A Plan of Removal was accepted on 3/3/2023 at 1:56 p.m. and reads as follows:<BR/>Plan of Removal <BR/>Immediate Plan of Removal <BR/>Identified resident is not currently in the facility:<BR/>Residents at risk of elopement have the potential to be affected. <BR/>Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy on 2/28/23. Any not completed in past 90 days or found to be inaccurate were completed by the Director of Nursing on 3/1/23. Identified residents at risk reviewed using the Elopement Risk Assessment for interventions on 2/28/23, by the Director of Nursing and any issues identified were corrected appropriately at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 2/28/23. <BR/>Licensed nurses will be re-educated on Abuse/Neglect, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This includes intervening if the resident verbalizes the desire to leave the facility or threatens to leave the facility or refuses to wear a wander guard. Licensed nurses will also be re-educated on documenting in progress notes, adding to the 24-hour report and updating care plans with changes of condition This education will be initiated on 2/28/23 by the Director of Nursing and completed by 3/2/23. The Director of Nursing will monitor for compliance.<BR/>Any member of target audience not receiving by 3/2/23 will receive prior to next scheduled shift. This education will be presented in the new hire orientation and for any agency staff by the Director of Nursing/charge nurse. <BR/>New admissions, readmissions and quarterly assessments will be reviewed in morning meeting beginning 3/2/23 Monday thru Friday as part of the clinical morning meeting process to review Elopement risks assessments for accuracy and interventions validated if indicated. The 24-hour report will be reviewed by the Director of Nursing/Assistant Director of Nursing for any documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. <BR/>The Medical Director was notified of the Immediate Jeopardy on 3/1/23. <BR/>Ad Hoc QAPI was held by the administrator on 3/1/23 to discuss the contents of this plan. <BR/>The administrator will oversee the compliance of this plan.<BR/>Monitoring of Plan or Removal on 3/2/2023 was as follows: <BR/>Interview on 3/2/2023 at 3:00 p.m., with hospital staff reported Resident #1 remains in the hospital in recovery from surgery. Hospital staff reported that Resident #1 has refused care by pulling out his picc line and still had delusional thoughts. Resident # 1 is scheduled to return to the facility once released from the hospital.<BR/> Reviewed elopement risk assessments dated 3/1/2023 completed and updated for Resident #2 and Resident #3, reflected both are at risk for wandering, elopement risk, and will reside on secure unit for their safety and wear a wander guard bracelet.<BR/>Observation conducted on 3/2/2023 at 3:30 p.m., of Resident #2 and Resident #3, on the secure unit. Resident #2 and Resident #3 appeared to be resting, they did not appear to be in any pain or distress. Resident # 2 and Resident # 3 was observed wearing their wander guard bracelets. <BR/>In an interview on 3/2/2023 at 2:10 p.m., LVN B stated she completed the elopement drill and has been in-serviced on the policy, procedures and steps to take when there is a missing resident. LVN B stated she had also been in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM is the abuse/neglect coordinator. <BR/>In an interview on 3/2/2023 at 2:20 p.m., LVN C stated she participated in the elopement drill today. She reported being in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacts the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. <BR/>In an interview on 3/2/2023 at 2:30 p.m., LVN D stated she worked the morning of the incident. She stated she worked on 3/1/2023 from 6am to 6pm she was coming on shift when LE came to facility and asked LVN A if they had a resident missing. LVN D stated LVN A was not aware that Resident #1 was missing. She stated whenever, she worked the 6pm to 6am shift she knows she have to walk all night and check on Resident #1 because he walks all through the night. She stated when she worked, she would have to know where all her residents are at all times for safety of the residents. LVN D stated she had participated in the elopement drill at facility and knows that steps to take when they have a resident missing. She stated she had also been in-serviced on abuse/neglect and documentation. <BR/>In an interview on 3/2/2023 at 2:40 p.m., CNA B stated she participated in the elopement drill today. CNA B stated they learned the code to call code white if they have a missing resident and they step to take to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed to report immediately when they see or suspect abuse/neglect. <BR/>In an interview on 3/2/2023 at 2:50 p.m. CNA C stated she participated in the elopement drill today. CNA C stated they learned the code to call code white if they have a missing resident and to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed report immediately. <BR/>In an interview on 3/2/2023 at 3:10 p.m., DON stated she and most of the staff have been trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained are either PRN (as needed) staff or staff that only worked in the summer. DON stated the rest of the staff even agency staff as they come to work have been trained over the elopement process, abuse/neglect, and documentation. <BR/>In an interview on 3/2/2023 at 3:20 p.m., the ADM stated all staff have been trained on the elopement process. He stated all staff participated in the elopement drill skills test on what to do if they have a missing resident. He stated it is his responsibility to ensure that all the residents in the facility are safe. ADM stated they are also looking at other ways to ensure the safety of the residents while maintain their independence. <BR/>In an interview on 3/3/2023 at 3:40p.m., the ADM, stated on 3/1/2023 he verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. <BR/>Record review of the AdHoc (for particular reason) QAPI(Quality assurance performance improvement) dated 3/1/2023 to address IJ(Immediate Jeopardy). <BR/>Monitoring completed on 3/3/2023 as follows: <BR/>Resident # 1 remains in hospital, Resident # 1 is scheduled to return to the facility once released from the hospital<BR/>Observation made on 3/3/2023 at 4:10 p.m., of Resident # 2 and Resident # 3 on secure unit, no concerns noted during observation.<BR/>Review of elopement assessments dated 2/28/2023, reflected all residents in facility were re-assessed for elopement risk. Two residents identified for secure unit /wander guard. These residents are currently on secure unit. <BR/>Review of care plan dated 2/28/2023 for Resident #1 and Resident # 2 with current interventions: <BR/>1. <BR/>Monitor for placement Q shift <BR/>2. <BR/>Monitor for proper functioning 24 hours a day <BR/>3. <BR/>Monitor resident in facility and document attempts to elope out of facility<BR/>4. <BR/>Assess quarterly for continued use of wander guard <BR/>5. <BR/>Explain to resident the policy and procedures for leaving the facility<BR/>6. <BR/>Resident will reside on the secure unit for safety <BR/>7. <BR/>Offer daily activities to address resident's interest <BR/>8. <BR/>Review periodically for continued need for secure placement <BR/>3/3/2023 Review of in-services completed: all nursing staff verified completion except one PRN staff.<BR/>3/2/2023- Documentation Expectations <BR/>3/2/2023- Resident refusal of wander guard / immediate reporting to charge nurse <BR/>2/28/2023- Safety <BR/>2/28/2023- Elopement Drill / Policy and procedure <BR/>2/28/2023- Abuse/Neglect <BR/>2/28/2023- Elopement, Care plans, New admissions, elopement risk assessment and Quarterly assessments<BR/> Record review of in-service sheet dated 2/28/2023 reflected 2 CNA's who work PRN had not completed the training. One nursing staff who only works in the summer had not received the training.<BR/> In an interview on 3/3/2023 at 4:15pm with BOM (business office manager), stated they have not had any new admissions, readmissions. <BR/>On 3/3/2023 at 4:40 p.m., the ADM was informed the (IJ)immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #21) reviewed for unnecessary medications.<BR/>The facility failed to ensure Resident #21 had behavior and side effect monitoring for his prescribed antidepressant medications Fluoxetine and Trazadone and his antipsychotic medication Abilify. <BR/>These failures could place president at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, and decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #21's face sheet dated 06/26/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), and Major Depressive disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.)<BR/>Review of Resident #21's admission MDS assessment dated [DATE] reflected Resident #21 was assessed to have a BIMS score of 8 indicate moderate cognitive impairment. Resident #21 was assessed to have inattention, disorganized thinking and altered levels of consciousness that fluctuates. Resident #21 was further assessed to have verbal behaviors one to three days a week.<BR/>Review of Resident #21's comprehensive care plan reflected a problem dated 06/25/2024 Psychotropic drug use Resident #21 is at risk for adverse consequences related to receiving antipsychotic medication for treatment of Psychosis related to Alzheimer's/Dementia. Approaches included Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms Monitor resident's behavior and response to medication .Quantitatively and objectively document the resident's behavior. <BR/>Review of Resident #21's consolidated physician orders reflected the following orders: <BR/>*Fluoxetine 40mg oral once daily dated 03/22/2024 , <BR/>*Trazodone 100 mg oral at bedtime dated 03/22/2024, <BR/>*Abilify 5mg once daily dated 03/22/2024, <BR/>*Behavior monitoring twice daily for antidepressant drug Fluoxetine and trazodone dated 03/04/2022, <BR/>*Monitor side effected twice daily for the antidepressant medication dated 03/04/2024, <BR/>*Behavior monitoring twice daily antipsychotic drug use Abilify dated 03/04/2024, and <BR/>*Monitor side effects of the antipsychotic medication Ability twice daily dated 03/04/2024.<BR/>Observation on 06/25/2024 at 12:05 PM revealed Resident #21 was in dining room eating his lunch. Resident #21 was noted to be shaking when feeding himself. No behaviors were observed. <BR/>Review of Resident #21's Consultant Pharmacist's Medication Regimen review dated 04/17/2024 reflected Please order BEHAVIOR MONITORING for TRAZODONE, ABILIFY .<BR/>Review of Resident #21's MAR dated 05/01/2024 through 05/31/2024 reflected orders were not completed on the following dates:<BR/>1) Behavior monitoring twice daily: antidepressant drug Fluoxetine <BR/>*05/01/2024,<BR/>*05/06/2024, <BR/>*05/10/2024 through 05/12/2024, <BR/>*05/18/2024 through 05/21/2024, and <BR/>*05/24/2024 through 05/31/2024.<BR/>2) Behavior monitoring twice daily: antidepressant drug Trazadone.<BR/>*05/01/2024, <BR/>*05/06/2024, <BR/>*05/10/2024 through 05/12/2024, <BR/>*05/18/2024 through 05/21/2024, and <BR/>*05/24/2024 through 05/31/2024.<BR/>3) Monitor for side effects twice daily Antidepressants. <BR/>*05/01/2024, <BR/>*05/02/2024, <BR/>*05/10/2024 through 05/13/2024, <BR/>*05/17/2024 through 05/21/2024, and <BR/>*05/24/2024 through 05/31/2024.<BR/>4) Behavior monitoring twice daily: Antipsychotic drug Abilify. <BR/>*05/01/2024, <BR/>*05/01/2024, <BR/>*05/06/2024, <BR/>*05/10/2024 through 05/13/2024, <BR/>*05/17/2024 through 05/21/2024, and<BR/>*05/24/2024 through 05/31/2024.<BR/>5) Monitor for side effects twice daily Antipsychotic drug use Abilify . <BR/>*05/01/2024, <BR/>*05/02/2024, <BR/>*05/06/2024, <BR/>*05/07/2024, <BR/>*05/10/2024 through 05/14/2024, <BR/>*05/17/2024 through 05/21/2024, and <BR/>*05/24/2024 through 05/31/2024.<BR/>In an interview on 06/26/2024 at 4:00 PM LVN A stated residents on psychotropic medications such as antidepressants and antipsychotics should be monitored for behaviors and medication side effects every shift. She stated sometimes it gets missed. <BR/>In an interview on 06/27/2024 at 10:01 AM the DON stated she expected staff to document and check for psychotropic medications such as antidepressants and antipsychotics side effects and behaviors. She stated moving forward she would have to monitor the MARs to make sure the monitoring is being done. <BR/>Review of the facility's policy Medication Management Program dated 07/13/2021 reflected The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements . Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life . 1) Reduce Unnecessary and Supplementary Medications . b) Review medication regimen to discontinue unnecessary drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for one of five residents reviewed for unnecessary medications. (Residents #21)<BR/>The facility failed to ensure Resident #21's PRN order for Haldol dated 05/06/2024 had a stop date transcribed onto the MAR to ensure the medication did not extend beyond 14 days causing Resident #21 to receive 7 doses beyond the physician ordered stop date of 05/20/2024.<BR/>This deficient practice placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs which include nausea, drowsiness, dizziness, confusion, constipation, diarrhea, and delirium and placed residents at risk for receiving unnecessary medications.<BR/>Findings included:<BR/>Review of Resident #21's face sheet dated 06/26/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), and Major Depressive disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.)<BR/>Review of Resident #21's admission MDS assessment dated [DATE] reflected Resident #21 was assessed to have a BIMS score of 8 indicate moderate cognitive impairment. Resident #21 was assessed to have inattention, disorganized thinking and altered levels of consciousness that fluctuates. Resident #21 was further assessed to have verbal behaviors one to three days a week.<BR/>Review of Resident #21's comprehensive care plan reflected a problem dated 06/25/2024 Psychotropic drug use Resident #21 is at risk for adverse consequences related to receiving antipsychotic medication for treatment of Psychosis related to Alzheimer's/Dementia. Approaches included Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms Monitor resident's behavior and response to medication .Quantitatively and objectively document the resident's behavior.<BR/>Review of Resident #21's consolidated physician orders reflected the following orders: <BR/>*dated 05/06/2024 Haloperidol 0.5mg one tab every 8 hours as needed for aggression. The order had a stop date of 05/07/2024. <BR/>*dated 05/07/2024 for Haloperidol 0.5mg one tab every 8 hours as needed for aggression with a stop date of 05/20/2024.<BR/>Review of Resident #21's MAR dated 05/01/2024 through 05/31/2024 reflected an entry for haloperidol 0.5mg one tab by mouth every eight hours as needed for aggression. No stop date was indicated on the MAR for the medication. The haloperidol was signed as given past the medication stop date on six occasions: 05/23/2024 through05/26/2024, 05/28/2024 and 05/30/2024.<BR/>In an interview on 06/26/2024 at 4:00 PM LVN A stated Resident #21's order for Haldol was only supposed to be for 14 days but when it was put on the MAR no end date was indicated so we continued to use the medication as needed.<BR/>In an interview on 06/27/2024 at 9:38 AM the DON stated she got the clarification for Resident #21's order for Haldol since on 05/06/2024 the order did not include a stop date so on 05/07/2024 it was clarified to have a stop date of 05/2024. The DON stated she put the order into the computer to include the stop date. She stated she did not print a new MAR she stated the nurses have access to the MARs in the computer. The DON stated they do not use the computer MARs to pass medications since they still use paper. The DON stated the change was on the change screen (24-hour report) and the nurses can see that. She stated there were a lot of steps done to prevent the error, but it occurred anyway Its Ridiculous<BR/>In an interview on 06/27/2024 at 9:45 AM LVN A stated any order change does show up on the change screen but if the MARs with changes are not printed out the changes could be missed. LVN A stated that was why Resident 21's Haldol was given past the discontinuation date.<BR/>Review of the facility's policy Medication Management Program dated 07/13/2021 reflected The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements . Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life . 1) Reduce Unnecessary and Supplementary Medications . b) Review medication regimen to discontinue unnecessary drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage, preparation, and service.<BR/>1. The facility dishwasher was out of sanitizer and still being used to wash dishes.<BR/>2. The CK/DM failed to sanitize the puree bowl between puree dishes and used unsanitized tongs to handle sausage during the puree process.<BR/>3. There was no system in place to accurately monitor holding temperatures for the pureed foods.<BR/>These failures placed residents at risk of food-borne illness.<BR/>Findings included:<BR/>1.<BR/>Observation on 04/26/23 at 12:26 PM revealed an Autochlor A5 Water Saver dishwasher (chemically sanitizing dishwasher) in the facility kitchen. When a wash/rinse cycle of the machine was conducted with a plastic coffee cup, the available chemical test strips did not indicate any presence of chlorine or other disinfecting fluid. DA D ran the dishwasher again and tried detecting chemical in the water on the surface of the coffee cup again, and no presence of chemical resulted. <BR/>During an interview on 04/26/23 at 12:30 PM, DA A stated he tested the chemical content of the dishwasher daily and had done so earlier that morning before breakfast. DA A stated he logged the results of his tests on a paper form hanging on the wall behind the dishwasher. DA A stated the chemical must have run out on the dishwasher. He stated the chemical content should have registered at 50 ppm. <BR/>During an interview on 04/26/23 at 12:40 PM, the ADM stated the chemical sanitizer had run out in the dishwasher, and he had just ensured an order was put in for more. He stated the facility would revert to disposable dishes until the chemical sanitizer was restored to the dishes. The ADM stated the residents had already been served lunch and were eating, and there was no way to guarantee they did not eat on dishes that had not been properly sanitized. <BR/>Review of the log hanging behind the dishwasher reflected an entry for 04/26/23 with a checkmark next to it and no further information. <BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>4-204.117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. The presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment. The automatic dispensing of these chemical agents, plus a method such as a flow indicator, flashing light, buzzer, or visible open air delivery system that alerts the operator that the chemicals are no longer being dispensed, ensures that utensils are subjected to an efficacious cleaning and sanitizing regimen.<BR/>2.<BR/>Observation on 04/25/23 at 11:04 AM revealed the CK/DM pureed one scoopful of broccoli in a food processor, rinsed the processor bowl under running water in a sink next to the preparation area without using any soap or sanitizing solution, poured the pureed broccoli into a small chafing dish, and pureed rice with milk in the food processor bowl. She then rinsed the food processor bowl in the nearby sink without using soap or sanitizer, poured the pureed rice into a small chafing dish, and pureed whole pinto beans. The CK/DM then poured the pinto beans into a small chafing dish and rinsed the food processor bowl in the same sink. There were still beans visible on the inside of the food processor. She then retrieved a chafing dish filled with Polish sausage from the cook area and pulled a pair of metal tongs out of the bottom of the sink where she had been pouring and rinsing the food processor bowl and retrieved a sausage link with the tongs. She proceeded to puree the sausage in the food processor bowl. <BR/>During an interview on 04/25/23 at 11:10 AM, CK/DM stated her last supervisor said she did not even have to rinse the food processor bowl in between pureeing different food items, but she did not like to leave food in there, so she rinsed some of it out. The CK/DM stated she was not a certified dietary manager and had been going to school to become certified, but she had to take over the dietary manager position when the last one quit, and she had not been able to attend her classes, because she was working so hard as the CK and DM. The CK/DM stated the town the facility was in was very small, and there were no options for dietary manager or cook applying for the jobs.<BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>The 3 compartment requirement allows for proper execution of the 3-step manual warewashing procedure. If properly used, the 3 compartments reduce the chance of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual warewashing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same 3 steps: 1. Application of cleaners and the removal of soil; 2. Removal of any abrasive and removal or dilution of cleaning chemicals; and 3. Sanitization. Refer also to the public health reason for &sect; 4-603.16.<BR/>3.<BR/>Observation on 04/25/23 at 11:48 AM revealed the CK/DM attempted to take the temperature of the pureed sausage, but there was too little food depth to measure with only one serving of each dish in each chafing dish. The CK/DM stated she did not have a way to measure the temperature of the pureed food and did not know she needed to do so. When asked if she did not regularly or daily take the holding temperature of the pureed foods, she stated she normally did that later on but did not clarify what that meant. <BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>Hot Holding In a January 2001 report, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) recommended that the minimum hot holding temperature specified in the Food Code: FDA believes that maintaining food at a temperature of 57&deg;C (135&deg;F) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness.<BR/>During an interview and record review on 04/27/23 at 08:44 AM, the LD stated she came to the facility in person once a month, and all her other duties were remote. The LD stated the company that owns the facility placed the responsibility for most of the kitchen inspections/sanitation reports with the dietary manager and administrator positions, but she did conduct her own kitchen inspection when she came to the building from a brief checklist. The LD stated the ADM did a weekly kitchen inspection, and the CK/DM was in there daily, so they were primarily responsible for any issues with kitchen sanitation. The LD stated some of the checklist items were marked N/A because the facility was so small and old they did not have the items. The checklist she worked from had the following items listed that were applicable to the facility:<BR/> -pot washing and dishwashing<BR/>-food temperature log<BR/>-no cross contamination during cooking<BR/>-clean dishes air drying with no wet items in racks.<BR/>The LD stated she did not routinely check the chemical dishwasher but left that up to the CK/DM, who needed to be ensuring it was done daily. The LD stated she would usually watch the CK/DM make the puree to make sure she was using the right thinner, but she had not noticed anything [NAME] with sanitation during purees. The LD stated the facility just had one small food processor and only one resident on a puree diet, so they did not cook food in big batches. The LD stated this made it difficult to measure the temperatures on the steam table. The LD stated she did not really know how to solve that problem, because the pureed foods did have to be maintained at the same 135 degrees as the other foods. The LD stated the food processor bowl should have been washed and sanitized in between dishes. The LD stated, since they prepared these foods in such small batches, they could not send the bowl through the dishwasher, but needed to wash it in soapy water by hands and sanitize in the approved sanitizing sink with a chlorine bleach component. The LD stated she did not know the protocol they had developed, but the food processor bowl needed to be washed and sanitized. The LD stated when the previous dietary manager left, the facility promoted the CK/DM while she was still working on her dietary manager certificate. The LD stated some of the instances of noncompliance in the kitchen were probably due to the CK/DM not having her full education as a food and nutrition services manager. The LD stated the CK/DM was not a certified dietary manager and had not worked more than two years as a food and nutrition services manager. The dietitian stated the potential result for all the identified failures in the kitchen could have been an outbreak of food-borne illness among the resident population. A copy of the most recent kitchen sanitation checklist was requested from the LD but not received prior to the end of survey. <BR/>During an interview on 04/27/23 at 02:15 PM, the ADM stated he monitored the kitchen by conducting weekly kitchen inspections and documented them on a checklist. The ADM stated he had not observed any of the issues noted during his inspections. The ADM stated the CK/DM was not a certified dietary manager. He stated she had started the class to become certified, and prior to the ADM taking his position, the previous administrator had cut staff in the kitchen. The ADM stated that resulted in the CK/DM having to take over the kitchen. The ADM stated he had the CK/DM call the certification school the day prior, and she learned she would have to start the classes over again. The ADM stated the failures identified in the kitchen could result in food borne illness for the residents. The ADM stated he would provide his completed kitchen inspection sheets but had not provided them prior to exit. <BR/>Review of facility's policy, titled Food Safety, and dated 08/01/20 did not include any policy related to holding temperatures, dishwasher operation, or cookware sanitization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 1 of 5 residents reviewed for immunizations. (Resident #8)<BR/>The facility failed to document in Resident #8's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. <BR/>This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal, or being informed of the benefits/risk which could cause respiratory complications and potential adverse health outcomes. <BR/>Findings include:<BR/>Review of Resident #8's face sheet dated 06/27/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).) , and acute respiratory failure with hypoxia (is a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide.).<BR/>Review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 was assessed to have a BIMS score of 6 indicating severe cognitive impairment. Resident #8 was further assessed to have been offered the influenza and pneumococcal vaccine and declined. <BR/>Review of Resident #8's comprehensive care plan reflected no entries regarding immunization status. <BR/>Review of Resident #8's consolidated physician orders reflected the following orders: <BR/>*dated 03/10/2022 Last Pneumonia vaccine received. <BR/>*dated 03/10/2022 May administer influenza vaccine annually. <BR/>Review of Resident #8's immunization records in the EMR reflected no pneumonia vaccine record. Further review reflected an entry for influenza vaccine dated 09/29/2023 indicating the vaccine was not administered related resident refused based on conscientious objection. Under the section if education provided to resident/family or POA the facility checked 'no' on the form. <BR/>In an interview on 06/27/2024 at 12:38 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization.<BR/>In an interview on 06/27/2024 at 12:45 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the MDS coordinator but since she was not at the facility anymore and the immunizations for Resident #8 got missed. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided.<BR/>Review of the facility's policy Immunization Recommendations for Patients, Residents and Health care Workers dated 07/15/2021 reflected The facility complies with current immunization and vaccination recommendations and requirements (where required), for patients, residents, and staff.1. Prior to offering or providing immunizations, applicable medical screening and evaluation will be provided. This screening may be done by a licensed health care provider, such as a physician. 2. Immunizations will not be given if determined to be medically contraindicated . One-time informed consent can be part of the admission process for influenza, pneumococcal, and other vaccines eliminating the need for annual consent except in states where annual consent is required. The facility will track all staff and resident vaccination status for all vaccines. Resident vaccination status will be documented in their medical record and include: Education provided to the resident or resident representative regarding the benefits and potential risks associated with the vaccines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 1 of 5 residents who were reviewed for immunizations. (Resident #7)<BR/>The facility failed to document in Resident #7's medical records for having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal.<BR/>This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. <BR/>Findings include:<BR/>Review of Resident #7's face sheet dated 06/27/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Anemia (Deficiency of healthy red blood cells in blood. Red blood cells are essential to carry oxygen to all parts of the body.) , Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) and right femur fracture.<BR/>Review of Resident #7's quarterly MDS assessment dated [DATE] reflected Resident #4 was assessed to have a BIMS score of 1 indicating severe cognitive impairment. <BR/>Review of Resident #7's comprehensive care plan reflected no entries regarding immunization status.<BR/>Review of Resident #7's consolidated physician orders reflected no entries regarding immunizations. <BR/>Review of Resident #7's immunization records in the EMR on 06/26/2024 reflected no entry regarding COVID-19 Vaccination. <BR/>In an interview on 06/27/2024 at 12:38 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization.<BR/>In an interview on 06/27/2024 at 12:45 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the MDS coordinator but since she was not at the facility anymore and the immunizations for Resident #7 got missed. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided.<BR/>Review of the facility's policy Immunization Recommendations for Patients, Residents and Health care Workers dated 07/15/2021 reflected The facility complies with current immunization and vaccination recommendations and requirements (where required), for patients, residents, and staff.1. Prior to offering or providing immunizations, applicable medical screening and evaluation will be provided. This screening may be done by a licensed health care provider, such as a physician. 2. Immunizations will not be given if determined to be medically contraindicated . One-time informed consent can be part of the admission process for influenza, pneumococcal, and other vaccines eliminating the need for annual consent except in states where annual consent is required. The facility will track all staff and resident vaccination status for all vaccines. Resident vaccination status will be documented in their medical record and include: Education provided to the resident or resident representative regarding the benefits and potential risks associated with the vaccines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for three of four residents (Resident #16, Resident #5, and Resident #10) reviewed for dignity.<BR/>1. <BR/>Resident #16's door and curtain were left open while he received wound care to his ankle. <BR/>2. <BR/>Resident #5's wound care was performed with the door to the hallway open and the privacy curtain was not pulled. <BR/>3. <BR/>Resident #10's wound care was performed with the privacy curtain partially closed, exposing his buttock and leg to anyone passing by in the hallway. <BR/>These failures placed residents at risk for an undignified existence due to exposure of body parts during medical treatments. <BR/>Findings include:<BR/>1.<BR/>Record review of Resident #16's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), non-pressure chronic ulcer (sore) of lower leg. <BR/>Record review of Resident #16's Care Plan dated 04/25/2023 reflected he had a pressure ulcer located on his left lateral ankle and he was to receive treatments as ordered. <BR/>Record review of Resident #16's Quarterly MDS dated [DATE] reflected he had a BIMS score of 14 indicating intact cognitive status. <BR/>Observation on 04/25/2023 at 10:06 AM of LVN A performing wound care to Resident #16's left ankle revealed the door to the hallway was left wide open during entire wound care procedure and the curtain was not closed. Numerous staff and residents passed though the hallway during the procedure. <BR/>2. <BR/>Record review of Resident #5's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Vascular Dementia (brain damage caused by multiple strokes), Type 2 Diabetes Mellitus with other circulatory complications (a chronic condition that affects the way the body processes blood sugar, if high blood sugar is too high it damages blood vessels), unspecified sequelae (a condition which is the consequence of a previous illness or injury) of Cerebral Infarction (brain stroke), and Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident #5's Physician orders dated 04/14/2023 reflected to non-pressure wound right posterior (bask) ankle full thickness. Float heels in bed and off load wound. [keep heels off bed to reduce pressure to wound].<BR/>Record review of Resident #5's Quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating intact cognitive status. <BR/>Observation on 04/26/2023 at 9:55 AM of LVN A performing wound care for Resident #5 revealed the door to the hallway was left open and the curtain was not closed during the entire procedure. Numerous staff and residents passed though the hallway during the procedure. <BR/>3.<BR/>Record review of Resident #10's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of age-related physical debility (state of general weakness), and unspecified open wound of right buttock.<BR/>Record review of Resident #10's Care Plan dated 12/13/2022 reflected he had a pressure ulcer/injury to the right gluteus (buttock). <BR/>Record review of Resident #10's Quarterly MDS dated [DATE] reflected he had a BIMS score of 15 indicating intact cognitive status. <BR/>Observation on 04/26/2023 at 10:26 AM of LVN A performing wound care for Resident #10's right buttock revealed the curtain was partially pulled back. Surveyor walked to door and was able to observe the residents exposed buttock and leg. <BR/>Interview on 04/26/2023 at 10:44 AM LVN A stated regarding Resident #16, #5, and #10's wound care, leaving the curtains and doors open during wound care was a HIPAA violation and violated the resident's privacy. <BR/>Interview on 04/27/2023 at 9:15 AM CNA B stated the curtains and door should be closed for respect and dignity for the residents while providing care. <BR/>Interview on 04/27/2023 at 9:32 AM CNA C stated staff should always pull the curtains and close the doors for resident privacy. She stated not closing the curtains and doors was a dignity issue. <BR/>Interview on 04/27/2023 at 10:00 AM the IDON stated, Staff should always provide privacy while giving care and no one should have visual access to their naked bodies at any time and it was a dignity issue. <BR/>Interview on 04/27/2023 at 10:15 AM the ADM stated his expectations would be for all staff to close doors during patient care. He stated leaving the leaving the doors open during care could be embarrassing to the residents. <BR/>Review of a facility Policy and Procedure dated 10/01/2023 and titled Patient/Resident Rights reflected The facility treats each resident with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure Resident #1 eloped from the facility on 2/28//2023 and fractured his right hip, that required surgery to treat. Resident #1 was found 2 &frac12; blocks away from the facility on the ground, he had fallen and was unable to get up. <BR/>This failure resulted in an identification of an (IJ) Immediate Jeopardy on 3/1/2023 at 6:06 p.m. The (IJ) Immediate Jeopardy template was provided to the ADM on 3/1/2023 at 6:06pm. While the (IJ) Immediate Jeopardy was removed on 3/3/2023 at 4:40 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal.<BR/>This failure could place all residents that are elopement risk and refuse to wear a wander guard at risk for accidents, harm, and/or death.<BR/>Findings included: <BR/>Review of Resident #1's face sheet dated 3/2/2023, reflected a 64- year- old man, admitted to the facility on [DATE]. Resident #1 was diagnosed with Parkinson's disease (a disease of the central nervous system that affects movements), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder) not due to a substance or known physiological condition, Insomnia ( a common sleep disorder that can make it hard to fall asleep), Paranoid schizophrenia ( a psychological disorder where the lines are blurred between what is real and what isn't), delusional disorder(a belief or altered reality that is persistently held despite evidence or agreement to the contrary) and heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). <BR/>Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 5 (indicates the resident does not have the cognitive ability to understand). The MDS also reflected Resident # 1 is ambulatory with no assistance. <BR/>Review of MAR dated 2/1/2023-2/282023, reflected the following orders: <BR/>Resident to reside on secure unit for personal safety - start 12/29/2020 open ended <BR/>9/1/2022- Resident may have trial integration off unit into general population- open ended <BR/>9/1/2022- May have wander guard -open ended<BR/>Record review of Resident #1's care plan dated 2/28/2023, reflected the following: Problem: Resident has been observed to leave the grounds within the past week without notifying staff despite reminders. Interventions: Explain to resident the policy and procedure for leaving the facility and review periodically for continued need for secure placement. The care plan did not reflect any updates of interventions in place for Resident #1 for the period of 9/1/2022 when Resident #1 came off the secure unit through 2/28/2023.<BR/>Record review of Risk elopement assessments for Resident #1 reflected the following:<BR/>-12/19/2017 Resident #1 was identified as risk for elopement, <BR/>-9/19/2021 was not an elopement risk, with no interventions,<BR/>-11/15/2022 Resident #1 was not an elopement risk, with no interventions, <BR/>-5/21/2022 reflected it was unknown if Resident # 1 was an elopement risk and to remain on secure unit for safety, and. <BR/>-2/23/2023 reflected Resident #1 was not a risk for elopement with the following interventions: Frequent monitoring how often not noted, keep behavior logs, review medications, utilizations of sign in/sign out logs, recreational activities, and music. <BR/>Record review of facility progress notes dated 6/2/2022- 2/28/2023 for Resident #1 reflected, no monitoring notes, no behavioral log, no sign in or out sheets used by Resident #1, or any notes regarding activities or music. There was one progress note dated 2/28/2023 regarding Resident #1's refusal to wear the wander guard. <BR/>In an interview on 3/1/2023 at 11:10 a.m., the hospital staff reported Resident #1 was brought into the hospital by EMS. She stated it was reported Resident #1 was found on the street trying to get up. The hospital staff stated Resident # 1 had a fractured right hip and was scheduled for surgery later in the day. She stated Resident # 1 was hallucinating and having delusional thoughts since he was admitted . <BR/>In an interview on 3/1/2023 with concerned citizen stated approximately 5:25am he and his son noticed Resident # 1 had fallen and was trying to get up. He stated they called 911 for assistance, he stated Resident #1 reported that he tripped over the curb and hurt his hip.<BR/>In an interview on 3/1/2023 at 12:29 p.m., LE stated EMS contacted them to come to the scene on 3/1/2023 around 5:45 a.m., LE stated they spoke with Resident #1 he was able to tell them the facility he came from, that he had fallen and was unable to get up. LE reported, Resident #1 was transported to the hospital due to his injury he sustained from falling. LE stated they went to facility and asked if anyone was missing? LE reported the staff they spoke to was not aware that anyone was missing at the time, LE stated they informed the facility of Resident #1 name and advised that he was transported to the hospital for further medical treatment. <BR/>Review of Police call for service report dated 2/28/2023, reflected the facility was notified at approximately 5:50am asking if they were missing anyone from the facility. LVN A, reported that she was not aware that anyone was missing at the time. LVN A was advised that Resident # 1 had been injured and was transported to the hospital.<BR/>In an interview on 3/1/2023 at 10:02 a.m., LVN A stated she was the nurse on duty last night, she stated they work 12 hours shifts 6pm to 6am. She stated Resident #1 has insomnia and walked all night looking for cigarettes. She stated she last saw Resident #1 at approximately 5:10 a.m. walking down the hall, when she was going to check on another resident who had pushed their call light. She stated she was contacted by the local police department at about 5:45 a.m. asking if they were missing anyone. She stated she was not aware that Resident #1 was missing and stated he must have gone out one of the back doors that does not have alarms. She stated Resident #1 had never attempted to elope from the facility. LVN A stated Resident #1 was found 2 &frac12; blocks from the facility, stated he was headed to the post office to return some counterfeit money. LVN A stated when she looked, it appeared that she had some money missing from her purse she had behind the nurse's station. LVN A stated she immediately contacted the hospital so that she could provide any information they needed for Resident #1, she stated she then made all other notifications to the ADM, DON, and Resident #1's guardian. <BR/>In an interview on 3/1/2023 at 11:19 a.m., Resident #1's Guardian stated he was admitted to the facility on [DATE] on the secure unit due to being an elopement risk. She stated he had previous elopements at previous placements and had attempted from this facility. Resident #1's Guardian stated she was notified by the facility that the secure unit would be shut down. She stated the facility completed another risk assessment for elopement and indicated Resident #1 was no longer at risk for elopement. Resident #1's Guardian stated Resident #1 was very familiar with the back doors at facility, she stated he often would go out the door when she visited as he was able to go in and out the doors as he pleased. Resident #1's Guardian stated she believed the facility shut down the secure unit due to staffing and census issues. Resident #1's Guardian stated Resident #1 refused to wear the wander guard bracelet and was unaware of any other interventions in place. She stated she was not aware of Resident #1 trying to elope since he initially admitted . Resident #1's Guardian stated she was also concerned that the incident happened at 5:45 a.m., but she did not get contacted about the incident until sometime after 7:00 a.m. <BR/>In an interview on 3/1/2023 at 1:30 p.m. the DON stated LVN A who was on duty that night, contacted her around 6:39 a.m. She stated LVN A reported that the police were just at the facility asking if they had a resident missing. The DON stated LVN A was not aware Resident #1 was missing at the time when she was contacted by the police. The DON stated she advised LVN A to make all notifications, she also stated that LVN A stated Resident #1 must have gone out one of the back doors because they do not lock or alarm. The DON stated none of the doors at the facility alarm when opened unless the resident has on a wander guard bracelet. The DON stated the other residents who are an elopement risk have on a wander guard bracelet and if they get within 10 feet of any of the doors the alarms will sound. The DON stated when she started at the facility in October 2022, Resident #1 was already off the secure unit, she stated he had never tried to elope before this time. The DON was asked about previous care plans and interventions for Resident #1 because he refused to wear the wander guard bracelet, she was not able to locate any documents. The DON was not able to locate any documentation regarding Resident #1's behaviors, monitoring of Resident #1, or any sign-in/or out sheets. <BR/>In an interview on 3/1/2023 at 4:30 p.m., the ADM stated all residents who have been identified as elopement risk wear a wander guard bracelet, he stated Resident #1 refused to wear his wander guard. The ADM stated he was not aware that Resident #1 tried to elope from the facility in the past he stated it must have been before he started at the facility. The ADM stated all residents have the right to be safe and it is his expectation that all residents are safe in the facility. The ADM stated the alarms on the doors alarm if the resident was wearing a wander guard and they come within 10 feet of any of the doors. The ADM stated they opened back up the secure unit on 2/28/2023. <BR/>Observation and test on 3/1/2023 of all doors in facility, reflected all doors are able to be opened without any alarms going off coming in or going out the doors. The door where staff believe Resident #1 went out leads out to the side parking lot on the south end of the building. The facility is located 2 blocks from an active railroad and busy street with blinking yellow light for traffic going through. <BR/>Observation on 3/1/2023 at 3:30pm of secure unit with code required secured doors. Observed two residents residing on the secure unit and staff working on the unit. <BR/>Reviewed facility Abuse/Neglect policy undated reflected: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. <BR/>Reviewed facility Elopement Risk Assessment policy dated 11/01/2017 reflected the following: All residents are assessed on admission for elopement risk utilizing an elopement risk form. All residents are re-assessed for elopement potential by the MDS nurse /social worker or designee periodically throughout a resident's stay and with a significant change. Interventions will be added to the resident's care plan after analyzing the information obtained. The baseline care plan will identify if a resident is admitted as an elopement risk on admission. <BR/>Reviewed QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. <BR/>An (IJ) Immediate Jeopardy was identified on 3/1/2023 at 6:06 p.m., due to the above failures. The ADM was notified on 3/1/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 3/1/2023 at 6:06pm, and a Plan of Removal (POR) was requested.<BR/>A Plan of Removal was accepted on 3/3/2023 at 1:56 p.m. and reads as follows:<BR/>Plan of Removal <BR/>Immediate Plan of Removal <BR/>Identified resident is not currently in the facility:<BR/>Residents at risk of elopement have the potential to be affected. <BR/>Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy on 2/28/23. Any not completed in past 90 days or found to be inaccurate were completed by the Director of Nursing on 3/1/23. Identified residents at risk reviewed using the Elopement Risk Assessment for interventions on 2/28/23, by the Director of Nursing and any issues identified were corrected appropriately at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 2/28/23. <BR/>Licensed nurses will be re-educated on Abuse/Neglect, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This includes intervening if the resident verbalizes the desire to leave the facility or threatens to leave the facility or refuses to wear a wander guard. Licensed nurses will also be re-educated on documenting in progress notes, adding to the 24-hour report and updating care plans with changes of condition This education will be initiated on 2/28/23 by the Director of Nursing and completed by 3/2/23. The Director of Nursing will monitor for compliance.<BR/>Any member of target audience not receiving by 3/2/23 will receive prior to next scheduled shift. This education will be presented in the new hire orientation and for any agency staff by the Director of Nursing/charge nurse. <BR/>New admissions, readmissions and quarterly assessments will be reviewed in morning meeting beginning 3/2/23 Monday thru Friday as part of the clinical morning meeting process to review Elopement risks assessments for accuracy and interventions validated if indicated. The 24-hour report will be reviewed by the Director of Nursing/Assistant Director of Nursing for any documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. <BR/>The Medical Director was notified of the Immediate Jeopardy on 3/1/23. <BR/>Ad Hoc QAPI was held by the administrator on 3/1/23 to discuss the contents of this plan. <BR/>The administrator will oversee the compliance of this plan.<BR/>Monitoring of Plan or Removal on 3/2/2023 was as follows: <BR/>Interview on 3/2/2023 at 3:00 p.m., with hospital staff reported Resident #1 remains in the hospital in recovery from surgery. Hospital staff reported that Resident #1 has refused care by pulling out his picc line and still had delusional thoughts. Resident # 1 is scheduled to return to the facility once released from the hospital.<BR/> Reviewed elopement risk assessments dated 3/1/2023 completed and updated for Resident #2 and Resident #3, reflected both are at risk for wandering, elopement risk, and will reside on secure unit for their safety and wear a wander guard bracelet.<BR/>Observation conducted on 3/2/2023 at 3:30 p.m., of Resident #2 and Resident #3, on the secure unit. Resident #2 and Resident #3 appeared to be resting, they did not appear to be in any pain or distress. Resident # 2 and Resident # 3 was observed wearing their wander guard bracelets. <BR/>In an interview on 3/2/2023 at 2:10 p.m., LVN B stated she completed the elopement drill and has been in-serviced on the policy, procedures and steps to take when there is a missing resident. LVN B stated she had also been in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM is the abuse/neglect coordinator. <BR/>In an interview on 3/2/2023 at 2:20 p.m., LVN C stated she participated in the elopement drill today. She reported being in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacts the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. <BR/>In an interview on 3/2/2023 at 2:30 p.m., LVN D stated she worked the morning of the incident. She stated she worked on 3/1/2023 from 6am to 6pm she was coming on shift when LE came to facility and asked LVN A if they had a resident missing. LVN D stated LVN A was not aware that Resident #1 was missing. She stated whenever, she worked the 6pm to 6am shift she knows she have to walk all night and check on Resident #1 because he walks all through the night. She stated when she worked, she would have to know where all her residents are at all times for safety of the residents. LVN D stated she had participated in the elopement drill at facility and knows that steps to take when they have a resident missing. She stated she had also been in-serviced on abuse/neglect and documentation. <BR/>In an interview on 3/2/2023 at 2:40 p.m., CNA B stated she participated in the elopement drill today. CNA B stated they learned the code to call code white if they have a missing resident and they step to take to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed to report immediately when they see or suspect abuse/neglect. <BR/>In an interview on 3/2/2023 at 2:50 p.m. CNA C stated she participated in the elopement drill today. CNA C stated they learned the code to call code white if they have a missing resident and to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed report immediately. <BR/>In an interview on 3/2/2023 at 3:10 p.m., DON stated she and most of the staff have been trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained are either PRN (as needed) staff or staff that only worked in the summer. DON stated the rest of the staff even agency staff as they come to work have been trained over the elopement process, abuse/neglect, and documentation. <BR/>In an interview on 3/2/2023 at 3:20 p.m., the ADM stated all staff have been trained on the elopement process. He stated all staff participated in the elopement drill skills test on what to do if they have a missing resident. He stated it is his responsibility to ensure that all the residents in the facility are safe. ADM stated they are also looking at other ways to ensure the safety of the residents while maintain their independence. <BR/>In an interview on 3/3/2023 at 3:40p.m., the ADM, stated on 3/1/2023 he verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. <BR/>Record review of the AdHoc (for particular reason) QAPI(Quality assurance performance improvement) dated 3/1/2023 to address IJ(Immediate Jeopardy). <BR/>Monitoring completed on 3/3/2023 as follows: <BR/>Resident # 1 remains in hospital, Resident # 1 is scheduled to return to the facility once released from the hospital<BR/>Observation made on 3/3/2023 at 4:10 p.m., of Resident # 2 and Resident # 3 on secure unit, no concerns noted during observation.<BR/>Review of elopement assessments dated 2/28/2023, reflected all residents in facility were re-assessed for elopement risk. Two residents identified for secure unit /wander guard. These residents are currently on secure unit. <BR/>Review of care plan dated 2/28/2023 for Resident #1 and Resident # 2 with current interventions: <BR/>1. <BR/>Monitor for placement Q shift <BR/>2. <BR/>Monitor for proper functioning 24 hours a day <BR/>3. <BR/>Monitor resident in facility and document attempts to elope out of facility<BR/>4. <BR/>Assess quarterly for continued use of wander guard <BR/>5. <BR/>Explain to resident the policy and procedures for leaving the facility<BR/>6. <BR/>Resident will reside on the secure unit for safety <BR/>7. <BR/>Offer daily activities to address resident's interest <BR/>8. <BR/>Review periodically for continued need for secure placement <BR/>3/3/2023 Review of in-services completed: all nursing staff verified completion except one PRN staff.<BR/>3/2/2023- Documentation Expectations <BR/>3/2/2023- Resident refusal of wander guard / immediate reporting to charge nurse <BR/>2/28/2023- Safety <BR/>2/28/2023- Elopement Drill / Policy and procedure <BR/>2/28/2023- Abuse/Neglect <BR/>2/28/2023- Elopement, Care plans, New admissions, elopement risk assessment and Quarterly assessments<BR/> Record review of in-service sheet dated 2/28/2023 reflected 2 CNA's who work PRN had not completed the training. One nursing staff who only works in the summer had not received the training.<BR/> In an interview on 3/3/2023 at 4:15pm with BOM (business office manager), stated they have not had any new admissions, readmissions. <BR/>On 3/3/2023 at 4:40 p.m., the ADM was informed the (IJ)immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of one medication carts and one of one loose pill reviewed for medication storage. <BR/>1. The facility failed to ensure the medications for Resident #2 were placed inside of the medication cart when the nurse left the cart for 12 minutes.<BR/>2. The facility failed to secure Resident #16's Oxcarbazepine after it fell on the floor.<BR/>This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences. <BR/>Findings included:<BR/>1.<BR/>Record review of Resident #2's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), Chronic Obstructive Pulmonary Disease (a group of lung disease that block airflow and make it difficult to breathe), Type 2 Diabetes Mellitus without complications (a chronic condition that affects the way the body processes blood sugar ), Anorexia (an eating disorder causing people to obsess about weight and what they eat), Shortness of breath, and Conduct Disorder (group of behavioral and emotional problems characterized by a disregard for others). <BR/>Observation on 04/26/2023 at 7:03 AM of a medication pass for Resident #2 by LVN A revealed she left a bottle of Vitamin D3, and inhalers Incuse Ellipta and Breo Ellipta on top of the medication cart while she went to retrieve additional medications out of the medication storage room. LVN A returned to the medication cart at 7:15 AM. LVN A then went into Resident #2's room to administer medications and left the bottle of Vitamin D3 on top of the medication cart. <BR/>Interview on 04/26/2023 07.26 AM LVN A stated by leaving medications on top of the cart, someone could have come by and taken or ingested them. She stated the potential side effect of ingesting the medications could be an allergic reaction. She stated the inhalers could burn their mouth. <BR/>Interview on 04/27/2023 at 10:00 AM the IDON stated medications should always be locked inside of the carts and if left out, anyone could get ahold of them and take them.<BR/>Interview on 04/27/2023 at 10:15 AM the ADM his expectations would be for the nurse to place mediations inside of the cart and lock it. He stated it was a big problem as the residents could come along and ingest the meds. I'm not a clinician so I do not know the potential risk of taking them.<BR/>Record review of a facility's Policy and Procedure dated 07/13/2021 titled Medication Management Programs reflected medications, chemicals or other dangerous articles are not to be left on top of the cart. <BR/>2. <BR/>Record review of Resident #16's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Bi-Polar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), need for assistance with personal care, Nightmare Disorder (pattern of repeated frightening and vivid dreams that affects quality of life) Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) Schizoaffective Disorder (chronic mental health disorder characterized by hallucinations or delusions and symptoms of a mood disorder such as mania [highs] or depression [lows]), non-pressure chronic ulcer (sore) of lower leg, and Neuromuscular dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem). <BR/>Record review of Resident #16's Care Plan dated 04/25/2023 reflected he had a pressure ulcer located on his left lateral ankle and he was to receive treatments as ordered. <BR/>Record review of Resident #16's Quarterly MDS dated [DATE] reflected he had a BIMS score of 14 indicating intact cognitive status. <BR/>Record review of the physician orders for Resident #16 reflected an order dated 01/13/23 for Oxcarbazepine/oxcarbazepine 300 mg one time per day. <BR/>Observation on 04/27/23 at 09:08 AM revealed a yellow medication tablet on the floor outside the dining room door. The DON was notified and retrieved the tablet. <BR/>During an interview on 04/27/23 at 10:00 AM, the IDON stated she had investigated the yellow tablet and discovered it was Oxcarbazepine prescribed to Resident #16. The IDON stated she had spoken to LVN A, who had administered Resident #16's medication that morning, and she stated she did not know what happened or how the pill ended up on the floor. The IDON stated LVN A claimed to have administered Oxcarbazepine to Resident #16 that morning as ordered. The IDON stated Resident #16 had told her immediately without her sharing any details that LVN A had dropped the pill during his medication administration that morning and had given him another one. <BR/>During an interview on 04/27/23 at 12:38 PM, LVN A stated she administered Resident #16's Oxcarbazepine as ordered and did not know what had happened with the tablet that had been found on the floor. She denied dropping a tablet or any other occurrence that could have resulted in an unsecured medication. She stated Resident #16 was taking the Oxcarbazepine for his depression and had no mood swings or adverse effects, because he had received his medication. When asked how she could be sure he received his Oxcarbazepine if it was found on the floor, she stated she did not know, but he had received it. LVN A stated she had watched him take his medications and had not walked away. LVN A stated a potential negative impact of the Oxcarbazepine being on the floor was that another resident could have picked it up and ingested it. <BR/>Review of a Mayo Clinic webpage found at Oxcarbazepine (Oral Route) Side Effects - Mayo Clinic and titled Oxcarbazepine (Oral Route) Side Effects reflected the following:<BR/>More common<BR/>Change in vision<BR/>change in walking or balance<BR/>clumsiness or unsteadiness<BR/>cough<BR/>crying<BR/>dizziness<BR/>double vision<BR/>false sense of well-being<BR/>feeling of constant movement of self or surroundings<BR/>fever<BR/>mental depression<BR/>sensation of spinning<BR/>sneezing<BR/>sore throat<BR/>uncontrolled back-and-forth or rolling eye movements<BR/>Less common<BR/>Agitation<BR/>awkwardness<BR/>bloody or cloudy urine<BR/>blurred vision<BR/>bruising<BR/>confusion about identity, place, and time<BR/>decreased urination<BR/>difficulty with focusing the eyes<BR/>dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position<BR/>fast or irregular heartbeat<BR/>frequent falls<BR/>frequent urge to urinate<BR/>headache<BR/>hoarseness<BR/>increased thirst<BR/>loss of consciousness<BR/>memory loss<BR/>muscle cramps<BR/>pain or burning while urinating<BR/>pain or tenderness around the eyes or cheekbones<BR/>problems with coordination<BR/>shaking or trembling of the arms, legs, hands, and feet<BR/>seizures<BR/>skin rash<BR/>stuffy or runny nose<BR/>tightness in the chest<BR/>trouble with walking<BR/>troubled breathing<BR/>unusual feelings<BR/>unusual tiredness or weakness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage, preparation, and service.<BR/>1. The facility dishwasher was out of sanitizer and still being used to wash dishes.<BR/>2. The CK/DM failed to sanitize the puree bowl between puree dishes and used unsanitized tongs to handle sausage during the puree process.<BR/>3. There was no system in place to accurately monitor holding temperatures for the pureed foods.<BR/>These failures placed residents at risk of food-borne illness.<BR/>Findings included:<BR/>1.<BR/>Observation on 04/26/23 at 12:26 PM revealed an Autochlor A5 Water Saver dishwasher (chemically sanitizing dishwasher) in the facility kitchen. When a wash/rinse cycle of the machine was conducted with a plastic coffee cup, the available chemical test strips did not indicate any presence of chlorine or other disinfecting fluid. DA D ran the dishwasher again and tried detecting chemical in the water on the surface of the coffee cup again, and no presence of chemical resulted. <BR/>During an interview on 04/26/23 at 12:30 PM, DA A stated he tested the chemical content of the dishwasher daily and had done so earlier that morning before breakfast. DA A stated he logged the results of his tests on a paper form hanging on the wall behind the dishwasher. DA A stated the chemical must have run out on the dishwasher. He stated the chemical content should have registered at 50 ppm. <BR/>During an interview on 04/26/23 at 12:40 PM, the ADM stated the chemical sanitizer had run out in the dishwasher, and he had just ensured an order was put in for more. He stated the facility would revert to disposable dishes until the chemical sanitizer was restored to the dishes. The ADM stated the residents had already been served lunch and were eating, and there was no way to guarantee they did not eat on dishes that had not been properly sanitized. <BR/>Review of the log hanging behind the dishwasher reflected an entry for 04/26/23 with a checkmark next to it and no further information. <BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>4-204.117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. The presence of adequate detergents and sanitizers is necessary to effect clean and sanitized utensils and equipment. The automatic dispensing of these chemical agents, plus a method such as a flow indicator, flashing light, buzzer, or visible open air delivery system that alerts the operator that the chemicals are no longer being dispensed, ensures that utensils are subjected to an efficacious cleaning and sanitizing regimen.<BR/>2.<BR/>Observation on 04/25/23 at 11:04 AM revealed the CK/DM pureed one scoopful of broccoli in a food processor, rinsed the processor bowl under running water in a sink next to the preparation area without using any soap or sanitizing solution, poured the pureed broccoli into a small chafing dish, and pureed rice with milk in the food processor bowl. She then rinsed the food processor bowl in the nearby sink without using soap or sanitizer, poured the pureed rice into a small chafing dish, and pureed whole pinto beans. The CK/DM then poured the pinto beans into a small chafing dish and rinsed the food processor bowl in the same sink. There were still beans visible on the inside of the food processor. She then retrieved a chafing dish filled with Polish sausage from the cook area and pulled a pair of metal tongs out of the bottom of the sink where she had been pouring and rinsing the food processor bowl and retrieved a sausage link with the tongs. She proceeded to puree the sausage in the food processor bowl. <BR/>During an interview on 04/25/23 at 11:10 AM, CK/DM stated her last supervisor said she did not even have to rinse the food processor bowl in between pureeing different food items, but she did not like to leave food in there, so she rinsed some of it out. The CK/DM stated she was not a certified dietary manager and had been going to school to become certified, but she had to take over the dietary manager position when the last one quit, and she had not been able to attend her classes, because she was working so hard as the CK and DM. The CK/DM stated the town the facility was in was very small, and there were no options for dietary manager or cook applying for the jobs.<BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>The 3 compartment requirement allows for proper execution of the 3-step manual warewashing procedure. If properly used, the 3 compartments reduce the chance of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual warewashing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same 3 steps: 1. Application of cleaners and the removal of soil; 2. Removal of any abrasive and removal or dilution of cleaning chemicals; and 3. Sanitization. Refer also to the public health reason for &sect; 4-603.16.<BR/>3.<BR/>Observation on 04/25/23 at 11:48 AM revealed the CK/DM attempted to take the temperature of the pureed sausage, but there was too little food depth to measure with only one serving of each dish in each chafing dish. The CK/DM stated she did not have a way to measure the temperature of the pureed food and did not know she needed to do so. When asked if she did not regularly or daily take the holding temperature of the pureed foods, she stated she normally did that later on but did not clarify what that meant. <BR/>Review of the 2022 FDA Food Code reflected the following: <BR/>Hot Holding In a January 2001 report, the National Advisory Committee on Microbiological Criteria for Foods (NACMCF) recommended that the minimum hot holding temperature specified in the Food Code: FDA believes that maintaining food at a temperature of 57&deg;C (135&deg;F) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness.<BR/>During an interview and record review on 04/27/23 at 08:44 AM, the LD stated she came to the facility in person once a month, and all her other duties were remote. The LD stated the company that owns the facility placed the responsibility for most of the kitchen inspections/sanitation reports with the dietary manager and administrator positions, but she did conduct her own kitchen inspection when she came to the building from a brief checklist. The LD stated the ADM did a weekly kitchen inspection, and the CK/DM was in there daily, so they were primarily responsible for any issues with kitchen sanitation. The LD stated some of the checklist items were marked N/A because the facility was so small and old they did not have the items. The checklist she worked from had the following items listed that were applicable to the facility:<BR/> -pot washing and dishwashing<BR/>-food temperature log<BR/>-no cross contamination during cooking<BR/>-clean dishes air drying with no wet items in racks.<BR/>The LD stated she did not routinely check the chemical dishwasher but left that up to the CK/DM, who needed to be ensuring it was done daily. The LD stated she would usually watch the CK/DM make the puree to make sure she was using the right thinner, but she had not noticed anything [NAME] with sanitation during purees. The LD stated the facility just had one small food processor and only one resident on a puree diet, so they did not cook food in big batches. The LD stated this made it difficult to measure the temperatures on the steam table. The LD stated she did not really know how to solve that problem, because the pureed foods did have to be maintained at the same 135 degrees as the other foods. The LD stated the food processor bowl should have been washed and sanitized in between dishes. The LD stated, since they prepared these foods in such small batches, they could not send the bowl through the dishwasher, but needed to wash it in soapy water by hands and sanitize in the approved sanitizing sink with a chlorine bleach component. The LD stated she did not know the protocol they had developed, but the food processor bowl needed to be washed and sanitized. The LD stated when the previous dietary manager left, the facility promoted the CK/DM while she was still working on her dietary manager certificate. The LD stated some of the instances of noncompliance in the kitchen were probably due to the CK/DM not having her full education as a food and nutrition services manager. The LD stated the CK/DM was not a certified dietary manager and had not worked more than two years as a food and nutrition services manager. The dietitian stated the potential result for all the identified failures in the kitchen could have been an outbreak of food-borne illness among the resident population. A copy of the most recent kitchen sanitation checklist was requested from the LD but not received prior to the end of survey. <BR/>During an interview on 04/27/23 at 02:15 PM, the ADM stated he monitored the kitchen by conducting weekly kitchen inspections and documented them on a checklist. The ADM stated he had not observed any of the issues noted during his inspections. The ADM stated the CK/DM was not a certified dietary manager. He stated she had started the class to become certified, and prior to the ADM taking his position, the previous administrator had cut staff in the kitchen. The ADM stated that resulted in the CK/DM having to take over the kitchen. The ADM stated he had the CK/DM call the certification school the day prior, and she learned she would have to start the classes over again. The ADM stated the failures identified in the kitchen could result in food borne illness for the residents. The ADM stated he would provide his completed kitchen inspection sheets but had not provided them prior to exit. <BR/>Review of facility's policy, titled Food Safety, and dated 08/01/20 did not include any policy related to holding temperatures, dishwasher operation, or cookware sanitization.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one of one staff (LVN A) observed for infection control practices.<BR/>1. <BR/>LVN A used a contaminated glove to touch and administer Resident #10's medications. <BR/>2. <BR/>LVN A failed to sanitize her hands and replace her gloves prior to performing wound care for Resident #5.<BR/>These failures could place residents who require assistance with medication administration and wound care at risk for healthcare associated cross-contamination and infections.<BR/>Findings include:<BR/>1.<BR/>Observation on 04/26/2023 at 7:35 AM of a medication pass for Resident #10 by LVN A who placed gloves on her hands then touched the medication administration record, keys, and medication cart drawers. LVN A then picked up a pill cup and her contaminated gloved finger was placed inside the cup it. She placed Prozac 20 Tizanidine 2mg, Divalproex DR 125 mg, and Zinc 50 mg in the cup with her contaminated gloves. She wiped her sweaty brow with her gloved right hand then administered the medications to Resident #10. <BR/>Interview on 04/26/2023 at 7:52 AM, LVN A stated it was an infection control issue for her to touch Resident #10's medications with her unclean gloved hand. <BR/>2<BR/>Observation on 04/26/2023 at 9:55 AM LVN A washed her hands, gloved, then went into Resident #5's room to perform wound care. LVN A then went back to the treatment cart in the hall, opened a drawer with her gloved hands and retrieved items. Without cleaning her hands or changing gloves, LVN A cleansed Resident #5's wound with gauze and wound cleanser, placed hydrogel dry dressings and wrapped the wound with a gauze wrap. <BR/>Interview on 04/26/2023 at 10:10 AM LVN A stated not washing her hands and changing her gloves prior to performing wound care was an infection control issue. <BR/>Interview on 04/27/2023 at 10:00 AM the IDON stated if contaminated gloves that have touched other surfaces touch the medications, then they are transferring bacteria to the medications and contaminating them. She stated if the residents ingest the contaminated medications, it could make them sick. <BR/>Interview on 04/27/2023 at 10:15 AM the ADM stated his expectations would be contaminated gloves should not touch the pills or the inside of the pill cup. He stated the pills could be contaminated and it could cause an illness. <BR/>Record review of a facility's Policy and Procedure dated 07/13/2021 titled Medication Management Programs reflected Administering the Medication pass 1. Wash hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure Resident #1 eloped from the facility on 2/28//2023 and fractured his right hip, that required surgery to treat. Resident #1 was found 2 &frac12; blocks away from the facility on the ground, he had fallen and was unable to get up. <BR/>This failure resulted in an identification of an (IJ) Immediate Jeopardy on 3/1/2023 at 6:06 p.m. The (IJ) Immediate Jeopardy template was provided to the ADM on 3/1/2023 at 6:06pm. While the (IJ) Immediate Jeopardy was removed on 3/3/2023 at 4:40 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal.<BR/>This failure could place all residents that are elopement risk and refuse to wear a wander guard at risk for accidents, harm, and/or death.<BR/>Findings included: <BR/>Review of Resident #1's face sheet dated 3/2/2023, reflected a 64- year- old man, admitted to the facility on [DATE]. Resident #1 was diagnosed with Parkinson's disease (a disease of the central nervous system that affects movements), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder) not due to a substance or known physiological condition, Insomnia ( a common sleep disorder that can make it hard to fall asleep), Paranoid schizophrenia ( a psychological disorder where the lines are blurred between what is real and what isn't), delusional disorder(a belief or altered reality that is persistently held despite evidence or agreement to the contrary) and heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). <BR/>Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 5 (indicates the resident does not have the cognitive ability to understand). The MDS also reflected Resident # 1 is ambulatory with no assistance. <BR/>Review of MAR dated 2/1/2023-2/282023, reflected the following orders: <BR/>Resident to reside on secure unit for personal safety - start 12/29/2020 open ended <BR/>9/1/2022- Resident may have trial integration off unit into general population- open ended <BR/>9/1/2022- May have wander guard -open ended<BR/>Record review of Resident #1's care plan dated 2/28/2023, reflected the following: Problem: Resident has been observed to leave the grounds within the past week without notifying staff despite reminders. Interventions: Explain to resident the policy and procedure for leaving the facility and review periodically for continued need for secure placement. The care plan did not reflect any updates of interventions in place for Resident #1 for the period of 9/1/2022 when Resident #1 came off the secure unit through 2/28/2023.<BR/>Record review of Risk elopement assessments for Resident #1 reflected the following:<BR/>-12/19/2017 Resident #1 was identified as risk for elopement, <BR/>-9/19/2021 was not an elopement risk, with no interventions,<BR/>-11/15/2022 Resident #1 was not an elopement risk, with no interventions, <BR/>-5/21/2022 reflected it was unknown if Resident # 1 was an elopement risk and to remain on secure unit for safety, and. <BR/>-2/23/2023 reflected Resident #1 was not a risk for elopement with the following interventions: Frequent monitoring how often not noted, keep behavior logs, review medications, utilizations of sign in/sign out logs, recreational activities, and music. <BR/>Record review of facility progress notes dated 6/2/2022- 2/28/2023 for Resident #1 reflected, no monitoring notes, no behavioral log, no sign in or out sheets used by Resident #1, or any notes regarding activities or music. There was one progress note dated 2/28/2023 regarding Resident #1's refusal to wear the wander guard. <BR/>In an interview on 3/1/2023 at 11:10 a.m., the hospital staff reported Resident #1 was brought into the hospital by EMS. She stated it was reported Resident #1 was found on the street trying to get up. The hospital staff stated Resident # 1 had a fractured right hip and was scheduled for surgery later in the day. She stated Resident # 1 was hallucinating and having delusional thoughts since he was admitted . <BR/>In an interview on 3/1/2023 with concerned citizen stated approximately 5:25am he and his son noticed Resident # 1 had fallen and was trying to get up. He stated they called 911 for assistance, he stated Resident #1 reported that he tripped over the curb and hurt his hip.<BR/>In an interview on 3/1/2023 at 12:29 p.m., LE stated EMS contacted them to come to the scene on 3/1/2023 around 5:45 a.m., LE stated they spoke with Resident #1 he was able to tell them the facility he came from, that he had fallen and was unable to get up. LE reported, Resident #1 was transported to the hospital due to his injury he sustained from falling. LE stated they went to facility and asked if anyone was missing? LE reported the staff they spoke to was not aware that anyone was missing at the time, LE stated they informed the facility of Resident #1 name and advised that he was transported to the hospital for further medical treatment. <BR/>Review of Police call for service report dated 2/28/2023, reflected the facility was notified at approximately 5:50am asking if they were missing anyone from the facility. LVN A, reported that she was not aware that anyone was missing at the time. LVN A was advised that Resident # 1 had been injured and was transported to the hospital.<BR/>In an interview on 3/1/2023 at 10:02 a.m., LVN A stated she was the nurse on duty last night, she stated they work 12 hours shifts 6pm to 6am. She stated Resident #1 has insomnia and walked all night looking for cigarettes. She stated she last saw Resident #1 at approximately 5:10 a.m. walking down the hall, when she was going to check on another resident who had pushed their call light. She stated she was contacted by the local police department at about 5:45 a.m. asking if they were missing anyone. She stated she was not aware that Resident #1 was missing and stated he must have gone out one of the back doors that does not have alarms. She stated Resident #1 had never attempted to elope from the facility. LVN A stated Resident #1 was found 2 &frac12; blocks from the facility, stated he was headed to the post office to return some counterfeit money. LVN A stated when she looked, it appeared that she had some money missing from her purse she had behind the nurse's station. LVN A stated she immediately contacted the hospital so that she could provide any information they needed for Resident #1, she stated she then made all other notifications to the ADM, DON, and Resident #1's guardian. <BR/>In an interview on 3/1/2023 at 11:19 a.m., Resident #1's Guardian stated he was admitted to the facility on [DATE] on the secure unit due to being an elopement risk. She stated he had previous elopements at previous placements and had attempted from this facility. Resident #1's Guardian stated she was notified by the facility that the secure unit would be shut down. She stated the facility completed another risk assessment for elopement and indicated Resident #1 was no longer at risk for elopement. Resident #1's Guardian stated Resident #1 was very familiar with the back doors at facility, she stated he often would go out the door when she visited as he was able to go in and out the doors as he pleased. Resident #1's Guardian stated she believed the facility shut down the secure unit due to staffing and census issues. Resident #1's Guardian stated Resident #1 refused to wear the wander guard bracelet and was unaware of any other interventions in place. She stated she was not aware of Resident #1 trying to elope since he initially admitted . Resident #1's Guardian stated she was also concerned that the incident happened at 5:45 a.m., but she did not get contacted about the incident until sometime after 7:00 a.m. <BR/>In an interview on 3/1/2023 at 1:30 p.m. the DON stated LVN A who was on duty that night, contacted her around 6:39 a.m. She stated LVN A reported that the police were just at the facility asking if they had a resident missing. The DON stated LVN A was not aware Resident #1 was missing at the time when she was contacted by the police. The DON stated she advised LVN A to make all notifications, she also stated that LVN A stated Resident #1 must have gone out one of the back doors because they do not lock or alarm. The DON stated none of the doors at the facility alarm when opened unless the resident has on a wander guard bracelet. The DON stated the other residents who are an elopement risk have on a wander guard bracelet and if they get within 10 feet of any of the doors the alarms will sound. The DON stated when she started at the facility in October 2022, Resident #1 was already off the secure unit, she stated he had never tried to elope before this time. The DON was asked about previous care plans and interventions for Resident #1 because he refused to wear the wander guard bracelet, she was not able to locate any documents. The DON was not able to locate any documentation regarding Resident #1's behaviors, monitoring of Resident #1, or any sign-in/or out sheets. <BR/>In an interview on 3/1/2023 at 4:30 p.m., the ADM stated all residents who have been identified as elopement risk wear a wander guard bracelet, he stated Resident #1 refused to wear his wander guard. The ADM stated he was not aware that Resident #1 tried to elope from the facility in the past he stated it must have been before he started at the facility. The ADM stated all residents have the right to be safe and it is his expectation that all residents are safe in the facility. The ADM stated the alarms on the doors alarm if the resident was wearing a wander guard and they come within 10 feet of any of the doors. The ADM stated they opened back up the secure unit on 2/28/2023. <BR/>Observation and test on 3/1/2023 of all doors in facility, reflected all doors are able to be opened without any alarms going off coming in or going out the doors. The door where staff believe Resident #1 went out leads out to the side parking lot on the south end of the building. The facility is located 2 blocks from an active railroad and busy street with blinking yellow light for traffic going through. <BR/>Observation on 3/1/2023 at 3:30pm of secure unit with code required secured doors. Observed two residents residing on the secure unit and staff working on the unit. <BR/>Reviewed facility Abuse/Neglect policy undated reflected: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. <BR/>Reviewed facility Elopement Risk Assessment policy dated 11/01/2017 reflected the following: All residents are assessed on admission for elopement risk utilizing an elopement risk form. All residents are re-assessed for elopement potential by the MDS nurse /social worker or designee periodically throughout a resident's stay and with a significant change. Interventions will be added to the resident's care plan after analyzing the information obtained. The baseline care plan will identify if a resident is admitted as an elopement risk on admission. <BR/>Reviewed QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. <BR/>An (IJ) Immediate Jeopardy was identified on 3/1/2023 at 6:06 p.m., due to the above failures. The ADM was notified on 3/1/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 3/1/2023 at 6:06pm, and a Plan of Removal (POR) was requested.<BR/>A Plan of Removal was accepted on 3/3/2023 at 1:56 p.m. and reads as follows:<BR/>Plan of Removal <BR/>Immediate Plan of Removal <BR/>Identified resident is not currently in the facility:<BR/>Residents at risk of elopement have the potential to be affected. <BR/>Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy on 2/28/23. Any not completed in past 90 days or found to be inaccurate were completed by the Director of Nursing on 3/1/23. Identified residents at risk reviewed using the Elopement Risk Assessment for interventions on 2/28/23, by the Director of Nursing and any issues identified were corrected appropriately at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 2/28/23. <BR/>Licensed nurses will be re-educated on Abuse/Neglect, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This includes intervening if the resident verbalizes the desire to leave the facility or threatens to leave the facility or refuses to wear a wander guard. Licensed nurses will also be re-educated on documenting in progress notes, adding to the 24-hour report and updating care plans with changes of condition This education will be initiated on 2/28/23 by the Director of Nursing and completed by 3/2/23. The Director of Nursing will monitor for compliance.<BR/>Any member of target audience not receiving by 3/2/23 will receive prior to next scheduled shift. This education will be presented in the new hire orientation and for any agency staff by the Director of Nursing/charge nurse. <BR/>New admissions, readmissions and quarterly assessments will be reviewed in morning meeting beginning 3/2/23 Monday thru Friday as part of the clinical morning meeting process to review Elopement risks assessments for accuracy and interventions validated if indicated. The 24-hour report will be reviewed by the Director of Nursing/Assistant Director of Nursing for any documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. <BR/>The Medical Director was notified of the Immediate Jeopardy on 3/1/23. <BR/>Ad Hoc QAPI was held by the administrator on 3/1/23 to discuss the contents of this plan. <BR/>The administrator will oversee the compliance of this plan.<BR/>Monitoring of Plan or Removal on 3/2/2023 was as follows: <BR/>Interview on 3/2/2023 at 3:00 p.m., with hospital staff reported Resident #1 remains in the hospital in recovery from surgery. Hospital staff reported that Resident #1 has refused care by pulling out his picc line and still had delusional thoughts. Resident # 1 is scheduled to return to the facility once released from the hospital.<BR/> Reviewed elopement risk assessments dated 3/1/2023 completed and updated for Resident #2 and Resident #3, reflected both are at risk for wandering, elopement risk, and will reside on secure unit for their safety and wear a wander guard bracelet.<BR/>Observation conducted on 3/2/2023 at 3:30 p.m., of Resident #2 and Resident #3, on the secure unit. Resident #2 and Resident #3 appeared to be resting, they did not appear to be in any pain or distress. Resident # 2 and Resident # 3 was observed wearing their wander guard bracelets. <BR/>In an interview on 3/2/2023 at 2:10 p.m., LVN B stated she completed the elopement drill and has been in-serviced on the policy, procedures and steps to take when there is a missing resident. LVN B stated she had also been in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM is the abuse/neglect coordinator. <BR/>In an interview on 3/2/2023 at 2:20 p.m., LVN C stated she participated in the elopement drill today. She reported being in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacts the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. <BR/>In an interview on 3/2/2023 at 2:30 p.m., LVN D stated she worked the morning of the incident. She stated she worked on 3/1/2023 from 6am to 6pm she was coming on shift when LE came to facility and asked LVN A if they had a resident missing. LVN D stated LVN A was not aware that Resident #1 was missing. She stated whenever, she worked the 6pm to 6am shift she knows she have to walk all night and check on Resident #1 because he walks all through the night. She stated when she worked, she would have to know where all her residents are at all times for safety of the residents. LVN D stated she had participated in the elopement drill at facility and knows that steps to take when they have a resident missing. She stated she had also been in-serviced on abuse/neglect and documentation. <BR/>In an interview on 3/2/2023 at 2:40 p.m., CNA B stated she participated in the elopement drill today. CNA B stated they learned the code to call code white if they have a missing resident and they step to take to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed to report immediately when they see or suspect abuse/neglect. <BR/>In an interview on 3/2/2023 at 2:50 p.m. CNA C stated she participated in the elopement drill today. CNA C stated they learned the code to call code white if they have a missing resident and to start the search process. She stated she had been trained on abuse/ neglect and documentation, she stated the ADM is the abuse/neglect coordinator and they needed report immediately. <BR/>In an interview on 3/2/2023 at 3:10 p.m., DON stated she and most of the staff have been trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained are either PRN (as needed) staff or staff that only worked in the summer. DON stated the rest of the staff even agency staff as they come to work have been trained over the elopement process, abuse/neglect, and documentation. <BR/>In an interview on 3/2/2023 at 3:20 p.m., the ADM stated all staff have been trained on the elopement process. He stated all staff participated in the elopement drill skills test on what to do if they have a missing resident. He stated it is his responsibility to ensure that all the residents in the facility are safe. ADM stated they are also looking at other ways to ensure the safety of the residents while maintain their independence. <BR/>In an interview on 3/3/2023 at 3:40p.m., the ADM, stated on 3/1/2023 he verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. <BR/>Record review of the AdHoc (for particular reason) QAPI(Quality assurance performance improvement) dated 3/1/2023 to address IJ(Immediate Jeopardy). <BR/>Monitoring completed on 3/3/2023 as follows: <BR/>Resident # 1 remains in hospital, Resident # 1 is scheduled to return to the facility once released from the hospital<BR/>Observation made on 3/3/2023 at 4:10 p.m., of Resident # 2 and Resident # 3 on secure unit, no concerns noted during observation.<BR/>Review of elopement assessments dated 2/28/2023, reflected all residents in facility were re-assessed for elopement risk. Two residents identified for secure unit /wander guard. These residents are currently on secure unit. <BR/>Review of care plan dated 2/28/2023 for Resident #1 and Resident # 2 with current interventions: <BR/>1. <BR/>Monitor for placement Q shift <BR/>2. <BR/>Monitor for proper functioning 24 hours a day <BR/>3. <BR/>Monitor resident in facility and document attempts to elope out of facility<BR/>4. <BR/>Assess quarterly for continued use of wander guard <BR/>5. <BR/>Explain to resident the policy and procedures for leaving the facility<BR/>6. <BR/>Resident will reside on the secure unit for safety <BR/>7. <BR/>Offer daily activities to address resident's interest <BR/>8. <BR/>Review periodically for continued need for secure placement <BR/>3/3/2023 Review of in-services completed: all nursing staff verified completion except one PRN staff.<BR/>3/2/2023- Documentation Expectations <BR/>3/2/2023- Resident refusal of wander guard / immediate reporting to charge nurse <BR/>2/28/2023- Safety <BR/>2/28/2023- Elopement Drill / Policy and procedure <BR/>2/28/2023- Abuse/Neglect <BR/>2/28/2023- Elopement, Care plans, New admissions, elopement risk assessment and Quarterly assessments<BR/> Record review of in-service sheet dated 2/28/2023 reflected 2 CNA's who work PRN had not completed the training. One nursing staff who only works in the summer had not received the training.<BR/> In an interview on 3/3/2023 at 4:15pm with BOM (business office manager), stated they have not had any new admissions, readmissions. <BR/>On 3/3/2023 at 4:40 p.m., the ADM was informed the (IJ)immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one of two kitchen staff (CK/DM) reviewed for sufficient staff. <BR/>The dietary manager (CK/DM) at the facility did not have a dietary manager certificate. <BR/>This failure placed residents at risk of unsatisfying food and food borne illness. <BR/>Findings included:<BR/>Observations on 04/25/23 at 9:30 AM, 04/25/23 at 11:04 AM, 04/26/23 at 12:40 PM, and 04/27/23 at 08:30 AM revealed CK/DM was working in the kitchen preparing the noon meal. DA D went in and out of the kitchen, retrieving and washing breakfast dishes. <BR/>During an interview on 04/27/23 at 08:44 AM, the LD stated she did not work fuill time at the facility and only visited onsite once a month. The LD stated she was aware the CK/DM was not certified, and that the CK/DM had stepped into the dietary manager role when the previous dietary manager quit. <BR/>During an interview on 04/27/23 at 01:52 PM, the CK/DM stated she had worked at the facility in the kitchen since 2017, and when the previous dietary manager quit, she took over the job of kitchen manager. The CK/DM stated she was the only daytime cook and acted as a dietary aide as well. She stated she was not certified, because she worked too much to finish the classes. She stated she was still planning to finish certification but had not been able to. The CK/DM stated the ADM had not provided any training for her about what to do in the kitchen, but the LD did provide some training. <BR/>During an interview on 04/27/23 at 02:15 PM, the ADM stated he had not known until that day (04/27/23) the CK/DM was not a certified dietary manager. The ADM stated he had started in his position the week before Christmas (December 2022) and had not been told the CK/DM was still uncertified and had not asked. He stated the CK/DM had started the class to become certified, and prior to the ADM taking his position, the previous administrator had cut staff in the kitchen. The ADM stated that resulted in the CK/DM having to take over the kitchen. The ADM stated he had the CK/DM call the certification school the day prior (04/26/23), and she learned she would have to start the classes over again. The ADM stated failures identified in the kitchen could be related to the CK/DM not having her full education, and these could result in food borne illness for the residents. Policy on certified dietary manager was requested but not provided prior to exit.

Based on observation, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for one of one kitchen.<BR/>The facility failed to provide puree recipes for the Dietary Manager to follow when preparing puree food. <BR/>This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health. <BR/>Findings included:<BR/>Observation on 06/26/2024 7:10 to 7:40 AM, Dietary Manager began to pureed eggs. She placed the eggs into the pureed blender and began to puree the eggs. She did not measure the eggs or have a recipe to follow. Observation of Dietary Manger pureed bacon The bacon was not the same size. One piece of bacon was shorter. The Dietary Manger place bread into the pureed blender and added water to the bread without measuring the water. She did not measure any food she pureed. <BR/>Interview on 06/26/2024 at 7:50 AM, Dietary Manger stated she was required to use juice such as orange or apple juice when she pureed bread but she always used water. When asked where her recipes were to pureed food, she stated she did not have any recipes and did not follow recipes when pureed food. She stated she always used her judgement on how much food to place into the food blender. She stated she had been cooking approximately 20 years and she knew how much food to use without measuring the food or follow a recipe. She stated she did not need a recipe. She exited the kitchen and entered her office to search if she did have recipes. The Dietary Manager stated she did not have the spring/ summer recipes to follow and she did not know how to get the recipes. <BR/>Interview via telephone on 06/26/2024 at 11:51 AM the Registered Dietician Consultant stated all recipes was online and everyone had access to these recipes. She stated she had shown the Dietary Manager how to access these recipes. She stated all cooks including the cooks with years of experience was expected to follow the recipes especially when they are pureeing food. She also stated it was very important to use the correct measurements. The Registered Dietician Consultant stated if the correct measurements were not used the consistency of the pureed food may not be correct. She stated water was never to be used in any foods when adding liquid during the puree process. She stated it was best practice to use broth, milk, or butter. She did not respond when asked what may happen to the pureed food if water was used as the liquid during the pureed process. <BR/>Interview on 06/27/2024 at 11:15 AM the Administrator stated the dietary manager had been working as a cook for a very long time and she knew what she was doing when she prepared pureed food or any type of food. He stated he did not agree with guessing how much food to be added when the dietary manager pureed the food when being observed on Tuesday (06/26/2024). He stated he was not going to answer if it was ok not to follow a resident when pureeing food. The Administrator stated when an employee had been pureeing food repetitive every day it became repetition and they knew how to measure the food without a recipe and knew what size scoop to use with all foods. He stated if a cook pureed food all the time they would have it memorized and would be able to correct the pureed food if it did not look right without using a recipe. <BR/>Record review of the Facility Policy on Nutrition Policies and Procedures revised on 08/01/2020 reflected prepare puree foods as per recipe.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one of two kitchen staff (CK/DM) reviewed for sufficient staff. <BR/>The dietary manager (CK/DM) at the facility did not have a dietary manager certificate. <BR/>This failure placed residents at risk of unsatisfying food and food borne illness. <BR/>Findings included:<BR/>Observations on 04/25/23 at 9:30 AM, 04/25/23 at 11:04 AM, 04/26/23 at 12:40 PM, and 04/27/23 at 08:30 AM revealed CK/DM was working in the kitchen preparing the noon meal. DA D went in and out of the kitchen, retrieving and washing breakfast dishes. <BR/>During an interview on 04/27/23 at 08:44 AM, the LD stated she did not work fuill time at the facility and only visited onsite once a month. The LD stated she was aware the CK/DM was not certified, and that the CK/DM had stepped into the dietary manager role when the previous dietary manager quit. <BR/>During an interview on 04/27/23 at 01:52 PM, the CK/DM stated she had worked at the facility in the kitchen since 2017, and when the previous dietary manager quit, she took over the job of kitchen manager. The CK/DM stated she was the only daytime cook and acted as a dietary aide as well. She stated she was not certified, because she worked too much to finish the classes. She stated she was still planning to finish certification but had not been able to. The CK/DM stated the ADM had not provided any training for her about what to do in the kitchen, but the LD did provide some training. <BR/>During an interview on 04/27/23 at 02:15 PM, the ADM stated he had not known until that day (04/27/23) the CK/DM was not a certified dietary manager. The ADM stated he had started in his position the week before Christmas (December 2022) and had not been told the CK/DM was still uncertified and had not asked. He stated the CK/DM had started the class to become certified, and prior to the ADM taking his position, the previous administrator had cut staff in the kitchen. The ADM stated that resulted in the CK/DM having to take over the kitchen. The ADM stated he had the CK/DM call the certification school the day prior (04/26/23), and she learned she would have to start the classes over again. The ADM stated failures identified in the kitchen could be related to the CK/DM not having her full education, and these could result in food borne illness for the residents. Policy on certified dietary manager was requested but not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one of one residents (Resident #2) reviewed for respiratory care. <BR/>The facility failed to ensure Resident #2's oxygen tubing was dated with the date it was changed. <BR/>This failure could place all residents who use respiratory equipment at risk for respiratory infections.<BR/>Findings included:<BR/>Record review of Resident #2's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (a group of lung disease that block airflow and make it difficult to breathe), and Shortness of breath, and Conduct Disorder (group of behavioral and emotional problems characterized by a disregard for others). <BR/>Record review of Resident #2's Quarterly MDS dated [DATE] reflected she had a BIMS score of 3 indicating severe cognitive impairment.<BR/>Observation on 04/25/2023 at 9:19 AM of Resident #2's oxygen tubing revealed it was not dated.<BR/>Observation and Interview on 04/25/2023 at 9:30 AM LVN A observed Resident #2's oxygen tubing and stated it was supposed to be changed out every Tuesday. She stated, I'm not sure what the policy is but I date it [tubing].<BR/>Interview on 04/27/2023 at 1:18 PM the IDON stated the company wide practice was to change the oxygen tubing weekly and by not changing the tubing weekly it could grow bacteria and the resident could end up with an infection.<BR/>Interview on 04/2720/23 at 10:15 AM the ADM stated oxygen tubing should be dated so they would know it was clean and not contaminated. He stated did not know potential outcome to the resident if the oxygen was not changed out weekly.<BR/>Record review of a facility's Policy and Procedure dated 04/01/2022 and titled Oxygen Therapy General Policy reflected label tubing and humidifier with date, time and practitioner initials.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one of one staff (LVN A) observed for infection control practices.<BR/>1. <BR/>LVN A used a contaminated glove to touch and administer Resident #10's medications. <BR/>2. <BR/>LVN A failed to sanitize her hands and replace her gloves prior to performing wound care for Resident #5.<BR/>These failures could place residents who require assistance with medication administration and wound care at risk for healthcare associated cross-contamination and infections.<BR/>Findings include:<BR/>1.<BR/>Observation on 04/26/2023 at 7:35 AM of a medication pass for Resident #10 by LVN A who placed gloves on her hands then touched the medication administration record, keys, and medication cart drawers. LVN A then picked up a pill cup and her contaminated gloved finger was placed inside the cup it. She placed Prozac 20 Tizanidine 2mg, Divalproex DR 125 mg, and Zinc 50 mg in the cup with her contaminated gloves. She wiped her sweaty brow with her gloved right hand then administered the medications to Resident #10. <BR/>Interview on 04/26/2023 at 7:52 AM, LVN A stated it was an infection control issue for her to touch Resident #10's medications with her unclean gloved hand. <BR/>2<BR/>Observation on 04/26/2023 at 9:55 AM LVN A washed her hands, gloved, then went into Resident #5's room to perform wound care. LVN A then went back to the treatment cart in the hall, opened a drawer with her gloved hands and retrieved items. Without cleaning her hands or changing gloves, LVN A cleansed Resident #5's wound with gauze and wound cleanser, placed hydrogel dry dressings and wrapped the wound with a gauze wrap. <BR/>Interview on 04/26/2023 at 10:10 AM LVN A stated not washing her hands and changing her gloves prior to performing wound care was an infection control issue. <BR/>Interview on 04/27/2023 at 10:00 AM the IDON stated if contaminated gloves that have touched other surfaces touch the medications, then they are transferring bacteria to the medications and contaminating them. She stated if the residents ingest the contaminated medications, it could make them sick. <BR/>Interview on 04/27/2023 at 10:15 AM the ADM stated his expectations would be contaminated gloves should not touch the pills or the inside of the pill cup. He stated the pills could be contaminated and it could cause an illness. <BR/>Record review of a facility's Policy and Procedure dated 07/13/2021 titled Medication Management Programs reflected Administering the Medication pass 1. Wash hands.