Levelland Nursing & Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA A) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide. The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. Findings included:Record review of CNA A's personnel file reflected a date of hire of [DATE]. The last Employability Stats Check Search that was completed on [DATE] reflected CNA A's NAR status would expire on [DATE]. There were not any disciplinary action forms in the personnel file reflecting any concerns with resident care. Record review of CNA A's time punch detail dated [DATE] reflected CNA A clocked in and worked from 9:57 PM until 6:07 AM. During an interview on [DATE] at 2:35 PM the DON stated that there was a concern with CNA A's nurse aide certificate. She stated that CNA A came to the facility or called her on Friday [DATE] that she needed help with her certificate. The DON stated she explained to CNA A she would need to go to the facility, and she would help her. She stated on Monday [DATE] CNA A went to the facility and handed her a paper that showed her certification expired on [DATE]. She stated she told the ADM that CNA A's certificate expired [DATE] and she would remove her from the schedule. She stated the ADM told her she would speak to the HR Manager to see about HR running the checks yearly. She stated the last day CNA A worked was Thursday [DATE]. She stated there were not any complaints or written warnings pertaining to resident care for CNA A during the time she worked at the facility after the certification expired. During an interview on [DATE] at 3:10 PM the ADM stated on Friday [DATE] it was brought to her attention by HR Manager that CNA A's certification had expired. She stated the HR Manager should have been doing the checks. She stated once it was brought to her attention on [DATE] she put a PIP in place and held an off-cycle QAPI Meeting. She stated that the plan of correction was for the HR Manager to complete a full audit of license by [DATE]. The DON would keep a binder of all nursing licensure and will review monthly for compliance. The DON/ADON will provide notification to nursing staff 60 days prior to the licensure expiration. The DON/ADON will provide any assistance needed to renew the licenses or certification. That she will monitor and make any changes as needed. She stated CNA A had not worked since they found out her certificate expired. During an interview on [DATE] at 3:20 PM the HR Manager stated the previous ADON and DON were the ones that were keeping up with checking for renewals for the CNAs. She did the annual reviews for Criminal History EMR and Licensing and the initial check for hiring staff. She stated in the last 5 months the facility had a new DON and ADON. She stated she was not aware that the new DON and ADON did not take over the job of checking the renewals. She stated the CNA A told her something about going on Tulip and her CNA certificate. She stated she went in Tulip and pulled up the certificate and saw it had expired, and she immediately notified the DON. She was told by the DON that CNA A could not be at the facility or working and she (DON) would have to get CNA A's shifts covered. She stated she completed an audit of all CNA's certificates as of [DATE] and no one else has expired.During an interview on [DATE] at 3:33 PM CNA A stated she was not aware her certification had expired. She stated that around [DATE] she provided the previous ADON with a paper about her certificate and the previous ADON told her she would take care of it. She stated then on [DATE] she received an email that her certificate expired. She stated she told the DON, and she told her she would help her to renew it. She stated she has been a CNA for over 30 years and had worked at the facility for over 20 years and never had any issues with getting her certificate renewed. She stated that she worked the night shift last night [DATE] and came to the facility after she woke up to try and get her certificate renewed. She stated she was not told she could not work while waiting to get her certificate renewed. During an interview on [DATE] the ADM stated she was sure CNA A did not work the night shift on [DATE] because they told CNA A she could not work until her certificate was renewed. She stated she would check her time punch detail to see, then stated she did clock in and work last night. She stated she told the DON that CNA A worked the night shift on [DATE] and the DON told her no, because CNA A was told last week she could not work. She stated that CNA A was made aware she could not work until her certificate was renewed. Record review of Off Cycle QA Meeting Document dated [DATE] reflected Identification of a system in need of immediate attention by QAPI Committee:A system failure was identified: On [DATE] it was found that a CNA license had lapsed while still working on the floor.Regional Compliance Nurse/ ADM/ DON initiated a Plan of Correction on [DATE]. HR will complete a full audit of license by [DATE].DON will keep a binder of all nursing licensures and will review monthly for compliance.DON/ADON will provide notification to nursing staff 60 days prior to licensure expiration.DON/ADON will provide any assistance needed to renew license or certification. ADM will oversee monthly for adherence.If either party determines that the system is not in compliance at any time during monitoring, the system will be discussed with QAAC for immediate change process. Record review of facility policy Credentialing of Nursing Services Personnel dated (Revised [DATE]) reflected the following: Policy StatementNursing services personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment.Policy Interpretation and Implementation2. Nursing personnel requiring a license/certification are not permitted to perform direct resident care services until all licensing/background checks have been completed.8. A copy of annual license renewals/certifications (as applicable) must be presented to the director of nursing services no later than February 1st each year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, supervision. <BR/>The facility failed to ensure Resident #1 received supervision and assistive devices to prevent accidents. Resident #1 was exit seeking and was able to elope and had fallen in the parking lot by the street. Staff were not aware of Resident #1's elopement and was found by Occupational Therapist that was off the clock. <BR/>An Immediate Jeopardy (IJ) was identified on 03/21/25 at 3:32 PM. The IJ template was provided to the facility on [DATE] at 3:32 PM. While the IJ was removed on 03/22/25 at 5:36 PM; however, the facility remained out of compliance at No actual harm, with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could place residents at risk for injuries due to not receiving the appropriate level of supervision.<BR/>Findings included:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>He felt tired or had little energy listed as 2-6 days.<BR/>He was listed as using a manual wheelchair.<BR/>He needed partial/moderate assistance to go from sitting to standing.<BR/>Record review of Resident #1's Care Plan, dated 01/10/25, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Record review of Resident #1's TAR for month of March 2025, revealed:<BR/>Resident #1 was placed on 1:1 observations from 03/12/2025-3/21/2025, but no wander guard was listed on TAR.<BR/>Record review of Resident #1's progress note dated 03/10/2025 at 2:59 PM, stated: 1300 Resident was at front door trying to get out of building. Wander guard applied to right wrist. Resident continues wandering<BR/>throughout the building. Family called and notified.<BR/>Recored review of Resident #1's progress note dated 03/10/2025 at 3:30 PM, stated: New order obtained from NP to place patient on one on one due to exit seeking behaviors.<BR/>Record review of Resident #1's Head to Toe Skin Assessment, dated 03/13/2025 at 6:32 PM, stated: right and left forearm and right elbow.<BR/>During an interview on 03/20/25 at 11:23 AM, Occupational Therapist A stated that she had seen Resident #1 outside around 3 pm. Occupational Therapist A stated that she had parked on the opposite end of the building, had made a left turn on the road, and then had seen someone standing with a walker in the parking lot. Occupational Therapist A stated that she had seen Resident #1 out of her peripheral vision. The Occupational Therapist A stated that he did not look like a visitor. The Occupational Therapist A stated that as she was parked, she had noticed Resident #1 had lost his balance and had seen him fall. The Occupational Therapist A stated that she had ran into the building and yelled out to Occupational Therapist B to assist. The Occupational Therapist A stated that she had ran to Resident #1 because he was in the street but barely on the side of the street. The Occupational Therapist B and Occupational Therapist A went to help Resident #1 up and at that point Physical Therapist came out with Resident #1's wheelchair. The Occupational Therapist A and Physical Therapist helped Resident #1 into the wheelchair and back into the building. The Occupational Therapist A stated that once they were back into the building, she wrote a statement. The Occupational Therapist A stated that she was off of the clock when this incident occurred. The Occupational Therapist A stated that her and the Physical Therapist C helped Resident #1, and she left after writing the statement. The Occupational Therapist A stated that she had not worked with Resident #1. The Occupational Therapist A stated that this was the second time that she had caught him. The Occupational Therapist A stated that the first time was around lunch, and she was on her way back from lunch. The Occupational Therapist A stated that Resident #1 was right at the door (outside of it, he just needed to let the door go). The Occupational Therapist A stated that Resident #1 did not have his walker at that time. The Occupational Therapist A stated that she had yelled for help from LVN D. The Occupational Therapist A stated that at that time they took him to get a wander guard. The Occupational Therapist A stated that was around noon and Resident #1 had not attempted to elope before that. The Occupational Therapist A stated that the first time that Resident #1 attempted to elope, he was not coherent, but he did make a comment saying something about needing a locker. The Occupational Therapist A stated that Resident #1 did not have a wander guard the first time he attempted to leave but on the second attempt, noticed a wander guard on Resident #1 because when Occupational Therapist A and Physical Therapist C brought Resident #1 back inside the wander guard went off. The Occupational Therapist A stated that she was not aware of any other elopements with residents. The Occupational Therapist A stated that she was not aware of any additional residents that exit seek. The Occupational Therapist A stated that she had not had any training regarding Resident #1's elopement. The Occupational Therapist A stated that she knows what it sounds like when the wander guard alerts and had been trained to go to the sound, each time the sound goes off and had been trained to go to the front door. <BR/>During an interview on 03/20/25 at 11:35 AM, LVN D stated that the steps to do a wander guard depended on the resident if they are an elopement risk. LVN D stated that they would have to do a wandering assessment. LVN D stated that the wandering assessment will let you know if the resident is high risk. LVN D stated that the nurse initiates the risk assessment. LVN D stated that Resident #1 was wanting to get out the day he eloped and that he was trying to get to the door. LVN D stated that she put a wander guard on him when he tried to get out the first time that day. LVN D stated that she was unsure of the actual date. LVN D stated that she used PCC (point click care) for the assessment. LVN D stated that Resident #1 was in his wheelchair, and he was rolling around right after lunch. LVN D stated that Resident #1 was already agitated that day. LVN D stated that Resident #1 was saying that he was looking for his wife before lunch and after lunch he had stated that he needed to get to his car. LVN D stated that Resident #1 does not usually ambulate using his wheelchair on his own but on this day, he was independently rolling on his own. LVN D stated that Resident #1 was going to the front door, and she had redirected him and brought him to the desk. LVN D stated that she had told Resident #1 that the weather was bad to try and distract him. LVN D stated that she cannot remember if she offered to call his daughter that day to distract him. LVN D did the assessment on Resident #1 and put a wander guard on him. LVN D stated that she did the assessment on Resident #1, and it showed that he needed the wander guard. LVN D stated that she put the wander guard on Resident #1 first and she kept him with her the remainder of her shift. LVN D was not sure what time she had gotten off work. LVN D stated that she had kept eyes on him. LVN D stated that she reported to LVN E that Resident #1 had a wander guard. LVN D stated that she had put a wander guard on Resident #1's right wrist. LVN D stated that she had made the DON, Administrator, and ADON aware that she had placed the wander guard on Resident #1 around lunch time. LVN D stated that no one ever reported to her that Resident #1 had attempted to get out, but she did her assessment based on what she observed. LVN D stated that she did not observe Resident #1 get out of the facility but was told when she was leaving that he had gotten out. LVN D stated that Resident #1 was found outside and had fallen in the front. LVN D stated that she was not sure where at in the front Resident #1 was found. LVN D stated that she had last saw Resident #1 when she was giving report at 2:15 PM during shift change. LVN D stated that she did receive additional training after the incident (elopement drill) and elopement training. LVN D stated that she had been trained to announce it and everyone needs to start looking. LVN D stated that the Charge nurse needs to be the stationary person to report back to. LVN D stated that at that point someone needs to go outside and look. LVN D stated that you would also report to Administrator and DON and then after 15 minutes we need to call the police officers and call family. LVN D later explained that she tested the wander guard against a remote and again against the door prior to placing it on Resident #1. She stated staff member (CNA F) was present when she tested against the door. <BR/>During an interview on 03/20/25 at 11:36 AM, the Physical Therapist C said she did not see Resident #1's elopement happen. She stated that she was in the front in the therapy area. The Physical Therapist C stated that she was unsure of the time and actual date but does know that it was daytime. The Physical Therapist C stated that earlier in the day before the elopement, the Occupational Therapist A was coming back in and saw Resident #1 standing at the door and she had brought him back inside. The Physical Therapist C stated that during the actual elopement, the Occupational Therapist A had thought that Resident #1 was a visitor and when she had realized that it was Resident #1, she had told nursing immediately what had happened. The Physical Therapist C stated that later that day she was in the therapy office and heard the door open and the Occupational Therapist A yell for the Occupational Therapist B. The Physical Therapist C stated that the Occupational Therapist A was leaving work and Resident #1 had gotten out of the door and off of the curb and had fallen. The Physical Therapist C stated she and the Occupation Therapist A had helped Resident #1 up and nursing had gotten him a wheelchair and brought him back into the building. The Physical Therapist C stated that the alarm did not go off on either the first or second time that Resident #1 eloped. The Physical Therapist C stated that when they hear the alarm, they move. The Physical Therapist C stated that one of them would have gone to check if the alarm had gone off; however, they did not hear it. The Physical Therapist C stated that they were trained to, hop up and get to it. The Physical Therapist C stated that Resident #1 had the wander guard on both times for the attempt and the actual elopement. The Physical Therapist C stated that the wander guard did not go off the first time, but it went off when Resident #1 was coming back through the door after he actually eloped. The Physical Therapist C stated that the wander guard alert system was working intermittently. The Physical Therapist C stated that nursing checks the wander guards, but she was unsure if it was the charge nurse or the DON. The Physical Therapist C stated that Resident #1 seemed unharmed when he actually eloped. The Physical Therapist C stated that when staff was bringing Resident #1 in from the actual elopement, he was telling the staff no that he wanted to go the other way. <BR/>During an observation on 03/20/2025 at 1:03 PM, State surveyor tested the front door. Alarm sounded. Staff x3 came. <BR/>During an interview on 03/20/2025 at 1:29 PM, CNA G stated that she was unsure of the exact date and time that Resident #1 was showing behaviors. CNA G stated that Resident #1 tried to get out prior to that actual elopement. CNA G stated that Resident #1 was yelling at staff, being physically abusive, and had bad language. CNA G stated that this was not Resident #1's normal behavior, but he was like this prior to his actual elopement. CNA G stated that she heard LVN D say that Resident #1 tried to leave. CNA G stated that they were watching him but did not do the 1:1. CNA G stated that the first time that Resident #1 tried to get out was when the wander guard was placed on him. CNA G stated that she had received a call while in the restroom and CNA H had stated that Resident #1 was outside. CNA G stated that she went out to help. CNA G stated that breaks are usually around 1:00 pm - 2:30 pm, so that would have to have been around the time Resident #1 was able to get out of the facility. CNA G stated that she was not too sure on the actual timing. CNA G stated that when she went outside, the resident, DON, and the Administrator, were coming inside. CNA G stated that the last time that she saw Resident #1 was approximately 10 minutes before the incident happened. CNA G stated that she did not hear the door alarm. CNA G stated that this had not happened with Resident #1 before, he had always talked about wanting to leave, but this was the first time that he eloped. <BR/>During an observation on 03/20/2025 at 3:22 PM, Resident #1 observed the wander guard on left arm. He looked at it. Did not say what it was for.<BR/>During an observation on 03/20/2025 at 4:37 PM-4:45 PM, tested the wander guard at the door near the room where the investigator was and the door down the right side (back) of the facility. The alert on the side and back of the facility have a faint sound. Staff did respond x3 to the side door and x 1 to the back door.<BR/>During an interview on 03/20/2025 at 6:00 PM, Family Member #1 stated he/she was notified by Family Member #2 that Resident #1 had eloped. Family Member #1 stated that Resident #1 had a wander guard since being admitted . Family member #1 stated that Resident #1 does not get around very well and was not sure how Resident #1 was able to get outside with the wander guard and being as low as Resident #1 was. Family member stated that as a result of the incident they would be trying to place Resident #1 somewhere else. <BR/>During an interview on 03/20/2025 at 6:05 PM, Physician stated that the facility may have notified his Nurse Practitioner about the elopement. Physician stated that he did not know if Resident #1 had a wander guard. Physician stated that Resident #1 had no elopement issues that he knew of. <BR/>During an interview on 03/20/2025 at 6:13 PM, Family Member #2 stated she did not know the exact date, but she was told Resident #1 got out the front door. Family Member #2 did not say how far Resident #1 had gotten. Family Member #2 stated that it was told to her in the day that Resident #1 had managed to get out the front door. Family Member #2 stated that she was not sure if it was LVN D or LVN E that notified her. Family Member #2 stated that Resident #1 did not have his wander guard and had not had it for a while, it had been several weeks. Family member #2 stated that she did not know why they had taken the wander guard off. Family member stated that the facility did not notify them of the wander guard being taken off the first time or that they had placed one on Resident #1 the day he eloped from the facility. Family member #2 stated that after Resident #1 had fallen, the day that he eloped and had fallen outside, they had put the wander guard back on Resident #1. Family member #2 stated that it was observed that it was off but had never asked, and just assumed it was because Resident #1 quit wandering and never questioned it. Family member #2 stated that they had noticed the wander guard, but no one had mentioned putting it back on Resident #1. Family member #2 stated that she had seen Resident #1 the next day and noticed that they had placed the wander guard back on. Family member #2 stated that their concern was Resident #1 was at the back of the building. Family member #2 stated that Resident #1 had to walk down a long hallway to get out of the building. Family member #2 stated that no one had paid attention and noticed it, and this was concerning. Family member #2 stated that their parking lot was right by the street. Family member #2 stated prior to this incident they never had concern about Resident #1's care, until this. Family member #2 stated that they were fine with the placement of the wander guard but if they had been told that they were going to take it off they would have declined for the safety of Resident #1, it never was an issue.<BR/>During an interview on 03/20/2025 at 6:35 PM, NP stated that she was notified on 03/10 that Resident #1 was trying to get out the front door and that he gotten out, right outside the door. NP stated it was her understanding that Resident #1 had not even gotten to the sidewalk. NP stated she was unaware that he gotten to the parking lot near the street. NP stated she received a text stating that they had put a wander guard on Resident #1 on 3/10. NP stated that she does not know if it was before or after he had actually eloped. NP stated her text that she had received stated I put a wander guard on Resident #1 because he was trying to get out of the building after lunch. The NP stated she had not had a text message that had showed that he had gotten out of the facility. NP stated she was unaware if Resident #1 had a wander guard prior to the placement on 03/10. NP stated she had never given an order for a wander guard to be taken off. NP stated they do notify her if they take it off and she has not had any notifications that one needed to be taken off of Resident #1. NP stated that they would have to had justification to take the wander guard off and put on. NP stated that she had a text on August 13 of 2024 that Resident #1 had tried to get out. NP stated that she did not know who texted because the number was not saved. NP stated that she had located the text says Resident #1 had gotten out. NP stated that she thought it was right outside of the door because she received a phone call letting her know they gotten Resident #1 back in. NP stated that when she calls about elopements and wander guard placements she will ask them what symptoms the resident had been having and what is the reason. NP stated that she had not received that information with Resident #1's case. NP stated that it was normal to have placed a wander guard after one attempt especially with Resident #1's case because the doors are unlocked from 7-8 PM. NP stated that it was case dependent in how they respond to elopements. NP stated it was situational. NP stated that in that facility it is almost impossible to actually monitor the front door and where the patient was going. NP stated that there was no way of watching that. NP stated that the wander guard was important because of the layout of the facility. NP stated that Resident #1 cannot walk fast, but fast enough. <BR/>During an observation at 9:15 AM, The facility is located on [NAME] Avenue with posted speed limit of 55 mph. The cross street is 114 with a posted speed limit of 65 mph. There was an observation of the restaurant across the street that receives business during the day hours. The day that Resident #1 had eloped on 03/10/2025, it was 78 degrees with wind. <BR/>During an observation and interview on 03/21/2025 at 9:38 AM, Maintenance Supervisor provided his checklist that he used to check the wander guard system. He stated he was required to check it weekly, but he does check the doors daily. He stated that he has not had any issues with the system.<BR/>During an observation on 03/21/2025 at 10:05-10:08 AM: Tested side door near the room where investigator was. Staff did not come down the hall until 10:08 AM x2.<BR/>During an interview on 03/21/2025 at 10:17 AM, LVN D stated that she had spoken with Family member #2. LVN D stated that she had told Family Member #2 that she had placed a wander guard on Resident #1. LVN D stated that it was an emergent reason to put the wander guard on because Resident #1 was actively trying to get out. LVN D stated that she was 1:1 with him until got off that day, then the aides took over. LVN D stated that she does not remember if she documented it, and which aides took over. LVN D stated that no one took over her nursing duties while she was 1:1. LVN D stated it was after lunch, and she did not have anything at that moment that she needed to do. LVN D stated that Resident #1 had never had a wander guard. LVN D stated that this was the first time that Resident #1 had a wander guard. LVN D stated that you have to document when you place or remove a wander guard. LVN D stated that you have to notify the doctor to place the order. LVN D stated that she did not know if she had placed it in her note. LVN D stated that there was an order for the wander guard to be checked and changed. LVN D stated that she was there when Resident #1 tried to get out of the door. LVN D stated that Resident #1 was on the right side of the door, and he pushed it. LVN D stated that the door sounded, and she went over there and grabbed Resident #1. LVN D stated that she notified the DON, Administrator, and the ADON. LVN D stated Resident #1 should have been placed on 1:1. LVN D stated that was the protocol for at least 15-minute checks. LVN D stated that she was never instructed to place Resident #1 on 1:1. LVN D stated that she just watched Resident #1 closely based on her nursing experience. <BR/>During an observation on 03/21/2025 at 10:37 AM, Resident #1 in his room, sleep in his recliner, wander guard on left arm.<BR/>During an interview on 03/21/2025 at 10:38 AM, CNA I stated that Resident #1 did not have a wander guard before. CNA I stated that she was not sure how Resident #1 had not had his wander guard and why it was taken off. CNA I stated that Resident #1 will wander but he was not looking to get out and Resident #1 will say he needs to go home. <BR/>During an interview on 03/21/2025 at 11:17 AM, ADON stated that Resident #1 had never had a wander guard before. ADON stated that the wander guard placed in March was the first one. ADON stated that the process for placing a wander guard was if the resident was showing signs an elopement assessment should be completed. ADON stated that the family should be notified of the behavior. ADON stated that the assessment would reveal a score and if the wander guard was needed. ADON stated that the family should be notified, and the documentation should reflect if they agree or disagree and then a consent should be signed if the family agree. ADON stated that if the family was not in agreement of the wander guard, then the resident can be placed on 24 hours observation and the family will try to identify a locked unit. ADON stated that it was not done in this case. ADON stated that she did not observe the placement of the wander guard on Resident #1. ADON stated that it was discussed as a group after Resident #1 had eloped. ADON stated that it had been discussed since Resident #1 was exit seeking and had not displayed that behavior before. ADON stated that labs were obtained with no findings. ADON stated that they discussed Resident #1 being placed on 1:1 and the Administrator had stated that they would need to find 1:1 staff for Resident #1. ADON stated that she did not know why the consent was not obtained or why the assessment was done afterwards. ADON stated that LVN D had reported the POA was called and given a verbal consent. ADON stated there was a call made to the NP. ADON stated she thought they had a consent. ADON stated that they had aids initially watching Resident #1. ADON stated that there was no observation log. ADON stated that the Administrator determined that it was an emergency and that was why the wander guard was placed on Resident #1. ADON stated that they were trained to document the placement of the wander guard and if it was taken off. ADON stated that they have to have justification to put a wander guard on and take it off. ADON stated that if it was not justified then the restraint is not justifiable. ADON stated that she thinks that this could have been prevented because when Resident #1 showed signs to want to leave the first time, the resident should have been monitored more frequently. ADON stated that Resident #1's room was right across from the nurse's station. ADON stated that Resident #1 was not quick and there was no reason someone did not see him. ADON stated that if they remove a wander guard an assessment should pop up in the system. ADON stated that if the assessment showed that Resident #1 no longer exhibited wandering then the nursing judgment would also be considered. ADON stated that the doctor should be called and get an order. ADON stated then the family should be called to remove the wander guard. ADON stated that she was familiar with the policy. ADON stated that the purpose of incident/accident prevention and supervision was safety of the resident. ADON stated that the incident could happen again if the policy was not followed. ADON stated that she did not see Resident #1 when he had eloped. ADON stated that she was told that Resident #1 was by the sidewalk onto the parking lot. ADON stated that the facility was by a busy road. ADON stated that Resident #1 does not have the ability to watch for traffic. ADON stated that she is aware that Resident #1 attempted to get out around lunch time. ADON stated that she was not aware that Resident #1 got out the second time. ADON stated that she was not aware that the wander guard was implemented prior to the assessment. ADON stated that she was not aware that Resident #1 had a wander guard prior to the one placed on 03/10/2025. ADON stated that she did not have any information regarding removal, and it should be care planned. ADON stated that she is not aware of Resident #1's scores from the past wandering assessments. ADON stated that the system to monitor incident/accident prevention and supervision would be to in-service staff and monitor to make sure nursing was following incident/accident policy, ensure that everything was documented, and make sure that there were follow ups and interventions for the resident. ADON stated that she had been trained on incident and accident prevention, supervision, and restraint policy. ADON stated that she would expect policy should be followed and incident and accidents should be prevented. ADON stated that everyone was responsible and there was no reason increased supervision did not occur on the first exit seeking attempt. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, the Administrator stated that she had been in the facility since November 2024 and that if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stated that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated that she did provide an elopement in-service. The Administrator stated that, Everyone is responsible for keeping the resident safe. The Administrator stated, I was told that they had completed the assessment first and then had called for a wander guard. The Administrator stated that it could be considered a restraint. The Administrator stated that LVN D had documented that Resident #1 had went to the door. The Administrator stated that the assessment would tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that she did an investigation. In her investigation she had not seen wander guard from any time before. The Administrator had not seen the high risk on all wandering assessments. She stated she did not look at the progress notes or assessments as a part of her investigation. The Administrator stated that she had not talked to the family since the elopement. She stated her team did tell her that they had notified the family. The Administrator stated that she did not follow up to check if the family had been notified. The Administrator stated that even in self-report all that was told to her was that the family was notified. The Administrator stated that she was unaware that the family had not been notified. The Administrator stated that the facility system to monitor incident and accident prevention was to review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated that she had been trained on incident and accident prevention. The Administrator stated they would have needed need to complete an assessment and then they would have to score a certain score, notify physician, notify family, sign the consent, before it could even be placed. It also would come with restrictions such as how often you would use it or when you remove it. The Administrator stated yes she was familiar with the policy for placing a wander guard. The Administrator stated that she was not aware that the assessment was completed after the restraint was placed on the resident, and once the IJ happened she learned of the situation. The Administrator stated that the system for monitoring for restraints was that she monitors when one is placed and would make sure DON had made her aware when one is placed, and she would follow up and have ADON monitor every week. The Administrator stated that she had been trained in restraints and her staff does complete orientation and annually as well. The Administrator stated that she had observed these residents (Resident #1, Resident #2, and Resident #3) with a wander guard on. The Administrator stated that her expectations in regard to restraint placement was that we are following our policy and that we are completing proper assessments before applying. The Administrator stated it was the responsibility of the charge nurses to apply restraints and complete assessments, and the responsibility of the ADON and DON to monitor. The Administrator stated that everyone was responsible for following the policy. The Administrator stated that there was no reason the assessment was completed after the placement of the wander guard as it relates to Resident #1, she thinks the nurse just wanted to be initiative-taking and was too initiative-taking. <BR/>During an interview on 03/21/2025 at 12:22 PM, the DON stated that the facility failed to prevent incidents and accidents allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident prompted the wander guard situation. The DON stated that Resident #1 did not get out of the door, but he was at t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 3 resident reviewed for resident rights. (Resident #1, Resident #2, and Resident #3)<BR/>The facility failed to ensure consents from responsible parties were given to place wander guard bracelets on Resident #1, Resident #2, and Resident #3. <BR/>This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects. <BR/>Findings included:<BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's Care Plan, dated 01/10/2025, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Resident #2:<BR/>Record Review of Resident #2's face sheet dated 03/20/25 revealed a [AGE] year-old female with an original admission date of 08/30/2020 and a readmission date of 10/23/2020 with the following diagnoses: seizures, intellectual disability, Microcephaly (a condition in which a baby's head is significantly smaller than expected often due to abnormal brain), scoliosis, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down, depression, hyperlipidemia (a condition in which there are high levels of fat particles in the blood). <BR/>Record review of Resident #2's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #2's Care Plan, dated 01/10/2025, revealed that Resident #2 was not care planned for wander guard. <BR/>Resident #3: <BR/>Record Review of Resident #3's face sheet dated 03/20/25 revealed a [AGE] year-old male with an admission date of 05/03/24 with the following diagnoses: dementia, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute kidney disease (a condition in which the kidneys suddenly cannot filter waste from the blood), urinary incontinence, high blood pressure, acid reflux, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). <BR/>Record review of Resident #3's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #3's Care Plan, dated 01/10/2025, revealed that Resident #3 was not care planned for wander guard. <BR/>During an interview on 03/20/2025 at 11:35 AM, LVN D stated that the steps to do a wander guard had depended on if resident was an elopement risk. LVN D stated that they would have to do a wandering assessment. LVN D stated that the Wandering Assessment would let you know if the resident was high risk. The nurse initiates the risk assessment. LVN D stated that Resident #1 had wanted to get out the day he eloped. LVN D stated that Resident #1 had tried to get out of the door. LVN D stated that she had put a wander guard on the resident when he tried to get out the first time. LVN D stated that she was unsure of the actual date. LVN D stated that they had used PCC (point click care) for the assessment. LVN D stated that she had done the assessment and had gotten a wander guard to put on the resident. LVN D stated that the assessment had showed that the resident needed the wander guard. LVN D stated that she had done the wander guard first and then she had done assessment. LVN D stated that she had reported to the oncoming nurse that she had placed a wander guard on the resident. LVN D stated that she had notified the DON, Administrator, and the ADON when she had placed the wander guard on Resident #1. LVN D stated that no one had ever reported to her that he had attempted to get out. LVN D stated that she had done her assessment based on what she observed. LVN D stated that she had not seen Resident #1 get out but when she was leaving when she was told that the resident had gotten out. LVN D stated that Resident #1 was found outside and had fallen in the front. LVN D stated that she had done an elopement training. LVN D stated that she had been trained to announce it and everyone needs to start looking. LVN D stated that the charge nurse would have been the one stationary person to report back to. LVN D stated that she would have reported to the Administrator, DON, and then after 15 minutes would need to notify the police and call the family. <BR/>During an interview on 03/20/2025 at 6:05 PM, Physician stated that the facility may have notified his Nurse Practitioner about the elopement. Physician stated that he did not know if Resident #1 had a wander guard. Physician stated that Resident #1 had no elopement issues that he knew of. <BR/>During an interview on 03/20/2025 at 6:13 PM, Family Member #2 stated she did not know the exact date, but she was told Resident #1 had gotten out the front door. Family member #2 did not say how far Resident #1 had gotten. Family member #2 stated that it was told to her in the day that Resident #1 had managed to get out the front door. Family member #2 stated that she was not sure if it was LVN D or LVN E that had notified her. Family member #2 stated that Resident #1 did not have his wander guard and had not had it for a while, it had been several weeks. Family member #2 stated that she did not know why they had taken the wander guard off. Family member stated that the facility did not notify them of the wander guard being taken off the first time or that they had placed one on Resident #1 the day he had eloped from the facility. Family member #2 stated that after Resident #1 had fallen, the day that he eloped and had fallen outside, they had put the wander guard back on Resident #1. Family member #2 stated that it was observed that it was off but had never asked, and just assumed it was because Resident #1 quit wandering and never questioned it. Family member #2 stated that they had noticed the wander guard, but no one had mentioned putting it back on Resident #1. Family member #2 stated that she had seen Resident #1 the next day and noticed that they had placed the wander guard back on. Family member #2 stated that their concern was Resident #1 was at the back of the building. Family member #2 stated that Resident #1 had to walk down a long hallway to get out of the building. Family member #2 stated that no one had paid attention and noticed it, and this is concerning. Family member #2 stated that their parking lot was right by the street. Family member #2 stated prior to this incident they never had concern about Resident #1's care, until this. Family member #2 stated that they were fine with the placement of the wander guard but if they had been told that they were going to take it off they would have declined for the safety of Resident #1, it never was an issue.<BR/>During an interview on 03/20/2025 at 6:35 PM, NP stated that she was notified on 03/10 that Resident #1 was trying to get out the front door and that he gotten out, right outside the door. NP stated it was her understanding that Resident #1 had not even gotten to the sidewalk. NP stated she was unaware that he gotten to the parking lot near the street. NP stated she received a text stating that they had put a wander guard on Resident #1 on 3/10. NP stated that she does not know if it was before or after he had actually eloped. NP stated her text that she had received stated I put a wander guard on Resident #1 because he was trying to get out of the building after lunch. The NP stated she had not had a text message that had showed that he had gotten out of the facility. NP stated she was unaware if Resident #1 had a wander guard prior to the placement on 03/10. NP stated she had never given an order for a wander guard to be taken off. NP stated they do notify her if they take it off and she has not had any notifications that one needed to be taken off of Resident #1. NP stated that they would have to had justification to take the wander guard off and put on. NP stated that she had a text on August 13 of 2024 that Resident #1 had tried to get out. NP stated that she did not know who texted because the number was not saved. NP stated that she had located the text says Resident #1 had gotten out. NP stated that she thought it was right outside of the door because she received a phone call letting her know they gotten Resident #1 back in. NP stated that when she calls about elopements and wander guard placements she will ask them what symptoms the resident had been having and what is the reason. NP stated that she had not received that information with Resident #1's case. NP stated that it was normal to have placed a wander guard after one attempt especially with Resident #1's case because the doors are unlocked from 7-8 PM. NP stated that it was case dependent in how they respond to elopements. NP stated it was situational. NP stated that in that facility it is almost impossible to actually monitor the front door and where the patient was going. NP stated that there was no way of watching that. NP stated that the wander guard was important because of the layout of the facility. NP stated that Resident #1 cannot walk fast, but fast enough. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, the Administrator stated that she had been in the facility since November 2024 and that if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stated that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated that she did provide an elopement in-service. The Administrator stated that, Everyone is responsible for keeping the resident safe. The Administrator stated, I was told that they had completed the assessment first and then had called for a wander guard. The Administrator stated that it could be considered a restraint. The Administrator stated that LVN D had documented that Resident #1 had went to the door. The Administrator stated that the assessment would tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that she did an investigation. In her investigation she had not seen wander guard from any time before. The Administrator had not seen the high risk on all wandering assessments. She stated she did not look at the progress notes or assessments as a part of her investigation. The Administrator stated that she had not talked to the family since the elopement. She stated her team did tell her that they had notified the family. The Administrator stated that she did not follow up to check if the family had been notified. The Administrator stated that even in self-report all that was told to her was that the family was notified. The Administrator stated that she was unaware that the family had not been notified. The Administrator stated that the facility system to monitor incident and accident prevention was to review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated that she had been trained on incident and accident prevention. The Administrator stated they would have needed need to complete an assessment and then they would have to score a certain score, notify physician, notify family, sign the consent, before it could even be placed. It also would come with restrictions such as how often you would use it or when you remove it. The Administrator stated yes she was familiar with the policy for placing a wander guard. The Administrator stated that the purpose of a consent specifically for restraints is the responsible party was consenting and good form of notification. The Administrator stated that the negative potential outcome of not obtaining a consent for a restraint would be a dignity concern. She stated that the family could have a concern for restraining. The Administrator stated that she was not aware that a consent was not in place but was aware now and all consent have been completed and in place. The Administrator stated that she was not aware that the assessment was completed after the restraint was placed on the resident, and once the IJ happened she learned of the situation. The Administrator stated that the system for monitoring for restraints was that she monitors when one is placed and would make sure DON had made her aware when one is placed, and she would follow up and have ADON monitor every week. The Administrator stated that she had been trained in restraints and her staff does complete orientation and annually as well. The Administrator stated that she had observed these residents (Resident #1, Resident #2, and Resident #3) with a wander guard on. The Administrator stated that her expectations in regard to restraint placement was that we are following our policy and that we are completing proper assessments before applying. The Administrator stated it was the responsibility of the charge nurses to apply restraints and complete assessments, and the responsibility of the ADON and DON to monitor. The Administrator stated that everyone was responsible for following the policy. The Administrator stated that there was no reason the assessment was completed after the placement of the wander guard as it relates to Resident #1, she thinks the nurse just wanted to be initiative-taking and was too initiative-taking. The Administrator stated that there was no reason a consent was not obtained from the family rep before the placement of the wander guard for Resident #1 and Resident #2. The Administrator stated that all consents and elopement risk assessment are in place and current. <BR/>During an interview on 03/21/2025 at 12:22 PM, The DON stated that the facility had failed to prevent incident and accident allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident had prompted the wander guard situation. The DON stated that Resident #1did not get out of the door but he was at the door. The DON stated that she spoke with LVN D and was told that Resident #1 had not gotten out of the door. The DON stated that she had spoken to Occupational Therapist A and was under the understanding that Occupational Therapist A was there with Resident #1 at the door the first time. The DON stated that Resident #1 had not exhibited any signs of wanting to leave the facility to her knowledge, prior to the elopement. The DON stated that after the incident had happened she did not talk to the aides to see if Resident #1 had exhibited any signs prior to the elopement. The DON stated that to her knowledge, Resident #1 had never had a wander guard. The DON stated that the implementation of the wander guard device on 03/10 was the first one. The DON stated that if Resident #1 had a wander guard device it would be documented. The DON stated that you would have to have justification to put one on and take one off. The DON stated that usually the assessments are quarterly and would also use nursing judgement. The DON stated that if Resident #1 continues to score high that would call for a wander guard. The DON stated that LVN D was looking at safety first and this was why she had placed the wander guard on him prior to completing the assessment. The DON stated that the wander guard would not have stopped him from leaving. The DON stated that she had observed LVN D place the wander guard on Resident #1 and he was not resistant to the placement. The DON stated that she had felt that the placement of the wander guard was an emergency. The DON stated that at that moment she was just thinking safety first. The DON stated that she did tell LVN D that she did have to get the assessment done and she did not place Resident #1 on 1:1. The DON stated that frequent rounding was done on Resident #1. The DON did not look at his assessments or look at progress notes and did not review care plan. The DON stated that she thinks that this could have been prevented. The DON stated that they could have acted quicker. The DON stated that they could have implemented interventions such as 1:1 at the time of the first attempt. The DON stated that she is not familiar with the policy for incident and accidents, but the purpose is to prevent harm The DON stated that someone could get hurt if the policy is not followed. The DON stated that they could get into trouble for not having proper paperwork and consents. The DON stated that she was not aware that Resident #1 had a wander guard prior to the one placed on 03/10. The DON stated that she was not aware of the assessment outcome scores but she was aware that the wander guard was placed prior to the assessment. The DON stated that she thought that LVN D had called the family prior to the placement of the wander guard. The DON stated that the system to monitor incident/accident prevention was that they educate staff through in-services. The DON stated that she had not had any specific training at the facility but had nursing experience to know that you have to prevent incident and accidents. The DON stated that she expects incidents/accidents to be prevented by following the policy. The DON stated that all staff are responsible and there was no reason increased supervision was not implemented. The DON stated that stated that she is familiar of the policy for placing a wander guard. Stated that assessing the resident's first and obtaining the consent and making sure that the resident is safe with the restraint, make sure to document, speak to family, and make sure have the proper monitoring system in place. , stated that the purpose of a consent specifically for restraints is to ensure safety for the residents, to ensure that family is aware of the restraint, and to protect themselves as the facility. The DON stated that the negative outcome of not obtaining a consent for a restraint puts the facility at risk of getting into trouble because if it is not signed or documented it did not happen. The DON stated she was not aware that a consent was not obtained. Stated once again she will have to quit assuming and follow up as a DON. Stated she will start doing that and she will own her mistakes. The DON stated that she was aware that the nurse placed Resident #1's wander guard and did the assessment afterwards. The DON stated that she talked to the LVN about that and at that moment she felt it was an emergency to just put that one and I agree with her that she needed to place that on him and do visual assessment and put that in the computer. She saw the risk that he was and needed to do that. The DON stated that the system to monitor restraints is that they have the little device to check the wander guards and when it is activated they check with the doors to make sure that they work. Stated that these are checked every shift. The DON stated that she had been trained on restraints. The DON stated staff had been trained on restraints as well. The DON stated that she can verify that she had been trained. The DON stated that she had observed the resident's (Resident #1, Resident #2, and Resident #3) with the wander guard on. The DON stated that her expectation in regard to restraint placement would be to ensure a proper assessment had been done, and that the proper consent paperwork is obtained, and of course the family is made aware. The DON stated that the nurses and administrator are responsible for restraints and following the policy because we are the one who assess the resident, place, and monitor. The DON stated the reason the assessment was completed after the placement was because the nurse felt that it was an emergency and that it needed to be placed right then. It was a nursing judgement. The DON stated that there is no reason a consent was not obtained other than the nurse felt that he was in danger and placed that because he was at risk of getting out of the building. The DON stated she did not have additional information just having to re-educate the staff. <BR/>Record review of facility provided policy, dated September 2022, titled, Identifying Involuntary Seclusion and Unauthorized Restraint, stated:<BR/>Policy Statement: <BR/>As a part of the abuse prevention strategy, volunteers, employees, and contractors, hired by this facility are expected to be able to identify involuntary seclusion and or unauthorized restraint of residents. <BR/>Policy Interpretation and Implementation:<BR/>4. Behavioral issues that arise among residents are managed according to strategies documented in the care plan and approved by the interdisciplinary team. <BR/>Unauthorized Physical Restraints:<BR/>1. <BR/>Restraints are free from the use of any physical restraints not required to treat their medical condition. <BR/>2. <BR/>Physical restraint is defined as any manual method, physical, or mechanical device, equipment, or material that meets all of the following criteria. <BR/>a. <BR/>Is attached or adjacent to a resident's body. <BR/>b. <BR/>Cannot be removed easily by the resident (in the same manner as it was applied by the staff).<BR/>4. Sometimes the use of restraints is not intentional, but this does not absolve the staff of the responsibility to recognize and report the unauthorized use of restraints. Examples of physical restraints (intentional or unintentional) include: <BR/> g. applying leg or arm restraints, hand mitts, soft ties, or vests that a resident cannot remove. <BR/>6. Risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints. <BR/>9. Obtaining a resident's or representative's permission to use a restraint when the restraint is unnecessary is prohibited. <BR/>10. The following examples demonstrate situations where restraints are used for staff convenience or discipline, and are therefore unauthorized:<BR/>a. Staff are too busy to monitor the resident, and their workload includes too many residents to provide monitoring. <BR/>b. The resident does not exercise good judgment, including forgetting about his/her physical limitations in standing, walking, or using the bathroom alone and will not wait for staff assistance.<BR/>c. Family have requested that the resident be restrained, as they are concerned about the resident falling especially during high activity times, such as during meals or when the staff are busy with other residents. <BR/>d. There is not enough staff on a particular shift or during the weekend and staffing levels were not changed. <BR/>e. new staff and/or temporary staff do not know the resident, how to approach, and/or how to address behavioral symptoms or care needs so they apply physical restraints.<BR/>f. Lack of staff education regarding the alternatives to the use of restraints as a method for preventing falls and accidents. <BR/>g. Restrain the resident to teach him/her a lesson due to negative feelings or a lack of respect toward the resident. <BR/>h. In response to a resident's wandering behavior, staff become frustrated and restrain a resident to a wheelchair and/or<BR/>11. Restraints that are used as a last resort to protect the safety of the resident and others must be accompanied by an order from the practitioner and documentation reflecting the circumstances that led up to the decision to restrain him or her. <BR/>Record review of facility provided policy, dated April 2017, titled, Use of Restraints, stated:<BR/>Policy Statement:<BR/>Restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms (s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented. <BR/>Policy Interpretation: <BR/>1. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. <BR/>2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. <BR/>6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans in that:<BR/>The facility failed to care plan for wander guards for Resident #1, Resident #2, and Resident #3.<BR/>This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns.<BR/>Findings included:<BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's Care Plan, dated 01/10/2025, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Resident #2:<BR/>Record Review of Resident #2's face sheet dated 03/20/25 revealed a [AGE] year-old female with an original admission date of 08/30/2020 and a readmission date of 10/23/2020 with the following diagnoses: seizures, intellectual disability, Microcephaly (a condition in which a baby's head is significantly smaller than expected often due to abnormal brain), scoliosis, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down, depression, hyperlipidemia (a condition in which there are high levels of fat particles in the blood). <BR/>Record review of Resident #2's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #2's Care Plan, dated 01/10/2025, revealed that Resident #2 was not care planned for wander guard. <BR/>Resident #3: <BR/>Record Review of Resident #3's face sheet dated 03/20/25 revealed a [AGE] year-old male with an admission date of 05/03/24 with the following diagnoses: dementia, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute kidney disease (a condition in which the kidneys suddenly cannot filter waste from the blood), urinary incontinence, high blood pressure, acid reflux, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). <BR/>Record review of Resident #3's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #3's Care Plan, dated 01/10/2025, revealed that Resident #3 was not care planned for wander guard. <BR/>During an interview with ADON on 03/21/2025 at 11:17 AM, ADON stated that she was not familiar with the care plan policy. She stated that the purpose of the care plan is to obtain care of the patient. ADON stated to ensure that they are providing that care, know the patient if a patient like to use certain things, and for preferences. ADON stated that if it is not care planned the staff do not know about the patient or what to do. ADON stated that the negative potential outcome is that the facility may not meet the needs of the patient. ADON stated that she was unaware that there were missing wander guard care plans. ADON stated that the system to monitor care plans is that the facility monitors care plans quarterly and MDS and nursing are usually to collaborate. ADON stated that they do chart reviews periodically. ADON stated that she had not been trained on care plans. ADON stated that she expects staff to have the components they need according to policy. ADON stated that it is the responsibility of the MDS, Nursing staff are responsible in following them. ADON stated that the MDS coordinator actually completes them (care plans) because they may not have been done. ADON stated that the MDS coordinator last day was 2/28/25. ADON stated that they did hire a new MDS Coordinator, and they are working on care plans now. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, The Administrator stated that she had been in the facility since November 2024 and if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stating that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated, I was told that they completed the assessment first and then called for a wander guard. The Administrator stated that it can be considered a restraint. The Administrator stated that the assessment will tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that the facility system to monitor incident and accident prevention is review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated she is familiar with the policy for care planning for wander guard. The Administrator stated that she expectations in regard to care plans is that she expects for it to be accurate and up to date and it should be tailored to each resident. The Administrator stated that it is the responsibility of the IDT to make sure care plans are completed, It's not just one person, its all of us. The Administrator stated that stated that there is no good excuse for the care plans not being completed. The Administrator stated that she thinks that it goes back to the time that she did not have and MDS but not a good excuse or a specific reason. The Administrator stated that she was not aware that the resident's identified did not have their wander guards care planned until it was brought to her attention by the other Surveyor. The Administrator stated that a care plan is the guidelines of how they provide care for that specific need for the resident. The Administrator stated that the negative potential outcome of not care planning triggered items is not providing proper care for that specific resident to the best of their ability. The Administrator stated that mostly nursing uses the care plans.<BR/>During an interview on 03/21/2025 at 12:22 PM, The DON stated that the facility failed to prevent incident and accident allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident prompted the wander guard situation. The DON stated that to her knowledge, Resident #1 had never had a wander guard. The DON stated that the implementation of the wander guard device on 03/10 was the first one. The DON stated that if Resident #1 had a wander guard device it would be documented. The DON stated that you have to have justification to put one on and take one off. The DON stated that usually the assessments are quarterly and also use nursing judgement. The DON stated that LVN D was looking at safety first and this was why she placed the wander guard on him prior to completing the assessment. The DON stated that she observed LVN D place the wander guard on Resident #1 and he was not resistant to the placement. The DON stated that she had felt that the placement of the wander guard was an emergency. The DON stated that if a resident had a wander guard, it should be care planned. The DON stated that a care plan provides details of what is going on with the resident and how to take care of them. The DON stated it is an overall story about the resident and needs. The DON stated that the negative potential outcome of not care planning triggered items is that if it is not care planned or documented then it could turn into not providing what is needed for them or meeting the resident's needs. The DON stated that she was not aware of the wander guard and behaviors were not care planned, until recently when she went in there and noticed that it was not care planned. The DON stated that when she noticed was on Friday 3/21/25. The DON stated that she assumed that it was done due to these residents being in the facility for so long. The DON stated that the person before her did not have it completed. The DON stated that when she looked it was not done, so she went in at that time and completed it. The DON stated that in regard to the facility system to monitor care plans is that she assumes that people know what needs to be done. The DON stated that she plans to go through each and every care plan to see what had or had not been taken care of. She stated that previously with old MDS, she would pull a 24-hour report and baseline and then DON would care plan it. The DON stated that they are in the process of re-training another person and communication also had played a role in the lack of care planning. She stated they will do risk meetings weekly with MDS and keep up to date with care plans. The DON stated that she had minimal training on care plans. She stated that her last MDS coordinator and her Corporate Nurse had given her training, but it was not much at all. The DON stated that therapy, activities, nursing, dietary, social worker, all use care plans. The DON stated that care plans are a summary of resident care and everything that they have going on from behaviors, needs, preferences. The DON stated if someone prefers to be eating in the dining by themselves that would be care planned.<BR/>Record review of facility provided policy, dated March 2022, titled, Care Plans-Baseline stated: <BR/>Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within-forty-eight hours of admission. <BR/>Policy Interpretation and Implementation:<BR/>1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following:<BR/>a. Initial goals based on admission orders and discussion with the resident representative. <BR/>b. Physician orders.<BR/>c. dietary orders.<BR/>d. Therapy services.<BR/>e. social services. <BR/>f. PASARR recommendation if applicable<BR/>2. The baseline care plan is used until the staff can conduct a comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan, no later than 21 days after admission. The baseline care plan is updated as needed to meet the needs until the comprehensive care plan is developed. <BR/>3. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment at 483.21<BR/>4. The resident and/or representative are provided a written summary of the baseline care plan that includes, but is not limited to the following:<BR/>a. The stated goals of the resident. <BR/>c. any services and treatments to be administered by the facility and personnel acting on behalf of the facility.<BR/>d. any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, supervision. <BR/>The facility failed to ensure Resident #1 received supervision and assistive devices to prevent accidents. Resident #1 was exit seeking and was able to elope and had fallen in the parking lot by the street. Staff were not aware of Resident #1's elopement and was found by Occupational Therapist that was off the clock. <BR/>An Immediate Jeopardy (IJ) was identified on 03/21/25 at 3:32 PM. The IJ template was provided to the facility on [DATE] at 3:32 PM. While the IJ was removed on 03/22/25 at 5:36 PM; however, the facility remained out of compliance at No actual harm, with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could place residents at risk for injuries due to not receiving the appropriate level of supervision.<BR/>Findings included:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>He felt tired or had little energy listed as 2-6 days.<BR/>He was listed as using a manual wheelchair.<BR/>He needed partial/moderate assistance to go from sitting to standing.<BR/>Record review of Resident #1's Care Plan, dated 01/10/25, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Record review of Resident #1's TAR for month of March 2025, revealed:<BR/>Resident #1 was placed on 1:1 observations from 03/12/2025-3/21/2025, but no wander guard was listed on TAR.<BR/>Record review of Resident #1's progress note dated 03/10/2025 at 2:59 PM, stated: 1300 Resident was at front door trying to get out of building. Wander guard applied to right wrist. Resident continues wandering<BR/>throughout the building. Family called and notified.<BR/>Recored review of Resident #1's progress note dated 03/10/2025 at 3:30 PM, stated: New order obtained from NP to place patient on one on one due to exit seeking behaviors.<BR/>Record review of Resident #1's Head to Toe Skin Assessment, dated 03/13/2025 at 6:32 PM, stated: right and left forearm and right elbow.<BR/>During an interview on 03/20/25 at 11:23 AM, Occupational Therapist A stated that she had seen Resident #1 outside around 3 pm. Occupational Therapist A stated that she had parked on the opposite end of the building, had made a left turn on the road, and then had seen someone standing with a walker in the parking lot. Occupational Therapist A stated that she had seen Resident #1 out of her peripheral vision. The Occupational Therapist A stated that he did not look like a visitor. The Occupational Therapist A stated that as she was parked, she had noticed Resident #1 had lost his balance and had seen him fall. The Occupational Therapist A stated that she had ran into the building and yelled out to Occupational Therapist B to assist. The Occupational Therapist A stated that she had ran to Resident #1 because he was in the street but barely on the side of the street. The Occupational Therapist B and Occupational Therapist A went to help Resident #1 up and at that point Physical Therapist came out with Resident #1's wheelchair. The Occupational Therapist A and Physical Therapist helped Resident #1 into the wheelchair and back into the building. The Occupational Therapist A stated that once they were back into the building, she wrote a statement. The Occupational Therapist A stated that she was off of the clock when this incident occurred. The Occupational Therapist A stated that her and the Physical Therapist C helped Resident #1, and she left after writing the statement. The Occupational Therapist A stated that she had not worked with Resident #1. The Occupational Therapist A stated that this was the second time that she had caught him. The Occupational Therapist A stated that the first time was around lunch, and she was on her way back from lunch. The Occupational Therapist A stated that Resident #1 was right at the door (outside of it, he just needed to let the door go). The Occupational Therapist A stated that Resident #1 did not have his walker at that time. The Occupational Therapist A stated that she had yelled for help from LVN D. The Occupational Therapist A stated that at that time they took him to get a wander guard. The Occupational Therapist A stated that was around noon and Resident #1 had not attempted to elope before that. The Occupational Therapist A stated that the first time that Resident #1 attempted to elope, he was not coherent, but he did make a comment saying something about needing a locker. The Occupational Therapist A stated that Resident #1 did not have a wander guard the first time he attempted to leave but on the second attempt, noticed a wander guard on Resident #1 because when Occupational Therapist A and Physical Therapist C brought Resident #1 back inside the wander guard went off. The Occupational Therapist A stated that she was not aware of any other elopements with residents. The Occupational Therapist A stated that she was not aware of any additional residents that exit seek. The Occupational Therapist A stated that she had not had any training regarding Resident #1's elopement. The Occupational Therapist A stated that she knows what it sounds like when the wander guard alerts and had been trained to go to the sound, each time the sound goes off and had been trained to go to the front door. <BR/>During an interview on 03/20/25 at 11:35 AM, LVN D stated that the steps to do a wander guard depended on the resident if they are an elopement risk. LVN D stated that they would have to do a wandering assessment. LVN D stated that the wandering assessment will let you know if the resident is high risk. LVN D stated that the nurse initiates the risk assessment. LVN D stated that Resident #1 was wanting to get out the day he eloped and that he was trying to get to the door. LVN D stated that she put a wander guard on him when he tried to get out the first time that day. LVN D stated that she was unsure of the actual date. LVN D stated that she used PCC (point click care) for the assessment. LVN D stated that Resident #1 was in his wheelchair, and he was rolling around right after lunch. LVN D stated that Resident #1 was already agitated that day. LVN D stated that Resident #1 was saying that he was looking for his wife before lunch and after lunch he had stated that he needed to get to his car. LVN D stated that Resident #1 does not usually ambulate using his wheelchair on his own but on this day, he was independently rolling on his own. LVN D stated that Resident #1 was going to the front door, and she had redirected him and brought him to the desk. LVN D stated that she had told Resident #1 that the weather was bad to try and distract him. LVN D stated that she cannot remember if she offered to call his daughter that day to distract him. LVN D did the assessment on Resident #1 and put a wander guard on him. LVN D stated that she did the assessment on Resident #1, and it showed that he needed the wander guard. LVN D stated that she put the wander guard on Resident #1 first and she kept him with her the remainder of her shift. LVN D was not sure what time she had gotten off work. LVN D stated that she had kept eyes on him. LVN D stated that she reported to LVN E that Resident #1 had a wander guard. LVN D stated that she had put a wander guard on Resident #1's right wrist. LVN D stated that she had made the DON, Administrator, and ADON aware that she had placed the wander guard on Resident #1 around lunch time. LVN D stated that no one ever reported to her that Resident #1 had attempted to get out, but she did her assessment based on what she observed. LVN D stated that she did not observe Resident #1 get out of the facility but was told when she was leaving that he had gotten out. LVN D stated that Resident #1 was found outside and had fallen in the front. LVN D stated that she was not sure where at in the front Resident #1 was found. LVN D stated that she had last saw Resident #1 when she was giving report at 2:15 PM during shift change. LVN D stated that she did receive additional training after the incident (elopement drill) and elopement training. LVN D stated that she had been trained to announce it and everyone needs to start looking. LVN D stated that the Charge nurse needs to be the stationary person to report back to. LVN D stated that at that point someone needs to go outside and look. LVN D stated that you would also report to Administrator and DON and then after 15 minutes we need to call the police officers and call family. LVN D later explained that she tested the wander guard against a remote and again against the door prior to placing it on Resident #1. She stated staff member (CNA F) was present when she tested against the door. <BR/>During an interview on 03/20/25 at 11:36 AM, the Physical Therapist C said she did not see Resident #1's elopement happen. She stated that she was in the front in the therapy area. The Physical Therapist C stated that she was unsure of the time and actual date but does know that it was daytime. The Physical Therapist C stated that earlier in the day before the elopement, the Occupational Therapist A was coming back in and saw Resident #1 standing at the door and she had brought him back inside. The Physical Therapist C stated that during the actual elopement, the Occupational Therapist A had thought that Resident #1 was a visitor and when she had realized that it was Resident #1, she had told nursing immediately what had happened. The Physical Therapist C stated that later that day she was in the therapy office and heard the door open and the Occupational Therapist A yell for the Occupational Therapist B. The Physical Therapist C stated that the Occupational Therapist A was leaving work and Resident #1 had gotten out of the door and off of the curb and had fallen. The Physical Therapist C stated she and the Occupation Therapist A had helped Resident #1 up and nursing had gotten him a wheelchair and brought him back into the building. The Physical Therapist C stated that the alarm did not go off on either the first or second time that Resident #1 eloped. The Physical Therapist C stated that when they hear the alarm, they move. The Physical Therapist C stated that one of them would have gone to check if the alarm had gone off; however, they did not hear it. The Physical Therapist C stated that they were trained to, hop up and get to it. The Physical Therapist C stated that Resident #1 had the wander guard on both times for the attempt and the actual elopement. The Physical Therapist C stated that the wander guard did not go off the first time, but it went off when Resident #1 was coming back through the door after he actually eloped. The Physical Therapist C stated that the wander guard alert system was working intermittently. The Physical Therapist C stated that nursing checks the wander guards, but she was unsure if it was the charge nurse or the DON. The Physical Therapist C stated that Resident #1 seemed unharmed when he actually eloped. The Physical Therapist C stated that when staff was bringing Resident #1 in from the actual elopement, he was telling the staff no that he wanted to go the other way. <BR/>During an observation on 03/20/2025 at 1:03 PM, State surveyor tested the front door. Alarm sounded. Staff x3 came. <BR/>During an interview on 03/20/2025 at 1:29 PM, CNA G stated that she was unsure of the exact date and time that Resident #1 was showing behaviors. CNA G stated that Resident #1 tried to get out prior to that actual elopement. CNA G stated that Resident #1 was yelling at staff, being physically abusive, and had bad language. CNA G stated that this was not Resident #1's normal behavior, but he was like this prior to his actual elopement. CNA G stated that she heard LVN D say that Resident #1 tried to leave. CNA G stated that they were watching him but did not do the 1:1. CNA G stated that the first time that Resident #1 tried to get out was when the wander guard was placed on him. CNA G stated that she had received a call while in the restroom and CNA H had stated that Resident #1 was outside. CNA G stated that she went out to help. CNA G stated that breaks are usually around 1:00 pm - 2:30 pm, so that would have to have been around the time Resident #1 was able to get out of the facility. CNA G stated that she was not too sure on the actual timing. CNA G stated that when she went outside, the resident, DON, and the Administrator, were coming inside. CNA G stated that the last time that she saw Resident #1 was approximately 10 minutes before the incident happened. CNA G stated that she did not hear the door alarm. CNA G stated that this had not happened with Resident #1 before, he had always talked about wanting to leave, but this was the first time that he eloped. <BR/>During an observation on 03/20/2025 at 3:22 PM, Resident #1 observed the wander guard on left arm. He looked at it. Did not say what it was for.<BR/>During an observation on 03/20/2025 at 4:37 PM-4:45 PM, tested the wander guard at the door near the room where the investigator was and the door down the right side (back) of the facility. The alert on the side and back of the facility have a faint sound. Staff did respond x3 to the side door and x 1 to the back door.<BR/>During an interview on 03/20/2025 at 6:00 PM, Family Member #1 stated he/she was notified by Family Member #2 that Resident #1 had eloped. Family Member #1 stated that Resident #1 had a wander guard since being admitted . Family member #1 stated that Resident #1 does not get around very well and was not sure how Resident #1 was able to get outside with the wander guard and being as low as Resident #1 was. Family member stated that as a result of the incident they would be trying to place Resident #1 somewhere else. <BR/>During an interview on 03/20/2025 at 6:05 PM, Physician stated that the facility may have notified his Nurse Practitioner about the elopement. Physician stated that he did not know if Resident #1 had a wander guard. Physician stated that Resident #1 had no elopement issues that he knew of. <BR/>During an interview on 03/20/2025 at 6:13 PM, Family Member #2 stated she did not know the exact date, but she was told Resident #1 got out the front door. Family Member #2 did not say how far Resident #1 had gotten. Family Member #2 stated that it was told to her in the day that Resident #1 had managed to get out the front door. Family Member #2 stated that she was not sure if it was LVN D or LVN E that notified her. Family Member #2 stated that Resident #1 did not have his wander guard and had not had it for a while, it had been several weeks. Family member #2 stated that she did not know why they had taken the wander guard off. Family member stated that the facility did not notify them of the wander guard being taken off the first time or that they had placed one on Resident #1 the day he eloped from the facility. Family member #2 stated that after Resident #1 had fallen, the day that he eloped and had fallen outside, they had put the wander guard back on Resident #1. Family member #2 stated that it was observed that it was off but had never asked, and just assumed it was because Resident #1 quit wandering and never questioned it. Family member #2 stated that they had noticed the wander guard, but no one had mentioned putting it back on Resident #1. Family member #2 stated that she had seen Resident #1 the next day and noticed that they had placed the wander guard back on. Family member #2 stated that their concern was Resident #1 was at the back of the building. Family member #2 stated that Resident #1 had to walk down a long hallway to get out of the building. Family member #2 stated that no one had paid attention and noticed it, and this was concerning. Family member #2 stated that their parking lot was right by the street. Family member #2 stated prior to this incident they never had concern about Resident #1's care, until this. Family member #2 stated that they were fine with the placement of the wander guard but if they had been told that they were going to take it off they would have declined for the safety of Resident #1, it never was an issue.<BR/>During an interview on 03/20/2025 at 6:35 PM, NP stated that she was notified on 03/10 that Resident #1 was trying to get out the front door and that he gotten out, right outside the door. NP stated it was her understanding that Resident #1 had not even gotten to the sidewalk. NP stated she was unaware that he gotten to the parking lot near the street. NP stated she received a text stating that they had put a wander guard on Resident #1 on 3/10. NP stated that she does not know if it was before or after he had actually eloped. NP stated her text that she had received stated I put a wander guard on Resident #1 because he was trying to get out of the building after lunch. The NP stated she had not had a text message that had showed that he had gotten out of the facility. NP stated she was unaware if Resident #1 had a wander guard prior to the placement on 03/10. NP stated she had never given an order for a wander guard to be taken off. NP stated they do notify her if they take it off and she has not had any notifications that one needed to be taken off of Resident #1. NP stated that they would have to had justification to take the wander guard off and put on. NP stated that she had a text on August 13 of 2024 that Resident #1 had tried to get out. NP stated that she did not know who texted because the number was not saved. NP stated that she had located the text says Resident #1 had gotten out. NP stated that she thought it was right outside of the door because she received a phone call letting her know they gotten Resident #1 back in. NP stated that when she calls about elopements and wander guard placements she will ask them what symptoms the resident had been having and what is the reason. NP stated that she had not received that information with Resident #1's case. NP stated that it was normal to have placed a wander guard after one attempt especially with Resident #1's case because the doors are unlocked from 7-8 PM. NP stated that it was case dependent in how they respond to elopements. NP stated it was situational. NP stated that in that facility it is almost impossible to actually monitor the front door and where the patient was going. NP stated that there was no way of watching that. NP stated that the wander guard was important because of the layout of the facility. NP stated that Resident #1 cannot walk fast, but fast enough. <BR/>During an observation at 9:15 AM, The facility is located on [NAME] Avenue with posted speed limit of 55 mph. The cross street is 114 with a posted speed limit of 65 mph. There was an observation of the restaurant across the street that receives business during the day hours. The day that Resident #1 had eloped on 03/10/2025, it was 78 degrees with wind. <BR/>During an observation and interview on 03/21/2025 at 9:38 AM, Maintenance Supervisor provided his checklist that he used to check the wander guard system. He stated he was required to check it weekly, but he does check the doors daily. He stated that he has not had any issues with the system.<BR/>During an observation on 03/21/2025 at 10:05-10:08 AM: Tested side door near the room where investigator was. Staff did not come down the hall until 10:08 AM x2.<BR/>During an interview on 03/21/2025 at 10:17 AM, LVN D stated that she had spoken with Family member #2. LVN D stated that she had told Family Member #2 that she had placed a wander guard on Resident #1. LVN D stated that it was an emergent reason to put the wander guard on because Resident #1 was actively trying to get out. LVN D stated that she was 1:1 with him until got off that day, then the aides took over. LVN D stated that she does not remember if she documented it, and which aides took over. LVN D stated that no one took over her nursing duties while she was 1:1. LVN D stated it was after lunch, and she did not have anything at that moment that she needed to do. LVN D stated that Resident #1 had never had a wander guard. LVN D stated that this was the first time that Resident #1 had a wander guard. LVN D stated that you have to document when you place or remove a wander guard. LVN D stated that you have to notify the doctor to place the order. LVN D stated that she did not know if she had placed it in her note. LVN D stated that there was an order for the wander guard to be checked and changed. LVN D stated that she was there when Resident #1 tried to get out of the door. LVN D stated that Resident #1 was on the right side of the door, and he pushed it. LVN D stated that the door sounded, and she went over there and grabbed Resident #1. LVN D stated that she notified the DON, Administrator, and the ADON. LVN D stated Resident #1 should have been placed on 1:1. LVN D stated that was the protocol for at least 15-minute checks. LVN D stated that she was never instructed to place Resident #1 on 1:1. LVN D stated that she just watched Resident #1 closely based on her nursing experience. <BR/>During an observation on 03/21/2025 at 10:37 AM, Resident #1 in his room, sleep in his recliner, wander guard on left arm.<BR/>During an interview on 03/21/2025 at 10:38 AM, CNA I stated that Resident #1 did not have a wander guard before. CNA I stated that she was not sure how Resident #1 had not had his wander guard and why it was taken off. CNA I stated that Resident #1 will wander but he was not looking to get out and Resident #1 will say he needs to go home. <BR/>During an interview on 03/21/2025 at 11:17 AM, ADON stated that Resident #1 had never had a wander guard before. ADON stated that the wander guard placed in March was the first one. ADON stated that the process for placing a wander guard was if the resident was showing signs an elopement assessment should be completed. ADON stated that the family should be notified of the behavior. ADON stated that the assessment would reveal a score and if the wander guard was needed. ADON stated that the family should be notified, and the documentation should reflect if they agree or disagree and then a consent should be signed if the family agree. ADON stated that if the family was not in agreement of the wander guard, then the resident can be placed on 24 hours observation and the family will try to identify a locked unit. ADON stated that it was not done in this case. ADON stated that she did not observe the placement of the wander guard on Resident #1. ADON stated that it was discussed as a group after Resident #1 had eloped. ADON stated that it had been discussed since Resident #1 was exit seeking and had not displayed that behavior before. ADON stated that labs were obtained with no findings. ADON stated that they discussed Resident #1 being placed on 1:1 and the Administrator had stated that they would need to find 1:1 staff for Resident #1. ADON stated that she did not know why the consent was not obtained or why the assessment was done afterwards. ADON stated that LVN D had reported the POA was called and given a verbal consent. ADON stated there was a call made to the NP. ADON stated she thought they had a consent. ADON stated that they had aids initially watching Resident #1. ADON stated that there was no observation log. ADON stated that the Administrator determined that it was an emergency and that was why the wander guard was placed on Resident #1. ADON stated that they were trained to document the placement of the wander guard and if it was taken off. ADON stated that they have to have justification to put a wander guard on and take it off. ADON stated that if it was not justified then the restraint is not justifiable. ADON stated that she thinks that this could have been prevented because when Resident #1 showed signs to want to leave the first time, the resident should have been monitored more frequently. ADON stated that Resident #1's room was right across from the nurse's station. ADON stated that Resident #1 was not quick and there was no reason someone did not see him. ADON stated that if they remove a wander guard an assessment should pop up in the system. ADON stated that if the assessment showed that Resident #1 no longer exhibited wandering then the nursing judgment would also be considered. ADON stated that the doctor should be called and get an order. ADON stated then the family should be called to remove the wander guard. ADON stated that she was familiar with the policy. ADON stated that the purpose of incident/accident prevention and supervision was safety of the resident. ADON stated that the incident could happen again if the policy was not followed. ADON stated that she did not see Resident #1 when he had eloped. ADON stated that she was told that Resident #1 was by the sidewalk onto the parking lot. ADON stated that the facility was by a busy road. ADON stated that Resident #1 does not have the ability to watch for traffic. ADON stated that she is aware that Resident #1 attempted to get out around lunch time. ADON stated that she was not aware that Resident #1 got out the second time. ADON stated that she was not aware that the wander guard was implemented prior to the assessment. ADON stated that she was not aware that Resident #1 had a wander guard prior to the one placed on 03/10/2025. ADON stated that she did not have any information regarding removal, and it should be care planned. ADON stated that she is not aware of Resident #1's scores from the past wandering assessments. ADON stated that the system to monitor incident/accident prevention and supervision would be to in-service staff and monitor to make sure nursing was following incident/accident policy, ensure that everything was documented, and make sure that there were follow ups and interventions for the resident. ADON stated that she had been trained on incident and accident prevention, supervision, and restraint policy. ADON stated that she would expect policy should be followed and incident and accidents should be prevented. ADON stated that everyone was responsible and there was no reason increased supervision did not occur on the first exit seeking attempt. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, the Administrator stated that she had been in the facility since November 2024 and that if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stated that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated that she did provide an elopement in-service. The Administrator stated that, Everyone is responsible for keeping the resident safe. The Administrator stated, I was told that they had completed the assessment first and then had called for a wander guard. The Administrator stated that it could be considered a restraint. The Administrator stated that LVN D had documented that Resident #1 had went to the door. The Administrator stated that the assessment would tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that she did an investigation. In her investigation she had not seen wander guard from any time before. The Administrator had not seen the high risk on all wandering assessments. She stated she did not look at the progress notes or assessments as a part of her investigation. The Administrator stated that she had not talked to the family since the elopement. She stated her team did tell her that they had notified the family. The Administrator stated that she did not follow up to check if the family had been notified. The Administrator stated that even in self-report all that was told to her was that the family was notified. The Administrator stated that she was unaware that the family had not been notified. The Administrator stated that the facility system to monitor incident and accident prevention was to review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated that she had been trained on incident and accident prevention. The Administrator stated they would have needed need to complete an assessment and then they would have to score a certain score, notify physician, notify family, sign the consent, before it could even be placed. It also would come with restrictions such as how often you would use it or when you remove it. The Administrator stated yes she was familiar with the policy for placing a wander guard. The Administrator stated that she was not aware that the assessment was completed after the restraint was placed on the resident, and once the IJ happened she learned of the situation. The Administrator stated that the system for monitoring for restraints was that she monitors when one is placed and would make sure DON had made her aware when one is placed, and she would follow up and have ADON monitor every week. The Administrator stated that she had been trained in restraints and her staff does complete orientation and annually as well. The Administrator stated that she had observed these residents (Resident #1, Resident #2, and Resident #3) with a wander guard on. The Administrator stated that her expectations in regard to restraint placement was that we are following our policy and that we are completing proper assessments before applying. The Administrator stated it was the responsibility of the charge nurses to apply restraints and complete assessments, and the responsibility of the ADON and DON to monitor. The Administrator stated that everyone was responsible for following the policy. The Administrator stated that there was no reason the assessment was completed after the placement of the wander guard as it relates to Resident #1, she thinks the nurse just wanted to be initiative-taking and was too initiative-taking. <BR/>During an interview on 03/21/2025 at 12:22 PM, the DON stated that the facility failed to prevent incidents and accidents allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident prompted the wander guard situation. The DON stated that Resident #1 did not get out of the door, but he was at t[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 6 of 18 confidential residents. <BR/>The facility failed to ensure 6 of 18 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, access to the Grievance forms, information of who the facility's grievance official was and their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. <BR/>This failure could place the residents at risk of unresolved grievances and decreased quality of life. <BR/>Findings include:<BR/>Interviews during Resident Council on, 10/16/2024 at 10:45 AM, attendees 6 of 18 confidential residents stated they did not know about the grievance process. They also stated they did not know where to obtain or submit a grievance form. They stated they did not know they could file a Grievance anonymously. They stated the Grievance procedure had never been discussed in Resident Council. They also stated they had not observed a posting of the Grievance procedure in prominent locations. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to acquire a grievance form, who to turn the form into, and what should happen once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Six Residents attended the meeting, and the six Residents in attendance had all been Residents of the facility for 6 months or longer. <BR/>Observation of blank greivance forms on 10/17/2024 at 12:30 PM; blank greivance forms were observed outside of the social services office. The facility did not include instructions regarding the Grievance procedure with a prominent posting. There was no signage indicating the forms were present nor instructions advising a resident of how to submit a Grievance. The facility also did not provide an option for a resident to be able to submit a grievance anonymously. <BR/>Interview with the DON on 10/17/2024 at 12:25 PM; the DON stated she was not aware of what the grievance policy was and would have to look it up. The DON stated the facility did not have an administrator at the time of the interview. The DON stated she thought the social worker was responsible for handling grievances. The DON stated she was not sure where grievance forms were held, but she thought the social worker kept them. The DON was unsure where grievances were documented. The DON stated if a grievance was filed, she would collaborate with staff and then meet with the resident to try to resolve the grievance. The DON stated all grievances were submitted to the facility's social worker, but the administrator or the DON was responsible for resolving grievances. The DON stated the social worker was unavailable for interview at that time. The DON was unsure of the timeframe to resolve a grievance, but she stated they would usually handle them right away. The DON stated residents were notified of their ability to file a grievance upon admission and during resident council meetings. The DON was unable to find a policy related to grievances, but she provided a policy of residents' rights which mentioned grievances. <BR/>Record Review of the undated document titled Residents' Rights, revised December 2016, revealed the following:<BR/>Policy Statement:<BR/>Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation:<BR/>U. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal;<BR/>V. have the facility respond to his or her grievances;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 6 (Residents #16, #17, #24, #26, #30 and #42) of 8 residents reviewed for respiratory care.<BR/>1. The facility failed to ensure that Resident #24 and Resident #42's oxygen tubing was replaced every seven (7) days.<BR/>2. The facility failed to ensure that oxygen tubing was dated for Resident #26 and Resident #30.<BR/>3. The facility failed to ensure that oxygen tubing was properly stored for Resident #16 and Resident #17.<BR/>These failures could place residents at risk for respiratory compromise and infection. <BR/>Findings included:<BR/>1. Resident #24<BR/>Review of Resident #24's face sheet revealed a [AGE] year-old female with an admission date of 10/08/21 with the following diagnoses: Alzheimer's Disease (brain disorder), Osteoarthritis (joint disease), Diabetes Mellitus (uncontrolled sugar in the blood), Hypoxemia (low oxygen in the blood), and Heart Failure (inadequate ability of the heart to pump blood). <BR/>Record review of Resident #24's annual MDS dated [DATE] revealed a BIMS score of 07, indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #24 used oxygen therapy while a resident. <BR/>Record review of Resident #24's comprehensive care plan, dated 10/07/24, revealed Resident #24 required oxygen therapy related to heart failure. <BR/>Record review of Resident #24's current Physician Orders dated 01/03/23 revealed an order for oxygen to be administered continuously at 2 liters/minute per nasal cannula (tube in nostrils) every shift related to hypoxemia (low oxygen in the blood). <BR/>Record review of Resident #24's current Physician Orders dated 01/03/23, revealed an order to change oxygen tubing and prefilled humidifier water every Thursday and Sunday, or when visibly soiled.<BR/>During an observation on 10/15/24 at 11:01 AM, Resident #24 had oxygen being administered at 2 liters/minute via nasal cannula. Oxygen tubing was dated 10/07/24. <BR/>During an observation on 10/16/24 at 10:18 AM, Resident #24 had oxygen being administered at 2 liters/minute via nasal cannula. Oxygen tubing was dated 10/07/24.<BR/>Resident #42<BR/>Review of Resident #42's face sheet revealed an [AGE] year-old male with an admission date of 09/19/24 with the following diagnoses: Thrombosis of Aorta (blood clot blocking the artery that carries blood from the heart), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Gastroesophageal Reflux Disease (digestive condition), Hypertension (high blood pressure), Benign Prostatic Hyperplasia (enlargement of prostate gland).<BR/>Record review of Resident #42's annual MDS dated [DATE] revealed a BIMS score of 06, indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #42 used oxygen therapy while a resident.<BR/>Record review of Resident #42's comprehensive care plan, dated 10/09/24, revealed Resident #42 required oxygen therapy related to Chronic Obstructive Pulmonary Disease.<BR/>Record review of Resident #42's current Physician Orders dated 10/16/24 revealed an order for oxygen to be administered continuously at 2 liters/minute per nasal cannula (tube in nostrils) every shift related to Chronic Obstructive Pulmonary Disease.<BR/>During an observation on 10/15/24 at 11:01 AM, Resident #42 had oxygen being administered at 2 liters/minute via nasal cannula. Oxygen tubing was dated 10/07/24. <BR/>During an observation on 10/16/24 at 10:22 AM, Resident #42 had oxygen being administered at 2 liters/minute via nasal cannula. Oxygen tubing was dated 10/07/24.<BR/>2. Resident #26<BR/>Review of Resident #26's face sheet revealed a [AGE] year-old female with an admission date of 02/19/19 with the following diagnoses: Alzheimer's Disease (brain disorder), Respiratory Failure (condition where the blood has inadequate oxygen), Chronic Kidney Disease (condition causing kidneys to not function properly), Heart Failure (inadequate ability of the heart to pump blood) and Hypertension (high blood pressure). <BR/>Record review of Resident #26's annual MDS dated [DATE] revealed a BIMS score of 06, indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #26 used oxygen therapy while a resident.<BR/>Record review of Resident #26's comprehensive care plan, dated 10/09/24, revealed Resident #26 required oxygen therapy related to Chronic Obstructive Pulmonary Disease.<BR/>Record review of Resident #26's current Physician Orders dated 10/16/24 revealed an order for oxygen to be administered continuously at 2 liters/minute per nasal cannula (tube in nostrils) every shift related to Chronic Obstructive Pulmonary Disease.<BR/>During an observation on 10/15/24 at 10:39 AM, Resident #26 had oxygen tubing and humidifier water that was not dated. <BR/>During an observation on 10/16/24 at 10:26 AM, Resident #26 had oxygen tubing and humidifier water that was not dated.<BR/>Resident #30<BR/>Review of Resident #30's face sheet revealed a [AGE] year-old male with an admission date of 02/26/20 with the following diagnoses: Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Hypertension (high blood pressure), Polyneuropathy (damage to nerves), Gastro-Esophageal Reflux Disease (digestive disease), and Congestive Heart Failure (inadequate ability of the heart to pump blood).<BR/>Record review of Resident #30's annual MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. <BR/>Record review of Resident #30's comprehensive care plan, dated 04/06/24, revealed Resident #30 required oxygen therapy related to Chronic Obstructive Pulmonary Disease.<BR/>Record review of Resident #30's current Physician Orders dated 08/26/22 revealed an order for oxygen to be administered at 2-5 liters/minute per nasal cannula (tube in nostrils) as needed related to Chronic Obstructive Pulmonary Disease.<BR/>During an observation on 10/15/24 at 10:46 AM, Resident #30 had oxygen tubing and humidifier water that was not dated.<BR/>3. Resident #17<BR/>Review of Resident #17's face sheet revealed an [AGE] year-old female with an admission date of 12/13/21 with the following diagnoses: Respiratory Failure (condition where the blood has inadequate oxygen), Heart Failure (inadequate ability of the heart to pump blood), Dyspnea (difficulty breathing), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Hypokalemia (low potassium) and Cognitive Communication Deficit (communication difficulty caused by cognitive impairment).<BR/>Record review of Resident #17's annual MDS dated [DATE] revealed a BIMS score of 10, indicating the resident had moderate cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #17 used oxygen therapy while a resident.<BR/>Record review of Resident #17's comprehensive care plan, dated 09/09/24, revealed Resident #17 required oxygen therapy related to ineffective gas exchange.<BR/>Record review of Resident #17's current Physician Orders dated 10/16/24 revealed an order for oxygen to be administered at 2-3 liters/minute per nasal cannula (tube in nostrils) every shift related to heart failure.<BR/>During an observation on 10/15/24 at 10:14 AM, Resident #17 had nasal cannula and oxygen tubing laying on the floor. <BR/>Resident #16<BR/>Review of Resident #16's face sheet revealed an [AGE] year-old female with an admission date of 01/18/22 with the following diagnoses: Alzheimer's Disease (brain disorder), Pulmonary Embolism (blockage of lung artery), Cerebral Infarction (stroke), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Obesity (overweight), Dysphagia (difficulty swallowing), and Hypertension (high blood pressure).<BR/>Record review of Resident #16's annual MDS dated [DATE] revealed a BIMS score of 07, indicating the resident had severe cognitive impairment. <BR/>Record review of Resident #16's current Physician Orders dated 10/16/24 revealed an order for oxygen to be administered at 2 liters/minute per nasal cannula (tube in nostrils) every shift related to Chronic Obstructive Pulmonary Disease.<BR/>During an observation on 10/15/24 at 10:23 AM, Resident #16 had nasal cannula and oxygen tubing laying on the floor.<BR/>During an interview on 10/17/24 at 11:29 AM with LVN A, she stated oxygen tubing should be stored in bags which were to be placed by the night shift. She stated tubing should not be on the floor and it was everyone's responsibility to monitor that tubing was kept in bags when not in use. She stated oxygen tubing should be changed and dated every week on Sunday on the night shift. She stated a potential negative outcome for failure to properly change and store oxygen tubing is infection. <BR/>During an interview on 10/17/24 at 11:36 AM with CNA A, she stated oxygen tubing should not be on the floor. She stated oxygen tubing should be placed in a bag when not in use and everyone was responsible for making sure tubing is stored correctly. She stated a potential negative outcome of not storing oxygen tubing correctly was spreading germs. <BR/>During an interview on 10/17/24 at 01:38 PM with the DON, she stated the facility policy for changing oxygen tubing was that it was changed every Sunday on the night shift. She said the night shift charge nurse was responsible for changing and dating oxygen tubing weekly on Sunday. She stated nursing administration was responsible for assuring oxygen tubing was changed, dated, and stored according to physician's orders and facility policy. She stated nursing administration monitored the proper dispensing of oxygen by conducting rounds in the facility. She stated staff were trained on proper dispensing of oxygen through in services conducted by nursing administration. The DON stated a potential negative outcome for failure to properly change, date and store oxygen tubing according to physician's orders, was an increased risk for infection and inadequate oxygen therapy. <BR/>Record review of the facility-provided policy titled Departmental (Respiratory Therapy) -Prevention of Infection, revised November 2011, revealed:<BR/>Purpose<BR/>The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. <BR/>Preparation<BR/> .<BR/> 2. Assemble the equipment and supplies needed.<BR/>Steps in the Procedure<BR/> .<BR/> 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed.<BR/> 8. Keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use.

**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 2 of 2 staff (Dietary staffs A and B), for 1 of 1 kitchen and 1 of 1 Activity room, in that:<BR/>1)The facility failed to ensure Dietary staff (Dietary staff A and B) used sanitizers as directed and sanitizer levels were maintained and tested according to manufacturer recommendations;<BR/>2) The facility failed to ensure Dietary staff (Dietary staff A and B) used good hygienic practices during dietary duties, <BR/>3) The facility failed to ensure hot and cold TCS foods were maintained at 41 degrees F or below or 135 degrees F and above, <BR/>4) The facility failed to ensure foods and food contact equipment were protected from possible contamination (refrigerator, Activity room), <BR/>5) The facility failed to ensure foods were in sound condition (expired hardboiled eggs), and<BR/>6) The facility failed to ensure food and nonfood contact surfaces were clean (Activity room stove and shelving, scoop holder). <BR/>These failures could place residents at risk of food contamination and foodborne illness. <BR/>The findings include:<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 9:54AM and concluded at 10:18 AM:<BR/>Dietary staff A was asked to test the dish machine chlorine sanitizer level, and she took the chlorine test strip and placed it under the water draining from the dish machine from the wash cycle. She did not initially test the chlorine sanitizer in the rinse cycle. Interview with Dishwasher A on 7/19/22 at 10:18 AM, she stated that she had worked in dietary a month.<BR/>There was no chlorine sanitizer dispensing from the dish machine. The rinse temperature at the dish machine was 120&deg;F and the chlorine level was 0 PPM instead of between 50-100 PPM<BR/>Interview on 7/19/22 at 10:05 AM the Dietary Manager stated, two days ago staff said that the dishwasher was not working. They pressed the button, primer, and it worked. They will wash in a three compartment sink until the dishwasher is repaired.<BR/>There were two unshielded lights in the kitchen refrigerator. <BR/>Personal drinks with a straw were stored on the tea station counter.<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 10:36 AM and concluded at 11:00 AM:<BR/>During an interview on 7/19/21 at 10:36 AM, Dietary staff A stated, the dish machine chlorine dispensing tube came off. Observation at the time revealed that the chlorine sanitizer tube that entered the dish machine was broken in half. She stated they called the repairman.<BR/>Personal drinks with covers were observed on the [NAME] table of the one compartment sink. There was a bowl of potatoes in the sink.<BR/>There was a soiled apron and backpack hooked on an equipment rack where dishes were stored, and food equipment stored.<BR/>Observation of Dietary staff B handwashing revealed that she touched the soiled front of the paper towel dispenser after washing her hands and re-contaminated her hands. She then dried her hands, turned off the water with the paper towels and donned a pair gloves. She continued with dietary duties.<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 11:26 AM and concluded at 12:45PM:<BR/>Dietary staff B stated that she was preparing seven pur&eacute;es. She placed green beans in the processor and pur&eacute;ed it. She then washed her hands and during the handwashing process she touched the soiled front of the paper towel dispenser, recontaminating her hands. She dried her hands and placed the paper towel in her pocket. <BR/>Dietary staff B then washed the blender in the three-compartment sink, rinsed and then submerged it in the Ecolab Oasis 146 Multi Quat Sanitizer for only 20 seconds and then set it aside to dry. She then took the lid and did the same thing and then submerged the lid in the quaternary sanitizer for only five seconds and then took it out to dry. She cleaned a pitcher in the three-compartment sink and only submerged it in the sanitizing rinse for five seconds. Then she set it out to dry. <BR/>Record review of the Ecolab Oasis 146 Multi Quat Sanitizer wall chart (https://www.gofacilipro.com/wall-charts/oasis-146-wall-chart) dated 2015 revealed the following documentation, . 150-400 ppm quat range . Directions for use. Apply oasis 146 multi quat sanitizer at proper use solution. Expose all surfaces of equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry <BR/>Record review of the label of the Oasis 146 Multi Quat sanitizer revealed the following, Directions for Use .expose for one minute . <BR/>Dietary staff B rewashed the blender container in the three-compartment sink and then submerge it in sanitizer for 10 seconds and then set it on the drain table to dry.<BR/>Dietary staff B washed her hands and touched the soiled front of the paper towel dispenser again which re-contaminated her hands. She then dried her hands, donned gloves and continued with dietary duties. She continued to process foods (pureed pasta and tomato sauce).<BR/>Temperatures were taken on the service line steamtable by Dietary staff B with the following results: <BR/>Ziti with beef 137.3&deg;F <BR/>Green beans 184&deg;F <BR/>Tomato sauce 100.2&deg;F<BR/>Pur&eacute;ed [NAME] beans 164&deg;F <BR/>Pur&eacute;ed ziti 164&deg;F <BR/>Mashed potatoes 113.7&deg;F. It was placed in an area of the steam table that had an open space.<BR/>Toasted bread 128&deg;F<BR/>Cucumber salad was on ice and was 47.5&deg;F<BR/>Lettuce salad was on ice and was 53&deg;F<BR/>Egg salad was 53.6&deg;F and the ice in the pan it was sitting in was melted. There was only a few scattered pieces of ice. The egg salad sandwiches were also in this pan of melted ice and it was 62.5&deg;F<BR/>On 7/19/22 at 12:11 PM the Dietary staff B was asked how the mashed potatoes were made. She stated, with milk and butter. It's a mix.<BR/>On 7/19/22 at 12:12 PM Dietary staff B covered the open space on the steam table with plastic.<BR/>On 7/19/22 at 12:13 PM Dietary staff B was asked when the egg salad was made. She stated the egg salad was made at 11:10 AM.<BR/>The meal service started at 12:15 PM. The mashed potatoes were not rapidly reheated to 165 degrees F and held at 135 degrees F or above. Adequate ice was not placed in the pan used to hold the egg salad foods at the steam table. <BR/>Observation of a container of Peeled Hard Cooked Eggs 10 pound was on a prep table. Further observation of the container revealed the following, Use by 13 July 2022.<BR/>On 7/19/22 at 12:19 PM the Dietary Manager and Dietary staff B were asked if these hard cooked eggs have been used to make the egg salad sandwiches and egg salad. They both stated yes.<BR/>On 7/19/22 at 12:37 PM an interview was conducted with the Dietary Manager about the expired hard-boiled eggs. She stated that she got the eggs at the store on 7/06/22 and marked it 7/06/22. She added that she did not see the use by date. She stated that when a delivery truck comes, she marks the date she gets the food.<BR/>Dietary staff A was observed washing her hands at the hand sink and she also touched the soiled front of the paper towel dispenser in order to dispense more towels. She used the towel and then continued to dry her hands with it. She donned a pair of gloves and handled condiments and insulated lids and covered trays.<BR/>On 7/19/22 at 1:15 PM an interview was conducted with the Dietary Manager. She stated that none of the egg salad was served.<BR/>~ The following observations were made during an Activity room tour that began on 7/19/22 at 1:00 PM and concluded at 1:12 PM:<BR/>On 7/19/22 at 1:00 PM an observation was made of the activity room sink area. There were boxes of bag chips stored under the drain line of the sink. Utensils and pans were inverted on a cloth towel on top of the small refrigerator. There was a dead bug on the towel. <BR/>The oven interior and browner area were soiled with dried food and dead bugs.<BR/>The cabinets had an uncovered portion cup of pepper and uncovered cup of oil. <BR/>The lower cabinets had dried spills.<BR/>On 7/19/22 at 1:13 PM an observation was made of the corridor ice machine room. The ice scoop holder was dirty on the interior and had an accumulation of sediment and water in the bottom of it.<BR/>On 7/21/22 at 8:46 AM the ice machine corridor's scoop Holder was still dirty with settlement at the bottom and wet.<BR/>~ The following observations were made during a kitchen tour that began on 7/21/22 at 11:41 AM and concluded at 1:07 PM:<BR/>Temperatures were taken by Dietary staff B. Temperatures were as follows: <BR/>Mac & cheese 167&deg;F <BR/>Stewed tomatoes 185&deg;F <BR/>Brown gravy 163&deg;F<BR/>Pur&eacute;es stewed tomatoes 169&deg;F <BR/>Pur&eacute;e macaroni and cheese and 167&deg;F <BR/>Mashed potatoes 125&deg;F. <BR/>On 7/21/22 at 11:20 AM Dietary staff B was interviewed as to how she made the mashed potatoes. She stated that she used milk and butter in it.<BR/>Peas 140&deg;F <BR/>Hamburger patties 120.7&deg;F.<BR/>White gravy 173&deg;F <BR/>Sliced bread<BR/>The refrigerator had unshielded lights as before.<BR/>Meal service ended at 12:49 PM. At 1:02 PM, the surveyor requested that they take temperatures on the service line. It was noted that the ground hamburger was not on a heat source on the steam table and was placed on a ledge of the steam table. <BR/>On 7/21/22 at 1:05 PM the ground hamburger was 106 degrees Fahrenheit. The temperature of the mashed potatoes was 140 degrees Fahrenheit. The hamburger patties were 106 degrees Fahrenheit. These TCS foods were not rapidly reheated to 165 degrees F. and held at 135 degrees or above.<BR/>On 7/21/22 at 4:54 PM an interview was conducted with the Dietary Manager regarding issues in the kitchen. Regarding the incorrect testing of the dish machine, she stated Dietary staff A was nervous, but did not know why she did it. She stated that she had conducted training on dish washing and testing. She was also told about hand washing and staff touching the paper towel dispenser and contaminating their hands. She stated she told staff not to touch the dispenser. She added that temperatures on the steam table should not be below 135 degrees Fahrenheit. She further stated that staff knew to reheat foods if they are cold. She stated if the above-mentioned issues continued in dietary, it could result in foodborne illness. She was also told about the holder for the ice maker ice scoop being dirty. She stated she thought the housekeeping department was responsible for cleaning it. <BR/>On 7/21/22 at 5:20 PM an interview with conducted with the Administrator. She stated the issues with dietary sanitation could result in affecting resident satisfaction. She was also asked what she expected from the dietary staff regarding these issues, and she stated they should correct issues on the spot. <BR/>On 7/25/22 at 4:30 PM and interview was conducted with the Activity Director regarding the activity room foods. She stated that the foods present were used for residents but they had thrown everything away after the survey. <BR/>Record review the facility policy titled Food: Preparation, HCSG Policy 016, Original 5/2014, Revised 9/2017 revealed the following documentation, Policy Statement. All foods are prepared in accordance with the FDA Food Code. <BR/>Procedures. <BR/>1. All staff practice proper handwashing techniques and glove use. <BR/>2. Dining services staff will be responsible for food preparation, for food procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. <BR/>3. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. <BR/>4. The Dining Services Director/Cook(s) Will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41&deg;F and/or less than 135&deg;F, or per state regulation . <BR/>9. The Cook(s) will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. <BR/>10. Time/Temperature Control for Safety (TCS) hot food items will be cooked to a minimum internal temperature for 15 seconds, as follows: <BR/>Poultry and stuffed foods 165&deg;F<BR/>Ground meat 155&deg;F<BR/>Fish, pork, other meats 145&deg;F . <BR/>11. When hot pur&eacute;e, ground, or diced food drop into the danger zone (below 135&deg;F), the mechanical [NAME] altered food must be reheated to 165&deg;F for 15 seconds if holding for hot service. <BR/>12. When reheating, foods will be rapidly heated to 165&deg;F for 15 seconds. If the food is not reheated within two hours it must be discarded. <BR/>13. All foods will be held at appropriate temperatures, greater than 135&deg;F (or as state regulations require) for hot holding, and less than 41&deg;F for cold food holding. <BR/>14. Temperature for TCS foods will be recorded at time of service and monitor periodically during meal service. <BR/>15. All staff will use serving utensils appropriately to prevent cross-contamination. <BR/>16. Prepare hot food items that are not intended for immediate service will be cooled using the following guidelines: <BR/>Place in shallow pans or cut/slice to promote rapid cooling.<BR/>TCS foods will be cooled from 135&deg;F to 70&deg; Fahrenheit within two hours.<BR/>TCS foods will be cool from 70&deg;F to 41&deg;F with them 4 hours.<BR/>Total cooling time cannot exceed six hours. The clock starts at 135&deg;F.<BR/>17. All TCS foods that are to be held for more than 24 hours at a temperature of 41&deg;F or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 7 of 8 refrigerators reviewed for food safety (room [ROOM NUMBER],209 211, 212,214, 216, and 218) in that:<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator. Inside of the refrigerator was a parfait, two cokes, an uncovered cookie, and an undated cupcake. <BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator. Inside of the refrigerator was an open coke, leftover takeout, and a bowl of sealed queso cheese. All food was undated.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>This failure could place resident at risk for food borne illnesses.<BR/>Findings include:<BR/>An observation during the duration of the survey (09/06/23-09/08/23) revealed the following:<BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. I observed a bag of nuts and licorice candy that were unlabeled.<BR/>room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. Inside was an open coke, leftover takeout, and a bowl of sealed queso cheese. All food was undated.<BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. An observation of a parfait, two cokes, an uncovered cookie, and an undated cupcake. <BR/>During an interview on 09/08/23 at 11:21 AM, the ADM said that family and residents are responsible for cleaning their fridges and monitoring the temperatures. He said although housekeeping would clean the outside, the contents were the residents and their family's responsibility. When asked who would be responsible for resident fridges if the resident was unable to and did not have family, he said the staff would have to. He said the previous company had the staff clean the outside of the fridge, including wiping it down, but not monitoring the temperature. He said he was not sure if this was covered in the policy. He said he was unsure if the residents were told during admission and that this information was not part of the admission packet. He said if the resident's refrigerators were not monitored, the potential negative outcome could be foodborne illness. He said he would have to check with his upper management regarding the expectation for the resident refrigerators. <BR/>During an interview on 09/08/23 at 12:32 PM, the DM said regarding the residents' refrigerators, the housekeepers are responsible for cleaning the refrigerator inside and out. She said the kitchen staff are not allowed in the residents' room. <BR/>Record review of the facility's policy titled Operational Policy and Procedure Manual for Long Term Care, undated revealed:<BR/>Food brought by Family/ Visitors (Revised March 2022)<BR/>Policy Statement<BR/>Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice<BR/>and a homelike environment with the nutritional and safety needs of residents.<BR/>4. Safe food handling practices are explained to family/visitors in a language and format they understand.<BR/>5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a<BR/>manner that it is clearly distinguishable from facility-prepared food.<BR/>a. Non-perishable foods are stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may<BR/>be stored without a lid.<BR/>b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator.<BR/>Containers are labeled with the resident's name, the item and the use by date.<BR/>6. The nursing staff will discard perishable foods on or before the use by date.<BR/>7. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious<BR/>signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration<BR/>dates).<BR/>8. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer<BR/>than 2 hours are discarded.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and 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 disease and infections for 4 of 17 residents (#25, 40, 43 and 101), in that:<BR/>1) <BR/>Improper hand hygiene and personal protective equipment was observed during incontinent care for 3 residents, Resident #25, Resident #43, and Resident #40.<BR/>2) <BR/>Failures to routinely clean/disinfect environmental surfaces in both patient rooms and common areas, as well as resident care equipment were documented.<BR/>3) <BR/>Unclear identification of proper transmission-based precautions (TBPs) was observed for Resident #101, who was on COVID quarantine due to recent return to the facility and vaccination status. Facility did not post proper Centers for Disease Control and Prevention (CDC) category of isolation for this resident, neither COVID isolation nor enhanced droplet-contact.<BR/>4) <BR/>Improper selection and use of personal protective equipment (PPE), including donning and doffing of PPE based on national standards set forth by the CDC.<BR/>These failures to follow proper infection prevention procedures place residents in the facility at risk of exposure to and transmission of communicable diseases and healthcare associated infections that can lead to an increased risk of serious illness, hospitalization. <BR/>Findings include:<BR/>Resident #101:<BR/>Record review of Physician Orders Summary and face sheet for Resident #101 revealed that he was admitted to the facility initially on 6/10/22 and was re-admitted on [DATE]. The resident was [AGE] years old and had a diagnoses of Essential (Primary) Hypertension, End Stage Renal Disease, Hemiplegia, Unspecified Affecting Left Nondominant Side, Unspecified Cirrhosis Of Liver, Acidosis, Hepatic Failure, Unspecified Without Coma, Anemia In Other Chronic Diseases Classified Elsewhere, Personal History Of Transient Ischemic Attack (Tia), And Cerebral Infarction Without Residual Deficits, Flaccid Hemiplegia Affecting Left Nondominant Side, Unspecified Abnormalities Of Gait And Mobility, Muscle Wasting And Atrophy, Not Elsewhere Classified, Unspecified Site, Other Dysphagia, and Cognitive Communication Deficit.<BR/>Record review of the physician's Order Summary for Resident #101 revealed an order stating, Isolation for 10 days for COVID protocol. every shift for covid prevention monitoring until 07/26/2022 at 23:59, Phone Active 07/16/2022, Start Date 07/18/2022, End Date 07/26/2022 .<BR/>Observation on 7/19/22 at 10:19 AM a resident tour was conducted on Hall 100. Resident #101 resided in room [ROOM NUMBER]. He was a re-admit. He has 3 signs posted on his door related to donning and doffing PPE instructions. There was a PPE cart present outside his door with Sani wipes and open boxes of gloves on top of the cart. There were N95 masks in the cabinet, gowns and face shields. The resident was in bed and the door was a jar. <BR/>On 7/19/22 at 10:30 AM an interview was conducted with LVN B regarding the residents on hall 100. She stated the Resident #101 was a readmit from the hospital on 7/16/22 and that he has end stage renal disease. She said he was on dialysis Monday, Wednesday, Friday and was very confused. He used a wheelchair due to hemiplegia and that he went to the hospital due to vomiting blood and had a G.I. bleed. She added that the hospital kept him a while. She said he also had a diagnosis that included liver cirrhosis.<BR/>Observation on 7/19/22 at 12:59 PM. Resident #101 was observed in bed, awake and the door was open.<BR/>Observation on 7/19/22 at 4:07 PM of room [ROOM NUMBER], there was no posted documentation of any kind as to what type of precautions the Resident #101 was on. CNA A exited the resident's room and disposed of her face mask in the corridor in the trashcan that was not covered. <BR/>Observation on 7/19/22 at 4:12 PM LVN C left room [ROOM NUMBER] and placed the N95 mask in the corridor trashcan which was not covered. <BR/>Observation on 7/21/22 at 10:33 AM Resident #101 was in the room and the door was open to his room.<BR/>On 7/21/22 at 4:20 PM an interview was conducted with NA B. She was asked about infection control regarding Resident #101. She stated staff were told to don all PPE including a shield, gloves, gown upon entering room [ROOM NUMBER]. She added staff should remove all the PPE prior to exiting the room and don't keep the door open. She said she learned that today from a surveyor. She stated she had been told that Resident #101 was on precautions because he's a new resident and on restrictions for COVID for two weeks. She added that she did not know if they specified the type of precautions. <BR/>On 7/21/22 at 4:31 PM an interview was conducted with LVN A. She stated when entering room [ROOM NUMBER], staff should wear a gown, mask, and gloves. She added that the facility did not have face shields. She stated that she just wears her face mask now. This is the one they say is for contact with him. She was asked what type of precautions Resident #101 was on. She stated staff were told just isolation. She added that she thought he was on airborne precautions.<BR/>On 7/21/22 at 4:34 PM an interview was conducted the DON regarding infection control. She stated that Resident #101 was on droplet precautions for COVID. She added she told staff to wear a gown, gloves, N95, surgical mask, face shield. If they have on face shield, they only have to wear a face mask or the option for N95. She stated the facility had face shields. She stated if staff failed to wear proper PPE, cross contamination could occur.<BR/>Observation on 7/21/22 at 4:45 PM revealed room [ROOM NUMBER] had a sign regarding specific precautions for Resident #101. The sign was dated March 2020 which stated the resident was on Enhanced Droplet-Contact Precautions.<BR/>Observation ;on 7/21/22 at 4:45 PM of the sign posted on Resident #101's room:<BR/>Enhanced droplet - contact precautions.<BR/>Perform hand hygiene<BR/>N95 or surgical face mask when entering room.<BR/>Eye protection when entering room.<BR/>Gown when entering room.<BR/>Gloves when entering room.<BR/>Private room and keep door closed . Spice 3/20 . Effective: March 20, 2020 .<BR/>During an observation of incontinent care on 07/20/22 at 8:27 am with CNA B for Resident #25, CNA B did not wash hands or wear gloves prior to gathering clean supplies for incontinent care. CNA B explained to Resident #25 the procedure that she would be helping the resident with. CNA B proceeded with incontinent care without washing her hands. CNA B placed on clean gloves to remove the front of the brief by pulling the brief down. CNA B used individual wipes with the one swipe method to provide incontinent care for Resident #25 by starting on the right side, then the left side, then the middle. CNA B removed the dirty gloves and placed on new pair of clean gloves without performing hand hygiene and rolled the resident to the right side and removed the remainder of the dirty brief and placed it in the designated trash. CNA B used individual wipes and the one swipe method to provide cleaning to the back side of the resident. CNA B then grabbed the clean brief and placed underneath the resident and then placed Resident #25 on her back. CNA B fastened the brief in the front. CNA B discarded all trash in the designated trash bag. CNA B her washed hands for 37 seconds using soap and water. CNA B then grabbed one paper towel and dried both hands and then used the same paper towel to turn off the water. <BR/>During an observation of incontinent care on 07/20/22 at 9:20 am with CNA C for Resident #43 in room [ROOM NUMBER], CNA C could not shut the door because the bed was too long. CNA C, with helper was CNA B. CNA C washed hands after last resident, gathered supplies in a clear bag, explained the procedure to the resident. CNA B washed hands correctly. CNA C - got soap while dripping water on floor, used dirty napkin from drying hands to turn off waterspout; provided privacy. CNA C used hand sanitizer, opened clean trash bag, put on clean gloves (both CNAs). CNA C opened clean brief on supply table, pulled back covers, lowered bed. Did not use gait belt to move resident, placed resident on back, raised bed, CNA C removed gloves, placed on new gloves, took off gloves, touching open clean brief with bare hands. CNA C had to leave room to get more gloves, not enough supplies, came back to room and washed hands shaking water off hands. Used dirty paper towel from drying hands to turn off waterspout. Placed on clean gloves, turned resident to one side to remove pants, took off dirty brief, used 1 wipe to wipe upper roll, 1 swipe method used 1 wipe, wiping top to bottom, 1 swipe method, finished removing dirty brief, wiping bottom, 1 swipe method, disposed of brief, did not use hand sanitizer after dirty brief to clean brief. She placed on clean gloves and replaced with clean brief. Gathered trash, CNA B used hand sanitizer, then washed her hands. CNA C went to wash her hands. CNA C used 1 paper towel to dry her hands and used the same paper towel to turn off the waterspout, did not use gait belt to move resident back to chair.<BR/>During an observation of incontinent care on 07/20/22 at 9:39 am with NA C for Resident #40 and helper - NA (Nurse Aid) A did not wash hands prior to gathering supplies; gathered supplies with bare hands. NA A washed hands, NA C washed hands, removed covers, gathered wipes and placed on bed; provided privacy, placed cover sheet over resident, removed dirty brief, used 1 swipe method 1 wipe, top to bottom, vagina, turned resident to right. Finished removing dirty brief, 1 wipe - 1 swipe method, put clean pad and clean brief under resident, placed on clean brief, did not use hand sanitizer. Did not change gloves. Did not wash hands after procedure.<BR/>In an interview on 07/20/22 at 10:26 am with CNA C, for failing to wash hands correctly while providing incontinent care. CNA stated that she has been trained in handwashing. CNA stated that the training occurs monthly and that the DON is responsible for making sure that the training is completed. CNA stated that she does understand where she went wrong and was not thinking, so she made a mistake. CNA stated that she didn't realize that she could not use the same napkin that dried her hands to turn off the sink spout. CNA stated that the negative potential outcome of not providing handwashing for the residents and staff would be the transmission of infection. CNA stated that it reduces the safety of staff and residents. CNA stated that by slowing down and thinking about her steps would help her to correct the problem and maybe some additional training. <BR/>In an interview on 07/20/2022 at 10:32 am with NA C for failing to wash hands correctly while providing incontinent care. NA stated that she has been trained in handwashing techniques. NA stated that she thinks the training is supposed to be every couple of weeks but is not certain on the time frame. NA stated that the training includes skills checks and computer training. NA stated that the DON is responsible for making sure that staff completes their training. NA stated that she messed up on remembering to do her handwashing because she was nervous. NA stated that the potential negative outcome of not providing hand washing for the residents and staff would be the spread of germs. <BR/>In an interview on 7/20/2022 at 10:41 am with CNA B, for failing to wash hands while providing incontinent care. CNA stated that she has been trained in handwashing and the facility provides weekly training for handwashing. CNA stated that she didn't realize that she needed to wash her hands prior to gathering supplies but she knows now. CNA stated that she is new and still learning. CNA stated that the potential negative outcome for not washing hands would be that she could cause cross contamination to other residents or even take germs home to her family. <BR/>In an interview on 07/20/2022 at 10:57 the DON stated that she will in service the three CNAs on hand washing. DON stated that the staff is provided monthly skills checks and computer training. DON stated that she will randomly pick different staff to do skills checks every month and each month is different staff members. DON stated that she will get with these staff members and provide further education. The DON stated that she expects that staff members wash their hands and wash them correctly while providing incontinent care. The DON stated that the negative potential outcome for not washing hands would cause cross contamination.<BR/>In an interview on 7/19/22 10:17 am room [ROOM NUMBER] Resident 22 stated that her sheets are visibly soiled. She stated the sheets are not changed often but did not recall a frequency.<BR/>In a follow-up observation on 07/19/22 at 1:25 pm, after the food arrived, a brief walkabout the room revealed 15 separate flies in the dining room.<BR/>In an observation on 7/19/22 at 3:26 pm, the restroom between rooms [ROOM NUMBERS], the toilet seat was stained and has visible blood; no residents are currently assigned to this room.<BR/>In an observation on 7/19/22 at 3:30 pm, in the Piano Room surveyor observed 4 mechanical lifts being stored in this room. Of the 4 Hoyer lifts, one was noted to have 10 separate areas of blood contamination and multiple other areas of the square are visibly contaminated with smears of yellow dried fluid and chunks of unknown substances. Over 70% of the blue square was visibly soiled on the part of the lift where the resident stands, the blue square at the bottom. In addition, there was visible blood spatter on the 2 blue pads that make direct contact with the residents' legs. In addition, a bottle of Pine-sol cleaner was stored in the cabinet next to empty plastic food containers that are re-usable. A total of 5 Hoyer batteries were noted in this room, 2 on the counter next to the sink and 3 on a bookshelf next to the piano; all 5 batteries were visibly and grossly contaminated with blood. <BR/>In an interview and observation on 7/20/22 at 11:25 am in room [ROOM NUMBER] with Resident #49, she stated her privacy curtain was replaced and she was told it was because someone was documenting the blood on the curtain the previous day. Surveyor told the resident that I had done that. She stated the blood was present since she admitted , so about 3 weeks. The floor is also clean today, food and blood clean. <BR/>In an interview on 7/20/22 11:52 with Resident #7's family member, she stated the only issues she has ever noticed is general cleanliness of building and not always enough staff to get to everyone timely, but they come when they can and are always very kind. Upon arrival she has found Resident #7 wet, but the staff respond immediately to care for her when she hits the call light. She stated Resident #7 has not had any rashes or skin breakdown and the facility calls her and notifies her of changes to her mother's condition. <BR/>In an observation on 7/20/22 12:13 pm a live spider noted to be in cabinet in room surveyors are meeting in on the 100 hall (room lacks a posted room number, but is next to room [ROOM NUMBER], closer to front of the building).<BR/>In an observation on 7/20/22 at 5:00 pm as the surveyor walked out of the building, a resident in a wheelchair was observed to be in the piano room next to the Hoyer Lift with blood and other contamination. In addition, the contaminated Hoyer from 7/19/22 and 1 other Hoyer have both been moved from their position on 7/19/22. Surveyor observed 1 Hoyer being transported down a resident hall. A blood drop was noted on same wall. <BR/>In an observation on 7/21/22 at 9:56 am two ceiling tiles were observed in the back dining room that were visibly soiled.<BR/>In an interview on 7/21/22 at 11:55 am with DON about Hoyer lifts, she stated they should be cleaned after each resident, and they are owned and serviced annually and as needed by a medical supply. She explained after admission and quarterly nurses evaluate transfer status of each resident. If the resident is a 3 they use a stand assist Hoyer (which is the type that was noted to be contaminated with blood) and a 4 they use a total assist Hoyer. When asked for policies related to Hoyers, the DON said she did not think they had one but would bring it if she found one. At 4:45 pm a policy was provided for lift systems (Hoyer).<BR/>In an interview and observation on 7/21/22 at 12:45 pm with Resident #49, a visible spot of contamination on the ceiling next to the new privacy curtain was observed and a staff member was informed and stated she would have someone clean it as soon as possible. Surveyor asked to test water temperature in the restroom and found it was 122 degrees Fahrenheit. Two flies were observed near the resident and her tray of food that was on her over the bed table.<BR/>In an observation on 7/21/22 at 2:10 pm at the meeting of the 100 hall and the main entry hallway, a large beetle was observed crawling through the hallway.<BR/>Transmission-based precautions & personal protective equipment (PPE):<BR/>On 7/19/2022 at 1:06 pm an observation of room [ROOM NUMBER], which houses a resident on quarantine who recently returned to the facility and is not vaccinated, revealed 2 signs were posted on the door outside of the room and 1 sign on the wall above the PPE container. The signs demonstrated proper donning and doffing of PPE, but no sign was present showing what precautions, based on the CDC categories of transmission-based precautions, the resident was placed on.<BR/>On 7/19/22 at 12:52 pm an observation revealed no gloves were in the PPE box where glove box should be.<BR/>On 7/19/22 at 1:45 pm outside of room [ROOM NUMBER], the only isolation room, the container of caviwipes outside of room on the PPE cart had a yellow sticky substance on the lid to the container. In addition, several vinyl clear gloves were on the PPE cart in a box marked not for medical use. Housekeeper A left isolation room wearing a surgical mask for the covid quarantined resident instead of the appropriate n95 mask. In addition, the door was open to this room. Surveyor looked inside the room to see where PPE was being discarded and noted two large yellow trash bins on the far wall in the patient zone, so Surveyor spoke to DON about proper doffing of PPE and disposal of the PPE should be in the resident room right next to the exit.<BR/>On 7/20/22 at 10:05 AM an observation was made of isolation room yellow barrels in the corridor in hall 100 while Housekeeper A was inside room [ROOM NUMBER] cleaning. Resident #101 resided in this room and was on contact and droplet precautions. The housekeeper was going in and out of the room, into the corridor, wearing her face mask, face shield, gown and gloves. She was cleaning in the room and had on a face shield with the facemask. There were no guidelines on the door excepted to CDC don and doff infographics which stated to doff inside the resident room. <BR/>When Housekeeper A came out of the room into the hall, she was handling her badge with her gloves on and she still had on her gown, facemask. She doffed in the corridor removing her gloves, face shield and gown and disposed of the in the yellow barrels. She then took the trash from the yellow barrels to the dumpster.<BR/>On 7/20/22 at 10:30 AM an interview was conducted with Housekeeper A with interpreter CNA A. She stated a gown, mask, gloves, and face shield were worn when entering an isolation room. She added that she was told to wear a face shield and N95 mask. She stated she was not wearing an N95 mask because she forgot and was nervous. <BR/>On 7/21/22 at 9:38 AM Housekeeper A was observed doffing gown and gloves in the corridor again and putting her gown and gloves in the trash bin on her housekeeping cart in the corridor.<BR/>On 7/21/20 to 9:40 AM an interview was conducted with Housekeeper A and she stated that they have been told to doff in the corridor outside of the room. Observation of the housekeeper cart trash bin revealed that there was an N95 mask and gown in the trash bin.<BR/>On 7/21/22 at 4:00 PM an interview was conducted with the Housekeeping District Manager in the absence of the facility Housekeeping/Laundry Supervisor. She stated the Facility Housekeeping Laundry Supervisor said staff were educated on infection control. Staff were to wear PPE which included an N95 mask, face shield and gown when cleaning isolation rooms. Before they crossed the threshold, they take everything off in the room. She added she had stopped and asked all of housekeeping staff about infection control. She stated she talked to Housekeeper A yesterday and the housekeeping staff were in-serviced on infection control. She added that not following infection control protocols exposes everyone to infections. She stated it would lead to more residents getting ill and it was important to use proper PPE.<BR/>Record review of the In-Service Record Log dated 7/20/22 at 1:00 PM delivered to the Housekeeping Department, Subjects: Proper wearing PPE in isolation rooms, Locking carts, N95 mask. The following documentation was listed under the Summary of Subject Material Covered: PPE - when and why we wear it. Isolation rooms - How to clean and what we wear. N95 mask - What they are used for and when to wear them .<BR/>Record review of the policy titled Lift, Transfer and Repositioning Policy published in 2010 by Sava Senior Care Administrative Services, LLC, the policy states all lift equipment shall be used and maintained in accordance with Manufacturers' instructions. The policy further states in the section titled Safety Committee that the Safety Committee's responsibilities will include b. Ensuring proper maintenance and storage of existing mechanical lifting devices. Cleaning of the device was not specifically addressed as the policy focused on proper use and safety related to the staff and resident use of the device.<BR/>Record review of the posted CDC posters on Resident #101's room revealed the following:<BR/>Sequence for Putting on Personal Protective Equipment . The type of PPE use will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE .CDC<BR/>How to Safely Remove Personal Protective Equipment Example 1 . There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes would potentially infectious materials. Here is one example. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Remove PPE in the following sequence . CDC<BR/>How to Safely Remove Personal Protective Equipment Example 2 . Here is another way to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient's room and closing the door. Remove PPE in the following sequence .CDC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility must maintain an effective pest control program so that the facility was free of pests, in the dining room, piano room and 3 of 16 resident rooms (201, 207 and 215), in that:<BR/>The facility failed to provide an effective pest control program for flies and insects in the facility.<BR/>These failures could place residents at risk for vector-borne diseases.<BR/>The findings include:<BR/>In an observation on 07/19/22 12:02 pm 3 surveyors arrived in dining room for resident observation of dining. Two light-based insect killing machines are present and neither were on; surveyor asked Maintenance Supervisor to plug the bug zapping lights. One machine had no plug attached and one was found and both lights (one on either side of the dining room) were plugged in and began functioning. 12 flies were observed in the dining area during at this time.<BR/>In an observation on 07/19/22 1:20 pm a fly was noticed on the support column, next to Resident #27, about 4 inches from the hand sanitizer installed on this column. At the same time, a fly was noted on Resident #35 in the dining room.<BR/>In an observation on 7/19/22 at 3:30 pm, in the Piano Room, multiple various bug carcasses were in cabinets and on the floor in this room. When surveyor opened a small white cabinet above the sink, 2 bug carcasses fell to the counter. One fly swatter was hanging on the wall and one was on top of the white cabinet above the sink.<BR/>In an interview and observation on 7/20/22 at 11:25 am in room [ROOM NUMBER] with Resident #49, 1 fly was observed in the resident room and resident commented that the facility had multiple flies in multiple rooms; resident stated that she went to the restroom this morning around 3 am and saw a cockroach in her restroom and held up her fingers to show size, 1.5-2.0 inches. Resident stated this is a normal experience in her restroom. On 7/20/22 at 11:31 am, surveyor opened restroom door and observed baby roach under toilet. In a corner under toilet there was a 1-2-inch gap between the wall and the base board that extends from the corner for about 8 inches.<BR/>In an interview on 7/20/22 at 1:08 pm with Resident #30 in room [ROOM NUMBER], she has fly swatter next to bed and says said flies are a constant issue that was worse at night or when she was lying in bed.<BR/>In an interview on 7/21/22 at 10:03 am with Resident #22 in room [ROOM NUMBER], we both noticed a fly, and she stated that she sees them often, especially in the dining room. She said one in her room was very friendly and follows her even to the restroom. Resident named the fly [NAME] and surveyor left to ask the DON for a fly swatter so Resident could kill [NAME] the Fly. The DON had a fly swatter and left to provide it to Resident #22.<BR/>Record review of the facility policy titled Operation 4: Nursing Operations - The Source, Chapter: Infection Control, Revision Date: December 2021, OP4 0825.00, Pest Control, revealed the following documentation, To provide an environment free of pest, the center will maintain a pest control contract that provides frequent treatment of the environment for pest. The contract will allow for additional visits by the pest control service when a problem is detected. The center will include bedbug extermination and expertise of the contractor in the choice of pest control contracted services.<BR/>Pest control program emphasis will be placed in kitchens, dining areas, laundries, central supply, loading dock/areas, construction activities, and other areas prone to infestations such as areas of overgrowth in adjoining property. To reduce the potential for pest to enter the center through windows that open to the outside, screens will be maintained. If no screens are present the window should not be opened.<BR/>Center staff will monitor the environment and properly report pest control problems to the supervisor, administrator, or Maintenance Director for action .

Based on Interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property for 2 of 5 (Hospitality Aide A and B) new hired employee's files reviewed background checks.<BR/>A. <BR/>The facility failed to complete criminal background, EMR and NAR checks on Hospitality Aide A before her employment date of 06/12/24.<BR/>B. <BR/>The facility failed to complete criminal background, EMR and NAR checks on Hospitality Aide B before her employment date of 06/12/24.<BR/>This failure could place residents as risk for abuse, neglect and exploitation. <BR/>Findings included:<BR/>Record review of Hospitality Aide A's Employment Work Agreement signed and dated 06/12/24, revealed that they were full time employees working 30-40 hours weekly.<BR/>Record review of Hospitality Aide A's time sheet's dated 06/24/24-08/24/24 revealed that her first date to work in the facility was 06/24/24 and she worked Monday through Friday from 7:00 AM-3:00 PM except for the following dates: 07/05/24 and 07/23/24. <BR/>Record review of Hospitality Aide B's Employment Work Agreement signed and dated 06/12/24, revealed that they were full time employees working 30-40 hours weekly. <BR/>Record review of Hospitality Aide B's time sheet's dated 06/24/24-08/24/24 revealed that her first date to work in the facility was 06/17/24 and she worked Monday through Friday from 7:00 AM-3:00 PM except for the following dates: 07/26/24. <BR/>During an interview on 08/07/24 at 1:55 PM, Hospitality Aide A stated she had worked at the facility for a couple of months and was contracted through an outside party to work there. She said before 08/07/24, she had not signed the new employee checklist or had her background checked. She stated she was unaware that her background had not been completed before she worked at the facility because she thought the outside party that connected her with employment had all her paperwork completed for her to work. She stated she signed the paperwork at the facility today to have her background checked and to show that she had been trained regarding ANE. She said her training included shadowing another CNA. She said she believed the ADM and the DON were responsible for completing her background before working. <BR/>During an interview on 08/07/24 at 1:59 PM, Hospitality Aide B stated she signed the ANE contract and was told on 08/07/24 that her background would be completed. She said that her background had not been completed, nor had she signed the ANE checklist before 08/07/24. She stated she did not know why it was important to have her background checked prior to working with residents. She stated that she did not have a criminal background.<BR/>During an interview on 08/07/24 at 2:04 PM, the DON stated the potential negative outcome of not checking the two hospitality aides' backgrounds before they worked at the facility was that they could be felons and potentially hurt the residents. She stated she would have to look at the facility policy. Still, she assumed it stated that anyone working at the facility had to have their background checked before working with the residents. She also stated it included hospitality aides. She stated she was unaware that the two hospitality aides' criminal backgrounds had not been completed before they worked. She stated she had observed the two aides working around residents but not providing personal care. She stated they don't provide actual care to the residents but have access to the residents. She stated the ADM was usually responsible for completing the criminal background, EMR, and NAR on all staff at the NF. She stated the Former ADM left on 08/02/24, and the ADM came on 08/05/24. She stated that the outside party did not complete a criminal background, EMR, and NAR because she asked the Career Consultant about it and said she had not. The DON stated she did not know how long the two aides had been working at the facility because ADON usually handled the workers that came from the outside party. She said the purpose of completing criminal backgrounds, EMR, and NAR was to keep residents safe. She stated they did not complete the criminal background because they thought the outside party ran them. She said the system to monitor criminal backgrounds, EMR, and NAR checks was the ADM conducted them all. She stated no one outside of the Former ADM ran the checks. She said she had been trained to ensure that all workers' backgrounds were checked. <BR/>During an interview on 08/07/24 at 2:13 PM, the ADM said the potential negative outcome of not completing criminal backgrounds, EMR and NAR was potential harm to the residents at the facility. She said the purpose of completing the checks on staff before they worked at the facility was to hire good employees. She said they didn't want someone with a history of violence, people with assault records, or criminal records. She said she was unaware that the two hospitality aides' backgrounds had not been completed and that they had hospitality aides at the facility. She stated that she was unaware of the program with the outside party and how it worked. She said she had been at the facility for only three days. She said the system to monitor criminal background checks was the Former ADM who ran the checks. She said she had been trained to have all workers' criminal backgrounds checked before working around residents. She said this included hospitality aides and volunteers. She said she had not observed the hospitality working with residents but had observed them making beds. She initially said the reason the system failed was because of the change in administrators but later stated that this may not have been the reason since the hospitality aides had been working before the transitions of administrators, so she did not have a reason why the criminal background, EMR, and NAR were not completed. She stated that the criminal backgrounds of hospitality aides should have been checked before they worked, and this was her expectation. In her experience as an administrator, she said the human resources department was responsible for ensuring the criminal background checks were done. <BR/>During an interview on 08/07/24 at 3:55 PM, the ADON stated the two hospitality aides had been working at the facility for a month. She said she gave the information to complete the criminal background, EMR, and NAR to the Former ADM. She stated she was unaware that the criminal background had not been completed. She stated that she signed a timecard for the hospitality aides every Friday and did not keep a copy of it. She said the potential negative outcome was they would not know if the staff had been convicted or arrested for anything that could result in the staff not providing adequate care to the residents. She stated that the system to monitor criminal background checks was once a person was hired, and the staff identification cards, and social security cards were provided to the administrator. She stated that the Former ADM would then tell them that the staff was clear about proceeding with the hiring process. She stated the two hospitality aides were hired through an outside party. She said that she observed the hospitality aides working, and they do not provide direct patient care. She said they pass ice, make beds, pick up linen and trash. She said they could answer call lights. She said the hospitality aides worked Monday through Friday, 7- 3 AM when she worked so that she could monitor them. She confirmed that they worked on 08/07/24 and that she was off on 08/07/24. She said the Former ADM was responsible for completing the criminal background, EMR, and NAR checks. She stated she had no reason why the check was not completed. <BR/>During an interview on 08/07/24 at 4:00 PM, the BOM stated that she ran the two hospitality aides' criminal history, EMR, and NAR on 08/07/24. She was unaware that the criminal backgrounds had not been completed for the two hospitality aides. She stated the Former ADM was responsible for completing the checks on all staff, and when he left, that duty had been passed to her. She stated she was not told this until 08/07/24. She stated the ADM told her to complete the background checks on the hospitality aides. She said the potential negative outcome was that the staff could have had a criminal background or penal code that barred them from working with residents. She said this could have affected the residents because the staff could have had a history of harming residents. She stated that it was not done because the hospitality aides came from an outside party that pays their wages, and it was thought that it was done. She said she had been trained that all staff, including hospitality aides, should have their criminal history completed. She stated there were no exceptions to this rule. She said working with the Former ADM was the first time the administrator ran the criminal history checks. She stated that there were no issues when she ran the background check. <BR/>During an interview on 08/07/24 at 4:07 PM, the Human Resource Representative stated she was unaware that two hospitality aides who had not had their criminal history checked were working at the facility. She said she was not physically housed at the facility and worked from home. She stated she does not complete background checks for the facility but was responsible for corporate duties such as training the business office manager and payroll. She stated that the human resource person at the facility was the Former ADM. She said she was unsure who was completing the background checks at the facility. She stated that the potential negative outcome was that the facility could hire someone who should not be there, which could be detrimental to the residents. She said this expectation had no exceptions, and all staff's criminal background should be completed.<BR/>During an interview on 08/07/24 at 4:14 PM, the Former ADM stated he did not complete their background because he was not officially theirs and had been hired through an outside party. He stated that he treated the hospitality aides like agency staff. He stated all he did was interview them. He stated the hospitality aides have been working since the end of May 2024 or the beginning of June 2024. He stated it was entirely his fault because he assumed the outside party did all the paperwork and ran background checks on the hospitality aides. He stated the potential negative outcome was the staff could have had allegations of abuse and convictions, and this could affect the residents because they could potentially be abused. He said he thought the criminal background checks had been done and expected all staff, with no exceptions, to have their criminal history checked. He stated the ADM and business office completed the checks before the residents worked. The Former ADM stated he did not feel that their system failed but that he treated the hospitality aides as if they were agency staff, and they were not. He stated he would have completed them once they were certified and hired as official staff at the nursing facility. <BR/>During an interview on 08/07/24 at 4:23 PM, the Career Consultant stated she was a career consultant for the outside party. She said the only thing they did was pay the wages for the staff, but it was up to the employer to complete the additional checks, such as criminal background, if that was a requirement for employment. She stated she did not remember if she had a specific conversation with the Former ADM but said if he brought it up, she would have told him they did not complete criminal background checks. She said the application process asked them if they had been convicted of a crime. She said that the staff could be dishonest and there was no way to confirm. <BR/>Record review of the facility policy, Credentialing of Nursing Services Personnel, revised May 2019 revealed: <BR/>Policy<BR/>A copy of all documents obtained during the verification and background check are filed in the employee's personnel file. Such records are filed accordance with current federal and state laws and facility policy to protect the confidentiality of information. <BR/>Record review of Hospitality Aide A's EMR report revealed that it was completed on 08/07/24 at 1:20 PM and no results found.<BR/>Record review of Hospitality Aide A's NAR report revealed that it was completed on 08/07/24 at 2:10 PM and no results found.<BR/>Record review of Hospitality Aide A's EMR report revealed that it was completed on 08/07/24 at 1:04 PM and no results found.<BR/>Record review of Hospitality Aide B's EMR report revealed that it was completed on 08/07/24 at 1:19 PM and no results found.<BR/>Record review of Hospitality Aide B's NAR report revealed that it was completed on 08/07/24 at 2:11 PM and no results found.<BR/>Record review of Hospitality Aide B's EMR report revealed that it was completed on 08/07/24 at 1:03 PM and no results found.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 3 resident reviewed for resident rights. (Resident #1, Resident #2, and Resident #3)<BR/>The facility failed to ensure consents from responsible parties were given to place wander guard bracelets on Resident #1, Resident #2, and Resident #3. <BR/>This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects. <BR/>Findings included:<BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's Care Plan, dated 01/10/2025, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Resident #2:<BR/>Record Review of Resident #2's face sheet dated 03/20/25 revealed a [AGE] year-old female with an original admission date of 08/30/2020 and a readmission date of 10/23/2020 with the following diagnoses: seizures, intellectual disability, Microcephaly (a condition in which a baby's head is significantly smaller than expected often due to abnormal brain), scoliosis, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down, depression, hyperlipidemia (a condition in which there are high levels of fat particles in the blood). <BR/>Record review of Resident #2's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #2's Care Plan, dated 01/10/2025, revealed that Resident #2 was not care planned for wander guard. <BR/>Resident #3: <BR/>Record Review of Resident #3's face sheet dated 03/20/25 revealed a [AGE] year-old male with an admission date of 05/03/24 with the following diagnoses: dementia, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute kidney disease (a condition in which the kidneys suddenly cannot filter waste from the blood), urinary incontinence, high blood pressure, acid reflux, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). <BR/>Record review of Resident #3's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #3's Care Plan, dated 01/10/2025, revealed that Resident #3 was not care planned for wander guard. <BR/>During an interview on 03/20/2025 at 11:35 AM, LVN D stated that the steps to do a wander guard had depended on if resident was an elopement risk. LVN D stated that they would have to do a wandering assessment. LVN D stated that the Wandering Assessment would let you know if the resident was high risk. The nurse initiates the risk assessment. LVN D stated that Resident #1 had wanted to get out the day he eloped. LVN D stated that Resident #1 had tried to get out of the door. LVN D stated that she had put a wander guard on the resident when he tried to get out the first time. LVN D stated that she was unsure of the actual date. LVN D stated that they had used PCC (point click care) for the assessment. LVN D stated that she had done the assessment and had gotten a wander guard to put on the resident. LVN D stated that the assessment had showed that the resident needed the wander guard. LVN D stated that she had done the wander guard first and then she had done assessment. LVN D stated that she had reported to the oncoming nurse that she had placed a wander guard on the resident. LVN D stated that she had notified the DON, Administrator, and the ADON when she had placed the wander guard on Resident #1. LVN D stated that no one had ever reported to her that he had attempted to get out. LVN D stated that she had done her assessment based on what she observed. LVN D stated that she had not seen Resident #1 get out but when she was leaving when she was told that the resident had gotten out. LVN D stated that Resident #1 was found outside and had fallen in the front. LVN D stated that she had done an elopement training. LVN D stated that she had been trained to announce it and everyone needs to start looking. LVN D stated that the charge nurse would have been the one stationary person to report back to. LVN D stated that she would have reported to the Administrator, DON, and then after 15 minutes would need to notify the police and call the family. <BR/>During an interview on 03/20/2025 at 6:05 PM, Physician stated that the facility may have notified his Nurse Practitioner about the elopement. Physician stated that he did not know if Resident #1 had a wander guard. Physician stated that Resident #1 had no elopement issues that he knew of. <BR/>During an interview on 03/20/2025 at 6:13 PM, Family Member #2 stated she did not know the exact date, but she was told Resident #1 had gotten out the front door. Family member #2 did not say how far Resident #1 had gotten. Family member #2 stated that it was told to her in the day that Resident #1 had managed to get out the front door. Family member #2 stated that she was not sure if it was LVN D or LVN E that had notified her. Family member #2 stated that Resident #1 did not have his wander guard and had not had it for a while, it had been several weeks. Family member #2 stated that she did not know why they had taken the wander guard off. Family member stated that the facility did not notify them of the wander guard being taken off the first time or that they had placed one on Resident #1 the day he had eloped from the facility. Family member #2 stated that after Resident #1 had fallen, the day that he eloped and had fallen outside, they had put the wander guard back on Resident #1. Family member #2 stated that it was observed that it was off but had never asked, and just assumed it was because Resident #1 quit wandering and never questioned it. Family member #2 stated that they had noticed the wander guard, but no one had mentioned putting it back on Resident #1. Family member #2 stated that she had seen Resident #1 the next day and noticed that they had placed the wander guard back on. Family member #2 stated that their concern was Resident #1 was at the back of the building. Family member #2 stated that Resident #1 had to walk down a long hallway to get out of the building. Family member #2 stated that no one had paid attention and noticed it, and this is concerning. Family member #2 stated that their parking lot was right by the street. Family member #2 stated prior to this incident they never had concern about Resident #1's care, until this. Family member #2 stated that they were fine with the placement of the wander guard but if they had been told that they were going to take it off they would have declined for the safety of Resident #1, it never was an issue.<BR/>During an interview on 03/20/2025 at 6:35 PM, NP stated that she was notified on 03/10 that Resident #1 was trying to get out the front door and that he gotten out, right outside the door. NP stated it was her understanding that Resident #1 had not even gotten to the sidewalk. NP stated she was unaware that he gotten to the parking lot near the street. NP stated she received a text stating that they had put a wander guard on Resident #1 on 3/10. NP stated that she does not know if it was before or after he had actually eloped. NP stated her text that she had received stated I put a wander guard on Resident #1 because he was trying to get out of the building after lunch. The NP stated she had not had a text message that had showed that he had gotten out of the facility. NP stated she was unaware if Resident #1 had a wander guard prior to the placement on 03/10. NP stated she had never given an order for a wander guard to be taken off. NP stated they do notify her if they take it off and she has not had any notifications that one needed to be taken off of Resident #1. NP stated that they would have to had justification to take the wander guard off and put on. NP stated that she had a text on August 13 of 2024 that Resident #1 had tried to get out. NP stated that she did not know who texted because the number was not saved. NP stated that she had located the text says Resident #1 had gotten out. NP stated that she thought it was right outside of the door because she received a phone call letting her know they gotten Resident #1 back in. NP stated that when she calls about elopements and wander guard placements she will ask them what symptoms the resident had been having and what is the reason. NP stated that she had not received that information with Resident #1's case. NP stated that it was normal to have placed a wander guard after one attempt especially with Resident #1's case because the doors are unlocked from 7-8 PM. NP stated that it was case dependent in how they respond to elopements. NP stated it was situational. NP stated that in that facility it is almost impossible to actually monitor the front door and where the patient was going. NP stated that there was no way of watching that. NP stated that the wander guard was important because of the layout of the facility. NP stated that Resident #1 cannot walk fast, but fast enough. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, the Administrator stated that she had been in the facility since November 2024 and that if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stated that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated that she did provide an elopement in-service. The Administrator stated that, Everyone is responsible for keeping the resident safe. The Administrator stated, I was told that they had completed the assessment first and then had called for a wander guard. The Administrator stated that it could be considered a restraint. The Administrator stated that LVN D had documented that Resident #1 had went to the door. The Administrator stated that the assessment would tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that she did an investigation. In her investigation she had not seen wander guard from any time before. The Administrator had not seen the high risk on all wandering assessments. She stated she did not look at the progress notes or assessments as a part of her investigation. The Administrator stated that she had not talked to the family since the elopement. She stated her team did tell her that they had notified the family. The Administrator stated that she did not follow up to check if the family had been notified. The Administrator stated that even in self-report all that was told to her was that the family was notified. The Administrator stated that she was unaware that the family had not been notified. The Administrator stated that the facility system to monitor incident and accident prevention was to review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated that she had been trained on incident and accident prevention. The Administrator stated they would have needed need to complete an assessment and then they would have to score a certain score, notify physician, notify family, sign the consent, before it could even be placed. It also would come with restrictions such as how often you would use it or when you remove it. The Administrator stated yes she was familiar with the policy for placing a wander guard. The Administrator stated that the purpose of a consent specifically for restraints is the responsible party was consenting and good form of notification. The Administrator stated that the negative potential outcome of not obtaining a consent for a restraint would be a dignity concern. She stated that the family could have a concern for restraining. The Administrator stated that she was not aware that a consent was not in place but was aware now and all consent have been completed and in place. The Administrator stated that she was not aware that the assessment was completed after the restraint was placed on the resident, and once the IJ happened she learned of the situation. The Administrator stated that the system for monitoring for restraints was that she monitors when one is placed and would make sure DON had made her aware when one is placed, and she would follow up and have ADON monitor every week. The Administrator stated that she had been trained in restraints and her staff does complete orientation and annually as well. The Administrator stated that she had observed these residents (Resident #1, Resident #2, and Resident #3) with a wander guard on. The Administrator stated that her expectations in regard to restraint placement was that we are following our policy and that we are completing proper assessments before applying. The Administrator stated it was the responsibility of the charge nurses to apply restraints and complete assessments, and the responsibility of the ADON and DON to monitor. The Administrator stated that everyone was responsible for following the policy. The Administrator stated that there was no reason the assessment was completed after the placement of the wander guard as it relates to Resident #1, she thinks the nurse just wanted to be initiative-taking and was too initiative-taking. The Administrator stated that there was no reason a consent was not obtained from the family rep before the placement of the wander guard for Resident #1 and Resident #2. The Administrator stated that all consents and elopement risk assessment are in place and current. <BR/>During an interview on 03/21/2025 at 12:22 PM, The DON stated that the facility had failed to prevent incident and accident allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident had prompted the wander guard situation. The DON stated that Resident #1did not get out of the door but he was at the door. The DON stated that she spoke with LVN D and was told that Resident #1 had not gotten out of the door. The DON stated that she had spoken to Occupational Therapist A and was under the understanding that Occupational Therapist A was there with Resident #1 at the door the first time. The DON stated that Resident #1 had not exhibited any signs of wanting to leave the facility to her knowledge, prior to the elopement. The DON stated that after the incident had happened she did not talk to the aides to see if Resident #1 had exhibited any signs prior to the elopement. The DON stated that to her knowledge, Resident #1 had never had a wander guard. The DON stated that the implementation of the wander guard device on 03/10 was the first one. The DON stated that if Resident #1 had a wander guard device it would be documented. The DON stated that you would have to have justification to put one on and take one off. The DON stated that usually the assessments are quarterly and would also use nursing judgement. The DON stated that if Resident #1 continues to score high that would call for a wander guard. The DON stated that LVN D was looking at safety first and this was why she had placed the wander guard on him prior to completing the assessment. The DON stated that the wander guard would not have stopped him from leaving. The DON stated that she had observed LVN D place the wander guard on Resident #1 and he was not resistant to the placement. The DON stated that she had felt that the placement of the wander guard was an emergency. The DON stated that at that moment she was just thinking safety first. The DON stated that she did tell LVN D that she did have to get the assessment done and she did not place Resident #1 on 1:1. The DON stated that frequent rounding was done on Resident #1. The DON did not look at his assessments or look at progress notes and did not review care plan. The DON stated that she thinks that this could have been prevented. The DON stated that they could have acted quicker. The DON stated that they could have implemented interventions such as 1:1 at the time of the first attempt. The DON stated that she is not familiar with the policy for incident and accidents, but the purpose is to prevent harm The DON stated that someone could get hurt if the policy is not followed. The DON stated that they could get into trouble for not having proper paperwork and consents. The DON stated that she was not aware that Resident #1 had a wander guard prior to the one placed on 03/10. The DON stated that she was not aware of the assessment outcome scores but she was aware that the wander guard was placed prior to the assessment. The DON stated that she thought that LVN D had called the family prior to the placement of the wander guard. The DON stated that the system to monitor incident/accident prevention was that they educate staff through in-services. The DON stated that she had not had any specific training at the facility but had nursing experience to know that you have to prevent incident and accidents. The DON stated that she expects incidents/accidents to be prevented by following the policy. The DON stated that all staff are responsible and there was no reason increased supervision was not implemented. The DON stated that stated that she is familiar of the policy for placing a wander guard. Stated that assessing the resident's first and obtaining the consent and making sure that the resident is safe with the restraint, make sure to document, speak to family, and make sure have the proper monitoring system in place. , stated that the purpose of a consent specifically for restraints is to ensure safety for the residents, to ensure that family is aware of the restraint, and to protect themselves as the facility. The DON stated that the negative outcome of not obtaining a consent for a restraint puts the facility at risk of getting into trouble because if it is not signed or documented it did not happen. The DON stated she was not aware that a consent was not obtained. Stated once again she will have to quit assuming and follow up as a DON. Stated she will start doing that and she will own her mistakes. The DON stated that she was aware that the nurse placed Resident #1's wander guard and did the assessment afterwards. The DON stated that she talked to the LVN about that and at that moment she felt it was an emergency to just put that one and I agree with her that she needed to place that on him and do visual assessment and put that in the computer. She saw the risk that he was and needed to do that. The DON stated that the system to monitor restraints is that they have the little device to check the wander guards and when it is activated they check with the doors to make sure that they work. Stated that these are checked every shift. The DON stated that she had been trained on restraints. The DON stated staff had been trained on restraints as well. The DON stated that she can verify that she had been trained. The DON stated that she had observed the resident's (Resident #1, Resident #2, and Resident #3) with the wander guard on. The DON stated that her expectation in regard to restraint placement would be to ensure a proper assessment had been done, and that the proper consent paperwork is obtained, and of course the family is made aware. The DON stated that the nurses and administrator are responsible for restraints and following the policy because we are the one who assess the resident, place, and monitor. The DON stated the reason the assessment was completed after the placement was because the nurse felt that it was an emergency and that it needed to be placed right then. It was a nursing judgement. The DON stated that there is no reason a consent was not obtained other than the nurse felt that he was in danger and placed that because he was at risk of getting out of the building. The DON stated she did not have additional information just having to re-educate the staff. <BR/>Record review of facility provided policy, dated September 2022, titled, Identifying Involuntary Seclusion and Unauthorized Restraint, stated:<BR/>Policy Statement: <BR/>As a part of the abuse prevention strategy, volunteers, employees, and contractors, hired by this facility are expected to be able to identify involuntary seclusion and or unauthorized restraint of residents. <BR/>Policy Interpretation and Implementation:<BR/>4. Behavioral issues that arise among residents are managed according to strategies documented in the care plan and approved by the interdisciplinary team. <BR/>Unauthorized Physical Restraints:<BR/>1. <BR/>Restraints are free from the use of any physical restraints not required to treat their medical condition. <BR/>2. <BR/>Physical restraint is defined as any manual method, physical, or mechanical device, equipment, or material that meets all of the following criteria. <BR/>a. <BR/>Is attached or adjacent to a resident's body. <BR/>b. <BR/>Cannot be removed easily by the resident (in the same manner as it was applied by the staff).<BR/>4. Sometimes the use of restraints is not intentional, but this does not absolve the staff of the responsibility to recognize and report the unauthorized use of restraints. Examples of physical restraints (intentional or unintentional) include: <BR/> g. applying leg or arm restraints, hand mitts, soft ties, or vests that a resident cannot remove. <BR/>6. Risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints. <BR/>9. Obtaining a resident's or representative's permission to use a restraint when the restraint is unnecessary is prohibited. <BR/>10. The following examples demonstrate situations where restraints are used for staff convenience or discipline, and are therefore unauthorized:<BR/>a. Staff are too busy to monitor the resident, and their workload includes too many residents to provide monitoring. <BR/>b. The resident does not exercise good judgment, including forgetting about his/her physical limitations in standing, walking, or using the bathroom alone and will not wait for staff assistance.<BR/>c. Family have requested that the resident be restrained, as they are concerned about the resident falling especially during high activity times, such as during meals or when the staff are busy with other residents. <BR/>d. There is not enough staff on a particular shift or during the weekend and staffing levels were not changed. <BR/>e. new staff and/or temporary staff do not know the resident, how to approach, and/or how to address behavioral symptoms or care needs so they apply physical restraints.<BR/>f. Lack of staff education regarding the alternatives to the use of restraints as a method for preventing falls and accidents. <BR/>g. Restrain the resident to teach him/her a lesson due to negative feelings or a lack of respect toward the resident. <BR/>h. In response to a resident's wandering behavior, staff become frustrated and restrain a resident to a wheelchair and/or<BR/>11. Restraints that are used as a last resort to protect the safety of the resident and others must be accompanied by an order from the practitioner and documentation reflecting the circumstances that led up to the decision to restrain him or her. <BR/>Record review of facility provided policy, dated April 2017, titled, Use of Restraints, stated:<BR/>Policy Statement:<BR/>Restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms (s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented. <BR/>Policy Interpretation: <BR/>1. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. <BR/>2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. <BR/>6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans in that:<BR/>The facility failed to care plan for wander guards for Resident #1, Resident #2, and Resident #3.<BR/>This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns.<BR/>Findings included:<BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's Care Plan, dated 01/10/2025, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Resident #2:<BR/>Record Review of Resident #2's face sheet dated 03/20/25 revealed a [AGE] year-old female with an original admission date of 08/30/2020 and a readmission date of 10/23/2020 with the following diagnoses: seizures, intellectual disability, Microcephaly (a condition in which a baby's head is significantly smaller than expected often due to abnormal brain), scoliosis, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down, depression, hyperlipidemia (a condition in which there are high levels of fat particles in the blood). <BR/>Record review of Resident #2's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #2's Care Plan, dated 01/10/2025, revealed that Resident #2 was not care planned for wander guard. <BR/>Resident #3: <BR/>Record Review of Resident #3's face sheet dated 03/20/25 revealed a [AGE] year-old male with an admission date of 05/03/24 with the following diagnoses: dementia, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute kidney disease (a condition in which the kidneys suddenly cannot filter waste from the blood), urinary incontinence, high blood pressure, acid reflux, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). <BR/>Record review of Resident #3's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #3's Care Plan, dated 01/10/2025, revealed that Resident #3 was not care planned for wander guard. <BR/>During an interview with ADON on 03/21/2025 at 11:17 AM, ADON stated that she was not familiar with the care plan policy. She stated that the purpose of the care plan is to obtain care of the patient. ADON stated to ensure that they are providing that care, know the patient if a patient like to use certain things, and for preferences. ADON stated that if it is not care planned the staff do not know about the patient or what to do. ADON stated that the negative potential outcome is that the facility may not meet the needs of the patient. ADON stated that she was unaware that there were missing wander guard care plans. ADON stated that the system to monitor care plans is that the facility monitors care plans quarterly and MDS and nursing are usually to collaborate. ADON stated that they do chart reviews periodically. ADON stated that she had not been trained on care plans. ADON stated that she expects staff to have the components they need according to policy. ADON stated that it is the responsibility of the MDS, Nursing staff are responsible in following them. ADON stated that the MDS coordinator actually completes them (care plans) because they may not have been done. ADON stated that the MDS coordinator last day was 2/28/25. ADON stated that they did hire a new MDS Coordinator, and they are working on care plans now. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, The Administrator stated that she had been in the facility since November 2024 and if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stating that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated, I was told that they completed the assessment first and then called for a wander guard. The Administrator stated that it can be considered a restraint. The Administrator stated that the assessment will tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that the facility system to monitor incident and accident prevention is review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated she is familiar with the policy for care planning for wander guard. The Administrator stated that she expectations in regard to care plans is that she expects for it to be accurate and up to date and it should be tailored to each resident. The Administrator stated that it is the responsibility of the IDT to make sure care plans are completed, It's not just one person, its all of us. The Administrator stated that stated that there is no good excuse for the care plans not being completed. The Administrator stated that she thinks that it goes back to the time that she did not have and MDS but not a good excuse or a specific reason. The Administrator stated that she was not aware that the resident's identified did not have their wander guards care planned until it was brought to her attention by the other Surveyor. The Administrator stated that a care plan is the guidelines of how they provide care for that specific need for the resident. The Administrator stated that the negative potential outcome of not care planning triggered items is not providing proper care for that specific resident to the best of their ability. The Administrator stated that mostly nursing uses the care plans.<BR/>During an interview on 03/21/2025 at 12:22 PM, The DON stated that the facility failed to prevent incident and accident allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident prompted the wander guard situation. The DON stated that to her knowledge, Resident #1 had never had a wander guard. The DON stated that the implementation of the wander guard device on 03/10 was the first one. The DON stated that if Resident #1 had a wander guard device it would be documented. The DON stated that you have to have justification to put one on and take one off. The DON stated that usually the assessments are quarterly and also use nursing judgement. The DON stated that LVN D was looking at safety first and this was why she placed the wander guard on him prior to completing the assessment. The DON stated that she observed LVN D place the wander guard on Resident #1 and he was not resistant to the placement. The DON stated that she had felt that the placement of the wander guard was an emergency. The DON stated that if a resident had a wander guard, it should be care planned. The DON stated that a care plan provides details of what is going on with the resident and how to take care of them. The DON stated it is an overall story about the resident and needs. The DON stated that the negative potential outcome of not care planning triggered items is that if it is not care planned or documented then it could turn into not providing what is needed for them or meeting the resident's needs. The DON stated that she was not aware of the wander guard and behaviors were not care planned, until recently when she went in there and noticed that it was not care planned. The DON stated that when she noticed was on Friday 3/21/25. The DON stated that she assumed that it was done due to these residents being in the facility for so long. The DON stated that the person before her did not have it completed. The DON stated that when she looked it was not done, so she went in at that time and completed it. The DON stated that in regard to the facility system to monitor care plans is that she assumes that people know what needs to be done. The DON stated that she plans to go through each and every care plan to see what had or had not been taken care of. She stated that previously with old MDS, she would pull a 24-hour report and baseline and then DON would care plan it. The DON stated that they are in the process of re-training another person and communication also had played a role in the lack of care planning. She stated they will do risk meetings weekly with MDS and keep up to date with care plans. The DON stated that she had minimal training on care plans. She stated that her last MDS coordinator and her Corporate Nurse had given her training, but it was not much at all. The DON stated that therapy, activities, nursing, dietary, social worker, all use care plans. The DON stated that care plans are a summary of resident care and everything that they have going on from behaviors, needs, preferences. The DON stated if someone prefers to be eating in the dining by themselves that would be care planned.<BR/>Record review of facility provided policy, dated March 2022, titled, Care Plans-Baseline stated: <BR/>Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within-forty-eight hours of admission. <BR/>Policy Interpretation and Implementation:<BR/>1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following:<BR/>a. Initial goals based on admission orders and discussion with the resident representative. <BR/>b. Physician orders.<BR/>c. dietary orders.<BR/>d. Therapy services.<BR/>e. social services. <BR/>f. PASARR recommendation if applicable<BR/>2. The baseline care plan is used until the staff can conduct a comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan, no later than 21 days after admission. The baseline care plan is updated as needed to meet the needs until the comprehensive care plan is developed. <BR/>3. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment at 483.21<BR/>4. The resident and/or representative are provided a written summary of the baseline care plan that includes, but is not limited to the following:<BR/>a. The stated goals of the resident. <BR/>c. any services and treatments to be administered by the facility and personnel acting on behalf of the facility.<BR/>d. any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the menu was followed and reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy for residents, for 1 out of 1 lunch served on 09/06/23 in that:<BR/>1. The facility failed to follow the approved dietary menu on 09/06/23 during the lunch period. <BR/>These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. <BR/>The findings include:<BR/>Record review of the facility's menu, dated Spring/Summer 2023, revealed the following:<BR/>Week 4 Wednesday: Turkey [NAME], Herbed Rice, wheat Roll, Margarine, Tropical Fruit, Coffee or Tea and Milk<BR/> An observation on 09/06/23 at 11:35 AM revealed staff serving the following: meatballs, brown gravy, green beans and mash potatoes.<BR/>During an interview on 09/06/23 at 12:15 PM, the D said the Regional Consulting Manager has trained her. She said they cook the same breakfast every day. She said she was trained to ensure she followed breakfast when state came. She said this was a challenge because she did not know when state would enter the facility. She said that they do not ever follow the menu. She said they cook what they have in the fridges. She said that she has an $8,000.00 a month budget that she has to follow, and she cannot get what was on the menu. She said the Regional Consultant told her it was okay to change the menu. She said that she and the Regional Consultant met with the residents to see what they would like, and they changed the menu. She said that she was trained that it was okay to change the menu to things that the residents may like better. <BR/>During an interview on 09/07/23 at 01:37 PM, Dietary [NAME] A said they normally do not follow the menu. She said they prepare the meals based on the available food in the kitchen. She said the DM chose the meal on 09/06/23, and they wanted something simple to make because they were receiving their weekly truck. She said they did not know how much time they would have to prepare and interact with the vendor delivering the truck. She said the DM decided what they would have the day before on 09/05/23. She said as long as the DM did not have to work the floor, then she was the person who prepared the menus each week. She said she did not know a potential negative outcome of following the menu. She said she was not sure why that would be important. <BR/>During an interview on 09/07/23 at 01:57 PM, Dietary Aide A said he could not give any information regarding the menu process because he had not been trained and does not deal with the menus. He said he received what was on the menu from the DM or the cook. <BR/>During an interview on 09/08/23 at 11:21 AM, the ADM said the DM and the Dietician ensured the menus were followed. He said he was not aware that they were not following the menus. He said he has not been formally trained in this area. He said that a potential negative outcome of not following the menu was the residents would not receive their dietary needs and could experience weight loss or nutritional value would not be there. He said the residents require a certain amount of nutrition, and following the menu helped the residents receive their nutrients. He said he expected the dietary staff to follow the menus. He said he had no system to monitor and ensure the menus were followed. He said the menu was a guide for staff that they should follow. He said the menu will show staff how to prepare the food and should ensure the residents receives the appropriate nutritional value. He said he did not know who approved the menu. He said he would sometimes look to see what they were eating and typically focus on lunch and dinner. He said he understood if the residents did not like what was on the menu, they could go through a process that involved the DM and the Dietician. He said he told the DM in the past that she could purchase what she needed, and he would worry about the cost. He said he was not aware of how much her monthly budget was. He said he was unsure about the facility policy related to changing the menu, but from his experience, the Dietician had to review it and sign off on it. He said the Dietician was the only person that could change the menu. <BR/>During an interview on 09/08/23 at 12:32 PM, the DM said she said the purpose of the menu was so that they would not get in trouble by state. She said the potential negative outcome of not following the menu was that you could get in trouble. She said she was trained to follow the menu when state was in the facility. She said she was trained and needed to especially ensure breakfast was followed. She said she would not change what she normally did for the three days that state was in the facility She said the residents at the facility were picky. She said the Dietician was aware that they were not following the menu. She said the Dietician was not concerned because they gave the residents food they liked. She said they chose between a meal and an alternative when looking at the menu approved by the dietitian. She said they do not follow breakfast or the alternative option. They keep the same meal for their alternative and breakfast. She said only 4 residents attended the meeting. When asked about 4 residents making the choices for the entire facility, she said they chose the pickiest residents. She said no other attempts were made to include other residents outside the attendees. <BR/>During an interview on 09/08/23 at 04:47 PM, the Dietician said she was aware that there were some items on the menu that staff crossed out because residents did not like some of the food. She said a meeting was held where the residents chose what they wanted on the menu. She said she believed this meeting was held in April 2023. She said this was when she approved the menu change. She said when there was a change or a substitution, the DM should log it on the substitution log. She said her understanding was that there was always an alternative. She said she could not name the exact alternative, but she thought the facility had an alternative available. She said she did not attend the meeting in April. She said she did not review the minutes. (Please note the surveyor requested the substitution log and it was not provided.)<BR/>During an interview on 09/08/23 at 05:04 PM, the Regional Consultant said she had been helping the DM because she was new. She said regarding the menus, she explained to the DM that she needed to follow the menu with no exception. She said they had a committee meeting and went over the menus. She said the residents in the meeting decided that they wanted one choice. She said it was decided to have the same breakfast daily. She said she told the DM to change the breakfast so that they would have different things daily. She said she, the DM, and the residents from the meeting decided to have a standing alternate menu. She said all foods do not have the same nutritional value. When asked about allowing 4 residents to make the decisions for the entire facility, she said that they spoke with everyone and invited the residents to the meeting, but the 4 who showed up were the ones who wanted to attend. She said the menu was supposed to be followed daily to ensure residents get the nutrition they need. She said she had encouraged the DM to read the policies and procedures because if she did not, the experiences she was going through (experience with the state surveyors) could happen.<BR/>Record review of the facility's policy titled Operational Policy and Procedure Manual for Long Term Care, undated revealed:<BR/>Menu (Revised October 2017)<BR/>Policy Statement<BR/>Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while<BR/>following established national guidelines for nutritional adequacy,<BR/>Policy Interpretation and Implementation<BR/>1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences),<BR/>2, Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance,<BR/>4. The dietitian reviews and approves all menus.<BR/>6. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived.<BR/>9. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an<BR/>alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified nondairy alternatives).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 7 of 8 refrigerators reviewed for food safety (room [ROOM NUMBER],209 211, 212,214, 216, and 218) in that:<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator. Inside of the refrigerator was a parfait, two cokes, an uncovered cookie, and an undated cupcake. <BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator. Inside of the refrigerator was an open coke, leftover takeout, and a bowl of sealed queso cheese. All food was undated.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator.<BR/>This failure could place resident at risk for food borne illnesses.<BR/>Findings include:<BR/>An observation during the duration of the survey (09/06/23-09/08/23) revealed the following:<BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. I observed a bag of nuts and licorice candy that were unlabeled.<BR/>room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. Inside was an open coke, leftover takeout, and a bowl of sealed queso cheese. All food was undated.<BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. <BR/>room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. An observation of a parfait, two cokes, an uncovered cookie, and an undated cupcake. <BR/>During an interview on 09/08/23 at 11:21 AM, the ADM said that family and residents are responsible for cleaning their fridges and monitoring the temperatures. He said although housekeeping would clean the outside, the contents were the residents and their family's responsibility. When asked who would be responsible for resident fridges if the resident was unable to and did not have family, he said the staff would have to. He said the previous company had the staff clean the outside of the fridge, including wiping it down, but not monitoring the temperature. He said he was not sure if this was covered in the policy. He said he was unsure if the residents were told during admission and that this information was not part of the admission packet. He said if the resident's refrigerators were not monitored, the potential negative outcome could be foodborne illness. He said he would have to check with his upper management regarding the expectation for the resident refrigerators. <BR/>During an interview on 09/08/23 at 12:32 PM, the DM said regarding the residents' refrigerators, the housekeepers are responsible for cleaning the refrigerator inside and out. She said the kitchen staff are not allowed in the residents' room. <BR/>Record review of the facility's policy titled Operational Policy and Procedure Manual for Long Term Care, undated revealed:<BR/>Food brought by Family/ Visitors (Revised March 2022)<BR/>Policy Statement<BR/>Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice<BR/>and a homelike environment with the nutritional and safety needs of residents.<BR/>4. Safe food handling practices are explained to family/visitors in a language and format they understand.<BR/>5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a<BR/>manner that it is clearly distinguishable from facility-prepared food.<BR/>a. Non-perishable foods are stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may<BR/>be stored without a lid.<BR/>b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator.<BR/>Containers are labeled with the resident's name, the item and the use by date.<BR/>6. The nursing staff will discard perishable foods on or before the use by date.<BR/>7. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious<BR/>signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration<BR/>dates).<BR/>8. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer<BR/>than 2 hours are discarded.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans in that:<BR/>The facility failed to care plan for wander guards for Resident #1, Resident #2, and Resident #3.<BR/>This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns.<BR/>Findings included:<BR/>Resident #1:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #1's Care Plan, dated 01/10/2025, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Resident #2:<BR/>Record Review of Resident #2's face sheet dated 03/20/25 revealed a [AGE] year-old female with an original admission date of 08/30/2020 and a readmission date of 10/23/2020 with the following diagnoses: seizures, intellectual disability, Microcephaly (a condition in which a baby's head is significantly smaller than expected often due to abnormal brain), scoliosis, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down, depression, hyperlipidemia (a condition in which there are high levels of fat particles in the blood). <BR/>Record review of Resident #2's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #2's Care Plan, dated 01/10/2025, revealed that Resident #2 was not care planned for wander guard. <BR/>Resident #3: <BR/>Record Review of Resident #3's face sheet dated 03/20/25 revealed a [AGE] year-old male with an admission date of 05/03/24 with the following diagnoses: dementia, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute kidney disease (a condition in which the kidneys suddenly cannot filter waste from the blood), urinary incontinence, high blood pressure, acid reflux, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). <BR/>Record review of Resident #3's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>Record review of Resident #3's Care Plan, dated 01/10/2025, revealed that Resident #3 was not care planned for wander guard. <BR/>During an interview with ADON on 03/21/2025 at 11:17 AM, ADON stated that she was not familiar with the care plan policy. She stated that the purpose of the care plan is to obtain care of the patient. ADON stated to ensure that they are providing that care, know the patient if a patient like to use certain things, and for preferences. ADON stated that if it is not care planned the staff do not know about the patient or what to do. ADON stated that the negative potential outcome is that the facility may not meet the needs of the patient. ADON stated that she was unaware that there were missing wander guard care plans. ADON stated that the system to monitor care plans is that the facility monitors care plans quarterly and MDS and nursing are usually to collaborate. ADON stated that they do chart reviews periodically. ADON stated that she had not been trained on care plans. ADON stated that she expects staff to have the components they need according to policy. ADON stated that it is the responsibility of the MDS, Nursing staff are responsible in following them. ADON stated that the MDS coordinator actually completes them (care plans) because they may not have been done. ADON stated that the MDS coordinator last day was 2/28/25. ADON stated that they did hire a new MDS Coordinator, and they are working on care plans now. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, The Administrator stated that she had been in the facility since November 2024 and if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stating that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated, I was told that they completed the assessment first and then called for a wander guard. The Administrator stated that it can be considered a restraint. The Administrator stated that the assessment will tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that the facility system to monitor incident and accident prevention is review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated she is familiar with the policy for care planning for wander guard. The Administrator stated that she expectations in regard to care plans is that she expects for it to be accurate and up to date and it should be tailored to each resident. The Administrator stated that it is the responsibility of the IDT to make sure care plans are completed, It's not just one person, its all of us. The Administrator stated that stated that there is no good excuse for the care plans not being completed. The Administrator stated that she thinks that it goes back to the time that she did not have and MDS but not a good excuse or a specific reason. The Administrator stated that she was not aware that the resident's identified did not have their wander guards care planned until it was brought to her attention by the other Surveyor. The Administrator stated that a care plan is the guidelines of how they provide care for that specific need for the resident. The Administrator stated that the negative potential outcome of not care planning triggered items is not providing proper care for that specific resident to the best of their ability. The Administrator stated that mostly nursing uses the care plans.<BR/>During an interview on 03/21/2025 at 12:22 PM, The DON stated that the facility failed to prevent incident and accident allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident prompted the wander guard situation. The DON stated that to her knowledge, Resident #1 had never had a wander guard. The DON stated that the implementation of the wander guard device on 03/10 was the first one. The DON stated that if Resident #1 had a wander guard device it would be documented. The DON stated that you have to have justification to put one on and take one off. The DON stated that usually the assessments are quarterly and also use nursing judgement. The DON stated that LVN D was looking at safety first and this was why she placed the wander guard on him prior to completing the assessment. The DON stated that she observed LVN D place the wander guard on Resident #1 and he was not resistant to the placement. The DON stated that she had felt that the placement of the wander guard was an emergency. The DON stated that if a resident had a wander guard, it should be care planned. The DON stated that a care plan provides details of what is going on with the resident and how to take care of them. The DON stated it is an overall story about the resident and needs. The DON stated that the negative potential outcome of not care planning triggered items is that if it is not care planned or documented then it could turn into not providing what is needed for them or meeting the resident's needs. The DON stated that she was not aware of the wander guard and behaviors were not care planned, until recently when she went in there and noticed that it was not care planned. The DON stated that when she noticed was on Friday 3/21/25. The DON stated that she assumed that it was done due to these residents being in the facility for so long. The DON stated that the person before her did not have it completed. The DON stated that when she looked it was not done, so she went in at that time and completed it. The DON stated that in regard to the facility system to monitor care plans is that she assumes that people know what needs to be done. The DON stated that she plans to go through each and every care plan to see what had or had not been taken care of. She stated that previously with old MDS, she would pull a 24-hour report and baseline and then DON would care plan it. The DON stated that they are in the process of re-training another person and communication also had played a role in the lack of care planning. She stated they will do risk meetings weekly with MDS and keep up to date with care plans. The DON stated that she had minimal training on care plans. She stated that her last MDS coordinator and her Corporate Nurse had given her training, but it was not much at all. The DON stated that therapy, activities, nursing, dietary, social worker, all use care plans. The DON stated that care plans are a summary of resident care and everything that they have going on from behaviors, needs, preferences. The DON stated if someone prefers to be eating in the dining by themselves that would be care planned.<BR/>Record review of facility provided policy, dated March 2022, titled, Care Plans-Baseline stated: <BR/>Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within-forty-eight hours of admission. <BR/>Policy Interpretation and Implementation:<BR/>1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following:<BR/>a. Initial goals based on admission orders and discussion with the resident representative. <BR/>b. Physician orders.<BR/>c. dietary orders.<BR/>d. Therapy services.<BR/>e. social services. <BR/>f. PASARR recommendation if applicable<BR/>2. The baseline care plan is used until the staff can conduct a comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan, no later than 21 days after admission. The baseline care plan is updated as needed to meet the needs until the comprehensive care plan is developed. <BR/>3. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment at 483.21<BR/>4. The resident and/or representative are provided a written summary of the baseline care plan that includes, but is not limited to the following:<BR/>a. The stated goals of the resident. <BR/>c. any services and treatments to be administered by the facility and personnel acting on behalf of the facility.<BR/>d. any updated information based on the details of the comprehensive care plan, as necessary.

Based on interview and record review, the facility failed to ensure that the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional for 1 of 1 Activity Director reviewed for qualifications, in that:<BR/>The facility failed to employ an Activity Director who was qualified. <BR/>This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.<BR/>The findings include:<BR/>On 7/19/22 at 1:30 PM an interview was conducted with the Activity Director. She was asked if she had finished her activity directors required course. She stated, she had not finished the course and was not sure when she would finish. She added that she had not started the course. She stated she had been hired as the Activity Director approximately two months previously. She was asked how her lack of qualifications could affect the residents. She stated she would not know what activities were effective and this could affect the residents. She stated that uses past activity calendars as guides for her program. She added that she had no experience in this field and was doing the best she knew how. <BR/>On 7/21/22 at 8:48 AM the Administrator was interviewed. She was asked about the qualifications of the Activity Director. She stated, the Activity Director had not completed her certification/required course. She added that they were waiting until she completed her probation to enroll her in the certification/qualifying course. She was asked how this situation could affect residents. She stated that the facility could not meet all the psychosocial needs of the residents.<BR/>Record review of the personnel file for the Activity Director revealed that she had no documentation that she met any of the qualifying requirements which included being licensed or registered and being an Occupational Therapist, Certified Occupational Therapy Assistant, Therapeutic Recreational Therapist, had 2 years of experience in a social or recreational program within the last 5 years (one being full time) or completed the State required Activity Directors course. <BR/>During the survey, 12 of 12 residents interviewed confidentially had no concerns with the activity program. Also 4 of 4 residents interviewed during the Resident Council on 7/20/22 at 9:35 AM revealed no issues with the activity programs. <BR/>Record review of the facility policy titled Operations 4: Clinical Operations, Activities Program, 0P4 0501.00, Chapter: Activities Operations, Revision Date: February 2017, revealed the following documentation, Policy. The facility provides an activity program designed to meet the interests, preferences, and physical, mental and psychosocial well-being of each resident as indicated on the comprehensive assessment and care plan. The activities program is staffed with personnel who have appropriate training and experience to meet the needs and interest of each resident. Individual (one-to-one) and group activities, plus on and offsite activities are included in the activities program. Fundamental information . Activities Director Qualifications. The Activities Director is a qualified therapeutic recreation specialist or activities professional that is:<BR/>License and registered, if applicable, by the state in which practicing;<BR/>Eligible for certification as an activities professional or as a therapeutic recreation specialist by a recognized accrediting body on or after October 1, 1990; or<BR/>Has two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program;<BR/>Is a qualified occupational therapist or occupational therapy assistant; or<BR/>Has successfully completed a training course approved by the state .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, supervision. <BR/>The facility failed to ensure Resident #1 received supervision and assistive devices to prevent accidents. Resident #1 was exit seeking and was able to elope and had fallen in the parking lot by the street. Staff were not aware of Resident #1's elopement and was found by Occupational Therapist that was off the clock. <BR/>An Immediate Jeopardy (IJ) was identified on 03/21/25 at 3:32 PM. The IJ template was provided to the facility on [DATE] at 3:32 PM. While the IJ was removed on 03/22/25 at 5:36 PM; however, the facility remained out of compliance at No actual harm, with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could place residents at risk for injuries due to not receiving the appropriate level of supervision.<BR/>Findings included:<BR/>Record Review of Resident #1's face sheet dated 03/20/25 revealed a [AGE] year-old male with an original admission date of 08/02/2024 and a readmission date of 01/10/25 with the following diagnoses: bacterial pneumonia (a serious lung infection caused by bacteria), metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural disease), type 2 diabetes mellitus, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), high blood pressure, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, abnormalities of gait and mobility, lack of coordination, repeated falls, muscle weakness, acute kidney failure, psychotic disorder with hallucinations. <BR/>Record review of Resident #1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed:<BR/>He had a BIMS (Brief Interview for Mental Status) listed as 3, he had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. <BR/>He felt tired or had little energy listed as 2-6 days.<BR/>He was listed as using a manual wheelchair.<BR/>He needed partial/moderate assistance to go from sitting to standing.<BR/>Record review of Resident #1's Care Plan, dated 01/10/25, revealed that Resident #1 was not care planned for wander guard. <BR/>Review of Resident #1's Care Plan updated 8/13/24 revealed:<BR/>Showed to be (dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility.<BR/>Record review of Resident #1's TAR for month of March 2025, revealed:<BR/>Resident #1 was placed on 1:1 observations from 03/12/2025-3/21/2025, but no wander guard was listed on TAR.<BR/>Record review of Resident #1's progress note dated 03/10/2025 at 2:59 PM, stated: 1300 Resident was at front door trying to get out of building. Wander guard applied to right wrist. Resident continues wandering<BR/>throughout the building. Family called and notified.<BR/>Recored review of Resident #1's progress note dated 03/10/2025 at 3:30 PM, stated: New order obtained from NP to place patient on one on one due to exit seeking behaviors.<BR/>Record review of Resident #1's Head to Toe Skin Assessment, dated 03/13/2025 at 6:32 PM, stated: right and left forearm and right elbow.<BR/>During an interview on 03/20/25 at 11:23 AM, Occupational Therapist A stated that she had seen Resident #1 outside around 3 pm. Occupational Therapist A stated that she had parked on the opposite end of the building, had made a left turn on the road, and then had seen someone standing with a walker in the parking lot. Occupational Therapist A stated that she had seen Resident #1 out of her peripheral vision. The Occupational Therapist A stated that he did not look like a visitor. The Occupational Therapist A stated that as she was parked, she had noticed Resident #1 had lost his balance and had seen him fall. The Occupational Therapist A stated that she had ran into the building and yelled out to Occupational Therapist B to assist. The Occupational Therapist A stated that she had ran to Resident #1 because he was in the street but barely on the side of the street. The Occupational Therapist B and Occupational Therapist A went to help Resident #1 up and at that point Physical Therapist came out with Resident #1's wheelchair. The Occupational Therapist A and Physical Therapist helped Resident #1 into the wheelchair and back into the building. The Occupational Therapist A stated that once they were back into the building, she wrote a statement. The Occupational Therapist A stated that she was off of the clock when this incident occurred. The Occupational Therapist A stated that her and the Physical Therapist C helped Resident #1, and she left after writing the statement. The Occupational Therapist A stated that she had not worked with Resident #1. The Occupational Therapist A stated that this was the second time that she had caught him. The Occupational Therapist A stated that the first time was around lunch, and she was on her way back from lunch. The Occupational Therapist A stated that Resident #1 was right at the door (outside of it, he just needed to let the door go). The Occupational Therapist A stated that Resident #1 did not have his walker at that time. The Occupational Therapist A stated that she had yelled for help from LVN D. The Occupational Therapist A stated that at that time they took him to get a wander guard. The Occupational Therapist A stated that was around noon and Resident #1 had not attempted to elope before that. The Occupational Therapist A stated that the first time that Resident #1 attempted to elope, he was not coherent, but he did make a comment saying something about needing a locker. The Occupational Therapist A stated that Resident #1 did not have a wander guard the first time he attempted to leave but on the second attempt, noticed a wander guard on Resident #1 because when Occupational Therapist A and Physical Therapist C brought Resident #1 back inside the wander guard went off. The Occupational Therapist A stated that she was not aware of any other elopements with residents. The Occupational Therapist A stated that she was not aware of any additional residents that exit seek. The Occupational Therapist A stated that she had not had any training regarding Resident #1's elopement. The Occupational Therapist A stated that she knows what it sounds like when the wander guard alerts and had been trained to go to the sound, each time the sound goes off and had been trained to go to the front door. <BR/>During an interview on 03/20/25 at 11:35 AM, LVN D stated that the steps to do a wander guard depended on the resident if they are an elopement risk. LVN D stated that they would have to do a wandering assessment. LVN D stated that the wandering assessment will let you know if the resident is high risk. LVN D stated that the nurse initiates the risk assessment. LVN D stated that Resident #1 was wanting to get out the day he eloped and that he was trying to get to the door. LVN D stated that she put a wander guard on him when he tried to get out the first time that day. LVN D stated that she was unsure of the actual date. LVN D stated that she used PCC (point click care) for the assessment. LVN D stated that Resident #1 was in his wheelchair, and he was rolling around right after lunch. LVN D stated that Resident #1 was already agitated that day. LVN D stated that Resident #1 was saying that he was looking for his wife before lunch and after lunch he had stated that he needed to get to his car. LVN D stated that Resident #1 does not usually ambulate using his wheelchair on his own but on this day, he was independently rolling on his own. LVN D stated that Resident #1 was going to the front door, and she had redirected him and brought him to the desk. LVN D stated that she had told Resident #1 that the weather was bad to try and distract him. LVN D stated that she cannot remember if she offered to call his daughter that day to distract him. LVN D did the assessment on Resident #1 and put a wander guard on him. LVN D stated that she did the assessment on Resident #1, and it showed that he needed the wander guard. LVN D stated that she put the wander guard on Resident #1 first and she kept him with her the remainder of her shift. LVN D was not sure what time she had gotten off work. LVN D stated that she had kept eyes on him. LVN D stated that she reported to LVN E that Resident #1 had a wander guard. LVN D stated that she had put a wander guard on Resident #1's right wrist. LVN D stated that she had made the DON, Administrator, and ADON aware that she had placed the wander guard on Resident #1 around lunch time. LVN D stated that no one ever reported to her that Resident #1 had attempted to get out, but she did her assessment based on what she observed. LVN D stated that she did not observe Resident #1 get out of the facility but was told when she was leaving that he had gotten out. LVN D stated that Resident #1 was found outside and had fallen in the front. LVN D stated that she was not sure where at in the front Resident #1 was found. LVN D stated that she had last saw Resident #1 when she was giving report at 2:15 PM during shift change. LVN D stated that she did receive additional training after the incident (elopement drill) and elopement training. LVN D stated that she had been trained to announce it and everyone needs to start looking. LVN D stated that the Charge nurse needs to be the stationary person to report back to. LVN D stated that at that point someone needs to go outside and look. LVN D stated that you would also report to Administrator and DON and then after 15 minutes we need to call the police officers and call family. LVN D later explained that she tested the wander guard against a remote and again against the door prior to placing it on Resident #1. She stated staff member (CNA F) was present when she tested against the door. <BR/>During an interview on 03/20/25 at 11:36 AM, the Physical Therapist C said she did not see Resident #1's elopement happen. She stated that she was in the front in the therapy area. The Physical Therapist C stated that she was unsure of the time and actual date but does know that it was daytime. The Physical Therapist C stated that earlier in the day before the elopement, the Occupational Therapist A was coming back in and saw Resident #1 standing at the door and she had brought him back inside. The Physical Therapist C stated that during the actual elopement, the Occupational Therapist A had thought that Resident #1 was a visitor and when she had realized that it was Resident #1, she had told nursing immediately what had happened. The Physical Therapist C stated that later that day she was in the therapy office and heard the door open and the Occupational Therapist A yell for the Occupational Therapist B. The Physical Therapist C stated that the Occupational Therapist A was leaving work and Resident #1 had gotten out of the door and off of the curb and had fallen. The Physical Therapist C stated she and the Occupation Therapist A had helped Resident #1 up and nursing had gotten him a wheelchair and brought him back into the building. The Physical Therapist C stated that the alarm did not go off on either the first or second time that Resident #1 eloped. The Physical Therapist C stated that when they hear the alarm, they move. The Physical Therapist C stated that one of them would have gone to check if the alarm had gone off; however, they did not hear it. The Physical Therapist C stated that they were trained to, hop up and get to it. The Physical Therapist C stated that Resident #1 had the wander guard on both times for the attempt and the actual elopement. The Physical Therapist C stated that the wander guard did not go off the first time, but it went off when Resident #1 was coming back through the door after he actually eloped. The Physical Therapist C stated that the wander guard alert system was working intermittently. The Physical Therapist C stated that nursing checks the wander guards, but she was unsure if it was the charge nurse or the DON. The Physical Therapist C stated that Resident #1 seemed unharmed when he actually eloped. The Physical Therapist C stated that when staff was bringing Resident #1 in from the actual elopement, he was telling the staff no that he wanted to go the other way. <BR/>During an observation on 03/20/2025 at 1:03 PM, State surveyor tested the front door. Alarm sounded. Staff x3 came. <BR/>During an interview on 03/20/2025 at 1:29 PM, CNA G stated that she was unsure of the exact date and time that Resident #1 was showing behaviors. CNA G stated that Resident #1 tried to get out prior to that actual elopement. CNA G stated that Resident #1 was yelling at staff, being physically abusive, and had bad language. CNA G stated that this was not Resident #1's normal behavior, but he was like this prior to his actual elopement. CNA G stated that she heard LVN D say that Resident #1 tried to leave. CNA G stated that they were watching him but did not do the 1:1. CNA G stated that the first time that Resident #1 tried to get out was when the wander guard was placed on him. CNA G stated that she had received a call while in the restroom and CNA H had stated that Resident #1 was outside. CNA G stated that she went out to help. CNA G stated that breaks are usually around 1:00 pm - 2:30 pm, so that would have to have been around the time Resident #1 was able to get out of the facility. CNA G stated that she was not too sure on the actual timing. CNA G stated that when she went outside, the resident, DON, and the Administrator, were coming inside. CNA G stated that the last time that she saw Resident #1 was approximately 10 minutes before the incident happened. CNA G stated that she did not hear the door alarm. CNA G stated that this had not happened with Resident #1 before, he had always talked about wanting to leave, but this was the first time that he eloped. <BR/>During an observation on 03/20/2025 at 3:22 PM, Resident #1 observed the wander guard on left arm. He looked at it. Did not say what it was for.<BR/>During an observation on 03/20/2025 at 4:37 PM-4:45 PM, tested the wander guard at the door near the room where the investigator was and the door down the right side (back) of the facility. The alert on the side and back of the facility have a faint sound. Staff did respond x3 to the side door and x 1 to the back door.<BR/>During an interview on 03/20/2025 at 6:00 PM, Family Member #1 stated he/she was notified by Family Member #2 that Resident #1 had eloped. Family Member #1 stated that Resident #1 had a wander guard since being admitted . Family member #1 stated that Resident #1 does not get around very well and was not sure how Resident #1 was able to get outside with the wander guard and being as low as Resident #1 was. Family member stated that as a result of the incident they would be trying to place Resident #1 somewhere else. <BR/>During an interview on 03/20/2025 at 6:05 PM, Physician stated that the facility may have notified his Nurse Practitioner about the elopement. Physician stated that he did not know if Resident #1 had a wander guard. Physician stated that Resident #1 had no elopement issues that he knew of. <BR/>During an interview on 03/20/2025 at 6:13 PM, Family Member #2 stated she did not know the exact date, but she was told Resident #1 got out the front door. Family Member #2 did not say how far Resident #1 had gotten. Family Member #2 stated that it was told to her in the day that Resident #1 had managed to get out the front door. Family Member #2 stated that she was not sure if it was LVN D or LVN E that notified her. Family Member #2 stated that Resident #1 did not have his wander guard and had not had it for a while, it had been several weeks. Family member #2 stated that she did not know why they had taken the wander guard off. Family member stated that the facility did not notify them of the wander guard being taken off the first time or that they had placed one on Resident #1 the day he eloped from the facility. Family member #2 stated that after Resident #1 had fallen, the day that he eloped and had fallen outside, they had put the wander guard back on Resident #1. Family member #2 stated that it was observed that it was off but had never asked, and just assumed it was because Resident #1 quit wandering and never questioned it. Family member #2 stated that they had noticed the wander guard, but no one had mentioned putting it back on Resident #1. Family member #2 stated that she had seen Resident #1 the next day and noticed that they had placed the wander guard back on. Family member #2 stated that their concern was Resident #1 was at the back of the building. Family member #2 stated that Resident #1 had to walk down a long hallway to get out of the building. Family member #2 stated that no one had paid attention and noticed it, and this was concerning. Family member #2 stated that their parking lot was right by the street. Family member #2 stated prior to this incident they never had concern about Resident #1's care, until this. Family member #2 stated that they were fine with the placement of the wander guard but if they had been told that they were going to take it off they would have declined for the safety of Resident #1, it never was an issue.<BR/>During an interview on 03/20/2025 at 6:35 PM, NP stated that she was notified on 03/10 that Resident #1 was trying to get out the front door and that he gotten out, right outside the door. NP stated it was her understanding that Resident #1 had not even gotten to the sidewalk. NP stated she was unaware that he gotten to the parking lot near the street. NP stated she received a text stating that they had put a wander guard on Resident #1 on 3/10. NP stated that she does not know if it was before or after he had actually eloped. NP stated her text that she had received stated I put a wander guard on Resident #1 because he was trying to get out of the building after lunch. The NP stated she had not had a text message that had showed that he had gotten out of the facility. NP stated she was unaware if Resident #1 had a wander guard prior to the placement on 03/10. NP stated she had never given an order for a wander guard to be taken off. NP stated they do notify her if they take it off and she has not had any notifications that one needed to be taken off of Resident #1. NP stated that they would have to had justification to take the wander guard off and put on. NP stated that she had a text on August 13 of 2024 that Resident #1 had tried to get out. NP stated that she did not know who texted because the number was not saved. NP stated that she had located the text says Resident #1 had gotten out. NP stated that she thought it was right outside of the door because she received a phone call letting her know they gotten Resident #1 back in. NP stated that when she calls about elopements and wander guard placements she will ask them what symptoms the resident had been having and what is the reason. NP stated that she had not received that information with Resident #1's case. NP stated that it was normal to have placed a wander guard after one attempt especially with Resident #1's case because the doors are unlocked from 7-8 PM. NP stated that it was case dependent in how they respond to elopements. NP stated it was situational. NP stated that in that facility it is almost impossible to actually monitor the front door and where the patient was going. NP stated that there was no way of watching that. NP stated that the wander guard was important because of the layout of the facility. NP stated that Resident #1 cannot walk fast, but fast enough. <BR/>During an observation at 9:15 AM, The facility is located on [NAME] Avenue with posted speed limit of 55 mph. The cross street is 114 with a posted speed limit of 65 mph. There was an observation of the restaurant across the street that receives business during the day hours. The day that Resident #1 had eloped on 03/10/2025, it was 78 degrees with wind. <BR/>During an observation and interview on 03/21/2025 at 9:38 AM, Maintenance Supervisor provided his checklist that he used to check the wander guard system. He stated he was required to check it weekly, but he does check the doors daily. He stated that he has not had any issues with the system.<BR/>During an observation on 03/21/2025 at 10:05-10:08 AM: Tested side door near the room where investigator was. Staff did not come down the hall until 10:08 AM x2.<BR/>During an interview on 03/21/2025 at 10:17 AM, LVN D stated that she had spoken with Family member #2. LVN D stated that she had told Family Member #2 that she had placed a wander guard on Resident #1. LVN D stated that it was an emergent reason to put the wander guard on because Resident #1 was actively trying to get out. LVN D stated that she was 1:1 with him until got off that day, then the aides took over. LVN D stated that she does not remember if she documented it, and which aides took over. LVN D stated that no one took over her nursing duties while she was 1:1. LVN D stated it was after lunch, and she did not have anything at that moment that she needed to do. LVN D stated that Resident #1 had never had a wander guard. LVN D stated that this was the first time that Resident #1 had a wander guard. LVN D stated that you have to document when you place or remove a wander guard. LVN D stated that you have to notify the doctor to place the order. LVN D stated that she did not know if she had placed it in her note. LVN D stated that there was an order for the wander guard to be checked and changed. LVN D stated that she was there when Resident #1 tried to get out of the door. LVN D stated that Resident #1 was on the right side of the door, and he pushed it. LVN D stated that the door sounded, and she went over there and grabbed Resident #1. LVN D stated that she notified the DON, Administrator, and the ADON. LVN D stated Resident #1 should have been placed on 1:1. LVN D stated that was the protocol for at least 15-minute checks. LVN D stated that she was never instructed to place Resident #1 on 1:1. LVN D stated that she just watched Resident #1 closely based on her nursing experience. <BR/>During an observation on 03/21/2025 at 10:37 AM, Resident #1 in his room, sleep in his recliner, wander guard on left arm.<BR/>During an interview on 03/21/2025 at 10:38 AM, CNA I stated that Resident #1 did not have a wander guard before. CNA I stated that she was not sure how Resident #1 had not had his wander guard and why it was taken off. CNA I stated that Resident #1 will wander but he was not looking to get out and Resident #1 will say he needs to go home. <BR/>During an interview on 03/21/2025 at 11:17 AM, ADON stated that Resident #1 had never had a wander guard before. ADON stated that the wander guard placed in March was the first one. ADON stated that the process for placing a wander guard was if the resident was showing signs an elopement assessment should be completed. ADON stated that the family should be notified of the behavior. ADON stated that the assessment would reveal a score and if the wander guard was needed. ADON stated that the family should be notified, and the documentation should reflect if they agree or disagree and then a consent should be signed if the family agree. ADON stated that if the family was not in agreement of the wander guard, then the resident can be placed on 24 hours observation and the family will try to identify a locked unit. ADON stated that it was not done in this case. ADON stated that she did not observe the placement of the wander guard on Resident #1. ADON stated that it was discussed as a group after Resident #1 had eloped. ADON stated that it had been discussed since Resident #1 was exit seeking and had not displayed that behavior before. ADON stated that labs were obtained with no findings. ADON stated that they discussed Resident #1 being placed on 1:1 and the Administrator had stated that they would need to find 1:1 staff for Resident #1. ADON stated that she did not know why the consent was not obtained or why the assessment was done afterwards. ADON stated that LVN D had reported the POA was called and given a verbal consent. ADON stated there was a call made to the NP. ADON stated she thought they had a consent. ADON stated that they had aids initially watching Resident #1. ADON stated that there was no observation log. ADON stated that the Administrator determined that it was an emergency and that was why the wander guard was placed on Resident #1. ADON stated that they were trained to document the placement of the wander guard and if it was taken off. ADON stated that they have to have justification to put a wander guard on and take it off. ADON stated that if it was not justified then the restraint is not justifiable. ADON stated that she thinks that this could have been prevented because when Resident #1 showed signs to want to leave the first time, the resident should have been monitored more frequently. ADON stated that Resident #1's room was right across from the nurse's station. ADON stated that Resident #1 was not quick and there was no reason someone did not see him. ADON stated that if they remove a wander guard an assessment should pop up in the system. ADON stated that if the assessment showed that Resident #1 no longer exhibited wandering then the nursing judgment would also be considered. ADON stated that the doctor should be called and get an order. ADON stated then the family should be called to remove the wander guard. ADON stated that she was familiar with the policy. ADON stated that the purpose of incident/accident prevention and supervision was safety of the resident. ADON stated that the incident could happen again if the policy was not followed. ADON stated that she did not see Resident #1 when he had eloped. ADON stated that she was told that Resident #1 was by the sidewalk onto the parking lot. ADON stated that the facility was by a busy road. ADON stated that Resident #1 does not have the ability to watch for traffic. ADON stated that she is aware that Resident #1 attempted to get out around lunch time. ADON stated that she was not aware that Resident #1 got out the second time. ADON stated that she was not aware that the wander guard was implemented prior to the assessment. ADON stated that she was not aware that Resident #1 had a wander guard prior to the one placed on 03/10/2025. ADON stated that she did not have any information regarding removal, and it should be care planned. ADON stated that she is not aware of Resident #1's scores from the past wandering assessments. ADON stated that the system to monitor incident/accident prevention and supervision would be to in-service staff and monitor to make sure nursing was following incident/accident policy, ensure that everything was documented, and make sure that there were follow ups and interventions for the resident. ADON stated that she had been trained on incident and accident prevention, supervision, and restraint policy. ADON stated that she would expect policy should be followed and incident and accidents should be prevented. ADON stated that everyone was responsible and there was no reason increased supervision did not occur on the first exit seeking attempt. <BR/>During an interview on 03/21/2025 at 12:00 PM and continued on 03/24/2025 at 6:17 PM, the Administrator stated that she had been in the facility since November 2024 and that if Resident #1 had a wander guard it would have been documented. The Administrator stated that if Resident #1 were placed on 1:1, it would have been documented and an order for the increased supervision. The Administrator stated that they would have completed an assessment first before placing the wander guard. The Administrator stated that they would also have to have an order to remove a wander guard. The Administrator stated that with Resident #1 eloping successfully, after he had already attempted, could have been prevented. The Administrator stated that Resident #1 had showed signs of wanting to leave and the facility failed to place him on 1:1 supervision. The Administrator stated that she did provide an elopement in-service. The Administrator stated that, Everyone is responsible for keeping the resident safe. The Administrator stated, I was told that they had completed the assessment first and then had called for a wander guard. The Administrator stated that it could be considered a restraint. The Administrator stated that LVN D had documented that Resident #1 had went to the door. The Administrator stated that the assessment would tell you if the Resident needed a wander guard. The Administrator stated that the guard will not stop the resident from getting out of the door, but it is an intervention. The Administrator stated that there is not a reason the assessment is done after the placement. The Administrator stated that she had not had anything on a 24-hour report for Resident #1. The Administrator stated that she did an investigation. In her investigation she had not seen wander guard from any time before. The Administrator had not seen the high risk on all wandering assessments. She stated she did not look at the progress notes or assessments as a part of her investigation. The Administrator stated that she had not talked to the family since the elopement. She stated her team did tell her that they had notified the family. The Administrator stated that she did not follow up to check if the family had been notified. The Administrator stated that even in self-report all that was told to her was that the family was notified. The Administrator stated that she was unaware that the family had not been notified. The Administrator stated that the facility system to monitor incident and accident prevention was to review risk management daily and take the information from morning meetings and address as they are reported. The Administrator stated that she had been trained on incident and accident prevention. The Administrator stated they would have needed need to complete an assessment and then they would have to score a certain score, notify physician, notify family, sign the consent, before it could even be placed. It also would come with restrictions such as how often you would use it or when you remove it. The Administrator stated yes she was familiar with the policy for placing a wander guard. The Administrator stated that she was not aware that the assessment was completed after the restraint was placed on the resident, and once the IJ happened she learned of the situation. The Administrator stated that the system for monitoring for restraints was that she monitors when one is placed and would make sure DON had made her aware when one is placed, and she would follow up and have ADON monitor every week. The Administrator stated that she had been trained in restraints and her staff does complete orientation and annually as well. The Administrator stated that she had observed these residents (Resident #1, Resident #2, and Resident #3) with a wander guard on. The Administrator stated that her expectations in regard to restraint placement was that we are following our policy and that we are completing proper assessments before applying. The Administrator stated it was the responsibility of the charge nurses to apply restraints and complete assessments, and the responsibility of the ADON and DON to monitor. The Administrator stated that everyone was responsible for following the policy. The Administrator stated that there was no reason the assessment was completed after the placement of the wander guard as it relates to Resident #1, she thinks the nurse just wanted to be initiative-taking and was too initiative-taking. <BR/>During an interview on 03/21/2025 at 12:22 PM, the DON stated that the facility failed to prevent incidents and accidents allowing Resident #1 to get out. The DON stated, I was in my office and was told that he was at the door. The DON stated that the incident prompted the wander guard situation. The DON stated that Resident #1 did not get out of the door, but he was at t[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature from 1 of 1 kitchen.<BR/>1) The facility failed to provide food that was palatable. <BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. <BR/>The findings include:<BR/>On 7/20/22 at 9:35 AM the Survey Resident Council Meeting and interview was conducted, and residents were asked about the food. Two of 4 residents voiced concerns about the temperature and flavor of the foods. One resident stated that it's always cold and has no flavor. Another resident stated she did not like the taste of the food. <BR/>During confidential interviews 5 of 12 residents voiced concerns about the food served. One resident stated the food was always cold, at all 3 meals. Another resident stated that the eggs were served burnt and lunch and dinner were always cold. One other resident stated that the food tastes nasty and lacked flavor. Yet another resident stated the food was cold and lacked flavor. Another resident stated that the food was terrible. <BR/>On 7/21/22 at 11:41 AM a kitchen observation was made:<BR/>Temperatures were taken by Dietary staff B and a test tray was requested at this time (11:41 AM) from the dining room service.<BR/>Temperatures were as follows: <BR/>Mac & cheese 167&deg;F and <BR/>Stewed tomatoes 185&deg;F <BR/>Brown gravy 163&deg;F<BR/>Pur&eacute;es stewed tomatoes 169&deg;F <BR/>Pur&eacute;e macaroni and cheese and 167&deg;F <BR/>Mashed potatoes 125&deg;F. <BR/>Peas 140&deg;F <BR/>Hamburger patties 120.7&deg;F<BR/>White gravy 173&deg;F <BR/>Sliced bread<BR/>Hall tray prep was started at 12:03 PM. Dining room service was started at 12:35 PM and ended at 12:49 PM.<BR/>On 7/21/22 at 12:48 PM the dining room service concluded. The test trays were taken directly from the steam table starting at 12:59 PM. At 1:02 PM, the surveyor requested that dietary staff take temperatures on the service line. It was observed that the ground hamburger was not on a heat source on the steam table and was sitting on a ledge of the steam table in a small pan. <BR/>Observation on 7/21/22 at 1:05 PM, the ground hamburger was 106 degrees Fahrenheit. The temperature of the mashed potatoes was 140 degrees Fahrenheit. The hamburger patties were 106 degrees Fahrenheit.<BR/>The test trays left the kitchen at 1:07 PM in insulated covers.<BR/>Observation on 7/21/22 at 1:08 PM, the test trays were sampled by surveyors with the following results:<BR/>Peas - bland, lukewarm<BR/>Mashed potatoes - Cold<BR/>Beef with gravy - Cold<BR/>Ground beef - cold<BR/>Macaroni and cheese - bland with little cheese flavor.<BR/>Pureed macaroni and cheese - bland with little cheese flavor and cold<BR/>Puree stewed tomatoes - cold<BR/>Seven of the 11 foods served had about palatability issues dealing with flavor and temperature. <BR/>On 7/21/22 at 4:54 PM an interview was conducted with the Dietary Manager regarding issues in the kitchen. She was also told about the palatability issues with the test tray. Regarding the cold food she stated the staff sometimes delay picking up the trays to deliver them. She was asked how unpalatable foods could affect the residents. She stated, staff could make more and reheat it. She added that it could decrease food intake. <BR/>On 7/21/22 at 5:20 PM an interview with conducted with the Administrator and dietary issues were reviewed with her. She stated food palatability issues could result in affecting the resident satisfaction. She also stated she expected dietary staff to correct these palatability issues on the spot. <BR/>Record review of the facility policy titled Food: Quality and Palatability, HCSG Policy 006, revealed the following documentation, Policy Statement. Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature . Definitions . Proper (safe and appetizing) temperature food should be at the appropriate temperature as determined by the type of food to ensure a resident satisfaction and minimizes the risk for scalding and burns. <BR/>Procedures. <BR/>1. The Dining Services Director and cook are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardize recipes. <BR/>2. The cooks prepare food in a sanitary manner utilizing the principles of hazard analysis critical control point (HACCP) and time and temperature guidelines as outlined in the federal food code . <BR/>4. The cook prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. [NAME] use proper cooking techniques to ensure color and flavor retention .

**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 2 of 2 staff (Dietary staffs A and B), for 1 of 1 kitchen and 1 of 1 Activity room, in that:<BR/>1)The facility failed to ensure Dietary staff (Dietary staff A and B) used sanitizers as directed and sanitizer levels were maintained and tested according to manufacturer recommendations;<BR/>2) The facility failed to ensure Dietary staff (Dietary staff A and B) used good hygienic practices during dietary duties, <BR/>3) The facility failed to ensure hot and cold TCS foods were maintained at 41 degrees F or below or 135 degrees F and above, <BR/>4) The facility failed to ensure foods and food contact equipment were protected from possible contamination (refrigerator, Activity room), <BR/>5) The facility failed to ensure foods were in sound condition (expired hardboiled eggs), and<BR/>6) The facility failed to ensure food and nonfood contact surfaces were clean (Activity room stove and shelving, scoop holder). <BR/>These failures could place residents at risk of food contamination and foodborne illness. <BR/>The findings include:<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 9:54AM and concluded at 10:18 AM:<BR/>Dietary staff A was asked to test the dish machine chlorine sanitizer level, and she took the chlorine test strip and placed it under the water draining from the dish machine from the wash cycle. She did not initially test the chlorine sanitizer in the rinse cycle. Interview with Dishwasher A on 7/19/22 at 10:18 AM, she stated that she had worked in dietary a month.<BR/>There was no chlorine sanitizer dispensing from the dish machine. The rinse temperature at the dish machine was 120&deg;F and the chlorine level was 0 PPM instead of between 50-100 PPM<BR/>Interview on 7/19/22 at 10:05 AM the Dietary Manager stated, two days ago staff said that the dishwasher was not working. They pressed the button, primer, and it worked. They will wash in a three compartment sink until the dishwasher is repaired.<BR/>There were two unshielded lights in the kitchen refrigerator. <BR/>Personal drinks with a straw were stored on the tea station counter.<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 10:36 AM and concluded at 11:00 AM:<BR/>During an interview on 7/19/21 at 10:36 AM, Dietary staff A stated, the dish machine chlorine dispensing tube came off. Observation at the time revealed that the chlorine sanitizer tube that entered the dish machine was broken in half. She stated they called the repairman.<BR/>Personal drinks with covers were observed on the [NAME] table of the one compartment sink. There was a bowl of potatoes in the sink.<BR/>There was a soiled apron and backpack hooked on an equipment rack where dishes were stored, and food equipment stored.<BR/>Observation of Dietary staff B handwashing revealed that she touched the soiled front of the paper towel dispenser after washing her hands and re-contaminated her hands. She then dried her hands, turned off the water with the paper towels and donned a pair gloves. She continued with dietary duties.<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 11:26 AM and concluded at 12:45PM:<BR/>Dietary staff B stated that she was preparing seven pur&eacute;es. She placed green beans in the processor and pur&eacute;ed it. She then washed her hands and during the handwashing process she touched the soiled front of the paper towel dispenser, recontaminating her hands. She dried her hands and placed the paper towel in her pocket. <BR/>Dietary staff B then washed the blender in the three-compartment sink, rinsed and then submerged it in the Ecolab Oasis 146 Multi Quat Sanitizer for only 20 seconds and then set it aside to dry. She then took the lid and did the same thing and then submerged the lid in the quaternary sanitizer for only five seconds and then took it out to dry. She cleaned a pitcher in the three-compartment sink and only submerged it in the sanitizing rinse for five seconds. Then she set it out to dry. <BR/>Record review of the Ecolab Oasis 146 Multi Quat Sanitizer wall chart (https://www.gofacilipro.com/wall-charts/oasis-146-wall-chart) dated 2015 revealed the following documentation, . 150-400 ppm quat range . Directions for use. Apply oasis 146 multi quat sanitizer at proper use solution. Expose all surfaces of equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry <BR/>Record review of the label of the Oasis 146 Multi Quat sanitizer revealed the following, Directions for Use .expose for one minute . <BR/>Dietary staff B rewashed the blender container in the three-compartment sink and then submerge it in sanitizer for 10 seconds and then set it on the drain table to dry.<BR/>Dietary staff B washed her hands and touched the soiled front of the paper towel dispenser again which re-contaminated her hands. She then dried her hands, donned gloves and continued with dietary duties. She continued to process foods (pureed pasta and tomato sauce).<BR/>Temperatures were taken on the service line steamtable by Dietary staff B with the following results: <BR/>Ziti with beef 137.3&deg;F <BR/>Green beans 184&deg;F <BR/>Tomato sauce 100.2&deg;F<BR/>Pur&eacute;ed [NAME] beans 164&deg;F <BR/>Pur&eacute;ed ziti 164&deg;F <BR/>Mashed potatoes 113.7&deg;F. It was placed in an area of the steam table that had an open space.<BR/>Toasted bread 128&deg;F<BR/>Cucumber salad was on ice and was 47.5&deg;F<BR/>Lettuce salad was on ice and was 53&deg;F<BR/>Egg salad was 53.6&deg;F and the ice in the pan it was sitting in was melted. There was only a few scattered pieces of ice. The egg salad sandwiches were also in this pan of melted ice and it was 62.5&deg;F<BR/>On 7/19/22 at 12:11 PM the Dietary staff B was asked how the mashed potatoes were made. She stated, with milk and butter. It's a mix.<BR/>On 7/19/22 at 12:12 PM Dietary staff B covered the open space on the steam table with plastic.<BR/>On 7/19/22 at 12:13 PM Dietary staff B was asked when the egg salad was made. She stated the egg salad was made at 11:10 AM.<BR/>The meal service started at 12:15 PM. The mashed potatoes were not rapidly reheated to 165 degrees F and held at 135 degrees F or above. Adequate ice was not placed in the pan used to hold the egg salad foods at the steam table. <BR/>Observation of a container of Peeled Hard Cooked Eggs 10 pound was on a prep table. Further observation of the container revealed the following, Use by 13 July 2022.<BR/>On 7/19/22 at 12:19 PM the Dietary Manager and Dietary staff B were asked if these hard cooked eggs have been used to make the egg salad sandwiches and egg salad. They both stated yes.<BR/>On 7/19/22 at 12:37 PM an interview was conducted with the Dietary Manager about the expired hard-boiled eggs. She stated that she got the eggs at the store on 7/06/22 and marked it 7/06/22. She added that she did not see the use by date. She stated that when a delivery truck comes, she marks the date she gets the food.<BR/>Dietary staff A was observed washing her hands at the hand sink and she also touched the soiled front of the paper towel dispenser in order to dispense more towels. She used the towel and then continued to dry her hands with it. She donned a pair of gloves and handled condiments and insulated lids and covered trays.<BR/>On 7/19/22 at 1:15 PM an interview was conducted with the Dietary Manager. She stated that none of the egg salad was served.<BR/>~ The following observations were made during an Activity room tour that began on 7/19/22 at 1:00 PM and concluded at 1:12 PM:<BR/>On 7/19/22 at 1:00 PM an observation was made of the activity room sink area. There were boxes of bag chips stored under the drain line of the sink. Utensils and pans were inverted on a cloth towel on top of the small refrigerator. There was a dead bug on the towel. <BR/>The oven interior and browner area were soiled with dried food and dead bugs.<BR/>The cabinets had an uncovered portion cup of pepper and uncovered cup of oil. <BR/>The lower cabinets had dried spills.<BR/>On 7/19/22 at 1:13 PM an observation was made of the corridor ice machine room. The ice scoop holder was dirty on the interior and had an accumulation of sediment and water in the bottom of it.<BR/>On 7/21/22 at 8:46 AM the ice machine corridor's scoop Holder was still dirty with settlement at the bottom and wet.<BR/>~ The following observations were made during a kitchen tour that began on 7/21/22 at 11:41 AM and concluded at 1:07 PM:<BR/>Temperatures were taken by Dietary staff B. Temperatures were as follows: <BR/>Mac & cheese 167&deg;F <BR/>Stewed tomatoes 185&deg;F <BR/>Brown gravy 163&deg;F<BR/>Pur&eacute;es stewed tomatoes 169&deg;F <BR/>Pur&eacute;e macaroni and cheese and 167&deg;F <BR/>Mashed potatoes 125&deg;F. <BR/>On 7/21/22 at 11:20 AM Dietary staff B was interviewed as to how she made the mashed potatoes. She stated that she used milk and butter in it.<BR/>Peas 140&deg;F <BR/>Hamburger patties 120.7&deg;F.<BR/>White gravy 173&deg;F <BR/>Sliced bread<BR/>The refrigerator had unshielded lights as before.<BR/>Meal service ended at 12:49 PM. At 1:02 PM, the surveyor requested that they take temperatures on the service line. It was noted that the ground hamburger was not on a heat source on the steam table and was placed on a ledge of the steam table. <BR/>On 7/21/22 at 1:05 PM the ground hamburger was 106 degrees Fahrenheit. The temperature of the mashed potatoes was 140 degrees Fahrenheit. The hamburger patties were 106 degrees Fahrenheit. These TCS foods were not rapidly reheated to 165 degrees F. and held at 135 degrees or above.<BR/>On 7/21/22 at 4:54 PM an interview was conducted with the Dietary Manager regarding issues in the kitchen. Regarding the incorrect testing of the dish machine, she stated Dietary staff A was nervous, but did not know why she did it. She stated that she had conducted training on dish washing and testing. She was also told about hand washing and staff touching the paper towel dispenser and contaminating their hands. She stated she told staff not to touch the dispenser. She added that temperatures on the steam table should not be below 135 degrees Fahrenheit. She further stated that staff knew to reheat foods if they are cold. She stated if the above-mentioned issues continued in dietary, it could result in foodborne illness. She was also told about the holder for the ice maker ice scoop being dirty. She stated she thought the housekeeping department was responsible for cleaning it. <BR/>On 7/21/22 at 5:20 PM an interview with conducted with the Administrator. She stated the issues with dietary sanitation could result in affecting resident satisfaction. She was also asked what she expected from the dietary staff regarding these issues, and she stated they should correct issues on the spot. <BR/>On 7/25/22 at 4:30 PM and interview was conducted with the Activity Director regarding the activity room foods. She stated that the foods present were used for residents but they had thrown everything away after the survey. <BR/>Record review the facility policy titled Food: Preparation, HCSG Policy 016, Original 5/2014, Revised 9/2017 revealed the following documentation, Policy Statement. All foods are prepared in accordance with the FDA Food Code. <BR/>Procedures. <BR/>1. All staff practice proper handwashing techniques and glove use. <BR/>2. Dining services staff will be responsible for food preparation, for food procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. <BR/>3. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. <BR/>4. The Dining Services Director/Cook(s) Will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41&deg;F and/or less than 135&deg;F, or per state regulation . <BR/>9. The Cook(s) will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. <BR/>10. Time/Temperature Control for Safety (TCS) hot food items will be cooked to a minimum internal temperature for 15 seconds, as follows: <BR/>Poultry and stuffed foods 165&deg;F<BR/>Ground meat 155&deg;F<BR/>Fish, pork, other meats 145&deg;F . <BR/>11. When hot pur&eacute;e, ground, or diced food drop into the danger zone (below 135&deg;F), the mechanical [NAME] altered food must be reheated to 165&deg;F for 15 seconds if holding for hot service. <BR/>12. When reheating, foods will be rapidly heated to 165&deg;F for 15 seconds. If the food is not reheated within two hours it must be discarded. <BR/>13. All foods will be held at appropriate temperatures, greater than 135&deg;F (or as state regulations require) for hot holding, and less than 41&deg;F for cold food holding. <BR/>14. Temperature for TCS foods will be recorded at time of service and monitor periodically during meal service. <BR/>15. All staff will use serving utensils appropriately to prevent cross-contamination. <BR/>16. Prepare hot food items that are not intended for immediate service will be cooled using the following guidelines: <BR/>Place in shallow pans or cut/slice to promote rapid cooling.<BR/>TCS foods will be cooled from 135&deg;F to 70&deg; Fahrenheit within two hours.<BR/>TCS foods will be cool from 70&deg;F to 41&deg;F with them 4 hours.<BR/>Total cooling time cannot exceed six hours. The clock starts at 135&deg;F.<BR/>17. All TCS foods that are to be held for more than 24 hours at a temperature of 41&deg;F or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and 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 disease and infections for 4 of 17 residents (#25, 40, 43 and 101), in that:<BR/>1) <BR/>Improper hand hygiene and personal protective equipment was observed during incontinent care for 3 residents, Resident #25, Resident #43, and Resident #40.<BR/>2) <BR/>Failures to routinely clean/disinfect environmental surfaces in both patient rooms and common areas, as well as resident care equipment were documented.<BR/>3) <BR/>Unclear identification of proper transmission-based precautions (TBPs) was observed for Resident #101, who was on COVID quarantine due to recent return to the facility and vaccination status. Facility did not post proper Centers for Disease Control and Prevention (CDC) category of isolation for this resident, neither COVID isolation nor enhanced droplet-contact.<BR/>4) <BR/>Improper selection and use of personal protective equipment (PPE), including donning and doffing of PPE based on national standards set forth by the CDC.<BR/>These failures to follow proper infection prevention procedures place residents in the facility at risk of exposure to and transmission of communicable diseases and healthcare associated infections that can lead to an increased risk of serious illness, hospitalization. <BR/>Findings include:<BR/>Resident #101:<BR/>Record review of Physician Orders Summary and face sheet for Resident #101 revealed that he was admitted to the facility initially on 6/10/22 and was re-admitted on [DATE]. The resident was [AGE] years old and had a diagnoses of Essential (Primary) Hypertension, End Stage Renal Disease, Hemiplegia, Unspecified Affecting Left Nondominant Side, Unspecified Cirrhosis Of Liver, Acidosis, Hepatic Failure, Unspecified Without Coma, Anemia In Other Chronic Diseases Classified Elsewhere, Personal History Of Transient Ischemic Attack (Tia), And Cerebral Infarction Without Residual Deficits, Flaccid Hemiplegia Affecting Left Nondominant Side, Unspecified Abnormalities Of Gait And Mobility, Muscle Wasting And Atrophy, Not Elsewhere Classified, Unspecified Site, Other Dysphagia, and Cognitive Communication Deficit.<BR/>Record review of the physician's Order Summary for Resident #101 revealed an order stating, Isolation for 10 days for COVID protocol. every shift for covid prevention monitoring until 07/26/2022 at 23:59, Phone Active 07/16/2022, Start Date 07/18/2022, End Date 07/26/2022 .<BR/>Observation on 7/19/22 at 10:19 AM a resident tour was conducted on Hall 100. Resident #101 resided in room [ROOM NUMBER]. He was a re-admit. He has 3 signs posted on his door related to donning and doffing PPE instructions. There was a PPE cart present outside his door with Sani wipes and open boxes of gloves on top of the cart. There were N95 masks in the cabinet, gowns and face shields. The resident was in bed and the door was a jar. <BR/>On 7/19/22 at 10:30 AM an interview was conducted with LVN B regarding the residents on hall 100. She stated the Resident #101 was a readmit from the hospital on 7/16/22 and that he has end stage renal disease. She said he was on dialysis Monday, Wednesday, Friday and was very confused. He used a wheelchair due to hemiplegia and that he went to the hospital due to vomiting blood and had a G.I. bleed. She added that the hospital kept him a while. She said he also had a diagnosis that included liver cirrhosis.<BR/>Observation on 7/19/22 at 12:59 PM. Resident #101 was observed in bed, awake and the door was open.<BR/>Observation on 7/19/22 at 4:07 PM of room [ROOM NUMBER], there was no posted documentation of any kind as to what type of precautions the Resident #101 was on. CNA A exited the resident's room and disposed of her face mask in the corridor in the trashcan that was not covered. <BR/>Observation on 7/19/22 at 4:12 PM LVN C left room [ROOM NUMBER] and placed the N95 mask in the corridor trashcan which was not covered. <BR/>Observation on 7/21/22 at 10:33 AM Resident #101 was in the room and the door was open to his room.<BR/>On 7/21/22 at 4:20 PM an interview was conducted with NA B. She was asked about infection control regarding Resident #101. She stated staff were told to don all PPE including a shield, gloves, gown upon entering room [ROOM NUMBER]. She added staff should remove all the PPE prior to exiting the room and don't keep the door open. She said she learned that today from a surveyor. She stated she had been told that Resident #101 was on precautions because he's a new resident and on restrictions for COVID for two weeks. She added that she did not know if they specified the type of precautions. <BR/>On 7/21/22 at 4:31 PM an interview was conducted with LVN A. She stated when entering room [ROOM NUMBER], staff should wear a gown, mask, and gloves. She added that the facility did not have face shields. She stated that she just wears her face mask now. This is the one they say is for contact with him. She was asked what type of precautions Resident #101 was on. She stated staff were told just isolation. She added that she thought he was on airborne precautions.<BR/>On 7/21/22 at 4:34 PM an interview was conducted the DON regarding infection control. She stated that Resident #101 was on droplet precautions for COVID. She added she told staff to wear a gown, gloves, N95, surgical mask, face shield. If they have on face shield, they only have to wear a face mask or the option for N95. She stated the facility had face shields. She stated if staff failed to wear proper PPE, cross contamination could occur.<BR/>Observation on 7/21/22 at 4:45 PM revealed room [ROOM NUMBER] had a sign regarding specific precautions for Resident #101. The sign was dated March 2020 which stated the resident was on Enhanced Droplet-Contact Precautions.<BR/>Observation ;on 7/21/22 at 4:45 PM of the sign posted on Resident #101's room:<BR/>Enhanced droplet - contact precautions.<BR/>Perform hand hygiene<BR/>N95 or surgical face mask when entering room.<BR/>Eye protection when entering room.<BR/>Gown when entering room.<BR/>Gloves when entering room.<BR/>Private room and keep door closed . Spice 3/20 . Effective: March 20, 2020 .<BR/>During an observation of incontinent care on 07/20/22 at 8:27 am with CNA B for Resident #25, CNA B did not wash hands or wear gloves prior to gathering clean supplies for incontinent care. CNA B explained to Resident #25 the procedure that she would be helping the resident with. CNA B proceeded with incontinent care without washing her hands. CNA B placed on clean gloves to remove the front of the brief by pulling the brief down. CNA B used individual wipes with the one swipe method to provide incontinent care for Resident #25 by starting on the right side, then the left side, then the middle. CNA B removed the dirty gloves and placed on new pair of clean gloves without performing hand hygiene and rolled the resident to the right side and removed the remainder of the dirty brief and placed it in the designated trash. CNA B used individual wipes and the one swipe method to provide cleaning to the back side of the resident. CNA B then grabbed the clean brief and placed underneath the resident and then placed Resident #25 on her back. CNA B fastened the brief in the front. CNA B discarded all trash in the designated trash bag. CNA B her washed hands for 37 seconds using soap and water. CNA B then grabbed one paper towel and dried both hands and then used the same paper towel to turn off the water. <BR/>During an observation of incontinent care on 07/20/22 at 9:20 am with CNA C for Resident #43 in room [ROOM NUMBER], CNA C could not shut the door because the bed was too long. CNA C, with helper was CNA B. CNA C washed hands after last resident, gathered supplies in a clear bag, explained the procedure to the resident. CNA B washed hands correctly. CNA C - got soap while dripping water on floor, used dirty napkin from drying hands to turn off waterspout; provided privacy. CNA C used hand sanitizer, opened clean trash bag, put on clean gloves (both CNAs). CNA C opened clean brief on supply table, pulled back covers, lowered bed. Did not use gait belt to move resident, placed resident on back, raised bed, CNA C removed gloves, placed on new gloves, took off gloves, touching open clean brief with bare hands. CNA C had to leave room to get more gloves, not enough supplies, came back to room and washed hands shaking water off hands. Used dirty paper towel from drying hands to turn off waterspout. Placed on clean gloves, turned resident to one side to remove pants, took off dirty brief, used 1 wipe to wipe upper roll, 1 swipe method used 1 wipe, wiping top to bottom, 1 swipe method, finished removing dirty brief, wiping bottom, 1 swipe method, disposed of brief, did not use hand sanitizer after dirty brief to clean brief. She placed on clean gloves and replaced with clean brief. Gathered trash, CNA B used hand sanitizer, then washed her hands. CNA C went to wash her hands. CNA C used 1 paper towel to dry her hands and used the same paper towel to turn off the waterspout, did not use gait belt to move resident back to chair.<BR/>During an observation of incontinent care on 07/20/22 at 9:39 am with NA C for Resident #40 and helper - NA (Nurse Aid) A did not wash hands prior to gathering supplies; gathered supplies with bare hands. NA A washed hands, NA C washed hands, removed covers, gathered wipes and placed on bed; provided privacy, placed cover sheet over resident, removed dirty brief, used 1 swipe method 1 wipe, top to bottom, vagina, turned resident to right. Finished removing dirty brief, 1 wipe - 1 swipe method, put clean pad and clean brief under resident, placed on clean brief, did not use hand sanitizer. Did not change gloves. Did not wash hands after procedure.<BR/>In an interview on 07/20/22 at 10:26 am with CNA C, for failing to wash hands correctly while providing incontinent care. CNA stated that she has been trained in handwashing. CNA stated that the training occurs monthly and that the DON is responsible for making sure that the training is completed. CNA stated that she does understand where she went wrong and was not thinking, so she made a mistake. CNA stated that she didn't realize that she could not use the same napkin that dried her hands to turn off the sink spout. CNA stated that the negative potential outcome of not providing handwashing for the residents and staff would be the transmission of infection. CNA stated that it reduces the safety of staff and residents. CNA stated that by slowing down and thinking about her steps would help her to correct the problem and maybe some additional training. <BR/>In an interview on 07/20/2022 at 10:32 am with NA C for failing to wash hands correctly while providing incontinent care. NA stated that she has been trained in handwashing techniques. NA stated that she thinks the training is supposed to be every couple of weeks but is not certain on the time frame. NA stated that the training includes skills checks and computer training. NA stated that the DON is responsible for making sure that staff completes their training. NA stated that she messed up on remembering to do her handwashing because she was nervous. NA stated that the potential negative outcome of not providing hand washing for the residents and staff would be the spread of germs. <BR/>In an interview on 7/20/2022 at 10:41 am with CNA B, for failing to wash hands while providing incontinent care. CNA stated that she has been trained in handwashing and the facility provides weekly training for handwashing. CNA stated that she didn't realize that she needed to wash her hands prior to gathering supplies but she knows now. CNA stated that she is new and still learning. CNA stated that the potential negative outcome for not washing hands would be that she could cause cross contamination to other residents or even take germs home to her family. <BR/>In an interview on 07/20/2022 at 10:57 the DON stated that she will in service the three CNAs on hand washing. DON stated that the staff is provided monthly skills checks and computer training. DON stated that she will randomly pick different staff to do skills checks every month and each month is different staff members. DON stated that she will get with these staff members and provide further education. The DON stated that she expects that staff members wash their hands and wash them correctly while providing incontinent care. The DON stated that the negative potential outcome for not washing hands would cause cross contamination.<BR/>In an interview on 7/19/22 10:17 am room [ROOM NUMBER] Resident 22 stated that her sheets are visibly soiled. She stated the sheets are not changed often but did not recall a frequency.<BR/>In a follow-up observation on 07/19/22 at 1:25 pm, after the food arrived, a brief walkabout the room revealed 15 separate flies in the dining room.<BR/>In an observation on 7/19/22 at 3:26 pm, the restroom between rooms [ROOM NUMBERS], the toilet seat was stained and has visible blood; no residents are currently assigned to this room.<BR/>In an observation on 7/19/22 at 3:30 pm, in the Piano Room surveyor observed 4 mechanical lifts being stored in this room. Of the 4 Hoyer lifts, one was noted to have 10 separate areas of blood contamination and multiple other areas of the square are visibly contaminated with smears of yellow dried fluid and chunks of unknown substances. Over 70% of the blue square was visibly soiled on the part of the lift where the resident stands, the blue square at the bottom. In addition, there was visible blood spatter on the 2 blue pads that make direct contact with the residents' legs. In addition, a bottle of Pine-sol cleaner was stored in the cabinet next to empty plastic food containers that are re-usable. A total of 5 Hoyer batteries were noted in this room, 2 on the counter next to the sink and 3 on a bookshelf next to the piano; all 5 batteries were visibly and grossly contaminated with blood. <BR/>In an interview and observation on 7/20/22 at 11:25 am in room [ROOM NUMBER] with Resident #49, she stated her privacy curtain was replaced and she was told it was because someone was documenting the blood on the curtain the previous day. Surveyor told the resident that I had done that. She stated the blood was present since she admitted , so about 3 weeks. The floor is also clean today, food and blood clean. <BR/>In an interview on 7/20/22 11:52 with Resident #7's family member, she stated the only issues she has ever noticed is general cleanliness of building and not always enough staff to get to everyone timely, but they come when they can and are always very kind. Upon arrival she has found Resident #7 wet, but the staff respond immediately to care for her when she hits the call light. She stated Resident #7 has not had any rashes or skin breakdown and the facility calls her and notifies her of changes to her mother's condition. <BR/>In an observation on 7/20/22 12:13 pm a live spider noted to be in cabinet in room surveyors are meeting in on the 100 hall (room lacks a posted room number, but is next to room [ROOM NUMBER], closer to front of the building).<BR/>In an observation on 7/20/22 at 5:00 pm as the surveyor walked out of the building, a resident in a wheelchair was observed to be in the piano room next to the Hoyer Lift with blood and other contamination. In addition, the contaminated Hoyer from 7/19/22 and 1 other Hoyer have both been moved from their position on 7/19/22. Surveyor observed 1 Hoyer being transported down a resident hall. A blood drop was noted on same wall. <BR/>In an observation on 7/21/22 at 9:56 am two ceiling tiles were observed in the back dining room that were visibly soiled.<BR/>In an interview on 7/21/22 at 11:55 am with DON about Hoyer lifts, she stated they should be cleaned after each resident, and they are owned and serviced annually and as needed by a medical supply. She explained after admission and quarterly nurses evaluate transfer status of each resident. If the resident is a 3 they use a stand assist Hoyer (which is the type that was noted to be contaminated with blood) and a 4 they use a total assist Hoyer. When asked for policies related to Hoyers, the DON said she did not think they had one but would bring it if she found one. At 4:45 pm a policy was provided for lift systems (Hoyer).<BR/>In an interview and observation on 7/21/22 at 12:45 pm with Resident #49, a visible spot of contamination on the ceiling next to the new privacy curtain was observed and a staff member was informed and stated she would have someone clean it as soon as possible. Surveyor asked to test water temperature in the restroom and found it was 122 degrees Fahrenheit. Two flies were observed near the resident and her tray of food that was on her over the bed table.<BR/>In an observation on 7/21/22 at 2:10 pm at the meeting of the 100 hall and the main entry hallway, a large beetle was observed crawling through the hallway.<BR/>Transmission-based precautions & personal protective equipment (PPE):<BR/>On 7/19/2022 at 1:06 pm an observation of room [ROOM NUMBER], which houses a resident on quarantine who recently returned to the facility and is not vaccinated, revealed 2 signs were posted on the door outside of the room and 1 sign on the wall above the PPE container. The signs demonstrated proper donning and doffing of PPE, but no sign was present showing what precautions, based on the CDC categories of transmission-based precautions, the resident was placed on.<BR/>On 7/19/22 at 12:52 pm an observation revealed no gloves were in the PPE box where glove box should be.<BR/>On 7/19/22 at 1:45 pm outside of room [ROOM NUMBER], the only isolation room, the container of caviwipes outside of room on the PPE cart had a yellow sticky substance on the lid to the container. In addition, several vinyl clear gloves were on the PPE cart in a box marked not for medical use. Housekeeper A left isolation room wearing a surgical mask for the covid quarantined resident instead of the appropriate n95 mask. In addition, the door was open to this room. Surveyor looked inside the room to see where PPE was being discarded and noted two large yellow trash bins on the far wall in the patient zone, so Surveyor spoke to DON about proper doffing of PPE and disposal of the PPE should be in the resident room right next to the exit.<BR/>On 7/20/22 at 10:05 AM an observation was made of isolation room yellow barrels in the corridor in hall 100 while Housekeeper A was inside room [ROOM NUMBER] cleaning. Resident #101 resided in this room and was on contact and droplet precautions. The housekeeper was going in and out of the room, into the corridor, wearing her face mask, face shield, gown and gloves. She was cleaning in the room and had on a face shield with the facemask. There were no guidelines on the door excepted to CDC don and doff infographics which stated to doff inside the resident room. <BR/>When Housekeeper A came out of the room into the hall, she was handling her badge with her gloves on and she still had on her gown, facemask. She doffed in the corridor removing her gloves, face shield and gown and disposed of the in the yellow barrels. She then took the trash from the yellow barrels to the dumpster.<BR/>On 7/20/22 at 10:30 AM an interview was conducted with Housekeeper A with interpreter CNA A. She stated a gown, mask, gloves, and face shield were worn when entering an isolation room. She added that she was told to wear a face shield and N95 mask. She stated she was not wearing an N95 mask because she forgot and was nervous. <BR/>On 7/21/22 at 9:38 AM Housekeeper A was observed doffing gown and gloves in the corridor again and putting her gown and gloves in the trash bin on her housekeeping cart in the corridor.<BR/>On 7/21/20 to 9:40 AM an interview was conducted with Housekeeper A and she stated that they have been told to doff in the corridor outside of the room. Observation of the housekeeper cart trash bin revealed that there was an N95 mask and gown in the trash bin.<BR/>On 7/21/22 at 4:00 PM an interview was conducted with the Housekeeping District Manager in the absence of the facility Housekeeping/Laundry Supervisor. She stated the Facility Housekeeping Laundry Supervisor said staff were educated on infection control. Staff were to wear PPE which included an N95 mask, face shield and gown when cleaning isolation rooms. Before they crossed the threshold, they take everything off in the room. She added she had stopped and asked all of housekeeping staff about infection control. She stated she talked to Housekeeper A yesterday and the housekeeping staff were in-serviced on infection control. She added that not following infection control protocols exposes everyone to infections. She stated it would lead to more residents getting ill and it was important to use proper PPE.<BR/>Record review of the In-Service Record Log dated 7/20/22 at 1:00 PM delivered to the Housekeeping Department, Subjects: Proper wearing PPE in isolation rooms, Locking carts, N95 mask. The following documentation was listed under the Summary of Subject Material Covered: PPE - when and why we wear it. Isolation rooms - How to clean and what we wear. N95 mask - What they are used for and when to wear them .<BR/>Record review of the policy titled Lift, Transfer and Repositioning Policy published in 2010 by Sava Senior Care Administrative Services, LLC, the policy states all lift equipment shall be used and maintained in accordance with Manufacturers' instructions. The policy further states in the section titled Safety Committee that the Safety Committee's responsibilities will include b. Ensuring proper maintenance and storage of existing mechanical lifting devices. Cleaning of the device was not specifically addressed as the policy focused on proper use and safety related to the staff and resident use of the device.<BR/>Record review of the posted CDC posters on Resident #101's room revealed the following:<BR/>Sequence for Putting on Personal Protective Equipment . The type of PPE use will vary based on the level of precautions required, such as standard and contact, droplet or airborne infection isolation precautions. The procedure for putting on and removing PPE should be tailored to the specific type of PPE .CDC<BR/>How to Safely Remove Personal Protective Equipment Example 1 . There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes would potentially infectious materials. Here is one example. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Remove PPE in the following sequence . CDC<BR/>How to Safely Remove Personal Protective Equipment Example 2 . Here is another way to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient's room and closing the door. Remove PPE in the following sequence .CDC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility must maintain an effective pest control program so that the facility was free of pests, in the dining room, piano room and 3 of 16 resident rooms (201, 207 and 215), in that:<BR/>The facility failed to provide an effective pest control program for flies and insects in the facility.<BR/>These failures could place residents at risk for vector-borne diseases.<BR/>The findings include:<BR/>In an observation on 07/19/22 12:02 pm 3 surveyors arrived in dining room for resident observation of dining. Two light-based insect killing machines are present and neither were on; surveyor asked Maintenance Supervisor to plug the bug zapping lights. One machine had no plug attached and one was found and both lights (one on either side of the dining room) were plugged in and began functioning. 12 flies were observed in the dining area during at this time.<BR/>In an observation on 07/19/22 1:20 pm a fly was noticed on the support column, next to Resident #27, about 4 inches from the hand sanitizer installed on this column. At the same time, a fly was noted on Resident #35 in the dining room.<BR/>In an observation on 7/19/22 at 3:30 pm, in the Piano Room, multiple various bug carcasses were in cabinets and on the floor in this room. When surveyor opened a small white cabinet above the sink, 2 bug carcasses fell to the counter. One fly swatter was hanging on the wall and one was on top of the white cabinet above the sink.<BR/>In an interview and observation on 7/20/22 at 11:25 am in room [ROOM NUMBER] with Resident #49, 1 fly was observed in the resident room and resident commented that the facility had multiple flies in multiple rooms; resident stated that she went to the restroom this morning around 3 am and saw a cockroach in her restroom and held up her fingers to show size, 1.5-2.0 inches. Resident stated this is a normal experience in her restroom. On 7/20/22 at 11:31 am, surveyor opened restroom door and observed baby roach under toilet. In a corner under toilet there was a 1-2-inch gap between the wall and the base board that extends from the corner for about 8 inches.<BR/>In an interview on 7/20/22 at 1:08 pm with Resident #30 in room [ROOM NUMBER], she has fly swatter next to bed and says said flies are a constant issue that was worse at night or when she was lying in bed.<BR/>In an interview on 7/21/22 at 10:03 am with Resident #22 in room [ROOM NUMBER], we both noticed a fly, and she stated that she sees them often, especially in the dining room. She said one in her room was very friendly and follows her even to the restroom. Resident named the fly [NAME] and surveyor left to ask the DON for a fly swatter so Resident could kill [NAME] the Fly. The DON had a fly swatter and left to provide it to Resident #22.<BR/>Record review of the facility policy titled Operation 4: Nursing Operations - The Source, Chapter: Infection Control, Revision Date: December 2021, OP4 0825.00, Pest Control, revealed the following documentation, To provide an environment free of pest, the center will maintain a pest control contract that provides frequent treatment of the environment for pest. The contract will allow for additional visits by the pest control service when a problem is detected. The center will include bedbug extermination and expertise of the contractor in the choice of pest control contracted services.<BR/>Pest control program emphasis will be placed in kitchens, dining areas, laundries, central supply, loading dock/areas, construction activities, and other areas prone to infestations such as areas of overgrowth in adjoining property. To reduce the potential for pest to enter the center through windows that open to the outside, screens will be maintained. If no screens are present the window should not be opened.<BR/>Center staff will monitor the environment and properly report pest control problems to the supervisor, administrator, or Maintenance Director for action .

**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 2 of 2 staff (Dietary staffs A and B), for 1 of 1 kitchen and 1 of 1 Activity room, in that:<BR/>1)The facility failed to ensure Dietary staff (Dietary staff A and B) used sanitizers as directed and sanitizer levels were maintained and tested according to manufacturer recommendations;<BR/>2) The facility failed to ensure Dietary staff (Dietary staff A and B) used good hygienic practices during dietary duties, <BR/>3) The facility failed to ensure hot and cold TCS foods were maintained at 41 degrees F or below or 135 degrees F and above, <BR/>4) The facility failed to ensure foods and food contact equipment were protected from possible contamination (refrigerator, Activity room), <BR/>5) The facility failed to ensure foods were in sound condition (expired hardboiled eggs), and<BR/>6) The facility failed to ensure food and nonfood contact surfaces were clean (Activity room stove and shelving, scoop holder). <BR/>These failures could place residents at risk of food contamination and foodborne illness. <BR/>The findings include:<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 9:54AM and concluded at 10:18 AM:<BR/>Dietary staff A was asked to test the dish machine chlorine sanitizer level, and she took the chlorine test strip and placed it under the water draining from the dish machine from the wash cycle. She did not initially test the chlorine sanitizer in the rinse cycle. Interview with Dishwasher A on 7/19/22 at 10:18 AM, she stated that she had worked in dietary a month.<BR/>There was no chlorine sanitizer dispensing from the dish machine. The rinse temperature at the dish machine was 120&deg;F and the chlorine level was 0 PPM instead of between 50-100 PPM<BR/>Interview on 7/19/22 at 10:05 AM the Dietary Manager stated, two days ago staff said that the dishwasher was not working. They pressed the button, primer, and it worked. They will wash in a three compartment sink until the dishwasher is repaired.<BR/>There were two unshielded lights in the kitchen refrigerator. <BR/>Personal drinks with a straw were stored on the tea station counter.<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 10:36 AM and concluded at 11:00 AM:<BR/>During an interview on 7/19/21 at 10:36 AM, Dietary staff A stated, the dish machine chlorine dispensing tube came off. Observation at the time revealed that the chlorine sanitizer tube that entered the dish machine was broken in half. She stated they called the repairman.<BR/>Personal drinks with covers were observed on the [NAME] table of the one compartment sink. There was a bowl of potatoes in the sink.<BR/>There was a soiled apron and backpack hooked on an equipment rack where dishes were stored, and food equipment stored.<BR/>Observation of Dietary staff B handwashing revealed that she touched the soiled front of the paper towel dispenser after washing her hands and re-contaminated her hands. She then dried her hands, turned off the water with the paper towels and donned a pair gloves. She continued with dietary duties.<BR/>~ The following observations and interviews were made during a kitchen tour that began on 7/19/22 at 11:26 AM and concluded at 12:45PM:<BR/>Dietary staff B stated that she was preparing seven pur&eacute;es. She placed green beans in the processor and pur&eacute;ed it. She then washed her hands and during the handwashing process she touched the soiled front of the paper towel dispenser, recontaminating her hands. She dried her hands and placed the paper towel in her pocket. <BR/>Dietary staff B then washed the blender in the three-compartment sink, rinsed and then submerged it in the Ecolab Oasis 146 Multi Quat Sanitizer for only 20 seconds and then set it aside to dry. She then took the lid and did the same thing and then submerged the lid in the quaternary sanitizer for only five seconds and then took it out to dry. She cleaned a pitcher in the three-compartment sink and only submerged it in the sanitizing rinse for five seconds. Then she set it out to dry. <BR/>Record review of the Ecolab Oasis 146 Multi Quat Sanitizer wall chart (https://www.gofacilipro.com/wall-charts/oasis-146-wall-chart) dated 2015 revealed the following documentation, . 150-400 ppm quat range . Directions for use. Apply oasis 146 multi quat sanitizer at proper use solution. Expose all surfaces of equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry <BR/>Record review of the label of the Oasis 146 Multi Quat sanitizer revealed the following, Directions for Use .expose for one minute . <BR/>Dietary staff B rewashed the blender container in the three-compartment sink and then submerge it in sanitizer for 10 seconds and then set it on the drain table to dry.<BR/>Dietary staff B washed her hands and touched the soiled front of the paper towel dispenser again which re-contaminated her hands. She then dried her hands, donned gloves and continued with dietary duties. She continued to process foods (pureed pasta and tomato sauce).<BR/>Temperatures were taken on the service line steamtable by Dietary staff B with the following results: <BR/>Ziti with beef 137.3&deg;F <BR/>Green beans 184&deg;F <BR/>Tomato sauce 100.2&deg;F<BR/>Pur&eacute;ed [NAME] beans 164&deg;F <BR/>Pur&eacute;ed ziti 164&deg;F <BR/>Mashed potatoes 113.7&deg;F. It was placed in an area of the steam table that had an open space.<BR/>Toasted bread 128&deg;F<BR/>Cucumber salad was on ice and was 47.5&deg;F<BR/>Lettuce salad was on ice and was 53&deg;F<BR/>Egg salad was 53.6&deg;F and the ice in the pan it was sitting in was melted. There was only a few scattered pieces of ice. The egg salad sandwiches were also in this pan of melted ice and it was 62.5&deg;F<BR/>On 7/19/22 at 12:11 PM the Dietary staff B was asked how the mashed potatoes were made. She stated, with milk and butter. It's a mix.<BR/>On 7/19/22 at 12:12 PM Dietary staff B covered the open space on the steam table with plastic.<BR/>On 7/19/22 at 12:13 PM Dietary staff B was asked when the egg salad was made. She stated the egg salad was made at 11:10 AM.<BR/>The meal service started at 12:15 PM. The mashed potatoes were not rapidly reheated to 165 degrees F and held at 135 degrees F or above. Adequate ice was not placed in the pan used to hold the egg salad foods at the steam table. <BR/>Observation of a container of Peeled Hard Cooked Eggs 10 pound was on a prep table. Further observation of the container revealed the following, Use by 13 July 2022.<BR/>On 7/19/22 at 12:19 PM the Dietary Manager and Dietary staff B were asked if these hard cooked eggs have been used to make the egg salad sandwiches and egg salad. They both stated yes.<BR/>On 7/19/22 at 12:37 PM an interview was conducted with the Dietary Manager about the expired hard-boiled eggs. She stated that she got the eggs at the store on 7/06/22 and marked it 7/06/22. She added that she did not see the use by date. She stated that when a delivery truck comes, she marks the date she gets the food.<BR/>Dietary staff A was observed washing her hands at the hand sink and she also touched the soiled front of the paper towel dispenser in order to dispense more towels. She used the towel and then continued to dry her hands with it. She donned a pair of gloves and handled condiments and insulated lids and covered trays.<BR/>On 7/19/22 at 1:15 PM an interview was conducted with the Dietary Manager. She stated that none of the egg salad was served.<BR/>~ The following observations were made during an Activity room tour that began on 7/19/22 at 1:00 PM and concluded at 1:12 PM:<BR/>On 7/19/22 at 1:00 PM an observation was made of the activity room sink area. There were boxes of bag chips stored under the drain line of the sink. Utensils and pans were inverted on a cloth towel on top of the small refrigerator. There was a dead bug on the towel. <BR/>The oven interior and browner area were soiled with dried food and dead bugs.<BR/>The cabinets had an uncovered portion cup of pepper and uncovered cup of oil. <BR/>The lower cabinets had dried spills.<BR/>On 7/19/22 at 1:13 PM an observation was made of the corridor ice machine room. The ice scoop holder was dirty on the interior and had an accumulation of sediment and water in the bottom of it.<BR/>On 7/21/22 at 8:46 AM the ice machine corridor's scoop Holder was still dirty with settlement at the bottom and wet.<BR/>~ The following observations were made during a kitchen tour that began on 7/21/22 at 11:41 AM and concluded at 1:07 PM:<BR/>Temperatures were taken by Dietary staff B. Temperatures were as follows: <BR/>Mac & cheese 167&deg;F <BR/>Stewed tomatoes 185&deg;F <BR/>Brown gravy 163&deg;F<BR/>Pur&eacute;es stewed tomatoes 169&deg;F <BR/>Pur&eacute;e macaroni and cheese and 167&deg;F <BR/>Mashed potatoes 125&deg;F. <BR/>On 7/21/22 at 11:20 AM Dietary staff B was interviewed as to how she made the mashed potatoes. She stated that she used milk and butter in it.<BR/>Peas 140&deg;F <BR/>Hamburger patties 120.7&deg;F.<BR/>White gravy 173&deg;F <BR/>Sliced bread<BR/>The refrigerator had unshielded lights as before.<BR/>Meal service ended at 12:49 PM. At 1:02 PM, the surveyor requested that they take temperatures on the service line. It was noted that the ground hamburger was not on a heat source on the steam table and was placed on a ledge of the steam table. <BR/>On 7/21/22 at 1:05 PM the ground hamburger was 106 degrees Fahrenheit. The temperature of the mashed potatoes was 140 degrees Fahrenheit. The hamburger patties were 106 degrees Fahrenheit. These TCS foods were not rapidly reheated to 165 degrees F. and held at 135 degrees or above.<BR/>On 7/21/22 at 4:54 PM an interview was conducted with the Dietary Manager regarding issues in the kitchen. Regarding the incorrect testing of the dish machine, she stated Dietary staff A was nervous, but did not know why she did it. She stated that she had conducted training on dish washing and testing. She was also told about hand washing and staff touching the paper towel dispenser and contaminating their hands. She stated she told staff not to touch the dispenser. She added that temperatures on the steam table should not be below 135 degrees Fahrenheit. She further stated that staff knew to reheat foods if they are cold. She stated if the above-mentioned issues continued in dietary, it could result in foodborne illness. She was also told about the holder for the ice maker ice scoop being dirty. She stated she thought the housekeeping department was responsible for cleaning it. <BR/>On 7/21/22 at 5:20 PM an interview with conducted with the Administrator. She stated the issues with dietary sanitation could result in affecting resident satisfaction. She was also asked what she expected from the dietary staff regarding these issues, and she stated they should correct issues on the spot. <BR/>On 7/25/22 at 4:30 PM and interview was conducted with the Activity Director regarding the activity room foods. She stated that the foods present were used for residents but they had thrown everything away after the survey. <BR/>Record review the facility policy titled Food: Preparation, HCSG Policy 016, Original 5/2014, Revised 9/2017 revealed the following documentation, Policy Statement. All foods are prepared in accordance with the FDA Food Code. <BR/>Procedures. <BR/>1. All staff practice proper handwashing techniques and glove use. <BR/>2. Dining services staff will be responsible for food preparation, for food procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. <BR/>3. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. <BR/>4. The Dining Services Director/Cook(s) Will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41&deg;F and/or less than 135&deg;F, or per state regulation . <BR/>9. The Cook(s) will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. <BR/>10. Time/Temperature Control for Safety (TCS) hot food items will be cooked to a minimum internal temperature for 15 seconds, as follows: <BR/>Poultry and stuffed foods 165&deg;F<BR/>Ground meat 155&deg;F<BR/>Fish, pork, other meats 145&deg;F . <BR/>11. When hot pur&eacute;e, ground, or diced food drop into the danger zone (below 135&deg;F), the mechanical [NAME] altered food must be reheated to 165&deg;F for 15 seconds if holding for hot service. <BR/>12. When reheating, foods will be rapidly heated to 165&deg;F for 15 seconds. If the food is not reheated within two hours it must be discarded. <BR/>13. All foods will be held at appropriate temperatures, greater than 135&deg;F (or as state regulations require) for hot holding, and less than 41&deg;F for cold food holding. <BR/>14. Temperature for TCS foods will be recorded at time of service and monitor periodically during meal service. <BR/>15. All staff will use serving utensils appropriately to prevent cross-contamination. <BR/>16. Prepare hot food items that are not intended for immediate service will be cooled using the following guidelines: <BR/>Place in shallow pans or cut/slice to promote rapid cooling.<BR/>TCS foods will be cooled from 135&deg;F to 70&deg; Fahrenheit within two hours.<BR/>TCS foods will be cool from 70&deg;F to 41&deg;F with them 4 hours.<BR/>Total cooling time cannot exceed six hours. The clock starts at 135&deg;F.<BR/>17. All TCS foods that are to be held for more than 24 hours at a temperature of 41&deg;F or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record in an effort to discontinue these drugs for 1 of 16 residents reviewed for unnecessary medication (Resident #15).<BR/>The facility did not ensure that Resident #15 medications had adequate indications for its use in that she was receiving Ativan for the diagnosis of Alzheimer's. <BR/>This failure could place the residents at risk for adverse consequences of medication.<BR/>Findings included:<BR/>Record review of Resident #15's face sheet, dated 09/06/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, dementia and anxiety disorder. <BR/>Record review of comprehensive MDS assessment dated [DATE] revealed Resident #15 was rarely/ never understood. The MDS revealed Resident #15 had a BIMS of 00 which indicated the resident's cognition was severely impaired. <BR/>Section N Medications Received:<BR/>During the last 7 days or since admission/entry or reentry if less than 7 days: 3 days of antianxiety<BR/>Record review of Resident #15's order summary report dated 09/06/23 revealed the following orders: <BR/>Ativan .5mg every 6 hours as needed related to Alzheimer's dated 06/21/23.<BR/>Ativan .5mg 3 times a day related to Alzheimer's dated 08/22/23. <BR/>Record review of Resident #15's medication administration record dated 09/01/23-09/08/23 revealed the following medication was given:<BR/>Ativan .5mg PRN was not given during the above mentioned time period.<BR/>Ativan .5mg from the 1st-8th at 8:00 AM, the 6th & the 7that 2:00 PM, 1st-5th at 5:00 PM and the 1st-7th at 8:00 PM.<BR/>Record review of a care plan dated 07/14/23 for Resident #15 did not reveal a focus for use of Ativan. <BR/>During an interview on 09/08/23 at 11:21 AM, the ADM said the DON and the pharmacist was responsible for ensuring the residents medications have the appropriate diagnosis. He said he was unaware that any residents in the facility were receiving antipsychotics to treat the diagnosis of Alzheimer's or dementia. He said he had not received any training regarding antipsychotics and improper diagnosis but understood that they have to be reviewed and go through a gradual dose reduction. He said a potential negative outcome for a resident taking an antipsychotic for the wrong diagnosis was that the diagnosis would not be treated. He said he could not think of any other outcome. He said he expected that when this was identified, there should be a conversation between the facility staff, pharmacy, and the doctor for the proper recommendation. Still, he would ultimately leave it up to the physician. He said he was aware that the diagnosis of Alzheimer's and dementia cannot get better but progressively worsen. He said he was unfamiliar with the black box warnings and was unaware if there was an increase in deaths associated with antipsychotics and the elderly population. <BR/>During an interview on 09/08/23 at 12:08 PM, the ADON said she knew Resident #15 was taking Ativan but was unaware that the medication diagnosis was for Alzheimer's. She said Resident #15 was on hospice. She said all nurses are responsible for ensuring the proper diagnosis was paired with the appropriate medication. She said the nurse entering the information should catch if there was a discrepancy. She said it was important because if residents were taking a medication that was not appropriate, it could have a contraindication. She said Ativan could not treat the diagnosis of Alzheimer's or dementia. She said she had training regarding antipsychotics, but it had been general training about long-term care. She said that they monitor side effects every shift. She said that she had not brought the inappropriate diagnosis to the doctor's attention. She said they had a system where they monitor and conduct chart reviews monthly. She said they had not conducted a chart review in a couple of months. She said a potential negative outcome could have been over-sedation. She said she does expect the diagnosis and the medication to match. <BR/>During an interview on 09/08/23 at 12:09 PM, the DON said she was aware that Resident #15 was taking Ativan for the diagnosis of Alzheimer's. She said she was unsure about Resident #15 as she had been at the facility as the DON for a short time, but certain medications are not paid for through hospice without the proper diagnosis. She said the nurses are responsible for identifying discrepancies once they receive the orders. She said that Ativan cannot make Alzheimer's better, but it can treat anxiety. She said she has received training in long-term care in general. She said the potential negative outcome was that residents in the elderly population and with the diagnosis of Alzheimer's are more at risk of having an opposite effect of the medication intention. She had not brought it to the doctor's attention that the diagnosis was inappropriate for the Ativan. She said her system to monitor was mainly on monitoring side effects. She said she expected the diagnosis to match the medication. <BR/>Record review of the facility's policy titled Use of Antipsychotic Medication Use, dated July 2022, revealed:<BR/>Policy Statement<BR/>Residents will not receive medications that are not clinically indicated to treat a specific condition.<BR/>Policy Interpretation and Implementation<BR/>Residents will only receive antipsychotics medications when necessary to treat specific conditions for which they are indicated and effective.