AUSTIN WELLNESS & REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #81) reviewed for comprehensive care plans in that:<BR/>Resident #81's comprehensive care plan did not address the resident's Hospice services. <BR/>This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.<BR/>The findings included:<BR/>Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply blood), bilateral occlusion and stenosis of carotid arteries (blockage of arteries that are on both sides of the next that carry blood to the brain), contractors of left shoulder, left wrist and left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).<BR/>Record review of Resident 81's Baseline Care Plan dated 12/22/2023 and locked date of 12/28/2023 revealed under Section 1, D, 6. General information and Initial Goals/Daily Preferences that Resident Prefers HOSPICE SERVICES with a hospice company.<BR/>Record review of Resident #81's admission MDS with an ARD/Target Date of 12/30/2023 revealed under Section O0110, Special Treatments, Procedures and Programs, under K1. Hospice care while a resident yes.<BR/>Record review of Resident #81's comprehensive care plan date initiated 12/22/2023 to 01/08/2024 revealed no mention on the care plan to address the resident's issue with hospice services.<BR/>Record review of Resident #81's revised comprehensive care plan dated 01/11/2024 revealed no mention on the care plan found to address Resident #81's hospice services.<BR/>Record review of Resident 81's consolidated Physician's Orders dated 01/11/2024 and last order review was 12/27/2023 revealed an order dated 12/22/2023 to admit to the facility under the care of a doctor for hospice care. OT (occupational therapy) splint/brace order for resident to wear on his LUE (left upper extremity) a carrot splint daily or as tolerated dated 01/08/2024. <BR/>Record review of Resident #81's revised comprehensive care plan dated 01/12/2024 revealed under the care plan of #81's DNR (do not resuscitate) with interventions/tasks the last bullet stated, Social Services to consult with resident and RP (responsible party) regarding their decision to continue DNR, Hospice with revision on 01/12/2024. <BR/>Interview on 01/12/2024 beginning at 8:47 a.m. with LVN U, the MDS Coordinator, revealed Resident #81 had orders for hospice dated 12/22/2023 and on the admission MDS dated [DATE] indicating section O reflects resident on hospice. Further interview with LVN U revealed as soon as they (facility) receive any order the care plan is updated. <BR/>Interview on 01/12/2024 at 9:30 a.m. LVN U stated even though previously during the day this surveyor had interviewed LVN U concerning Resident #81's care plan for Hospice, she had no idea how the word Hospice was added to the social worker's care plan with revision 01/12/2024.<BR/>Interview on 01/12/24 at 2:45 p.m. with the social worker concerning the DNR care plan for Resident #81 showing a revision of the care plan on 01/12/2024 revealed she had started writing Resident #81's care plan on 12/18/2023 for Resident #81's DNR on 12/22/2023 but, she had not made any revisions to the care plan she had no idea who added the word Hospice: on to the care plan.<BR/>A request was made for a copy of the facility policy and procedure regarding resident care plans from the Administrator but, was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 3 staff (CNA A, CNA T and LVN S) reviewed for infection control, in that:<BR/>1. CNA A, while providing peri-care to a male resident, did not change her gloves during the whole procedure.<BR/>2. CNA T, while providing peri-care to a male resident, did not sanitize her hands between glove changes.<BR/>3. LVN S, while looking at a catheter bag that was hanging from the bed side bottom bed frame and partially touching the floor, did not use gloves while handling the catheter bag and touched the tubing on Resident #7's bed without practicing hand hygiene. <BR/>These deficient practices could place residents at-risk for infections. <BR/>The findings included: <BR/>1. and 2. During an observation on 01/11/2024 at 11:27 a.m. with CNA A and CNA T providing incontinent/peri care to Resident #82. CNA T asked CNA A if she felt comfortable providing incontinent/peri care and CNA A stated Yes. This surveyor asked CNA A again if she felt she could provide incontinent/peri care to Resident #82 and she again stated Yes. CNA A and CNA T both provided the incontinent/peri care. After CNA A completed incontinent/peri care on Resident #82 in the front, CNA A kept her gloves on. CNA T continued to provide incontinent/peri care to the back side of Resident #82. During the procedure CNA T removed her gloves and without washing or sanitizing her hands donned another pair of clean gloves and folded the soiled brief and soiled wet wipes, and CNA A picked up the trash can and leaned over Resident #82 and CNA T tossed the soiled brief and soiled wet wipes into the trash can. CNA T, keeping the same pair of soiled gloves on, picked up the clean pull up sheet and placed it under the left side of the resident along with the clean brief. CNA T turned Resident #82 over to his back and then to his right side with CNA A's help. CNA A, wearing the same soiled gloves used to clean Resident #82 in the front, pulled the rest of the pull sheet and brief out from under the resident while CNA T held him. After turning the resident to his back, CNA A & CNA T, wearing the same soiled gloves, completed placing the brief on the Resident #82 and pulled down his gown, pulled up the top covers and placed his call light and bed controls within reach of the resident. CNA T then removed her soiled gloves. CNA A continued to wear the same soiled gloves she started out with at the beginning of the incontinent/peri care procedure.<BR/>During an interview on 01/11/2024 at 11:40 a.m. with CNA A, she was asked if she ever removed, sanitized and donned another pair of gloves during the incontinent/peri care procedure? CNA A confirmed she had not changed her gloves or sanitized her hands.<BR/>During an interview on 01/11/2024 at 11:42 a.m. with CNA A and CNA T, both confirmed they never used hand sanitizer or washed their hands while providing incontinent/peri care to Resident #82. When asked what can happen because of not changing gloves, sanitizing their hands and not providing peri care properly? Both stated infection control and Resident #82 could develop a UTI. When asked CNA A and CNA T what should they do now? CNA A stated I need to go back and go over the procedure again in the manual (facility nurse aide manual). CNA T did not say anything. When asked about the sanitizing of their hands CNA T stated we can get the sanitizer off the nurses cart or from the wall dispenser outside. CNA T stated she usually went and washed her hands. <BR/>On 01/11/2024 at 12:00 p.m. As this surveyor was walking down the hall, the DON stopped this surveyor and asked how the peri care went and this surveyor expressed her concerns with handwashing, sanitizing, donning gloves, procedure for incontinent/peri care and availability of hand sanitizer. DON stated they have hand sanitizer they can carry in their pockets. The DON stated CNA A was a newbie (new person just hired).<BR/>On 01/11/2024 at 12:05 p.m. this surveyor went with the DON to Central supply to see where the hand sanitizer was stored. The DON called CNA I who does Central Supply and Transportation to find the hand sanitizer in Central Supply. The DON stated it looks like we are going to have to do some more training. CNA I finally came into Central Supply carrying a bag with small bottles of hand sanitizer. DON asked CNA I where the small bottles of hand sanitizer was that are bigger than the tiny bottles and CNA I stated, we do not have those. The DON left to go check on another hall for the hand sanitizer. <BR/>On 01/11/2024 at 12:15 p.m. this surveyor continued to interview CNA I. when asked by the surveyor when do you know when to order hand sanitizer? CNA I stated when the nurse comes into the Central Supply room and writes on my Communication board, then I will order. <BR/>Review of CNA A and CNA T's Competency for hand washing/sanitizing their hands and donning gloves revealed CNA A was hired on 01/03/2024 and had not been given a competency evaluation for handwashing and incontinent/peri care but, had been a CNA before being hired. CNA T's date of hire was 06/20/2023 and had a competency evaluation for incontinent/peri care on 09/14/2023 which used the facility Policy and Procedure revision 06/2020 as the guideline for the competency evaluation. <BR/>3. During an observation and interview on 01/11/2024 at 1:25 p.m., LVN S looked at Resident #7's catheter bag that was touching the floor and repositioned it without utilizing any gloves and then touched the tubing that was lying on the bed beside the resident. LVN S said it was okay that the catheter bag was touching the floor because it was just the front cover part of the bag when asked by the Resident's daughter that was in the room, she then proceeded to touch the tubing. When this surveyor left the room after the observation and attempted to ask LVN S if she could talk about the catheter she walked off and said she had been off for 10 days, she did not comment further. <BR/>On 01/12/2024 at 11:45 p.m. with the DON, the DON stated no part of the catheter bag should be touching the floor and LVN S should have practiced proper hand hygiene and infection control while touching any part of the catheter. Our Catheter bags have a dignity cover that is permanently attached to them so it is actually one bag, we have a separate bag that should also be used to cover both portions of the bag and to ensure it is kept off of the floor. LVN S should have practiced proper hand hygiene and the catheter bag should not have been on the floor in anyway, no part of it should have been touching the floor. Those types of issues create the potential for infection control problems, I don't think it created an problems for the Resident but it did create potential and that should have never been an issue. <BR/>Review of the facility Policy and Procedure, Perineal Care (peri care/incontinent care), revision date 06/2020 stated in part, Purpose- to maintain cleanliness of the genital area, to reduce odor and prevent infection or skin breakdown. Policy- Perineal care is provided as part of resident's hygienic program XII. Note: Do not touch anything with soiled gloves after the procedure (i.e. curtain, siderails, clean linen, call bell, etc.) NOTE: The facility policy says to wash hands, put on gloves and provide the complete procedure to include turning, removing wet linen, placing dry linens or brief or both under the resident and reposition the resident BEFORE removing the gloves and replacing them and no mention of washing hands or sanitizing hands prior to adding a new pair of gloves.<BR/>Review of the facility Policy and Procedure for their Infection Prevention and Control Program with revision date 06/2020 revealed the following in part: Purpose- To ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements vi. Develop infection orientation and in-service training programs for all levels of Facility Staff .

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #1, 2 and 3) of 4 residents and 1 of 1 hallway observed for a clean environment. <BR/>1. The facility failed to ensure Resident #1, #2, and #3's bedroom floor was clean. <BR/>2. The facility failed to ensure the hallway floor was clean and had no foul odors. <BR/>This deficient practices could place residents at risk of a decreased quality of life. <BR/>Findings included: <BR/>During an interview on 02/21/24 at 8:40 a.m., the ADM revealed housekeepers followed the deep clean schedule. The ADM explained housekeepers deep cleaned twice a week and spot checked and cleaned residents' rooms and commonly shared areas daily. The ADM also revealed there were two housekeepers for each shift.<BR/>An observation on 02/21/24 at 10:38 a.m. revealed Resident #1's bedroom floor was sticky. <BR/>During an interview on 02/21/24 at 10:47 a.m., Resident #1 revealed she cleaned her own room. Resident #1 explained the floor was sticky because housekeeping did not mop it. <BR/>During an observation and interview on 02/21/24 at 11:14 a.m., Resident #2 revealed housekeeping cleaned his room daily. Resident #2 explained the floor was sticky because housekeeping had not been in his room that morning.<BR/>During an observation and interview on 02/21/24 at 11:31 a.m., Resident #3 and his family revealed the bedroom floor was sticky. Resident #3 and his family explained housekeeping did not thoroughly clean his room. <BR/>During an interview on 02/21/24 at 2:15 p.m., CNA A revealed housekeepers cleaned residents' rooms daily. CNA A also revealed she never received complaints about residents' rooms not being cleaned.<BR/>An observation on 02/21/24 at 2:31 p.m., revealed the hallway floor was sticky and had a urine and feces odor. <BR/>During an interview on 02/21/24 at 2:33 p.m., HK B revealed she worked at the facility for 15 days. HK B explained she cleaned residents' rooms once daily. HK B further explained she did not document residents' rooms she cleaned. HK B revealed she never received complaints about rooms not being cleaned. HK B also revealed she mopped the floor once a day. HK B explained there were housekeepers who worked at night from 1:00 p.m. through 8:00 p.m. HK B revealed there were no housekeepers who worked at night from 8:00 p.m. through 6:00 a.m. HK B did not know who cleaned from 8:00 p.m. through 6:00 a.m. if a resident had a mess.<BR/>During an interview on 02/21/24 at 2:45 p.m., HK C revealed she worked at the facility for one year. HK C explained she cleaned residents' rooms once daily. HK C further explained she did not document residents' rooms she cleaned. HK C explained she was out of the facility for the last three days. HK C explained housekeepers divided the hallway whenever a housekeeper was absent. HK C further explained housekeepers were assigned to designated sections of the hallway. HK C revealed other housekeepers did not clean their hallway sections. HK C revealed she observed hallway sections were not cleaned. HK C explained she informed HS about the housekeepers who did not do their job. HK C explained HS told her that she also observed that. HK C explained she was told to clean other residents' rooms that she was not assigned to because of the housekeepers not doing their responsibilities. HK C explained sometimes residents spilled beverages on the floor. HK C revealed she was assigned to clean the floor on 02/21/24. HK C revealed the person in charge of the floors mopped twice a week. HK C revealed she always received complaints from residents and families about floors being dirty. HK C explained HS was informed multiple times about the dirty floors. HK C revealed there were no housekeepers who worked from 9:00 p.m. through 6:00 a.m., HK C said she did not know who cleaned during that time.<BR/>During an interview on 02/21/24 at 3:16 p.m., HS revealed she worked at the facility for four weeks. HS said she expected housekeepers to mop residents' rooms and bathrooms twice daily. HS explained five deep cleanings were completed daily. HS further explained there was first shift who worked from 7:00 a.m. through 3:00 p.m. and second shift who worked from 1:00 p.m. through 8:00 p.m. HS revealed there was no third shift because residents were sleeping and lying down from 8:00 p.m. through 7:00 a.m. HS also revealed CNAs helped housekeepers if residents' had spills or rooms were dirty from 8:00 p.m. through 7:00 a.m. HS revealed housekeeping closets were fully stocked and CNAs had access to the closets. HS also revealed she had a daily deep clean and weekly checklist she was preparing that had not taken into effect because she was still finalizing the checklists. HS explained housekeepers used the old checklists for the time being while she finalized the new ones. HS revealed she spot checked to make sure housekeepers cleaned residents' rooms and hallways. HS also revealed she had two housekeepers per shift. HS revealed she in-serviced housekeepers on housekeeping duties on 02/21/24. HS also revealed she observed residents' rooms and hallway floors were sticky. HS explained the former HS let housekeepers slack off. <BR/>During an interview on 02/22/24 at 12:06 p.m., the ADM revealed housekeepers did not have a deep clean log or documentation reflecting they completed their duties. The ADM explained housekeepers had designated areas of the building they were responsible for cleaning.<BR/>Record review of the facility's staff schedule, dated 02/16/24, 02/18/24 and 02/19/24, reflected there were two housekeeping staff who worked from 6:06 a.m. through 2:57 p.m. and three housekeeping staff who worked from 12:31 p.m. through 9:01 p.m. There were no housekeepers who worked from 9:01 p.m. through 6:06 a.m.<BR/>Record review of the facility's housekeeping general policy and procedure, revised 08/20, reflected the following,<BR/>Purpose: To ensure that the Facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors.<BR/>Policy: <BR/>I. The Facility maintains an adequate, qualified Housekeeping Staff to ensure that all areas of the Facility and its furnishings are clean and sanitary at all times.<BR/>IV. All rooms of the Facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents.<BR/>Procedure: <BR/>A. The Housekeeping Department is responsible for completing the daily, weekly, and monthly cleaning procedures.<BR/>A. The Housekeeping Supervisor determines the cleaning schedule by completing the Housekeeping Schedule Form.<BR/>C. The Housekeeping Staffs general duties are to:<BR/>i. Sweep and mop, or vacuum, all floors.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 3 staff (CNA A, CNA T and LVN S) reviewed for infection control, in that:<BR/>1. CNA A, while providing peri-care to a male resident, did not change her gloves during the whole procedure.<BR/>2. CNA T, while providing peri-care to a male resident, did not sanitize her hands between glove changes.<BR/>3. LVN S, while looking at a catheter bag that was hanging from the bed side bottom bed frame and partially touching the floor, did not use gloves while handling the catheter bag and touched the tubing on Resident #7's bed without practicing hand hygiene. <BR/>These deficient practices could place residents at-risk for infections. <BR/>The findings included: <BR/>1. and 2. During an observation on 01/11/2024 at 11:27 a.m. with CNA A and CNA T providing incontinent/peri care to Resident #82. CNA T asked CNA A if she felt comfortable providing incontinent/peri care and CNA A stated Yes. This surveyor asked CNA A again if she felt she could provide incontinent/peri care to Resident #82 and she again stated Yes. CNA A and CNA T both provided the incontinent/peri care. After CNA A completed incontinent/peri care on Resident #82 in the front, CNA A kept her gloves on. CNA T continued to provide incontinent/peri care to the back side of Resident #82. During the procedure CNA T removed her gloves and without washing or sanitizing her hands donned another pair of clean gloves and folded the soiled brief and soiled wet wipes, and CNA A picked up the trash can and leaned over Resident #82 and CNA T tossed the soiled brief and soiled wet wipes into the trash can. CNA T, keeping the same pair of soiled gloves on, picked up the clean pull up sheet and placed it under the left side of the resident along with the clean brief. CNA T turned Resident #82 over to his back and then to his right side with CNA A's help. CNA A, wearing the same soiled gloves used to clean Resident #82 in the front, pulled the rest of the pull sheet and brief out from under the resident while CNA T held him. After turning the resident to his back, CNA A & CNA T, wearing the same soiled gloves, completed placing the brief on the Resident #82 and pulled down his gown, pulled up the top covers and placed his call light and bed controls within reach of the resident. CNA T then removed her soiled gloves. CNA A continued to wear the same soiled gloves she started out with at the beginning of the incontinent/peri care procedure.<BR/>During an interview on 01/11/2024 at 11:40 a.m. with CNA A, she was asked if she ever removed, sanitized and donned another pair of gloves during the incontinent/peri care procedure? CNA A confirmed she had not changed her gloves or sanitized her hands.<BR/>During an interview on 01/11/2024 at 11:42 a.m. with CNA A and CNA T, both confirmed they never used hand sanitizer or washed their hands while providing incontinent/peri care to Resident #82. When asked what can happen because of not changing gloves, sanitizing their hands and not providing peri care properly? Both stated infection control and Resident #82 could develop a UTI. When asked CNA A and CNA T what should they do now? CNA A stated I need to go back and go over the procedure again in the manual (facility nurse aide manual). CNA T did not say anything. When asked about the sanitizing of their hands CNA T stated we can get the sanitizer off the nurses cart or from the wall dispenser outside. CNA T stated she usually went and washed her hands. <BR/>On 01/11/2024 at 12:00 p.m. As this surveyor was walking down the hall, the DON stopped this surveyor and asked how the peri care went and this surveyor expressed her concerns with handwashing, sanitizing, donning gloves, procedure for incontinent/peri care and availability of hand sanitizer. DON stated they have hand sanitizer they can carry in their pockets. The DON stated CNA A was a newbie (new person just hired).<BR/>On 01/11/2024 at 12:05 p.m. this surveyor went with the DON to Central supply to see where the hand sanitizer was stored. The DON called CNA I who does Central Supply and Transportation to find the hand sanitizer in Central Supply. The DON stated it looks like we are going to have to do some more training. CNA I finally came into Central Supply carrying a bag with small bottles of hand sanitizer. DON asked CNA I where the small bottles of hand sanitizer was that are bigger than the tiny bottles and CNA I stated, we do not have those. The DON left to go check on another hall for the hand sanitizer. <BR/>On 01/11/2024 at 12:15 p.m. this surveyor continued to interview CNA I. when asked by the surveyor when do you know when to order hand sanitizer? CNA I stated when the nurse comes into the Central Supply room and writes on my Communication board, then I will order. <BR/>Review of CNA A and CNA T's Competency for hand washing/sanitizing their hands and donning gloves revealed CNA A was hired on 01/03/2024 and had not been given a competency evaluation for handwashing and incontinent/peri care but, had been a CNA before being hired. CNA T's date of hire was 06/20/2023 and had a competency evaluation for incontinent/peri care on 09/14/2023 which used the facility Policy and Procedure revision 06/2020 as the guideline for the competency evaluation. <BR/>3. During an observation and interview on 01/11/2024 at 1:25 p.m., LVN S looked at Resident #7's catheter bag that was touching the floor and repositioned it without utilizing any gloves and then touched the tubing that was lying on the bed beside the resident. LVN S said it was okay that the catheter bag was touching the floor because it was just the front cover part of the bag when asked by the Resident's daughter that was in the room, she then proceeded to touch the tubing. When this surveyor left the room after the observation and attempted to ask LVN S if she could talk about the catheter she walked off and said she had been off for 10 days, she did not comment further. <BR/>On 01/12/2024 at 11:45 p.m. with the DON, the DON stated no part of the catheter bag should be touching the floor and LVN S should have practiced proper hand hygiene and infection control while touching any part of the catheter. Our Catheter bags have a dignity cover that is permanently attached to them so it is actually one bag, we have a separate bag that should also be used to cover both portions of the bag and to ensure it is kept off of the floor. LVN S should have practiced proper hand hygiene and the catheter bag should not have been on the floor in anyway, no part of it should have been touching the floor. Those types of issues create the potential for infection control problems, I don't think it created an problems for the Resident but it did create potential and that should have never been an issue. <BR/>Review of the facility Policy and Procedure, Perineal Care (peri care/incontinent care), revision date 06/2020 stated in part, Purpose- to maintain cleanliness of the genital area, to reduce odor and prevent infection or skin breakdown. Policy- Perineal care is provided as part of resident's hygienic program XII. Note: Do not touch anything with soiled gloves after the procedure (i.e. curtain, siderails, clean linen, call bell, etc.) NOTE: The facility policy says to wash hands, put on gloves and provide the complete procedure to include turning, removing wet linen, placing dry linens or brief or both under the resident and reposition the resident BEFORE removing the gloves and replacing them and no mention of washing hands or sanitizing hands prior to adding a new pair of gloves.<BR/>Review of the facility Policy and Procedure for their Infection Prevention and Control Program with revision date 06/2020 revealed the following in part: Purpose- To ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements vi. Develop infection orientation and in-service training programs for all levels of Facility Staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 7 of 12 (Resident # 4, Resident #27, Resident #41, Resident # 48, Resident # 66, Resident # 76 and Resident #186) residents reviewed for resident rights. <BR/>1. <BR/>The facility failed to promote Resident # 4, Resident #27, Resident #41, Resident # 48, Resident # 66, and Resident # 76's dignity while dining when staff did not complete serving meals to one table at a time before moving to the next table to serve meals without finishing serving meals at the prior table.<BR/>2. <BR/>The facility failed to promote Resident # 186's dignity when staff delivered her lunch meal and left the meal on the tray without setting it up or removing delivery tray.<BR/>These failures put residents at risk of experiencing humiliation, degradation, and a decreased quality of life. <BR/>The findings included:<BR/>1. Record review of Resident # 4's admission face sheet dated 3/6/25 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident # 4 had diagnosed of traumatic subdural hemorrhage (brain bleed), dysphagia (swallowing difficulty of food and liquids), protein calorie malnutrition, dementia (a group of thinking and social symptoms that interferes with daily functioning), hypertension (elevated blood pressure), repeated falls, cognitive communication deficit (communication difficulty arising from problems with cognition), and osteoporosis (weak and brittle bones).<BR/>Record review of Resident # 4's MDS assessment dated [DATE] reflected a BIMS score was not recorded. Section GG (functional abilities) reflected extensive assistance was required for all ADLs.<BR/>Record review of Resident # 4's care plan indicated focus of ADL self-care performance deficit related to musculoskeletal impairment dated 12/29/22 with target date of 5/27/25. Interventions included the resident required eating assistance with setup and cueing to eat. Further review indicated the resident had the potential for nutritional problems related to the risk for malnutrition. Interventions included the resident had a hospice aide in facility 2 times a day, 5 times per week to assist patient with meals. The facility was to monitor, record, and report to the MD PRN signs and symptoms of malnutrition, emaciation (abnormally thin or weak), cachexia(great loss of weight and muscle), muscle wasting, significant weight loss: 3 pounds in 1 week, more than 5% in 1 month, more than 7.5% in 3 months, more than 10% in 6 months.<BR/>Record review of Resident # 4's physician orders reflected she was ordered a regular, pureed texture diet, with a house shake supplement ordered with meals ordered 1/14/25, and med pass dietary supplement ordered 2 times daily ordered 4/24/23.<BR/>2. Record review of Resident # 27's admission face dated 3/6/24 reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident # 27 diagnosis of autistic disorder (neurodevelopmental disorder characterized by repetitive, restricted, and inflexible patterns of behavior), adult failure to thrive, convulsions, protein calorie malnutrition, anemia (lack of blood), muscle wasting and atrophy(muscle loss), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), epilepsy (seizure disorder), developmental disorder of speech and language, hypothyroidism (underactive thyroid), and cognitive communication deficit (communication difficulty arising from problems with cognition).<BR/>Record review of Resident # 27's MDS dated [DATE] reflected a BIMS score not recorded. Section GG functional abilities indicated extensive assistance required for all ADL's.<BR/>Record review of Resident # 27's care plan dated 3/8/24 reflected an ADL self-care performance deficit related to activity intolerance. Interventions of eating the resident requires 1 staff participation to eat.<BR/>Record review of Resident # 27's physician orders reflected regular diet pureed texture ordered 4/22/24.<BR/>3. Record review of Resident # 41's admission face sheet dated 3/6/25 reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident # 41 diagnosis of chronic obstructive pulmonary disease (a group of lung disease characterized by airflow obstruction that makes breathing difficult), type 2 diabetes (long term condition in which the body has trouble controlling blood sugar levels), dysphagia (difficulty swallowing liquids and solids), peripheral vascular disease (a condition in which the blood vessels outside the heart and brain become narrow or blocked and restrict blood flow), developmental disorder, hypertension (high blood pressure), and cognitive communication deficit (communication difficulty arising from problems with cognition).<BR/>Record review of Resident # 41's MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Section GG functional abilities indicated resident is independent for eating. Further review indicated resident is Moderate assistance for toileting, bathing, dressing, and transfers.<BR/>Record review of Resident # 41's care plan dated 1/30/23 revised on 6/1/24 reflected an ADL self-care performance deficit related impaired balance. Interventions of eating resident requires set up assistance to eat.<BR/>Record review of Resident # 41's physician order reflected an order of regular diet mechanical soft texture with chopped meat ordered 8/11/22.<BR/>4. Record review of Resident # 48's admission face sheet dated 3/6/25 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident # 48 diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), dysphagia (swallowing difficulty with liquids and solids), chronic kidney disease stage 3, hypertension (high blood pressure), protein calorie malnutrition, cerebral infarction (stroke), and need for assistance with personal care. <BR/>Record review of Resident # 48's MDS dated [DATE] reflected a BIMS score of 3 indicating severe cognitive impairment. Section GG functional abilities indicated set up assistance for eating. Max assistance for dressing, toileting, bathing, and transfers.<BR/>Record review of Resident # 48's care plan dated 3/28/23 and revised on 12/16/24 reflected an ADL self-care performance deficit. Interventions had no documentation concerning eating.<BR/>Record review of Resident # 48's physician orders reflected regular diet pureed texture house shake included with meals ordered 2/3/25. Med pass supplement ordered 3/13/23.<BR/>5. Record review of Resident # 66's admission face sheet dated 3/6/25 reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident # 66 diagnosis of GERD (a chronic condition where stomach contents including acid flow back up into the esophagus causing irritation, pain, and potential damage), anemia (lack of blood), protein calorie malnutrition, dysphagia (difficulty swallowing liquids or solids), chronic obstructive pulmonary disease (a group of lung disease characterized by airflow obstruction that makes breathing difficult), aphasia(difficulty speaking), cerebral infarction (stroke), type 2 diabetes (long term condition in which the body has trouble controlling blood sugar levels), cognitive communication deficit (communication difficulty arising from problems with cognition), protein calorie malnutrition, and kidney failure. <BR/>Record review of Resident # 66's MDS dated [DATE] reflected a BIMS score not recorded. Section GG functional abilities indicated supervision of set up assistance for eating. Extensive assistance for toileting, transfers, and bed mobility.<BR/>Record review of Resident # 66's care plan dated 11/17/23 revised on 12/17/24 reflected an ADL self-care performance deficit related to amputation and stroke. Interventions not documented for resident eating assistance.<BR/>Record review of Resident # 66's physician orders reflected regular diet mechanical soft texture mildly thick consistency ordered 4/24/24. Med pass supplement ordered 1/10/24.<BR/>6. Record review of Resident # 76's admission face sheet dated 3/6/25 reflected a [AGE] year-old male admitted on [DATE]. Resident # 76 diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic pain, hyperlipidemia (elevated level of fat particles in the blood), hypertension (high blood pressure), congestive heart failure, and cognitive communication deficit (communication difficulty arising from problems with cognition).<BR/>Record review of Resident # 76's MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Section GG functional abilities indicated 1-person physical assist for eating and bed mobility, and limited assist for toileting and transfers.<BR/>Record review of Resident # 76's care plan dated 9/28/24 reflected an ADL self-care performance deficit. Interventions of eating resident can hold cup, feed self, eats finger foods independently.<BR/>Record review of Resident # 76's physician orders reflected regular diet mechanical soft texture thin consistency double portions ordered 9/27/24.<BR/>7. Record review of Resident # 186's admission face sheet dated 3/6/25 reflected a [AGE] year-old female admitted on [DATE]. Resident # 186 diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), type 2 diabetes (long term condition in which the body has trouble controlling blood sugar levels, hyperlipidemia (elevated levels of fat particles in the blood), hypertension (high blood pressure), cerebral infarction with hemiplegia and hemiparesis affecting right dominant side (stroke with paralysis affecting right dominant side).<BR/>Record review of Resident # 186's MDS dated [DATE] reflected a BIMS score not recorded. No functional abilities were documented. <BR/>Record review of Resident # 186's care plan dated 3/3/25 reflected an ADL self-care performance deficit. Interventions eating resident can hold cup, feed self, eat finger foods independently.<BR/>Record review of Resident # 186's physician orders reflected a regular diet and texture ordered 2/14/25.<BR/>Observation of lunch meal service on 3/3/25 revealed the following starting at 12:06 PM: <BR/>All residents at sitting at 8 tables were not being served before the staff moved on to serving the next table. <BR/>First table, Resident # 48 received meal tray at 12:06 PM, Resident # 76 received tray at 12:08 PM, and Resident # 186 received tray at 12:15 PM. When Resident # 186 received meal tray, food items were not removed from tray and set up for resident. Meal tray was set in front of resident while staff went to continue passing more meal trays.<BR/>Second table, Resident # 66 received meal tray at 12:06 PM, Resident # 41 received meal tray at 12:12 PM.<BR/>Third table, Resident # 27 received meal tray at 12:04 PM, and at 12:17 PM, CNA F set down to feed Resident # 27. At 12:20 PM, CNA F left from feeding Resident # 27 after attempting 2 bites. At 12:25 PM, Treatment Nurse sat down to feed Resident # 27, at which time, 3 more bites were fed to Resident # 27 before the feeding of Resident # 27 stopped. No other attempts were made to feed Resident # 27 nor was an alternative or supplement offered the remainder of the meal service. Resident # 4 received meal tray at 12:10 PM and was told by staff I will come back to feed you. At 12:20, DON sat down to feed Resident # 4. DON attempted to feed Resident #4. 3 bites were offered, then DON got up and told another staff member that Resident # 4 refused to eat. No other attempts were made to feed Resident # 4 nor was an alternative or supplement offered the remainder of meal service.<BR/>Interview on 3/3/25 at 1:00 PM with CNA F revealed CNA F stated Resident # 27 refused to eat and kept spitting food out so I quit attempting to feed him and told staff he refused. CNA F stated I then left the dining room because I had other duties to attend to. CNA F stated I can't make a resident eat. <BR/>Interview with ADM on 03/05/25 07:05 PM revealed ADM stated it was his expectation that proper hand hygiene bee performed during meal tray and that all residents at a table are served before moving to the next table and beginning service there. ADM was unsure if serving part of the resident s at the table and not serving the rest before moving to another table was a dignity issue or not. ADM stated it was the responsibility of all staff in the dining room to ensure hand hygiene was happening and to ensure all residents at a table had been served before moving to the next table. <BR/>Record review of dining services standards policy dated December 2020 reflected under heading purpose: Residents are provided a positive meal experience. Under heading policy: The facility staff will ensure the residents are provided with a positive meal experience. Under heading procedure: Meal Distribution:<BR/>i. <BR/>Meals are served table by table.<BR/>ii. <BR/>All items are removed from trays and are appropriately placed in front of the patient/resident, packages are opened, and lids are removed.<BR/>iii. <BR/>Substitutions are offered.<BR/> .<BR/>b. <BR/>Assistance- adaptive devices are provided; foods, and beverages are set-up to promote independence; patients/residents are properly positioned, encouraged, cued, and assisted as needed. Patients/Residents are properly dressed, with dentures, glasses, and hearing aids in place as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs for 1 of 13 (Resident #81) residents reviewed for call lights on the 2100 hall in that:<BR/>The facility failed to ensure Residents #81's call light was within reach and placed for easy access.<BR/>The deficient practice could place residents at risk of not receiving care or attention needed and risk of falling. <BR/>The Findings Included:<BR/>Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply blood), bilateral occlusion and stenosis of carotid arteries (blockage of arteries that are on both sides of the next that carry blood to the brain), contractures of left shoulder, left wrist and left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).<BR/>Record review of Resident 81's Baseline Care Plan dated 12/22/2023 and locked date of 12/28/2023 revealed under Section 1, B, 1 - 2. Under Communication Resident #81 can communicate easily with staff and understands the staff.<BR/>Record review of Resident #81's admission MDS with an ARD/Target Date of 12/30/2023 revealed Resident #81 had a BIMS score of 14 indicating the resident had intact cognition response (able to make needs known). <BR/>Record review of Resident #81's comprehensive care plan date initiated 12/22/2023 to 01/08/2024 revealed the care plan did not address the resident's issue with the call light.<BR/>Record review of Resident #81's revised comprehensive care plan dated 01/11/2024 revealed a care plan which addressed Resident #81 frequently repositioning his call light with revision on 01/11/2024. <BR/>Record review of Resident 81's consolidated Physician's Orders dated 01/11/2024 and last order review was 12/27/2023 revealed an order dated 12/22/2023 to admit to the facility under the care of a doctor for hospice care. OT (occupational therapy) splint/brace order for resident to wear on his LUE (left upper extremity) a carrot splint daily or as tolerated dated 01/08/2024. <BR/>Observation on 01/09/2024 at 11:47 a.m. in Resident #81's room revealed the resident lying in his bed and his call light was hanging close to the top of his privacy curtain and not within reach. <BR/>Observation on 01/10/2024 at 9:45 am- revealed Resident #81 was lying in his bed with the call light lying on the floor at the floor of Resident #81's bed and not within reach.<BR/>Interview on 01/10/2024 at 9:48 a.m. with CNA F confirming Resident #81's call light was lying on the floor at the foot of Resident #81's bed and was not within reach of the resident. When asked why the call light was on the floor, CNA F stated Resident #81 will mess with the call light. When asked if you know Resident 81 will mess with the call light what should you do? CNA F stated check on him more often.<BR/>Interview on 01/11/2024 at 9:30 a.m. with the DON concerning Resident #81's call light and where it was observed on 01/09/2024 at 11:47 a.m. close to the top of the resident's privacy curtain and not within reach and 01/10/2024 at 9:45 a.m. on the floor at the foot of Resident #81's bed and was not within reach. The DON stated the call light was to be within the resident's reach and if it was not the resident could not get help when he needed it and could also fall. The DON stated it was everyone's responsibility to make sure the resident has the call light within reach.<BR/>Interview on 01/11/2024 at 10:05 a.m. with LVN U, MDS Coordinator, confirmed the call light for Resident #81 was placed on the care plan on 01/11/2024.<BR/>Request was made for a copy of the facility policy and procedure regarding the resident call lights from the Administrator, however the policy was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all residents had the right to request, refuse, and/or discontinue treatment to participate in or refuse to participate in experimental research, and to formulate an advance directive for 5 of 30 residents (Residents #22, #81, #235, and #40) reviewed for advanced directives. <BR/>1. <BR/>The facility failed to ensure Resident # 22's admission face sheet included an accurate advanced directive, as it listed both Full Code and a DNR (Do Not Resuscitate) on file. Resident # 22's care plan included documentation of the DNR on file.<BR/>2. <BR/>The facility failed to ensure Resident # 81 had documentation on file in their records concerning their wishes on their advance directive status.<BR/>3. <BR/>The facility failed to ensure Resident # 235 had documentation of their advanced directive on the admission face sheet, although the care plan included documentation wishing to be a Full Code. No Full Code documentation in Resident # 235 records.<BR/>4. <BR/>The facility failed to ensure Resident #40 had an advanced directive documented on his summary report<BR/>These failures could place residents at risk for not having their end of life wishes honored and incomplete records.<BR/>Findings include:<BR/>1. Record review of Resident #22 admission face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses which included metabolic encephalopathy (brain dysfunction caused by imbalances in the body's chemical processes and systemic illness), acute kidney failure, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), repeated falls, cognitive communication deficit (difficulties in communicating), depression, anxiety disorder, muscle wasting and atrophy, asthma and polyneuropathy. Resident #22 listed as a Full Code under Advance Directives.<BR/>Record review of Resident #22 Comprehensive MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. Section GG functional abilities reflected mobility device of wheelchair, independent for eating, partial to moderate assist for (toileting, dressing, putting on/taking off footwear, and transfers), maximum assist for bathing.<BR/>Record review of Resident #22 care plan, dated [DATE], reflected the resident had a DNR on file. Resident # 22 has an ADL self-care performance deficit related to hemiplegia, limited mobility, and musculoskeletal impairment with interventions of limited assistance with toileting, dressing, and transfers. Extensive assistance required with bathing and extensive assistive device usage with transfers.<BR/>Record review of Resident #22 OOHR-DNR order, dated [DATE], reflected document was complete with signatures of Resident # 22, physician and witnesses.<BR/>2. Record review of Resident #81's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included Cerebral Infarction (an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain), Hyperlipidemia (imbalance of cholesterol in your blood), Hypertensive Heart Disease (conditions caused by high blood pressure), Angina Pectoris (chest pain caused by reduced blood flow to the heart), Myalgia (pain in a muscle or group of muscles), Acute Kidney Failure (illness, infection, or injury damages the kidneys), and Cognitive Communication Deficit (brain injuries that affects a person's ability to communicate effectively).<BR/>Record review of Resident #81's Minimum Data Set Assessment, dated on [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Minimum Data Set Assessment didn't reflect any Full Code or Do Not Resuscitate information.<BR/>Record review of Resident #81's Care Plan, last revised on [DATE], reflected a focus on Resident #81 having Cognitive Communication Deficit, Hypertensive Heart Disease, Angina Pectoris, and Acute Kidney Failure in which there was no form of documentation found reflecting appropriate advanced directive actions for Full Code and or Do Not Resuscitate protocols. <BR/>Record review on of care plan, admission, and Point Click Care documentation for Resident #81 didn't reflect having any documentation for advance directives.<BR/>3. Record review of Resident #235 admission face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 235 had diagnoses which included rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), tremors (a rhythmic involuntary movement of a body part), atrial fibrillation (irregular heart rate), autistic disorder (a lifelong developmental disability that affects how a person communicates, interacts with others, learns, and behaves), obsessive compulsive disorder (excessive thoughts that lead to repetitive behaviors), cerebral palsy (a congenital disorder of movement, muscle tone, or posture), anxiety disorder (persistent and excessive worry that interferes with daily activities) and lack of normal physiological development in childhood. No advance directive documentation was recorded on the admission face sheet.<BR/>Record review of Resident #235 admission MDS, dated [DATE], did not reflect a BIMS score or functional abilities recorded. The Comprehensive MDS was in progress at time of the review.<BR/>Record review of Resident #235 care plan, dated [DATE], reflected Resident #235 was a Full Code status. <BR/> 4. Record review of Resident #40's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), need for assistance with personal care, dementia, acquired absence of right leg below knee, acquired absence of left leg above knee, aphasia (a disorder that affects how you communicate), diabetes mellitus type 2 (a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure), and gastrostomy status (an enteral feeding tube). Resident #40's face sheet did not indicate any Advanced Directives. <BR/>Record review of Resident #40 's Quarterly MDS assessment, dated [DATE], did not reflect a BIMS score. Resident #40 required substantial/maximal assistance for all activities of daily living. <BR/>Record review of Resident #40's Care Plan, dated [DATE], reflected Resident #40 had a Full Code CPR order in place with initial date of [DATE]. The goal was the request for CPR to be initiated would be followed. Interventions included review of Resident #40's medical record to ensure proper documents were signed, consult with nursing staff on changes in health, and counsel with the resident and family regarding any emotional concern arising from the decision. <BR/>Record review of Resident #40's Order Summary Report, dated [DATE], reflected he had an order for Full code may use AED, dated [DATE]. <BR/>In an interview on [DATE] at 3:24 PM with the Social Worker stated the facility is in charge of putting in Full Code and Do Not Resuscitate information into the care plan, but there wasn't a designated person in charge of handling Full Code and Do Not Resuscitate information. The Social Worker stated this information was usually already filled out before they saw the resident. The Do Not Resuscitate or Full Code request was not on the medical face sheet of each client, which meant it's more than likely not within the system electronically and believed this was something entered by the nursing department or a doctor. The Social Worker provided Determination of Life Prolonging Procedures form for Resident #81 in which it didn't specify the information needed as well as it was, dated on [DATE], after the Department discovered it wasn't inputted or documented into the facility's Point Click Care sections for residents for Do Not Resuscitate in which it was not located in the residents face sheet, care plan, or anywhere else. Its important to know what actions need to take place to follow the advance directives. <BR/>In an interview on [DATE] at 2:35 PM with the ADON, she stated the facility had a hard copy of Do Not Resuscitate and it's supposed to be in the resident's care plans. Everything would be in the care plans. She stated the social worker, and the nurses were to check for a Do Not Resuscitate if it's been scanned in. If they didn't have it, they're full code until they could physically see or scan it in. She met the family and asked them what they wanted as well. There's no system in place and couldn't provide a reason for as to why nor who is in charge. At the nurse's station they had a book that had their Do Not Resuscitate status book and were at both nurse's station. She stated it's important to have Do Not Resuscitate or Full Code in resident's charts. It's important because potentially there could be an issue if it's not in the chart for Do Not Resuscitate.<BR/>Record review of the facility's Advance Directives policy, revised 08/2020, reflected: <BR/>Advance Directives Operational Manual - Social Services<BR/>I. At the time of admission, admission Staff or designee will inquire about the existence of an Advance Directive. The admission Staff will inform and provide written information to all adult residents concerning the right to accept or refuse medical treatment.<BR/>II. The Facility will honor resident's Advance Directives and will provide the resident with;-<BR/>information related to Advance Directives upon admission<BR/>III. If no Advance Directive exists, the Facility provides the resident with an opportunity to complete the Advance Directive Form upon resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 10 residents (Resident #185, and Resident #135) reviewed for baseline care plans.<BR/>The facility failed to ensure baseline care plans were completed for Resident #185 and Resident #135. <BR/>The facility failed to develop a baseline care plan that reflected the need for Resident #185's wandering and agitation for Resident #185 <BR/> The facility failed to develop a baseline care plan that reflected the individuals needs of Resident #135. <BR/>This failure puts all residents at risk of not getting their needs met. <BR/>Findings included:<BR/>1. review of Resident #185's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with pertinent diagnoses of depression, unspecified dementia (degenerative brain disease causing memory loss), and insomnia (the inability to sleep.)<BR/>Review of resident #185's MDS dated [DATE] states he has a BIMS score of 4, indicating severe cognitive impairment and needs supervised assistance for ADL's. <BR/>Review of Resident #185's Comprehensive Care Plan dated 03/03/25 reflected he had an ADL self-care deficit and facility staff should encourage resident to participate to the fullest extent possible with each interaction. <BR/>Review of Resident #185's progress notes dated 02/15/25 revealed 3:00 pm Resident #185 was very agitated and having behaviors. No PRN medications were available. Contacted NP on call, new medication orders received. 5:00 pm medication was not effective patient persists with behavior and being physically aggressive with staff when trying to redirect.<BR/>Review of Resident #185's progress notes dated 02/16/25 at 5:58 pm revealed Resident is awake and alert however resident wanders down the hallway and into other resident's rooms. Resident takes redirection well at first, but then becomes somewhat agitated after multiple redirections. Resident is ambulatory and requires assist with ADL care, and bed mobility. Resident makes needs known. <BR/>Observation and interview of Resident #185 at 10:35 am revealed he was muttering to himself. He stated that he was trying to find his room because he had to use the bathroom but wasn't sure where it was. He stated he was frustrated because he hadn't been able to find it all day. <BR/>Interview with LVN B on 03/05/25 at 2:25 pm, she stated that Resident #185 had a hard time adjusting to the facility. He was aggressive but had settled down recently. LVN B stated that she was aware of Resident #185's behaviors by observing him but had not read his care plan. She stated she might find other things to help ideas to calm him down on the care plan. When asked about the progress note from 02/16/25, she stated that information should probably be on the care plan. She stated it's the DON or ADON's job to place items on the care plan. <BR/>2. Resident #135 is a [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses of muscle wasting and weakness, unspecified dementia (a degenerative brain disorder causing memory loss) and a cognitive communication deficit (inability to understand or communicate effectively.) <BR/>Review of Resident #135's admission MDS was completed 02/14/25 and did not have relevant information to functional capacities or BIMS scores. <BR/>Review of Resident #135's Comprehensive Care Plan had a single focus of Elopement Risk and a goal that the resident will remain safe within the facility. <BR/>Observation of Resident #135 on 03/04/25 at 2:15 pm revealed 4 mm long fingernails that were chipped and had sharp edges. Resident's toenails were visibly protruding through her socks. <BR/>Interview with Resident #135 on 03/04/25 at 2:15 she stated that she doesn't know why her fingernails were so long. Normally, her daughter would come take her to the nail salon, but it's been a couple months. She was unsure when she would get her nails done next, but always liked to have her nails done. <BR/>Interview with CNA on 03/05/25 at 3:30 pm revealed that Resident #135 should have her fingernails done on shower day. She said she is forgetful and sometimes she is unsure where she is at. She stated she did not know why they were not completed, and it is the CNA's job to groom the resident's fingernails. She stated that she should look in the care plan to find a resident's preference for assisting her in her ADL's.<BR/>Interview on 3/5/25 at 7:05 PM with Admin revealed he expected the staff to follow regulations and all pertinent information be included on care plans. Admin stated it was the responsibility of the IDT team to complete care plans. Admin stated if care plans are not completed and accurate that it could negatively affect the quality of life of the residents.<BR/>Interview with the ADON on 03/06/25 at 12:30 pm, she stated everything should be in the care plans. She was supposed to do a part of the baseline care plans and they tried to get the comprehensive care plans done once a week. Even if they were to admit on a Saturday, she would go up and do the care plans. She stated the nurses were able to place items on a new care plan and could be done by anyone in the facility. She was unsure why multiple residents' baseline care plans had not been completed. She stated that if they did not have a care plan, they may not address all their issues.<BR/>No Care Plan policy was provided from the admin before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 8 residents (Residents #31, and #38) reviewed for activities. <BR/>The facility failed to provide Residents #31 and #38 with individual or group activities.<BR/>This failure could place residents at risk for a decline in their physical, mental, and psychosocial well-being. <BR/>Findings include: <BR/>1. Record review of Resident #31's face sheet, dated 10/01/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included Spastic Diplegic Cerebral Palsy (both of the legs have abnormal stiffness), Dysphagia (difficulty swallowing), Aneurysm (abnormal bulge or ballooning in the wall of a blood vessel), Cognitive Communication Deficit (brain injuries that affects a person's ability to communicate effectively), Lack of Coordination (difficulties in smoothly and accurately executing voluntary movements. It can impact daily activities and is often associated with neurological disorders or injuries), Muscle Weakness (lack of muscle strength, doesn't produce a normal muscle contraction or movement), Reduced Mobility (refers to limitations in a person's ability to move or use a vehicle due to physical, sensory, or mental disabilities, age, or other reasons), and Seborrheic Dermatitis (skin condition that causes scaly patches, inflamed skin and stubborn dandruff).<BR/>Record review of Resident #31's annual Minimum Data Set Assessment, dated 02/14/2025, reflected a BIMS score of 00, which indicated low cognitive impairment. Section GG functional abilities reflected Eating: Not applicable, not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Oral hygiene, Toileting hygiene, Shower/bathe self, Upper body dressing, Lower body dressing, putting on/taking off footwear, and Personal hygiene: Dependent, helper did all of the effort. Resident did none of the effort to complete the activity. Or the assistance of 2 or more helpers was required for the resident to complete the activity.<BR/>Record review of Resident #31's Care Plan, last revised on 10/01/2025, reflected a focus on Resident #31 having impaired cognitive function/dementia or impaired thought processes neurological symptoms. Engage the resident in simple, structured activities that avoid overly demanding tasks. Resident was dependent on staff.<BR/>Record review of Resident #31's care plan, dated 03/05/2025 at 2:40 PM, reflected the resident has impaired cognitive function/dementia or impaired thought processes neurological symptoms. Engage the resident in simple, structured activities that avoid overly demanding tasks. The resident prefers (specify the activities). Keep the resident's, routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. The resident was dependent on staff for activities, cognitive stimulation, social interaction cognitive deficits, disease process (pneumonitis, Inflammation of lung tissue), immobility, and physical limitations. All staff to converse with resident while providing care. Introduce resident to residents with similar background, interests and encourage/facilitate interaction. Invite resident to scheduled activities. <BR/>Record review was conducted reflected 1:1 activity binder log being provided for Resident #31 for the month of February 2025 didn't show any documentation for the resident being provided 1:1 activities, nor was there any updated list for the month of March 2025 and any past months reflecting 1:1 activities being documented for the resident. <BR/>Record review of Point Click Care (where the facility documents resident information) didn't show any documentation for 1:1 activities being completed or noted for Resident #31. <BR/>In an observation and attempted interview with Resident #31 on 03/03/2025 at 12:10 PM, The State Surveyor attempted to speak with Resident #31 and ask questions, but the resident was unable to speak. The resident is confirmed nonverbal. Resident #31 was not participating in 1:1 activities or group activities.<BR/>In an observation on 03/04/2025 at 2:30 PM, revealed Resident #31 was not participating in 1:1 activities or group activities.<BR/>In an observation on 03/05/2025 at 3:00 PM, revealed Resident #31 was not participating in 1:1 activities or group activities. <BR/>In an observation on 03/06/2025 at 12:00 PM, revealed Resident #31 was not participating in 1:1 activities or group activities.<BR/>In an interview with the Activity Director on 03/05/2025 at 3:15 PM, the Activity Director stated Resident #31 was bed bound in which they played music to him, read to him, spoke to him, he watched television in his room, passed out snacks if his diet allowed when they had events that involved food, or if there was an event in which other's got a gift then she took him a gift as well. She tried to help make him part of activities although he was bed bound. She didn't provide any documentation or reasons for why activities weren't documented for residents as she is new to the facility and implementing logs.<BR/>In an interview with CNA G on 03/05/2025 at 4:25 PM, CNA G stated Resident #31 was bed bound. He was usually in the bed watching television and she hadn't seen him participate in activities or activities being provided in his room outside of television. <BR/>Record review of Resident # 38's admission face sheet, dated 3/4/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included cerebral infarction (stroke), hypertension (elevated blood pressure), traumatic subdural hemorrhage (bleeding in the brain), quadriplegia (paralysis that affects all 4 limbs), dysphagia (swallowing disorder), cognitive communication disorder (difficulties in communicating), type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar levels), protein calorie malnutrition, major depressive disorder (clinical depression), seizures (uncontrolled jerking loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), paraplegia (paralysis that affects the lower half of the body), chronic pain due to trauma, aphasia (language disorder that affects communication ability), and need for assistance with personal care.<BR/>Record review of Resident #38's quarterly MDS, dated [DATE], reflected a BIMS score of 00, which indicated severe cognitive impairment. Section GG functional abilities reflected substantial/maximal assistance for eating, upper body dressing, and oral hygiene. Dependent for toileting hygiene, bathing, lower body dressing, personal hygiene, putting on/taking off footwear, sit to lying, rolling from side to side and all transfers.<BR/>Record review of Resident # 38's care plan, with a creation date of 10/9/23 and a target date of 2/2/25, reflected a focus which included the following: Resident #38 needs in room socialization and sensory stimulation with intervention of the activity director will provide the resident with one-on-one visits with sensory stimulation at least 3 times per week. Focus Resident # 38 is dependent on staff for activities, cognitive stimulation, social interaction related to immobility and physical limitations. Interventions of all staff to converse with resident while providing care. Introduce resident to other residents with similar background interests and encourage/facilitate interaction. Establish and record resident prior level of activity involvement and interest by talking with resident, caregivers, and family on admission and as necessary.<BR/>Record review of one-on-one activity log for February 2025 reflected no recorded documentation of one-on-one activities provided to Resident #38. March one on one activity log was not provided for review. Prior months one on one activity log were not provided for review.<BR/>Observation and interview on 3/3/25 at 2:22 PM revealed. Resident #38 stated he did not do activities since he couldn't get out of bed or move his arms or legs.<BR/>Observation and interview on 03/04/25 at 10:54 AM revealed Resident #38 was in bed resting with splint on left hand. <BR/>Interview on 3/5/25 at 2:40 PM with LVN C revealed Resident #38 could not use the call lights due to his condition. LVN C stated she believed different call devices were attempted for use with the resident, but he was unable to use those as well as he had no feeling in his feet or legs, and he shook his head continuously so nothing could be put by his head to push. LVN C stated the resident just hollered out when he needed something. LVN C stated the facility offered a hydration program and took cookies and drinks around to the residents. LVN C stated she offered the resident a drink every 2 hours.<BR/>Interview on 3/6/25 at 12:35 PM with the DON and the ADON revealed Resident #38 went to activities a few times a week. He'd be pushed into whatever activity was going on. <BR/>Interview on 3/6/25 at 1:44 PM with the Admin revealed the activities staff should be doing 1-1 and the family or resident would tell the activity staff what they liked. The Admin stated I'm not sure what the regulations were for activities. The Admin stated the Activities Director was responsible for documenting 1-1 activities with residents. The Admin stated if residents who needed 1-1 activities were not getting these then this could negatively affect residents by depression and feelings of isolation.<BR/>In an interview on 03/06/2025 at 2:35 PM, the ADON and the DON stated they were trained in activities that residents had the right to say no. The residents did group activities, crafts, bingo, beads, outings, and going to Target and Walmart. For 1:1 activities, they provided reading, and talking to the residents. Residents who were bed bound, the Activity Director went in to do hand massages, paint nails, exercise resident's hands which was with physical therapy, but they didn't know much for 1:1 activities was being done for bed bound residents. They couldn't think of all residents who required 1:1 activities. Resident #31 loved the television, and they couldn't think of any activities that were done for him. They hadn't seen anything completed for him in prior months with activities or 1:1 activities. The Activity Director was in charge of monitoring activities and making sure all resident's had access to participating in activities. Activities were offered to all residents, and if the resident didn't want to, the Activity Director would offer coloring books and any other activities from her office. They are unaware of activity coverage on the weekends or what activities take place, but there were volunteers who came in to sing to residents and sound baths provided by hospice in which were done weekly. There were church services offered. All residents were offered to participate in activities, but they may need more encouraging at times. They were unaware of documentation occurring for residents' participation nor 1:1 activities prior to now. They didn't know of any other 1:1 activities being offered to Resident #31 or the activities they just advised us. They stated it could affect a resident's quality of life by making the resident feel alone and not have social stimulation. It could have long-term effects on residents if they didn't receive activities. <BR/>In an interview on 03/06/2025 at 1:43 PM with Administrator, he stated residents who were bed bound, what was done for them was 1:1 activities and speaking with families to see what the resident liked. The Activity Director was responsible for making sure 1:1 residents received activities. A negative outcome if a resident didn't receive 1:1 activity services, could be that it could make a resident feel isolated. <BR/>Record review of the facility's Activities Program Policy, revised date 6/2020, reflected: <BR/>Activities Program Operational Manual - Activities<BR/>Purpose<BR/>To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning.<BR/>Policy<BR/>I. The Facility provides an Activity Program designed to meet the needs, interests, and preferences of residents. The activities are varied and work to address the needs and interests identified through the assessment process.

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one of eight residents (Resident #37) reviewed for nutrition status maintenance.<BR/>1. The facility failed to obtain consistent weights for Resident #37. <BR/>These failures could place residents at risk of further weight loss, malnutrition, and a decreased quality of life.<BR/>Record review of the dietitian's orders, dated 01/22/25, stated resident was on house supplement with meals. Recommended 1:1 assistance with meals. <BR/>Record review of physician's notes from a visit, dated 12/31/24, reflected Resident #37 was on a mechanical soft with chopped meat texture, thin liquids. Refer to RD for evaluation and treat for weight loss recommendations. <BR/>Observation and interview with Resident #37 on 03/03/25 at 2:45 PM revealed the resident in bed watching TV. She stated she had not been to eat recently and was not hungry.<BR/>Interview with RA on 03/06/25 at 10:25 AM revealed she was in charge of weighing residents for 8 years. She was trained by the assistant director of nursing when she first stated. Her routine was to weigh all the residents between the 1st and the 5th of each month. If they were 5 pounds or less, she would weigh them again at a later time. If the weight loss continued, she would inform the ADON. If the weight loss triggered for significant the ADON would tell her to add that resident to a weekly weights list she kept in her office. She stated if she saw someone losing weight, she would ask them to be weighed immediately to make sure they were stable. She knew Resident # 37 should have been weighed weekly, but thought she was better after her last doctor's visit. She was unsure why she stopped even though she wasn't told to. She stated the resident could have been sicker or they wouldn't catch anything that could be seriously wrong with the residents.<BR/>Interview with the ADON on 03/06/25 at 12:30 PM revealed she was aware Resident #37 had been losing weight. She knew the resident was on house shakes, but was not aware they were not making it to her trays. She knew the resident needed assistance getting to the dining room, but did not keep track of her attendance. She stated when weight loss was triggered, she would contact the doctor, the family, and the dietitian if the doctor ordered it. She stated the dietitian recommendations should have been followed. She stated people who were new admits should be weighed weekly as well as people who were triggered for weight loss. She stated it was her job to communicate to the Restorative Aid who would weigh the residents and report back to her any further weight loss. She was unsure how Resident #37 stopped being weighed weekly. She stated if someone isn't weighed weekly, they could develop further illness and it could contribute to an early death.<BR/>Interview with the Admin on 03/06/25 he expected the Restorative Aid to weigh any resident weekly who had triggered for weight loss. He stated any weight loss should be reported to the DON, ADON, and the doctor. He expected all staff to follow the dietitian and doctor's recommendation. He was unsure why the recommendations were not followed and why she was not weighed weekly. He stated the policy for people with unintended weight loss was to weigh them weekly.<BR/>Attempted interview with Resident #37's RP on 03/03/25 was unsuccessful.<BR/>Record review of the facility's policy titled, Assessment and Management of Resident Weights, dated 06/2020, reflected <BR/>F. Residents with significant weight change will be weight at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals of care.<BR/>Record review of Evidence Based Practice Guidelines of Unintended Weight Loss in Older Adults from the Academy of Nutrition and Dietetics, dated 01/04/16, reflected, Strong Imperative for Monitoring and Evaluating Anthropometric Measurements. The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss until the body weight has been stabilized to determine effectiveness of medical nutrition therapy. Studies support an associate between unintended weight loss and increased mortality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #186 and Resident #32) reviewed for pharmaceutical services. <BR/>The facility failed to document controlled medications from the medication cart on the narcotic count sheets for Resident #186 and Resident #32. <BR/>This failure could place residents at risk to medication errors . <BR/>Findings include: <BR/>1. Record review of Resident #186's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction (weakness and loss of strength in upper and lower limbs), diabetes mellitus type 2, hypertension (high blood pressure), dementia (memory problem), hyperlipidemia (elevated lipids circulating in the blood), bipolar disorder (a state of abnormally elevated arousal, affect, and energy level), and depression (low mood/chemical imbalance). <BR/>Record review of Resident #186's Care Plan, dated 02/14/25, reflected she had impaired cognitive function/dementia or impaired thought processes. The goal was for Resident #186 to be able to communicate basic needs on a daily basis by staff identifying who they were and using her preferred name at each interaction, face the resident when speaking and make eye contact, reduce any distractions, and speak in consistent, simple, directive sentences. <BR/>Record review of Resident #186's Progress Note entry, dated 03/05/25, reflected the resident received a dose of Tramadol 50mg 1 tablet PO Q6H PRN for pain on 03/05/25 at 08:17 AM and at 11:41 AM. <BR/>Record review of a Medication Administration Record for Resident #186 reflected: <BR/>Tramadol 50mg 1 tablet PO Q6H PRN for pain level 5-10 given to the resident on 03/01/25 at 03:21 AM and on 03/05/25 at 08:17 AM. <BR/>Record review of the Individual Control Drug Record, dated 02/15/25, reflected the last medication count of the blister pack was on 03/04/25 and had 19 pills left. LVN A had written 18 in the amount remaining space but did not sign the medication out with a date, time, or number of pill(s) given. <BR/>Observation of the medication cart on 03/05/25 at 4:30 PM revealed Resident #32's blister pack of Tramadol, dated 02/15/25, had 18 pills left in the blister pack. <BR/>Observation of the medication cart on 03/05/25 at 4:30 PM revealed LVN A counted the Tramadol in the blister pack and viewed the Individual Control Drug Record, dated 02/15/25, with no signature, date, time, and number of pill(s) given in front of the state surveyor . <BR/>2. Record review of Resident #32's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Addisonian crisis (acute adrenal insufficiency), cognitive communication deficit (difficulty communicating), acute respiratory failure with hypoxia (inflammatory lung injury), major depressive disorder (A period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had a majority of specified symptoms, such as problems with sleep, eating, energy, concentration, or self-worth), anxiety , borderline personality disorder (a mental health condition characterized by pervasive instability in moods, behavior, self-image, and functioning), hypothyroidism (underactive thyroid gland), epilepsy (seizures), cerebral palsy (group of movement disorders that appear in early childhood), unsteadiness on feet, and adult failure to thrive (happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). <BR/> Record review of Resident #32 's Quarterly MDS assessment, dated 11/23/24, reflected a BIMS score of 15, which indicated cognition was little to not affected. The MDS reflected Resident #32 required partial/moderate assistance for her activities of daily living, and she used a wheelchair . <BR/>Record review of Resident #32's Care Plan, dated 01/23/24, reflected Resident #32 used anti-anxiety medications, Alprazolam, related to adjustment issues and anxiety disorder. The goal was Resident #32 would show decreased episodes of signs and symptoms of anxiety. Interventions included giving anti-anxiety medication as ordered by the physician, and monitoring/documenting side effects and effectiveness. <BR/> Record review of Resident #32's Physician Orders reflected an order date of 02/20/25 for Alprazolam 1mg 1 tablet PO Q12H PRN for anxiety, muscle spasms for 14 days. The Physician Orders had an end date of 03/06/25. <BR/>Record review of the Individual Control Drug Record, dated 03/03/25, reflected the last medication count of the blister pack was on 03/04/25 and had 10 pills left in the blister pack. LVN A wrote 9 in the amount remaining space but did not sign the medication out with a date, time, or number of pill(s) given. <BR/>Record review of Resident #32's Progress Note entry, dated 03/05/25, reflected the resident received a dose of Alprazolam 1mg 1 tablet PO Q12H PRN for anxiety, muscle spasms for 14 days on 03/05/25 at 08:50 AM, and documented as effective on 03/05/25 at 10:50 AM. <BR/> Record review of Resident #32's Medication Administration Record dated 03/05/25 reflected: <BR/>Alprazolam 1mg 1 tablet PO Q12H PRN for anxiety, muscle spasms for 14 days given to the resident on 03/05/25 at 08:50 AM. <BR/>Observation of the medication cart on 03/05/25 at 4:30 PM revealed a blister pack of Alprazolam, dated 03/03/25, which had 9 pills left in the blister pack. <BR/>Interview on 03/05/25 at 04:34 PM revealed LVN A administered the prescribed PRN medication to Resident #186 and Resident #32 during her shift, but she did not complete the narcotic count sheets . LVN A stated she should have completed the narcotic count and signed the medication out before administering to the resident, and the risks to the residents were not getting their medication in a timely manner, increased pain, and increased anxiety. <BR/>Interview on 03/06/25 at 12:45 PM with the ADON, who stated she did a weekly narcotic count and needed to be more diligent to look at the narcotic book and count. She stated narcotic count was conducted at the beginning and at the end of each shift by two nurses. The ADON stated it was now her responsibility to conduct monitoring of controlled substance count/medication administration and ordering resident medications. The ADON stated a potential negative outcome to the residents when controlled substances were not signed out/medications were not given on time included an overdose could occur, or the resident could have a lot of side effects from not getting a medication on time. The ADON stated she conducted training recently on narcotic counts because she found an incomplete narcotic count sheet. <BR/>Record review of the facility's policy titled Inventory Control of Controlled Substances, dated 12/01/17, reflected: <BR/>Facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record. These records should include: <BR/>1.1.1 Resident name, <BR/>1.1.2 Prescription number, <BR/>1.1.3 Medication name, strength, dosage form, dosage, <BR/>1.1.4 Total quantity received by facility, <BR/>1.1.5 Date and time of administration, <BR/>1.1.6 Quantity remaining, and <BR/>1.1.7 Name and signature of person administering the medication.

**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 and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally for 3 (Resident # 10, Resident # 35, and Resident # 42) of 10 residents reviewed for food preferences and for 1(Lunch on 3/4/25) of 5 meals observed in that:<BR/>1. <BR/> The test tray of the lunch meal on 03/04/25 was unappetizing in appearance (no seasoning observed, and the pureed food items had all run together)<BR/>a. <BR/> the rolled silverware for the regular texture tray napkin was wet and soggy <BR/>b. <BR/>the pureed carrots for the pureed texture tray tasted only of very tart orange juice <BR/>c. <BR/>the pureed dinner roll tasted very doughy and underdone. <BR/>2. <BR/>The facility failed to obtain food preferences for 3 residents (Resident # 10, Resident # 35, and Resident # 42).<BR/>This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. <BR/>The findings include:<BR/>1. Record review of Resident # 10's admission face sheet dated 3/6/25 reflected an [AGE] year-old female admitted on [DATE]. Resident # 10 diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), dysphagia (swallowing difficulty with liquids and solids), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (clinical depression), hypertension (elevated blood pressure), hyperlipidemia (increased fat particles in the blood), chronic kidney disease, adult failure to thrive, chronic pain syndrome, and GERD (a chronic condition where stomach contents including acid flow back up into the esophagus causing irritation, pain, and potential damage).<BR/>Record review of Resident # 10's MDS assessment dated [DATE] reflected a BIMS score of 14 indicating intact cognition. Section GG (functional) abilities indicated supervision required for bed mobility, eating, and toileting, and extensive assistance required for transfers.<BR/>Record review of Resident # 10's care plan dated 6/2/24 reflected an ADL self-care performance deficit. Interventions included the resident needed assistance with bathing, dressing, and bed mobility. No interventions for eating were documented.<BR/>Record review of Resident # 10's physician orders reflected a diet order of Regular diet with mechanical soft texture ordered 2/24/25.<BR/>2. Record review of Resident # 35's admission face sheet dated 3/6/25 reflected a [AGE] year-old female admitted on [DATE]. Resident # 35 diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, GERD (a chronic condition where stomach contents including acid flow back up into the esophagus causing irritation, pain, and potential damage), depression, hepatitis A, and anemia (lack of blood).<BR/>Record review of Resident # 35's MDS dated [DATE] reflected a BIMS score of 13 indicating intact cognition. Section GG functional abilities for Resident # 35 indicated supervision or set up assistance for bed mobility, eating and toileting.<BR/>Record review of Resident # 35's care plan dated 7/5/24 reflected an ADL self-care performance deficit with eating interventions of the resident being able to hold cup, feed self, and eat finger foods independently.<BR/>Record review of Resident # 35's physician orders reflected a diet order of regular diet regular texture ordered 6/20/24.<BR/>3. Record review of Resident # 42's admission face sheet dated 3/6/24 reflected a [AGE] year-old male admitted on [DATE]. Resident # 42 diagnosis of heart failure, cirrhosis of liver (chronic liver damage), protein calorie malnutrition, chronic kidney disease stage 3, type 2 diabetes (long term condition in which the body has trouble controlling blood sugar levels), hypertension (high blood pressure), amputation of right leg below knee, amputation of left great toe, atrial fibrillation (rapid heart rate), and cognitive communication deficit (communication difficulty arising from problems with cognition).<BR/>Record review of Resident # 42's MDS dated [DATE] reflected a BIMS score of 3 indicating severe cognition impairment. Section GG functional abilities indicated Resident # 42 required limited assistance for bed mobility, transfers, and toileting, and Supervision setup required for eating.<BR/>Record review of Resident # 42's care plan dated 6/2/24 reflected an ADL self-care performance deficit related to amputation. Interventions include for task of eating the resident can feed self, eat finger foods independently.<BR/>Record review of Resident # 42's physician orders reflected a diet order of regular diet regular texture, thin consistency, low protein and NAS related to protein calorie malnutrition.<BR/>4. Observation of lunch test tray on 3/4/25 at 12:50 PM revealed regular texture meal consisted of cheesy Dijon chicken, broccoli rice casserole, glazed carrots, dinner roll, and chocolate cake. No condiments or beverage were provided on meal tray. Silverware rolled in paper napkin was wet and soggy. Meal was appropriate temperature and had good flavor. Cake for dessert was very dry and needed moisture or frosting for palatability. Pureed texture meal tray consisted of pureed chicken, pureed broccoli rice casserole, pureed carrots, pureed dinner roll, and chocolate pudding. No condiments or beverage were provided on meal tray. Meal was appropriate temperature, and the appearance of meal tray was unappetizing as all food items had run together with carrot liquid all over plate. Chicken and broccoli rice casserole had good flavor. Dinner roll flavor was very doughy and undercooked. Carrot flavor had a very overpowering of tart orange juice and did not taste of carrots at all.<BR/>Interview with Resident # 42 on 3/3/25 at 1:40 PM Resident #42 stated the food is terrible and wants more choices. Resident overbed table has a bowl of boiled eggs, a piece of pork loin, and several packages of cookies. Resident states he has not talked to any kitchen staff to request his preferences. Resident states the kitchen staff do not speak English and can't read English either. Resident states he wants 2 or 3 over medium eggs, sausage, juice, milk, and coffee for breakfast. <BR/>Interview with Resident # 10 on 3/3/25 at 2:03 PM revealed she is upset because she did not receive her dinner meal last night. Resident stated she was brought a disposable box with a sandwich and chip crumbs no beverage. Resident states the food is terrible. Resident states she must ask for coffee daily. Resident states no one has ever came to speak with her about her meal preferences.<BR/>Interview with Resident # 35 on 3/3/25 at 2:35 PM revealed the food was ok, just not her preference, and breakfast are always cold. Resident states she lived there for a year and never had anybody come ask her preferences.<BR/>Interview on 3/5/25 at 5:40 PM with the DM revealed he had recently taken the position of the DM in November of the prior year. DM stated he had received training for the position from the prior DM and a sister facility DM. DM stated that he would visit with each resident upon admit obtaining meal preferences and that meal preferences are put on the resident meal ticket slip and then written on the dry erase board hanging in the kitchen in front of where trays are assembled. DM stated that if meal preferences or allergies are not documented on the resident meal ticket slip, it could negatively affect residents by potentially receiving food items they do not like or are allergic too which could result in sickness or weight loss. DM stated it was his responsibility to obtain food preferences and to document information on the meal ticket slip. DM stated he was unaware that the test trays had been served without condiments. DM stated he was also unaware about the napkin becoming wet and soggy and could not explain how that occurred. DM stated the cooks taste the food prior to service but he was unsure if the cook had tasted the pureed food prior to service.<BR/>Interview on 3/5/25 at 7:05 PM with the ADM revealed he expected a food profile completed for all residents and any preferences or allergies to be added to their meal ticket slip. ADM stated if meal preferences or allergies were not added to meal ticket slips, it could negatively affect the residents by potential weight loss and diminished quality of life. ADM stated the DM was responsible for obtaining resident meal preferences and adding them to the meal ticket slips.<BR/>Record review of dining service standards policy dated December 2020 reflected under heading purpose: Residents are provided a positive meal experience. Under heading policy: The facility staff will ensure the residents are provided with a positive meal experience. Under heading procedure: Meal Selection- meal selection is done either by patient/resident preference driven selections, pre-selected menus or point of service selection.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: <BR/>1. A metal pan covered with white wax style paper covering approximately 6 chicken breasts was placed on a shelf in the bottom of the walk-in cooler, the chicken was removed from the manufacturer's box and was not completely covered or in an enclosed container. <BR/>2. Six loaves of raisin bread with no dates or labeling of any type on the individual loaves and when the raisin bread was removed from the original manufacturer's box, placed on a metal tray with the date it was taken out of the freezer by the Food Service Supervisor.<BR/>These failures could place residents at risk for food-born illness, and food contamination. <BR/>Findings included:<BR/>Observation on 05/09/2023 at 8:45 a.m. in the dry storage room revealed: <BR/>1. Approximately 6 partially chicken breasts in a metal pan partially covered, allowing air to reach the chicken breasts. <BR/>2. Six loaves of raisin bread with no manufacture's dates of any type found on the loaves.<BR/>Interview with the Food Services Supervisor on 01/09/2024 at 10:40 a.m. following the initial tour of the walk-in cooler, the Food Services Supervisor replied when the chicken is covered with the paper it is okay, that is the way we do it. She did not further reply about any questions related to the chicken. When asked about the dates of the raisin bread and how she knew if the bread was fresh, she said we take it out of the box frozen and put a date on the tray. She was unable to provide any other information regarding the bread or locate any type of date on any of the 6 loaves of bread and said that is how we do it here, we throw away the box it comes in. <BR/>Interview on 01/11/2024 at 3:00 p.m., the Dietician stated all items should be stored according to the facility policy and that the Food Services Supervisor had not told her about the observation of the chicken covered by the white wax style paper in the walk-in cooler. The Dietician stated raw chicken should be completely covered when stored in the cooler, it does not sound like it was and said she would talk to the Food Service Supervisor about that to ensure chicken was stored properly. The Dietician stated the observed raisin bread was removed from the manufacturer's box and a label was placed on the metal tray that reflected when the bread was removed from the freezer, however there was no other type of date on the bread. The Dietician stated she did not feel either affected the residents in anyway. <BR/>Review of the facility policy titled Food Storage, Revised 11/2023, revealed the following: II. Frozen Meat/Poultry and Food Guidelines, D. Thawing: Thaw food at 41 degrees or below in a covered container in a refrigerator. <BR/>. <BR/>Record Review Revealed The U.S. Public Health Service, Food Code, dated 2017 revealed the following regarding marking the date of food when prepared and when the original container was opened: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking<BR/>(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: <BR/>(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; <BR/>(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 3 staff (CNA A, CNA T and LVN S) reviewed for infection control, in that:<BR/>1. CNA A, while providing peri-care to a male resident, did not change her gloves during the whole procedure.<BR/>2. CNA T, while providing peri-care to a male resident, did not sanitize her hands between glove changes.<BR/>3. LVN S, while looking at a catheter bag that was hanging from the bed side bottom bed frame and partially touching the floor, did not use gloves while handling the catheter bag and touched the tubing on Resident #7's bed without practicing hand hygiene. <BR/>These deficient practices could place residents at-risk for infections. <BR/>The findings included: <BR/>1. and 2. During an observation on 01/11/2024 at 11:27 a.m. with CNA A and CNA T providing incontinent/peri care to Resident #82. CNA T asked CNA A if she felt comfortable providing incontinent/peri care and CNA A stated Yes. This surveyor asked CNA A again if she felt she could provide incontinent/peri care to Resident #82 and she again stated Yes. CNA A and CNA T both provided the incontinent/peri care. After CNA A completed incontinent/peri care on Resident #82 in the front, CNA A kept her gloves on. CNA T continued to provide incontinent/peri care to the back side of Resident #82. During the procedure CNA T removed her gloves and without washing or sanitizing her hands donned another pair of clean gloves and folded the soiled brief and soiled wet wipes, and CNA A picked up the trash can and leaned over Resident #82 and CNA T tossed the soiled brief and soiled wet wipes into the trash can. CNA T, keeping the same pair of soiled gloves on, picked up the clean pull up sheet and placed it under the left side of the resident along with the clean brief. CNA T turned Resident #82 over to his back and then to his right side with CNA A's help. CNA A, wearing the same soiled gloves used to clean Resident #82 in the front, pulled the rest of the pull sheet and brief out from under the resident while CNA T held him. After turning the resident to his back, CNA A & CNA T, wearing the same soiled gloves, completed placing the brief on the Resident #82 and pulled down his gown, pulled up the top covers and placed his call light and bed controls within reach of the resident. CNA T then removed her soiled gloves. CNA A continued to wear the same soiled gloves she started out with at the beginning of the incontinent/peri care procedure.<BR/>During an interview on 01/11/2024 at 11:40 a.m. with CNA A, she was asked if she ever removed, sanitized and donned another pair of gloves during the incontinent/peri care procedure? CNA A confirmed she had not changed her gloves or sanitized her hands.<BR/>During an interview on 01/11/2024 at 11:42 a.m. with CNA A and CNA T, both confirmed they never used hand sanitizer or washed their hands while providing incontinent/peri care to Resident #82. When asked what can happen because of not changing gloves, sanitizing their hands and not providing peri care properly? Both stated infection control and Resident #82 could develop a UTI. When asked CNA A and CNA T what should they do now? CNA A stated I need to go back and go over the procedure again in the manual (facility nurse aide manual). CNA T did not say anything. When asked about the sanitizing of their hands CNA T stated we can get the sanitizer off the nurses cart or from the wall dispenser outside. CNA T stated she usually went and washed her hands. <BR/>On 01/11/2024 at 12:00 p.m. As this surveyor was walking down the hall, the DON stopped this surveyor and asked how the peri care went and this surveyor expressed her concerns with handwashing, sanitizing, donning gloves, procedure for incontinent/peri care and availability of hand sanitizer. DON stated they have hand sanitizer they can carry in their pockets. The DON stated CNA A was a newbie (new person just hired).<BR/>On 01/11/2024 at 12:05 p.m. this surveyor went with the DON to Central supply to see where the hand sanitizer was stored. The DON called CNA I who does Central Supply and Transportation to find the hand sanitizer in Central Supply. The DON stated it looks like we are going to have to do some more training. CNA I finally came into Central Supply carrying a bag with small bottles of hand sanitizer. DON asked CNA I where the small bottles of hand sanitizer was that are bigger than the tiny bottles and CNA I stated, we do not have those. The DON left to go check on another hall for the hand sanitizer. <BR/>On 01/11/2024 at 12:15 p.m. this surveyor continued to interview CNA I. when asked by the surveyor when do you know when to order hand sanitizer? CNA I stated when the nurse comes into the Central Supply room and writes on my Communication board, then I will order. <BR/>Review of CNA A and CNA T's Competency for hand washing/sanitizing their hands and donning gloves revealed CNA A was hired on 01/03/2024 and had not been given a competency evaluation for handwashing and incontinent/peri care but, had been a CNA before being hired. CNA T's date of hire was 06/20/2023 and had a competency evaluation for incontinent/peri care on 09/14/2023 which used the facility Policy and Procedure revision 06/2020 as the guideline for the competency evaluation. <BR/>3. During an observation and interview on 01/11/2024 at 1:25 p.m., LVN S looked at Resident #7's catheter bag that was touching the floor and repositioned it without utilizing any gloves and then touched the tubing that was lying on the bed beside the resident. LVN S said it was okay that the catheter bag was touching the floor because it was just the front cover part of the bag when asked by the Resident's daughter that was in the room, she then proceeded to touch the tubing. When this surveyor left the room after the observation and attempted to ask LVN S if she could talk about the catheter she walked off and said she had been off for 10 days, she did not comment further. <BR/>On 01/12/2024 at 11:45 p.m. with the DON, the DON stated no part of the catheter bag should be touching the floor and LVN S should have practiced proper hand hygiene and infection control while touching any part of the catheter. Our Catheter bags have a dignity cover that is permanently attached to them so it is actually one bag, we have a separate bag that should also be used to cover both portions of the bag and to ensure it is kept off of the floor. LVN S should have practiced proper hand hygiene and the catheter bag should not have been on the floor in anyway, no part of it should have been touching the floor. Those types of issues create the potential for infection control problems, I don't think it created an problems for the Resident but it did create potential and that should have never been an issue. <BR/>Review of the facility Policy and Procedure, Perineal Care (peri care/incontinent care), revision date 06/2020 stated in part, Purpose- to maintain cleanliness of the genital area, to reduce odor and prevent infection or skin breakdown. Policy- Perineal care is provided as part of resident's hygienic program XII. Note: Do not touch anything with soiled gloves after the procedure (i.e. curtain, siderails, clean linen, call bell, etc.) NOTE: The facility policy says to wash hands, put on gloves and provide the complete procedure to include turning, removing wet linen, placing dry linens or brief or both under the resident and reposition the resident BEFORE removing the gloves and replacing them and no mention of washing hands or sanitizing hands prior to adding a new pair of gloves.<BR/>Review of the facility Policy and Procedure for their Infection Prevention and Control Program with revision date 06/2020 revealed the following in part: Purpose- To ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements vi. Develop infection orientation and in-service training programs for all levels of Facility Staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was unable to conduct activities of daily living independently, received the necessary services to maintain good grooming and personal hygiene for 2 of 4 residents reviewed for quality of life (Resident #3 and Resident #4). <BR/>1. The facility failed to provide scheduled bath/showers for Resident #3. <BR/>2. The facility failed to provide scheduled bath/showers for Resident #4. <BR/>These failures could place residents who required assistance from staff for ADL's at risk of poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.<BR/>Findings included:<BR/>1. Review of Resident #3's face sheet, dated 04/07/2024, reflected a [AGE] year-old female initially admitted on [DATE] with re-admission date of 2/15/24 after a three-day hospitalization, diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain), epilepsy (brain disorder causing seizures).<BR/>Review of Resident #3's MDS, dated [DATE] revealed a BIMS score of 15 indicating no cognition impairments. Section GG, Functional Abilities and Goals, indicated Resident #3 required supervision or touching assistance with bathing. <BR/>Review of Resident #3's Care Plan, revised 08/01/2023, reflected a self- care deficit related to hemiplegia, interventions included to encourage the resident to participate to the fullest extent possible .<BR/>Review of the facility shower schedule, undated, revealed that Resident #3 was scheduled to shower every week on Tuesday, Thursday, and Saturday during the 2:00 PM to 10:00 PM shift. Indicating from Resident #3's readmission date of 2/15/24 through 04/05/2024, if given 3 showers a week, a total of 22 showers scheduled. <BR/>Review of Resident #3's Shower Sheets, request for the dates of 02/15/2024 through 04/05/2024, reflected documentation that Resident #3 received 8 of 22 scheduled showers, on 2/24, 2/29, 3/9, 3/12, 3/16, 3/21, 4/2 and 4/4. <BR/>Review of Resident #3's Progress Noted from 02/15/2024 through 04/05/2024 revealed there was no documentation regarding a shower refusal. <BR/>During an interview on 04/06/2024 at 9:20 AM with Resident #3 revealed when asked about showers she stated she was supposed to get one 3 days a week but usually they did not give her one because there were no towels. She stated a family member brought her washcloths so that she can wash herself, best she can from the bathroom sink, which does not make her feel as clean as a shower would. <BR/>2. Review of Resident #4's face sheet, dated 04/07/2024, reflected a [AGE] year-old female initially admitted on [DATE] with re-admission date of 1/23/24, diagnoses including Cerebral Palsy (a motor disability that causes weakness and/or problems using muscles), Epilepsy (brain disorder causing seizures), unsteadiness on feet and adult failure to thrive.<BR/>Review of Resident #4's MDS, dated [DATE] revealed a BIMS score of 15 indicating no cognition impairments. Section GG, Functional Abilities and Goals, was not completed. <BR/>Review of Resident #4's Care Plan, revised 11/29/2023, reflected a self- care deficit, interventions included the resident required assistance of one staff while bathing/showering. <BR/>Review of the facility shower schedule, undated, revealed that Resident #4 was scheduled to shower every week on Monday, Wednesday, and Friday during the 2:00 PM to 10:00 PM shift. Indicating from readmission date of 1/24/24 thru 04/05/2024, if given 3 showers a week, a total of 30 showers scheduled. <BR/>Review of Resident #4's Shower Sheets, request for the dates of 01/24/2024 through 04/05/2024, reflected documentation that Resident #4 received 4 of 30 scheduled showers on 1/29, 2/09, 2/13 and 3/2. <BR/>Review of Resident #4's Progress Noted from 01/24/2024 through 04/05/2024 revealed there was no documentation regarding the resident refusing a shower. <BR/>During an interview on 04/06/2024 at 10:15 AM, Resident #4 revealed when asked about frequency of showers she stated she had not had a shower in over two weeks. She stated she does not ask anymore she waits for staff to ask her. <BR/>During an interview on 04/06/2024 at 3:01 PM, RN A revealed she knew when a resident was given a shower because the staff gave her a shower sheet. She signs the sheet and puts it in the shower book. RN A stated if she was given a shower sheet with refusal on it, she will talk to the resident. Refusals are sometimes documented in the nurses notes by the nurse. She has not known of a problem with showers being given. <BR/>During an interview on 04/07/2024 at 11AM, CNA E revealed that he only knows of one way to document that a shower was given, he uses the shower sheets, and gives to the nurse. He stated there are residents that refuse a shower, and they make a shower sheet saying that when it happens. CNA E stated he can usually get his showers done because the assignment will be 3 to 4 residents a day . He stated if something happens that they are unable to get a shower done that was scheduled they let the next shift know. <BR/>During an interview on 04/07/2024 at 11:20 AM, CNA F revealed that he gets all his assigned showers completed. He stated he documents on a shower sheet form, there is a section to fill out if refused. All shower sheets are given to the nurse. CNA F stated the only times he does not get a shower completed is when there are no towels. He stated he does not document anywhere when that happens. <BR/>During an interview on 04/07/2024 at 1:26 PM, the facility Administrator revealed the shower sheets provided were how they are keeping track of showers given. There may have been a documentation system with the prior owners, but no longer have that system. Policy states a minimum of one shower a week, but residents are scheduled for three showers a week, scheduled showers should be occurring. <BR/>Record review of the facility's policy titled Showering a Resident, undated, included the purpose of the policy as A shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors.; and Residents are offered a shower at minimum of once weekly and given per resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 10 residents (Resident #185, and Resident #135) reviewed for baseline care plans.<BR/>The facility failed to ensure baseline care plans were completed for Resident #185 and Resident #135. <BR/>The facility failed to develop a baseline care plan that reflected the need for Resident #185's wandering and agitation for Resident #185 <BR/> The facility failed to develop a baseline care plan that reflected the individuals needs of Resident #135. <BR/>This failure puts all residents at risk of not getting their needs met. <BR/>Findings included:<BR/>1. review of Resident #185's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with pertinent diagnoses of depression, unspecified dementia (degenerative brain disease causing memory loss), and insomnia (the inability to sleep.)<BR/>Review of resident #185's MDS dated [DATE] states he has a BIMS score of 4, indicating severe cognitive impairment and needs supervised assistance for ADL's. <BR/>Review of Resident #185's Comprehensive Care Plan dated 03/03/25 reflected he had an ADL self-care deficit and facility staff should encourage resident to participate to the fullest extent possible with each interaction. <BR/>Review of Resident #185's progress notes dated 02/15/25 revealed 3:00 pm Resident #185 was very agitated and having behaviors. No PRN medications were available. Contacted NP on call, new medication orders received. 5:00 pm medication was not effective patient persists with behavior and being physically aggressive with staff when trying to redirect.<BR/>Review of Resident #185's progress notes dated 02/16/25 at 5:58 pm revealed Resident is awake and alert however resident wanders down the hallway and into other resident's rooms. Resident takes redirection well at first, but then becomes somewhat agitated after multiple redirections. Resident is ambulatory and requires assist with ADL care, and bed mobility. Resident makes needs known. <BR/>Observation and interview of Resident #185 at 10:35 am revealed he was muttering to himself. He stated that he was trying to find his room because he had to use the bathroom but wasn't sure where it was. He stated he was frustrated because he hadn't been able to find it all day. <BR/>Interview with LVN B on 03/05/25 at 2:25 pm, she stated that Resident #185 had a hard time adjusting to the facility. He was aggressive but had settled down recently. LVN B stated that she was aware of Resident #185's behaviors by observing him but had not read his care plan. She stated she might find other things to help ideas to calm him down on the care plan. When asked about the progress note from 02/16/25, she stated that information should probably be on the care plan. She stated it's the DON or ADON's job to place items on the care plan. <BR/>2. Resident #135 is a [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses of muscle wasting and weakness, unspecified dementia (a degenerative brain disorder causing memory loss) and a cognitive communication deficit (inability to understand or communicate effectively.) <BR/>Review of Resident #135's admission MDS was completed 02/14/25 and did not have relevant information to functional capacities or BIMS scores. <BR/>Review of Resident #135's Comprehensive Care Plan had a single focus of Elopement Risk and a goal that the resident will remain safe within the facility. <BR/>Observation of Resident #135 on 03/04/25 at 2:15 pm revealed 4 mm long fingernails that were chipped and had sharp edges. Resident's toenails were visibly protruding through her socks. <BR/>Interview with Resident #135 on 03/04/25 at 2:15 she stated that she doesn't know why her fingernails were so long. Normally, her daughter would come take her to the nail salon, but it's been a couple months. She was unsure when she would get her nails done next, but always liked to have her nails done. <BR/>Interview with CNA on 03/05/25 at 3:30 pm revealed that Resident #135 should have her fingernails done on shower day. She said she is forgetful and sometimes she is unsure where she is at. She stated she did not know why they were not completed, and it is the CNA's job to groom the resident's fingernails. She stated that she should look in the care plan to find a resident's preference for assisting her in her ADL's.<BR/>Interview on 3/5/25 at 7:05 PM with Admin revealed he expected the staff to follow regulations and all pertinent information be included on care plans. Admin stated it was the responsibility of the IDT team to complete care plans. Admin stated if care plans are not completed and accurate that it could negatively affect the quality of life of the residents.<BR/>Interview with the ADON on 03/06/25 at 12:30 pm, she stated everything should be in the care plans. She was supposed to do a part of the baseline care plans and they tried to get the comprehensive care plans done once a week. Even if they were to admit on a Saturday, she would go up and do the care plans. She stated the nurses were able to place items on a new care plan and could be done by anyone in the facility. She was unsure why multiple residents' baseline care plans had not been completed. She stated that if they did not have a care plan, they may not address all their issues.<BR/>No Care Plan policy was provided from the admin before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of five residents reviewed for quality of care.<BR/>The facility failed to conduct a fall/skin assessment or conduct neuros consistently after unwitnessed falls for Residents #1 and #2. <BR/>These deficient practices could place residents at risk of harm, injuries, or hospitalization.<BR/>Findings included:<BR/>Resident #1 <BR/>Review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including COPD (a chronic lung disease), morbid obesity, TBI, and a risk of falling.<BR/>Review of Resident #1's quarterly MDS assessment, dated 07/17/24, reflected a BIMS of 8, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she had not experienced any falls since admission.<BR/>Review of Resident #1's quarterly care plan, dated 09/03/24, reflected she was a moderate risk for falls related to gait/balance problems with an intervention of evaluation and treating as ordered or PRN. The care plan was not revised or updated to include additional interventions after she experienced falls on 08/21/24, 08/23/24, and 08/24/24.<BR/>Review of Resident #1's progress notes, dated 08/21/24 at 8:28 PM and documented by LVN A , reflected the following:<BR/>[Resident #1] noted lying on her right side in front her wheelchair I missed my bed while transferring myself I just sled [sic] off the chair I have no pain from the fallstated [sic] assessed for injuries none noted assisted to the bed .<BR/>Review of Resident #1's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 08/21/24. <BR/>Review of Resident #1's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted after the fall on 08/21/24 at 7:23 PM. <BR/>Review of Resident #1's progress notes, dated 08/23/24 at 3:22 PM and documented by RN B , reflected the following:<BR/>[Resident #1] had an unwitnessed fall in her room. She denied hitting her head on the floor. Head to toe examination was done and no obvious injuries were noted .<BR/>Review of Resident #1's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 08/23/24. <BR/>Review of Resident #1's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted after the fall on 08/23/24 at 5:52 PM. <BR/>Review of Resident #1's Fall Risk Evaluation, dated 08/23/24, reflected she was a high risk for falls.<BR/>Review of Resident #1's progress notes, dated 08/24/24 at 7:34 AM and documented by LVN C , reflected the following:<BR/>CNA called this nurse. This nurse entered room and found [Resident #1] lying on the bathroom floor in prone position. Put [Resident #1] back to wheelchair with 3 people assistant [sic]. [Resident #1] able to explain the situation. I was self-transferred [sic] to use toilet and fell. [Resident #1] complained pain on left hip and forehead 10 out of 10. [Resident #1] has a big bump on top of left eye. It's getting bigger. Sent to (hospital) .<BR/>Review of Resident #1's progress notes, dated 08/24/24 at 1:32 PM and documented by LVN C, reflected the following:<BR/>[Resident #1] came back with EMS stretcher. [Resident #1] companied [sic] of pain left hip and left side of forehead. Gave pain medication. CT scan is cleared .<BR/>Review of Resident #1's ER discharge documentation, dated 08/24/24, reflected she was seen for a hematoma of scalp.<BR/>Review of Resident #1's Fall Risk Evaluation, dated 08/24/24, reflected she was a moderate risk for falls. <BR/>Review of Resident #1's progress notes, dated 09/02/24 at 9:37 AM and documented by LVN C, reflected the following:<BR/>[Resident #1] was found on the floor at 8:20 AM, face down and bleeding from the forehead. [Resident #1] was unresponsive and without a pulse .<BR/>Review of Resident #1's hospice note, dated 09/02/24, reflected the following:<BR/> .ME contacted at 10:37 AM spoke with the investigator (name), gave ME all information on [Resident #1] and past falls that occurred. ME stated that they will be picking up the body d/t falls . [Resident #1]'s left eye is dark purple d/t fall last weekend.<BR/>On 09/03/24 at 11:27 AM, all neurological checks for Resident #1 for the past month were requested from the ADM.<BR/>During an interview on 09/03/24 at 12:00 PM, the ADM stated he was being told that there was only one neurological check conducted and had a copy of the one from 08/23/24.<BR/>During an interview on 09/03/24 at 5:03 PM, the DON stated the last time she saw Resident #1 was on 08/30/24. She stated she remembered she had bruising from a fall by her left eye but could not remember the color. She stated it was the nurses' responsibility to document bruising in the residents' progress notes and skin assessments. The DON was asked if it met her expectations that the bruise was not documented and she stated, Well, it was fading .<BR/>Resident #2 <BR/>Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including mild intellectual disabilities, age-related physical debility, unsteadiness on feet, and other lack of coordination.<BR/>Review of Resident #2's significant change in status MDS assessment, dated 07/26/24, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she had experienced a fall since admission that resulted in a major injury.<BR/>Review of Resident #2's quarterly care plan, dated 06/12/24, reflected she had an actual fall with an intervention of checking range of motion daily. The care plan was not revised or updated to include additional interventions after she experienced falls on 06/14/24, 07/21/24, and 07/27/24.<BR/>Review of Resident #2's progress notes, dated 06/14/24 at 7:17 PM and documented by LVN B , reflected the following:<BR/>[Resident #2] was transferred to the hospital post fall. The documentation did not reflect what/how the fall occurred.<BR/>Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 06/14/24. <BR/>Review of Resident #2's assessments in her EMR, on 09/04/24, reflected six neurological checks were conducted; 06/14/24 at 10:14 PM and 06/15/24 at 6:27 AM, 6:34 AM, 6:42 AM, 1:24 PM, and 11:37 PM. <BR/>Review of Resident #2's ER documentation, dated 06/14/24, reflected the primary impression was a scalp contusion.<BR/>Review of Resident #2's progress notes, dated 06/19/24 at 12:44 PM and documented by the DON, reflected the following:<BR/>[Resident #2] was sent to the hospital for further evaluation . There was no documentation reflecting why further evaluation was needed. <BR/>Review of Resident #2's progress notes, dated 07/21/24 at 1:25 PM and documented by LVN E , reflected the following:<BR/> . [Resident #2] was found kneeling on the floor, using her hands to hold the upper body up. She was morning [sic] in pain, while bleeding from the back of her head . 911 was called .<BR/>Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 07/21/24. <BR/>Review of Resident #2's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted on 07/21/24 12:00 PM. <BR/>Review of Resident #2's progress notes, dated 07/27/24 at 12:39 AM and documented by LVN A, reflected the following:<BR/>[Resident #2] returned from (hospital) . [Resident #2] has dx of L1 fracture and well as seventh left side rib fracture .<BR/>Review of Resident #2's progress notes, dated 07/27/24 at 5:14 PM and documented by LVN B, reflected the following:<BR/>[Resident #2] fell in the hallway while using her walker to ambulate .<BR/>Review of Resident #2's progress notes, dated 07/30/24 at 9:34 AM and documented by LVN B, reflected the following:<BR/> . history of falls. Intervention for frequent falls will include use of helmet as an intervention. The helmet was not listed as an intervention in her care plan, nor was there a physician order for a helmet.<BR/>Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 07/27/24. <BR/>During an interview on 09/03/24 at 12:50 PM, LVN F stated if a resident had an unwitnessed fall, a head-to-toe assessment would need to be conducted. She stated she would document the fall and conduct neuros every 15 minutes X4, every 30 minutes X4, and so on for 72 hours. She stated neuro checks were documented in the residents' EMR, not on paper. <BR/>During an interview on 09/03/24 at 2:37 PM, the DON stated after a resident has a fall the nurse is to complete an assessment. She stated after the assessment is complete, if there was no injury, the nurse would get the resident up. She stated the nurse then had to monitor the resident for three days. She stated if it was an unwitnessed fall you had to treat it as a head injury so neuro checks would need to be documented for 72 hours, a fall assessment would need to be completed, and one more thing, but I cannot remember what it was. She stated she was responsible for ensuring neuro checks were done and to complete any missing items. She stated it would not meet her expectations if neuro checks were not documented after a fall and maybe the nurses did them on paper - I am sure it is there. <BR/>During an interview on 09/03/24 at 2:44 PM, LVN G stated neuro checks and fall assessments were documented in the residents' EMR, not on paper.<BR/>During an interview on 09/03/24 at 2:50 PM, RN H stated neuro checks and fall assessments were documented in the residents' EMR, not on paper. <BR/>During an interview on 09/03/24 at 4:17 PM, the ADM stated if an aide found a resident on the ground, they should notify the nurse immediately who would conduct a fall assessment and beigin doing neuros. He stated all falls were discussed in the morning meetings and the DON was responsible for ensuring all assessments were being completed. He stated a negative outcome of not completing all proper assessments could be that an injury could go missed, or if they hit their head, they could have a brain bleed .<BR/>During an interview on 09/03/24 at 4:52 PM, the DON stated she started an in-service (that day) on neurological checks being documented on an observation sheet (paper). She stated she started the in-service because she could not find the missing neuro checks in the computer for Resident #1 and #2.<BR/>During a telephone interview on 09/04/24 at 9:39 AM, Resident #1 and #2's MD stated he was notified of their increase in falls. He stated if a resident had an unwitnessed fall or hit their head, he would expect neurological checks to be conducted for 72 hours to ensure there was not a change in condition. He stated he would have expected the facility to have put new interventions in place when the falls increased.<BR/>Review of the in-service entitled Falls, dated 09/03/24, reflected the following:<BR/>Neurological checks must be done on all falls, witnessed and unwitnessed falls.<BR/>Neuro checks will be done:<BR/>Q 15 minutes X 4<BR/>Q 30 minutes X 4<BR/>One hour X 4<BR/>Every 8 hours until completion of 72 hours<BR/>Review of the facility's Fall Evaluation and Prevention Policy, revised 08/2020, reflected the following:<BR/>Purpose: To ensure that the resident's environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistance to prevent accidents. The facility will evaluate residents for their fall risk and develop interventions for prevention . The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed.<BR/>Following a fall, the following steps should be undertaken:<BR/>-Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status. <BR/>- If there was a loss of consciousness or the fall was unwitnessed, neuro signs should be initiated and checked for at least 72 hours.<BR/>- Following the resident's evaluation, transfer the resident to the appropriate surface and evaluate further if indicated. Monitor closely for indications of pain or discomfort in any area, reddened or discolored areas, or other signs of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 elopement.<BR/>Resident #1 walked out of the facility unattended on 03/15/2024 at about 9:00PM until the police found him at about 10:00 PM from a place approximately 1.5 miles away from the facility. EMS organized by the police to take him to the hospital and at the hospital it was confirmed that resident had hairline fracture above the left eye and cheek with lacerations on left eye lid, left wrist, and lower and upper lips, and abrasions on hands. The facility staff was not aware the resident was missing until the family called the facility. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 4:55 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 03/25/24 at 6:00 PM. While the IJ was removed on 03/27/24, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could affect residents by placing them at risk of physical harm, pain and mental anguish, or emotional distress.<BR/>Findings Included:<BR/>Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged on 03/17/2024. His diagnoses included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), Prostatic Hyperplasia (enlarged prostate gland), Hypothyroidism, Hearing Loss-Left ear, and Abnormal Involuntary Movements. <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. <BR/>Record review of Resident #1's Baseline Care Plan dated 03/10/24 reflected Resident #1 had no history of falls and no elopement risk.<BR/>Record review of Resident #1's Elopement Risk Evaluation dated 03/16/24 reflected a score of 14.00 indicating Resident #1 was at imminent risk for elopement. No Elopement Risk Evaluation completed prior to the elopement. <BR/>Record review of the care plan completed after the incident, dated 03/16/24 reflected , Resident #1 was at risk for elopement related to Elopement Evaluation Risk Score. No care plan was completed prior to the elopement incident. <BR/>Record review of the Weekly Skin Check dated 03/16/24 reflected Resident #1 had lacerations on left eye lid, left wrist and lower and upper lips. <BR/>Record review of Trauma Informed assessment dated [DATE] reflected Resident #1 felt scared, helpless, or horrified related to the sudden event of elopement with fall. <BR/>Record review of facility's incident report to HHSC dated 03/18/24 reflected, on 3/15/2024 the ADM was notified by MDS C that on 03/15/24, Resident #1 was being transported to the hospital for further evaluation and treatment related to fall with injury after found him outside the facility at a place half a mile away. The facility came to know about this incident when the FM of Resident #1 notified the facility over the phone at 10:20PM, that the resident was off the property. She also informed the facility that resident was on his way to the hospital. At the hospital it was revealed that Resident #1 had a hairline fracture above the left eye and the left cheek. Resident also had abrasions on his hands. <BR/>Record review of Nurses Progress Notes for Resident #1 by RN B on 03/16/24 at 6:41 AM, reflected Resident arrived from [Hospital] ER. Resident arrived with acute head injury orbital fracture, lip laceration Zygomatic arch fracture. Wander guard was placed on resident right lower leg. Notified doctor of return. Family is aware of return. Resident is comfortable at this time. <BR/>During an interview over the phone on 03/25/24 at 10:30 AM, Resident #1's FM stated she was out of the state when the incident of the elopement occurred. She stated at about 10:00PM the police called and talked to her over the phone and said that they went and picked Resident #1 up from a place approx. 1.5 miles away from the facility. She said the police reported that they responded to a 911 call from a community member who found Resident #1 with injuries braced on his parked car. She said the police organized EMS and transported him to the nearby hospital for further assessment and treatment. The FM stated the facility was unaware of Resident #1's disappearance from the facility until she called and informed the FR at the facility at about 10:20 PM. FM stated, initially when she asked about Resident #1, the FR stated Resident #1 resides at the 2nd floor and she would transfer FM's call to the 2nd floor nursing station so that FM could request the staff to talk to him. <BR/>During an interview over the phone on 03/25/24 at 11:00 AM, FR stated she worked as the receptionist at the facility from 6:00 PM to 10:30 PM, Monday to Friday. She said, on 03/15/24 at about 10:20 PM she received a phone call from Resident #1's FM asking if Resident #1 was there at the facility. FR said, she replied to FM that Resident #1 was living on the 2nd floor, and she would transfer the call to the nursing station at the 2nd floor so that the FM could talk to the staff there. FR said, FM then reported to FR that she was checking if staff was aware of what was going on and then reported that the police had picked up Resident #1 from a place about 1.5 miles away from the facility at about 10:00 PM and admitted to a hospital nearby due to the injuries he had. FR stated she or anyone at the facility was aware until then that Resident #1 was absconded from the facility. FR said at about 10:00 PM LVN A at the 2nd floor enquired her if she saw Resident #1 at the 1st floor as they could not find him at the 2nd floor. FR stated they were under the impression that Resident #1 was wandering around within the facility until they heard about his elopement from the facility from the FM. FR said, on 03/13/24 Resident #1 was persistently requesting to her to let him leave the facility and made unsuccessful efforts to open the coded front door at two different occasions. FR stated this behavior from him was evident since his admission on [DATE] and LVN A from 2nd floor requested her to have a [NAME] on Resident #1. She stated she also had informed LVN A about his attempts for unauthorized exit. FR stated she had a watch on him whenever he was on 1st floor and ensured that he did not exit through the front door on 03/15/24 as she was the only one who allowed the visitors to come and go from the facility. She stated the front door was secured with code numbers and only the staff members knew the code number. FR said she believed Resident #1 might have exited through the emergency fire exit door situated at the back of the facility. FR added, though the back door secured by code numbers, the lock can be override if the handle of the door holds down for some time. The door will be opened with an alarm though the alarm would not be heard at the reception area. <BR/>During an interview on 03/25/24 at 10:00 AM, MDS C stated she worked at the facility in the morning shift until 5PM. She said, on 03/15/24 at about 10:30PM she received a phone call at home from FR stating Resident#1 eloped from the facility and had a fall. FR reported to her that the police found him about 1.5 miles away from the facility with lacerations on his body and admitted him to a nearby hospital for treatment. MDS C stated, as per her understanding the staff at 2nd floor did not find him there at about 9.45PM and then they informed FR to have a watch on him if he appears at the front door. She stated it appeared the staff came to know his exit out of the facility only after the FM passed on that information<BR/>During a telephone interview on 03/25/24 at 10:30, LVN A stated she worked in the afternoon shift on 03/15/24 with the responsibility of the hall where Resident #1 resided. She said on 03/15/24 Resident #1 accepted his night medication at 9:00PM in his room. At about 9:45PM one of the CNAs noticed that Resident #1 was not in his room and his name tag at the door also was missing. LVN A stated she immediately informed FR to check if he was there at the reception area and by that time the information about his elopement was received from the FM of Resident #1. LVN A stated according to her Resident #1 was not an elopement risk as he mostly stayed in his room. When this investigator asked her about an incident of his two unsuccessful attempts to get out of the facility on 03/13/24 in the evening, reported by FR, LVN A stated those were the only attempts she was aware of. <BR/>During a phone interview on 03/25/24 at 3:00PM, RN B stated she was the night nurse at the facility and was not aware of what was going on with Resident #1 until 10:00 PM as she was not in charge of his hall. RN B stated the staff at the facility came to know through the FM about Resident #1's disappearance and subsequent incident of finding him outside the facility. RN B stated Resident #1 arrived back at the facility on 03/16/24 at about 6:00 AM from the hospital. She said she had a nurse-to-nurse communication from the nurse at the hospital. RN B stated, the nurse from the hospital reported Resident #1 had an acute head injury, orbital fracture, lip laceration and Zygomatic Arch (the most lateral projection of the midface) fracture. She stated she had recorded this in the progress note in the electronic medical record. <BR/>During an interview on 03/26/24 at 10:00 AM, LVN C stated she worked at the facility for more than a year and worked the morning shift. She said she did not work on the hall where Resident #1 resided. LVN C stated the nursing stations at the 2nd floor were equipped with alarms and any attempt to open the doors downstairs trigger the alarm. She added, staff immediately go down to ensure no elopement attempt was made by any residents. LVN C stated she did not know what really happened on that day as the incident occurred on the night shift. <BR/>In an interview and observation walk through with the ADM on 03/25/24 at 3:00 PM, she stated Resident #1 must have exited through the emergency fire exit door at the back, adjacent to the kitchen. ADM stated she believed it was not an elopement since the facility was not a locked facility. She added, stopping anyone from leaving the facility, when they wanted to, was a violation of resident rights. The ADM stated Resident #1 had a BIMS score of 13, indicated intact cognition to make independent decisions. The ADM stated there was residents at the facility who regularly go Out-On-Pass to the community and return within the stipulated time (72 hours). When this investigator asked if Resident #1 left the facility as per the policies and procedures for Out-On-Pass, she stated, he was not. The ADM also stated, Resident #1 neither signed any AMA documents nor declined to sign one and exited without the knowledge of any staff members. Observation of the emergency exit door revealed there was an instruction posted on the door explaining how to override the passcode in case of any emergency however an alarm went off when opened without the passcode. The ADM said since the door was away from the reception it was difficult to hear the alarm from the reception area. Observation of the front door revealed, it was secured by number code and the entrance and exit was controlled by the receptionist. There were no other exit doors at the facility.<BR/>During an interview on 03/26/24 at 12:50 PM, the DON stated he started working at the facility about a week ago, after the elopement incident of Resident #1 occurred. He stated he was well informed about the incident. The DON defined an elopement as, a resident leaving the facility without any notice or knowledge of the facility. The DON stated it appeared there was some shortfall in the security measures at the backdoor as it was believed Resident # 1 accessed the back door for his exit on 03/15/24. The DON stated it seemed the elopement risk evaluation and nursing judgement also was not accurate as there was no management plan, like usage of a wander band in place. The DON stated, when an alarm would be heard at nursing stations, the staff was supposed to go down to the 1st floor and make sure the alarm went off not because of any resident's attempt for an unauthorized exit. <BR/>During an interview on 03/26/24 at 1:10 PM, MDS C stated she did not know how Resident #1 got out of the facility. She stated she was the MDS nurse and was helping the administrator within her scope of practice as an LVN, in the absence of a DON at that time. She stated the act of Resident #1 was elopement if he exited the facility without the knowledge of the staff and without completing Out-On-Pass paperwork or without signing an AMA form. <BR/>Review of undated facility policy Elopement Risk Reduction Approaches reflected. <BR/>Planning:<BR/>As necessary, provide new residents (to the facility, wing, unit ,etc.) with additional staff assistance until they are comfortable in their new environment .<BR/> Ensure that residents are able to move freely, are monitored and remain safe .<BR/> .Training:<BR/>Facility staff needs to know:<BR/> . The resident's propensity to wander and the triggering conditions <BR/> The consequences of unsafe wandering, the protocols to follow to minimize successful exiting and the procedures to follow when resident is lost .<BR/>Promote identification of residents who are at risk of elopement. Ensure that photographs of residents who wander are maintained in an accessible but secure location and that receptionist, activities and clinical staff and others in appropriate positions to help are able to recognize at-risk residents and to assist in redirecting them <BR/> .Environment: <BR/> Ensure that staff alert and elopement alarm/warning systems are the least intrusive and burdensome possible <BR/> After conferring with fire and other appropriate officials, minimize the risk of elopement. <BR/>An Immediate Jeopardy was identified on 03/25/24 at 4:55 PM. The IJ Template was provided to the facility ADM on 03/25/24 at 6:00 PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 03/26/24 at 7:01 PM and indicated the following:<BR/>Plan of Removal <BR/>Immediate Jeopardy <BR/>On 03/25/2024 an abbreviated survey was initiated at the facility. On 03/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: <BR/>F689 - The facility failed to provide an environment free of accident hazards to minimize elopement risk. <BR/>Action: Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>Start Date: 3/17/2024. <BR/>Completion Date: 3/17/2024 <BR/>Action: All residents re-evaluated for risk of elopement via assessment on 3/25/2024. No additional residents were identified based on evaluation. Elopement Binder up to date and remains at reception desk. DON ensured all residents who are imminent risk for elopement are donning a wander guard for safety. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: DON or Designee <BR/>Action: Medical Director notified of IJ on 3/25/2024 <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Administrator <BR/>Action: Physician orders related to residents on wander guard placement reviewed and updated for all residents <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible: Medical Director or Designee <BR/>Action: In-services completed with all staff (facility does not use agency, all staff to include PRN staff) related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). As new employees are hired they will be in-serviced on all protocols in hire process. <BR/>Start Date: 3/25/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: In-service completed with all staff (facility does not use agency, all staff to include PRN staff) that if resident has more than one request to leave that elopement/wandering risk assessment completed and wander guard placed if applicable as intervention for safety. Elopement risk reduction approaches policy reviewed with all staff. As new employees are hired they will be in-serviced on protocol in hire process. <BR/>Start Date: 3/26/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: QAPI meeting held related to IJ. Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT, and Medical Director (via phone) present. <BR/>Start Date: 3/26/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible Administrator <BR/>Action: HR and Administrator in-serviced by Regional Clinical Specialist on all in-services, to include Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON, and Elopement risk reduction. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Regional Clinical Specialist<BR/>The surveyor confirmed the facility implemented their plan of removal sufficiently from 03/25/24 through 03/27/24 to remove the IJ by: <BR/>1. Record review of Resident #1's face sheet confirmed Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>2. Record review of an Inservice to all nursing and CNA staff was completed on 03/27/24 by ADM and HR related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). <BR/>HR and Administrator were in-serviced on the above topics by Regional Clinical Specialist <BR/>3. Record review of the medical records of all the resident at the facility revealed all residents re-evaluated for risk of elopement via assessment on 3/25/2024 and ensured all residents who are an imminent or moderate risk for elopement had wander guards for safety. <BR/>4. Record review of the Elopement Binder revealed it was up to date and remains at reception desk. Copies of them were available at Nursing stations. <BR/>5. Record review on 03/27/24 of the medical records of all residents revealed physician orders related to residents on wander guard placement reviewed and no additional residents added to the existing residents with elopement risk.<BR/>6. Record review of the minutes of the QAPI meeting that was conducted for discussing elopement prevention on 03/26/24 revealed that the medical Director attended via Phone and Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT were physically attended the meeting. <BR/>Interviews conducted with RN C on 03/27/24 at 10:15 AM; LVN A on 03/26/24 at 11:00 AM; LVN C on 03/26/24 at 10:00AM. CNA A on 03/27/24 at 11:15AM, revealed nurses was in serviced on 03/27/24. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, taking mid night census, do head count to make sure no resident missing. <BR/>ADM was notified that while the IJ was removed on 03/27/24 at 00:00, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 3 residents (Resident #1) reviewed for PASRR.<BR/>The facility failed to ensure Resident #1 was referred for Specialized OT and PT evaluations and services after these were agreed upon during his IDT meeting on 12/11/23. <BR/>This failure placed Resident #1 at risk of decline in functional ADLs. <BR/>Findings included:<BR/>Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included spina bifida (birth defect that occurs when the spine and the spinal cord do not develop completely), abnormal posture, lack of coordination, unsteadiness on feet, malaise (feeling uncomfortable, ill or lack of energy but you cannot explain the cause), need for assistance with personal care, muscle, weakness, mild cognitive impairment of uncertain, ideology, bipolar disorder, major depressive disorder, and anxiety disorder.<BR/>Review of the quarterly MDS assessment for Resident #1 reflected a BIMS score of 15, indicating intact cognition. It also reflected he received 0 minutes of PT or OT and 0 minutes of restorative treatment (range of motion exercises with unskilled staff).<BR/>Review of the care plan for Resident #1 reflected the following: [Resident #1] is PASRR positive for MI/DD and receives specialized services through MHMR. [Resident #1] will receive indicated specialized services as ordered through review date. PT/OT/ST per recommendations.<BR/>Review of the annual PASRR PCSP form for Resident #1 dated 12/11/23 reflected the IDT was composed of Resident #1, the former DON, the LIDDA, a facility RN, the DOR, and the former MDS nurse. It reflected that the following services were agreed upon: specialized assessment for OT and PT, specialized OT and PT.<BR/>Review of OT progress notes for Resident #1 reflected an evaluation for specialized services dated 03/26/24 and a subsequent episode of care.<BR/>Review of PT progress notes for Resident #1 reflected an evaluation for specialized services dated 03/29/24 and a subsequent episode of care.<BR/>Observation and interview on 05/20/24 at 11:30 AM revealed Resident #1 seated in a customized manual wheelchair in the doorway of his room. He had contractures (joint deformity) in both hands and both legs. He stated he was in therapy but he did not want to go that day, because he had a headache. <BR/>During an interview on 05/20/24 at 11:50 AM, the DOR stated she was present at Resident #1's PASRR IDT meeting on 12/11/23, but she had no role in requesting the services they had agreed upon in the portal. She stated her job was to initiate the evaluations and ensure services were provided once they were approved. She stated Resident #1 was receiving specialized habilitative OT and PT.<BR/>During an interview on 05/20/24 at 01:00 PM, the ADM stated the MDSN was responsible for inputting the request for specialized services decided upon by the IDT. He stated the MDS nurse who was part of the IDT for Resident #1 on 12/11/23 no longer worked at the facility, and the current MDSN worked remotely and only worked on nights and weekends. He stated he was new to the facility and not completely sure what role each department head had in the PASRR process. <BR/>During an interview on 05/20/24 at 01:42 PM, the CSM stated he handled social services in the building and coordinated the meetings for the PASRR IDT. He stated beyond that, he had no role in coordination of PASRR services and did not know much about what was involved. <BR/>An attempt was made to contact the MDSN by telephone on 05/20/24 at 02:18 PM and again at 07:35 PM. A voicemail was left but no return contact received. <BR/>During an interview on 05/20/24 at 02:46 PM, the ADM stated he had not developed a procedure for monitoring that PASRR services were requested in a timely manner, because he had only been working at the facility for a week and a half. The ADM stated he had not dug too much into what was previously done for Resident #1, but he knew the services had to be requested right after they were agreed upon and not several months later. He stated a potential negative impact of the failure was residents could decline and experience loss of mobility and freedom. He stated the facility did not have policy specific to PASRR, but they used the RAI manual (handbook for MDS activities).

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #1, 2 and 3) of 4 residents and 1 of 1 hallway observed for a clean environment. <BR/>1. The facility failed to ensure Resident #1, #2, and #3's bedroom floor was clean. <BR/>2. The facility failed to ensure the hallway floor was clean and had no foul odors. <BR/>This deficient practices could place residents at risk of a decreased quality of life. <BR/>Findings included: <BR/>During an interview on 02/21/24 at 8:40 a.m., the ADM revealed housekeepers followed the deep clean schedule. The ADM explained housekeepers deep cleaned twice a week and spot checked and cleaned residents' rooms and commonly shared areas daily. The ADM also revealed there were two housekeepers for each shift.<BR/>An observation on 02/21/24 at 10:38 a.m. revealed Resident #1's bedroom floor was sticky. <BR/>During an interview on 02/21/24 at 10:47 a.m., Resident #1 revealed she cleaned her own room. Resident #1 explained the floor was sticky because housekeeping did not mop it. <BR/>During an observation and interview on 02/21/24 at 11:14 a.m., Resident #2 revealed housekeeping cleaned his room daily. Resident #2 explained the floor was sticky because housekeeping had not been in his room that morning.<BR/>During an observation and interview on 02/21/24 at 11:31 a.m., Resident #3 and his family revealed the bedroom floor was sticky. Resident #3 and his family explained housekeeping did not thoroughly clean his room. <BR/>During an interview on 02/21/24 at 2:15 p.m., CNA A revealed housekeepers cleaned residents' rooms daily. CNA A also revealed she never received complaints about residents' rooms not being cleaned.<BR/>An observation on 02/21/24 at 2:31 p.m., revealed the hallway floor was sticky and had a urine and feces odor. <BR/>During an interview on 02/21/24 at 2:33 p.m., HK B revealed she worked at the facility for 15 days. HK B explained she cleaned residents' rooms once daily. HK B further explained she did not document residents' rooms she cleaned. HK B revealed she never received complaints about rooms not being cleaned. HK B also revealed she mopped the floor once a day. HK B explained there were housekeepers who worked at night from 1:00 p.m. through 8:00 p.m. HK B revealed there were no housekeepers who worked at night from 8:00 p.m. through 6:00 a.m. HK B did not know who cleaned from 8:00 p.m. through 6:00 a.m. if a resident had a mess.<BR/>During an interview on 02/21/24 at 2:45 p.m., HK C revealed she worked at the facility for one year. HK C explained she cleaned residents' rooms once daily. HK C further explained she did not document residents' rooms she cleaned. HK C explained she was out of the facility for the last three days. HK C explained housekeepers divided the hallway whenever a housekeeper was absent. HK C further explained housekeepers were assigned to designated sections of the hallway. HK C revealed other housekeepers did not clean their hallway sections. HK C revealed she observed hallway sections were not cleaned. HK C explained she informed HS about the housekeepers who did not do their job. HK C explained HS told her that she also observed that. HK C explained she was told to clean other residents' rooms that she was not assigned to because of the housekeepers not doing their responsibilities. HK C explained sometimes residents spilled beverages on the floor. HK C revealed she was assigned to clean the floor on 02/21/24. HK C revealed the person in charge of the floors mopped twice a week. HK C revealed she always received complaints from residents and families about floors being dirty. HK C explained HS was informed multiple times about the dirty floors. HK C revealed there were no housekeepers who worked from 9:00 p.m. through 6:00 a.m., HK C said she did not know who cleaned during that time.<BR/>During an interview on 02/21/24 at 3:16 p.m., HS revealed she worked at the facility for four weeks. HS said she expected housekeepers to mop residents' rooms and bathrooms twice daily. HS explained five deep cleanings were completed daily. HS further explained there was first shift who worked from 7:00 a.m. through 3:00 p.m. and second shift who worked from 1:00 p.m. through 8:00 p.m. HS revealed there was no third shift because residents were sleeping and lying down from 8:00 p.m. through 7:00 a.m. HS also revealed CNAs helped housekeepers if residents' had spills or rooms were dirty from 8:00 p.m. through 7:00 a.m. HS revealed housekeeping closets were fully stocked and CNAs had access to the closets. HS also revealed she had a daily deep clean and weekly checklist she was preparing that had not taken into effect because she was still finalizing the checklists. HS explained housekeepers used the old checklists for the time being while she finalized the new ones. HS revealed she spot checked to make sure housekeepers cleaned residents' rooms and hallways. HS also revealed she had two housekeepers per shift. HS revealed she in-serviced housekeepers on housekeeping duties on 02/21/24. HS also revealed she observed residents' rooms and hallway floors were sticky. HS explained the former HS let housekeepers slack off. <BR/>During an interview on 02/22/24 at 12:06 p.m., the ADM revealed housekeepers did not have a deep clean log or documentation reflecting they completed their duties. The ADM explained housekeepers had designated areas of the building they were responsible for cleaning.<BR/>Record review of the facility's staff schedule, dated 02/16/24, 02/18/24 and 02/19/24, reflected there were two housekeeping staff who worked from 6:06 a.m. through 2:57 p.m. and three housekeeping staff who worked from 12:31 p.m. through 9:01 p.m. There were no housekeepers who worked from 9:01 p.m. through 6:06 a.m.<BR/>Record review of the facility's housekeeping general policy and procedure, revised 08/20, reflected the following,<BR/>Purpose: To ensure that the Facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors.<BR/>Policy: <BR/>I. The Facility maintains an adequate, qualified Housekeeping Staff to ensure that all areas of the Facility and its furnishings are clean and sanitary at all times.<BR/>IV. All rooms of the Facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents.<BR/>Procedure: <BR/>A. The Housekeeping Department is responsible for completing the daily, weekly, and monthly cleaning procedures.<BR/>A. The Housekeeping Supervisor determines the cleaning schedule by completing the Housekeeping Schedule Form.<BR/>C. The Housekeeping Staffs general duties are to:<BR/>i. Sweep and mop, or vacuum, all floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #81) reviewed for comprehensive care plans in that:<BR/>Resident #81's comprehensive care plan did not address the resident's Hospice services. <BR/>This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.<BR/>The findings included:<BR/>Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply blood), bilateral occlusion and stenosis of carotid arteries (blockage of arteries that are on both sides of the next that carry blood to the brain), contractors of left shoulder, left wrist and left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).<BR/>Record review of Resident 81's Baseline Care Plan dated 12/22/2023 and locked date of 12/28/2023 revealed under Section 1, D, 6. General information and Initial Goals/Daily Preferences that Resident Prefers HOSPICE SERVICES with a hospice company.<BR/>Record review of Resident #81's admission MDS with an ARD/Target Date of 12/30/2023 revealed under Section O0110, Special Treatments, Procedures and Programs, under K1. Hospice care while a resident yes.<BR/>Record review of Resident #81's comprehensive care plan date initiated 12/22/2023 to 01/08/2024 revealed no mention on the care plan to address the resident's issue with hospice services.<BR/>Record review of Resident #81's revised comprehensive care plan dated 01/11/2024 revealed no mention on the care plan found to address Resident #81's hospice services.<BR/>Record review of Resident 81's consolidated Physician's Orders dated 01/11/2024 and last order review was 12/27/2023 revealed an order dated 12/22/2023 to admit to the facility under the care of a doctor for hospice care. OT (occupational therapy) splint/brace order for resident to wear on his LUE (left upper extremity) a carrot splint daily or as tolerated dated 01/08/2024. <BR/>Record review of Resident #81's revised comprehensive care plan dated 01/12/2024 revealed under the care plan of #81's DNR (do not resuscitate) with interventions/tasks the last bullet stated, Social Services to consult with resident and RP (responsible party) regarding their decision to continue DNR, Hospice with revision on 01/12/2024. <BR/>Interview on 01/12/2024 beginning at 8:47 a.m. with LVN U, the MDS Coordinator, revealed Resident #81 had orders for hospice dated 12/22/2023 and on the admission MDS dated [DATE] indicating section O reflects resident on hospice. Further interview with LVN U revealed as soon as they (facility) receive any order the care plan is updated. <BR/>Interview on 01/12/2024 at 9:30 a.m. LVN U stated even though previously during the day this surveyor had interviewed LVN U concerning Resident #81's care plan for Hospice, she had no idea how the word Hospice was added to the social worker's care plan with revision 01/12/2024.<BR/>Interview on 01/12/24 at 2:45 p.m. with the social worker concerning the DNR care plan for Resident #81 showing a revision of the care plan on 01/12/2024 revealed she had started writing Resident #81's care plan on 12/18/2023 for Resident #81's DNR on 12/22/2023 but, she had not made any revisions to the care plan she had no idea who added the word Hospice: on to the care plan.<BR/>A request was made for a copy of the facility policy and procedure regarding resident care plans from the Administrator but, was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 elopement.<BR/>Resident #1 walked out of the facility unattended on 03/15/2024 at about 9:00PM until the police found him at about 10:00 PM from a place approximately 1.5 miles away from the facility. EMS organized by the police to take him to the hospital and at the hospital it was confirmed that resident had hairline fracture above the left eye and cheek with lacerations on left eye lid, left wrist, and lower and upper lips, and abrasions on hands. The facility staff was not aware the resident was missing until the family called the facility. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 4:55 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 03/25/24 at 6:00 PM. While the IJ was removed on 03/27/24, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could affect residents by placing them at risk of physical harm, pain and mental anguish, or emotional distress.<BR/>Findings Included:<BR/>Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged on 03/17/2024. His diagnoses included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), Prostatic Hyperplasia (enlarged prostate gland), Hypothyroidism, Hearing Loss-Left ear, and Abnormal Involuntary Movements. <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. <BR/>Record review of Resident #1's Baseline Care Plan dated 03/10/24 reflected Resident #1 had no history of falls and no elopement risk.<BR/>Record review of Resident #1's Elopement Risk Evaluation dated 03/16/24 reflected a score of 14.00 indicating Resident #1 was at imminent risk for elopement. No Elopement Risk Evaluation completed prior to the elopement. <BR/>Record review of the care plan completed after the incident, dated 03/16/24 reflected , Resident #1 was at risk for elopement related to Elopement Evaluation Risk Score. No care plan was completed prior to the elopement incident. <BR/>Record review of the Weekly Skin Check dated 03/16/24 reflected Resident #1 had lacerations on left eye lid, left wrist and lower and upper lips. <BR/>Record review of Trauma Informed assessment dated [DATE] reflected Resident #1 felt scared, helpless, or horrified related to the sudden event of elopement with fall. <BR/>Record review of facility's incident report to HHSC dated 03/18/24 reflected, on 3/15/2024 the ADM was notified by MDS C that on 03/15/24, Resident #1 was being transported to the hospital for further evaluation and treatment related to fall with injury after found him outside the facility at a place half a mile away. The facility came to know about this incident when the FM of Resident #1 notified the facility over the phone at 10:20PM, that the resident was off the property. She also informed the facility that resident was on his way to the hospital. At the hospital it was revealed that Resident #1 had a hairline fracture above the left eye and the left cheek. Resident also had abrasions on his hands. <BR/>Record review of Nurses Progress Notes for Resident #1 by RN B on 03/16/24 at 6:41 AM, reflected Resident arrived from [Hospital] ER. Resident arrived with acute head injury orbital fracture, lip laceration Zygomatic arch fracture. Wander guard was placed on resident right lower leg. Notified doctor of return. Family is aware of return. Resident is comfortable at this time. <BR/>During an interview over the phone on 03/25/24 at 10:30 AM, Resident #1's FM stated she was out of the state when the incident of the elopement occurred. She stated at about 10:00PM the police called and talked to her over the phone and said that they went and picked Resident #1 up from a place approx. 1.5 miles away from the facility. She said the police reported that they responded to a 911 call from a community member who found Resident #1 with injuries braced on his parked car. She said the police organized EMS and transported him to the nearby hospital for further assessment and treatment. The FM stated the facility was unaware of Resident #1's disappearance from the facility until she called and informed the FR at the facility at about 10:20 PM. FM stated, initially when she asked about Resident #1, the FR stated Resident #1 resides at the 2nd floor and she would transfer FM's call to the 2nd floor nursing station so that FM could request the staff to talk to him. <BR/>During an interview over the phone on 03/25/24 at 11:00 AM, FR stated she worked as the receptionist at the facility from 6:00 PM to 10:30 PM, Monday to Friday. She said, on 03/15/24 at about 10:20 PM she received a phone call from Resident #1's FM asking if Resident #1 was there at the facility. FR said, she replied to FM that Resident #1 was living on the 2nd floor, and she would transfer the call to the nursing station at the 2nd floor so that the FM could talk to the staff there. FR said, FM then reported to FR that she was checking if staff was aware of what was going on and then reported that the police had picked up Resident #1 from a place about 1.5 miles away from the facility at about 10:00 PM and admitted to a hospital nearby due to the injuries he had. FR stated she or anyone at the facility was aware until then that Resident #1 was absconded from the facility. FR said at about 10:00 PM LVN A at the 2nd floor enquired her if she saw Resident #1 at the 1st floor as they could not find him at the 2nd floor. FR stated they were under the impression that Resident #1 was wandering around within the facility until they heard about his elopement from the facility from the FM. FR said, on 03/13/24 Resident #1 was persistently requesting to her to let him leave the facility and made unsuccessful efforts to open the coded front door at two different occasions. FR stated this behavior from him was evident since his admission on [DATE] and LVN A from 2nd floor requested her to have a [NAME] on Resident #1. She stated she also had informed LVN A about his attempts for unauthorized exit. FR stated she had a watch on him whenever he was on 1st floor and ensured that he did not exit through the front door on 03/15/24 as she was the only one who allowed the visitors to come and go from the facility. She stated the front door was secured with code numbers and only the staff members knew the code number. FR said she believed Resident #1 might have exited through the emergency fire exit door situated at the back of the facility. FR added, though the back door secured by code numbers, the lock can be override if the handle of the door holds down for some time. The door will be opened with an alarm though the alarm would not be heard at the reception area. <BR/>During an interview on 03/25/24 at 10:00 AM, MDS C stated she worked at the facility in the morning shift until 5PM. She said, on 03/15/24 at about 10:30PM she received a phone call at home from FR stating Resident#1 eloped from the facility and had a fall. FR reported to her that the police found him about 1.5 miles away from the facility with lacerations on his body and admitted him to a nearby hospital for treatment. MDS C stated, as per her understanding the staff at 2nd floor did not find him there at about 9.45PM and then they informed FR to have a watch on him if he appears at the front door. She stated it appeared the staff came to know his exit out of the facility only after the FM passed on that information<BR/>During a telephone interview on 03/25/24 at 10:30, LVN A stated she worked in the afternoon shift on 03/15/24 with the responsibility of the hall where Resident #1 resided. She said on 03/15/24 Resident #1 accepted his night medication at 9:00PM in his room. At about 9:45PM one of the CNAs noticed that Resident #1 was not in his room and his name tag at the door also was missing. LVN A stated she immediately informed FR to check if he was there at the reception area and by that time the information about his elopement was received from the FM of Resident #1. LVN A stated according to her Resident #1 was not an elopement risk as he mostly stayed in his room. When this investigator asked her about an incident of his two unsuccessful attempts to get out of the facility on 03/13/24 in the evening, reported by FR, LVN A stated those were the only attempts she was aware of. <BR/>During a phone interview on 03/25/24 at 3:00PM, RN B stated she was the night nurse at the facility and was not aware of what was going on with Resident #1 until 10:00 PM as she was not in charge of his hall. RN B stated the staff at the facility came to know through the FM about Resident #1's disappearance and subsequent incident of finding him outside the facility. RN B stated Resident #1 arrived back at the facility on 03/16/24 at about 6:00 AM from the hospital. She said she had a nurse-to-nurse communication from the nurse at the hospital. RN B stated, the nurse from the hospital reported Resident #1 had an acute head injury, orbital fracture, lip laceration and Zygomatic Arch (the most lateral projection of the midface) fracture. She stated she had recorded this in the progress note in the electronic medical record. <BR/>During an interview on 03/26/24 at 10:00 AM, LVN C stated she worked at the facility for more than a year and worked the morning shift. She said she did not work on the hall where Resident #1 resided. LVN C stated the nursing stations at the 2nd floor were equipped with alarms and any attempt to open the doors downstairs trigger the alarm. She added, staff immediately go down to ensure no elopement attempt was made by any residents. LVN C stated she did not know what really happened on that day as the incident occurred on the night shift. <BR/>In an interview and observation walk through with the ADM on 03/25/24 at 3:00 PM, she stated Resident #1 must have exited through the emergency fire exit door at the back, adjacent to the kitchen. ADM stated she believed it was not an elopement since the facility was not a locked facility. She added, stopping anyone from leaving the facility, when they wanted to, was a violation of resident rights. The ADM stated Resident #1 had a BIMS score of 13, indicated intact cognition to make independent decisions. The ADM stated there was residents at the facility who regularly go Out-On-Pass to the community and return within the stipulated time (72 hours). When this investigator asked if Resident #1 left the facility as per the policies and procedures for Out-On-Pass, she stated, he was not. The ADM also stated, Resident #1 neither signed any AMA documents nor declined to sign one and exited without the knowledge of any staff members. Observation of the emergency exit door revealed there was an instruction posted on the door explaining how to override the passcode in case of any emergency however an alarm went off when opened without the passcode. The ADM said since the door was away from the reception it was difficult to hear the alarm from the reception area. Observation of the front door revealed, it was secured by number code and the entrance and exit was controlled by the receptionist. There were no other exit doors at the facility.<BR/>During an interview on 03/26/24 at 12:50 PM, the DON stated he started working at the facility about a week ago, after the elopement incident of Resident #1 occurred. He stated he was well informed about the incident. The DON defined an elopement as, a resident leaving the facility without any notice or knowledge of the facility. The DON stated it appeared there was some shortfall in the security measures at the backdoor as it was believed Resident # 1 accessed the back door for his exit on 03/15/24. The DON stated it seemed the elopement risk evaluation and nursing judgement also was not accurate as there was no management plan, like usage of a wander band in place. The DON stated, when an alarm would be heard at nursing stations, the staff was supposed to go down to the 1st floor and make sure the alarm went off not because of any resident's attempt for an unauthorized exit. <BR/>During an interview on 03/26/24 at 1:10 PM, MDS C stated she did not know how Resident #1 got out of the facility. She stated she was the MDS nurse and was helping the administrator within her scope of practice as an LVN, in the absence of a DON at that time. She stated the act of Resident #1 was elopement if he exited the facility without the knowledge of the staff and without completing Out-On-Pass paperwork or without signing an AMA form. <BR/>Review of undated facility policy Elopement Risk Reduction Approaches reflected. <BR/>Planning:<BR/>As necessary, provide new residents (to the facility, wing, unit ,etc.) with additional staff assistance until they are comfortable in their new environment .<BR/> Ensure that residents are able to move freely, are monitored and remain safe .<BR/> .Training:<BR/>Facility staff needs to know:<BR/> . The resident's propensity to wander and the triggering conditions <BR/> The consequences of unsafe wandering, the protocols to follow to minimize successful exiting and the procedures to follow when resident is lost .<BR/>Promote identification of residents who are at risk of elopement. Ensure that photographs of residents who wander are maintained in an accessible but secure location and that receptionist, activities and clinical staff and others in appropriate positions to help are able to recognize at-risk residents and to assist in redirecting them <BR/> .Environment: <BR/> Ensure that staff alert and elopement alarm/warning systems are the least intrusive and burdensome possible <BR/> After conferring with fire and other appropriate officials, minimize the risk of elopement. <BR/>An Immediate Jeopardy was identified on 03/25/24 at 4:55 PM. The IJ Template was provided to the facility ADM on 03/25/24 at 6:00 PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 03/26/24 at 7:01 PM and indicated the following:<BR/>Plan of Removal <BR/>Immediate Jeopardy <BR/>On 03/25/2024 an abbreviated survey was initiated at the facility. On 03/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: <BR/>F689 - The facility failed to provide an environment free of accident hazards to minimize elopement risk. <BR/>Action: Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>Start Date: 3/17/2024. <BR/>Completion Date: 3/17/2024 <BR/>Action: All residents re-evaluated for risk of elopement via assessment on 3/25/2024. No additional residents were identified based on evaluation. Elopement Binder up to date and remains at reception desk. DON ensured all residents who are imminent risk for elopement are donning a wander guard for safety. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: DON or Designee <BR/>Action: Medical Director notified of IJ on 3/25/2024 <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Administrator <BR/>Action: Physician orders related to residents on wander guard placement reviewed and updated for all residents <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible: Medical Director or Designee <BR/>Action: In-services completed with all staff (facility does not use agency, all staff to include PRN staff) related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). As new employees are hired they will be in-serviced on all protocols in hire process. <BR/>Start Date: 3/25/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: In-service completed with all staff (facility does not use agency, all staff to include PRN staff) that if resident has more than one request to leave that elopement/wandering risk assessment completed and wander guard placed if applicable as intervention for safety. Elopement risk reduction approaches policy reviewed with all staff. As new employees are hired they will be in-serviced on protocol in hire process. <BR/>Start Date: 3/26/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: QAPI meeting held related to IJ. Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT, and Medical Director (via phone) present. <BR/>Start Date: 3/26/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible Administrator <BR/>Action: HR and Administrator in-serviced by Regional Clinical Specialist on all in-services, to include Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON, and Elopement risk reduction. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Regional Clinical Specialist<BR/>The surveyor confirmed the facility implemented their plan of removal sufficiently from 03/25/24 through 03/27/24 to remove the IJ by: <BR/>1. Record review of Resident #1's face sheet confirmed Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>2. Record review of an Inservice to all nursing and CNA staff was completed on 03/27/24 by ADM and HR related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). <BR/>HR and Administrator were in-serviced on the above topics by Regional Clinical Specialist <BR/>3. Record review of the medical records of all the resident at the facility revealed all residents re-evaluated for risk of elopement via assessment on 3/25/2024 and ensured all residents who are an imminent or moderate risk for elopement had wander guards for safety. <BR/>4. Record review of the Elopement Binder revealed it was up to date and remains at reception desk. Copies of them were available at Nursing stations. <BR/>5. Record review on 03/27/24 of the medical records of all residents revealed physician orders related to residents on wander guard placement reviewed and no additional residents added to the existing residents with elopement risk.<BR/>6. Record review of the minutes of the QAPI meeting that was conducted for discussing elopement prevention on 03/26/24 revealed that the medical Director attended via Phone and Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT were physically attended the meeting. <BR/>Interviews conducted with RN C on 03/27/24 at 10:15 AM; LVN A on 03/26/24 at 11:00 AM; LVN C on 03/26/24 at 10:00AM. CNA A on 03/27/24 at 11:15AM, revealed nurses was in serviced on 03/27/24. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, taking mid night census, do head count to make sure no resident missing. <BR/>ADM was notified that while the IJ was removed on 03/27/24 at 00:00, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for 5 (Residents #1, #2, #3, #4, and #5) of 6 residents reviewed for care plans, in that: <BR/>Residents #1, #2, #3, #4, and #5's comprehensive care plans were not reviewed and revised after their quarterly MDS assessments were completed. <BR/>These deficient practices could place residents at risk of current needs not being met. <BR/>Findings included: <BR/>Record review of Resident #1's admission Record, dated 05/21/24, revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses, which included: unspecified atherosclerosis (The build-up of fats, cholesterol, and other substances in and on the artery walls), unspecified severe protein-calorie malnutrition, morbid (severe) obesity due to excess calories, dementia (A group of thinking and social symptoms that interferes with daily functioning), and unspecified depression. <BR/>Record review of Resident #1's Quarterly MDS Assessment, dated 04/17/24, revealed Resident #1 had a BIMS score of 3, which indicated Resident #1 had severe cognitive impairment. <BR/>Record review of Resident #1's Care Plan Review History, dated 05/21/24, revealed Resident #1's comprehensive care plan was last reviewed and completed on 01/09/24. <BR/>Record review of Resident #2's admission Record, dated 05/23/24, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses, which included: traumatic subdural hemorrhage without loss of consciousness (A type of traumatic brain injury), unsteadiness on feet, dementia, essential (primary) hypertension (A condition in which the force of the blood against the artery walls is too high), stage 1 pressure ulcer of sacral region (occur when a bony prominence, such as the sacrum, is subjected to prolonged pressure and can result in soft tissue injury), generalized muscle weakness, age-related osteoporosis (deterioration in bone mass and micro-architecture, with increasing risk to fragility fractures), unspecified lack of coordination, repeated falls, and cognitive communication deficit. <BR/>Record review of Resident #2's Quarterly MDS Assessment, dated 04/16/24, revealed Resident #2 had a BIMS score of 7, which indicated Resident #2 had severe cognitive impairment. <BR/>Record review of Resident #2's Care Plan Review History, dated 05/23/24, revealed Resident #2's comprehensive care plan was last reviewed and completed on 01/08/24. Resident #2 also had a comprehensive care plan started on 03/24/24 that did not have a completion date, which indicated the comprehensive care plan was incomplete. <BR/>Record review of Resident #3's admission Record, dated 05/23/24, revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses, which included: acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, major depressive disorder, muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unspecified depression, legal blindness, essential hypertension, unsteadiness on feet, other lack of coordination, and presence of cardiac pacemaker. <BR/>Record review of Resident #3's Comprehensive MDS Assessment, dated 04/19/24, revealed Resident #3 had a BIMS score of 15, which indicated Resident #3 was cognitively intact. <BR/>Record review of Resident #3's Care Plan Review History, dated 05/23/24, revealed Resident #3's comprehensive care plan was last reviewed and completed on 11/29/23. Resident #3 also had a comprehensive care plan started on 02/26/24 that did not have a completion date, which indicated the comprehensive care plan was incomplete. <BR/>Record review of Resident #4's admission Record, dated 05/23/24, revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses, which included: unspecified Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), dementia, mild neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness), other recurrent depressive disorders, cognitive communication deficit, unsteadiness on feet, other lack of coordination, unspecified anxiety disorder, essential hypertension, unspecified chronic kidney disease, repeated falls, unspecified pain, and acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). <BR/>Record review of Resident #4's Quarterly MDS Assessment, dated 03/08/24, revealed Resident #4 had a BIMS score of 15, which indicated Resident #4 was cognitively intact. <BR/>Record review of Resident #4's Care Plan Review History, dated 05/23/24, revealed Resident #4's comprehensive care plan was last reviewed and completed on 12/30/23. Resident #4 also had a comprehensive care plan started on 02/27/24 that did not have a completion date, which indicated the comprehensive care plan was incomplete. <BR/>Record review of Resident #5's admission Record, dated 05/23/24, revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses, which included: cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), other lack of coordination, acquired absence of left leg above knee, non-pressure chronic ulcer of skin, unspecified dementia, acquired absence of right left below knee, mild protein-calorie malnutrition, muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), repeated falls, other reduced mobility, generalized muscle weakness, unsteadiness on feet, unspecified lack of coordination, and other symptoms and signs involving cognitive functions and awareness. <BR/>Record review of Resident #5's Quarterly MDS Assessment, dated 04/30/24, revealed Resident #5 had a BIMS score of 9, which indicated Resident #5 was moderately impaired in her cognition. <BR/>Record review of Resident #5's Care Plan Review History, dated 05/23/24, revealed Resident #5's comprehensive care plan was last reviewed and completed on 01/08/24. <BR/>During an interview on 05/21/24 at 1:30 p.m., the ADM revealed the facility's Care Planning policy and procedure would be the closest document regarding when revision and timing for residents' MDS assessments and care plans needed to be completed. The ADM stated he was aware that some residents' care plans were overdue for a review and revision. The ADM did not state what the risk to residents were if residents' care plans were not reviewed and revised. The ADM stated the facility was working on the MDS assessment and care plan revision and timing issue. The ADM also stated the former MDS coordinator was terminated last year (December 2023) for not doing her job in completing MDS assessments and care plans. The ADM was not aware Residents #1, #2, #3, #4, and #5's care plans have not been reviewed and revised. The ADM stated the SW was reviewing and revising residents' care plans. The ADM did not know who appointed SW to review and revise care plans, when SW began the task, how he monitored to ensure care plans were reviewed and revised and how he was ensuring care plans were accurately completed other than discussing care plans during daily meetings in the morning and if the SW was trained on reviewing and revising residents' care plans . The ADM also stated the current MDS Coordinator (MDS Coordinator A) was part-time and only worked on completing residents' MDS assessments. The ADM stated he oversaw residents' MDS assessments and care plans to ensure timely completion. <BR/>During an interview on 05/21/24 at 4:05 p.m., the SW revealed he had been helping with residents' care plans since 03/18/24 . The SW explained he arranged care plan meetings and reviewed and revised care plans. The SW further explained he was appointed by the previous company who owned the facility to review and revise care plans at the beginning of his employment. The SW stated he was not trained on how to review and revise residents' care plans . The SW explained he reached out to other facilities to learn how to review and revise care plans. The SW explained the ADM oversaw to ensure residents' care plans were reviewed and revised. The SW explained residents' care plans were reviewed and revised quarterly, annually, whenever there was a significant change in condition, and as needed. The SW did not know who was responsible for reviewing and revising residents' care plans. The SW explained reviewing and revising residents' care plans was not his responsibility and job duty and he performed the tasks because he took on more work and it was assigned to him. The SW stated he was the only staff member who worked on reviewing and completing residents' care plans. The SW stated MDS Coordinator A only worked on residents' MDS assessments, was PRN and did not communicate with him. The SW stated residents' health and safety could be affected if residents' care plans were not reviewed and revised within the required timeframes. <BR/>During an interview on 05/21/24 at 4:37 p.m., the DON revealed MDS Coordinator A telecommunicated. The DON explained MDS Coordinator A worked some days at home and some days at the facility. The DON stated the SW reviewed and revised residents' care plans. The DON did not know if SW was trained on reviewing and revising residents' care plans. The DON did not know who oversaw residents' care plans to ensure the care plans were completed within required timeframes. The DON stated residents' health and well-being could be affected if residents' care plans were not reviewed and revised. <BR/>During an interview on 05/21/24 at 5:11 p.m., MDS Coordinator A revealed he worked part-time and had been helping with completing residents' MDS assessments during the weekends. MDS Coordinator A stated he was the only staff member who worked on completing residents' MDS assessments. MDS Coordinator A stated he was not responsible for reviewing and revising residents' comprehensive care plans. MDS Coordinator A stated the SW was scheduling residents' care plan meetings. MDS Coordinator A also stated the ADM oversaw to ensure residents' MDS assessments and care plans were completed. MDS Coordinator A stated residents' MDS assessments were reviewed and revised whenever resident had a significant change in condition and quarterly. MDS Coordinator A stated if there were 2 or more changes in residents' ADLs, then he would review and revise residents' MDS assessment because he considered residents' status to be a significant change. MDS Coordinator A also stated residents' health and safety could be affected if residents' care plans were not reviewed and completed. <BR/>Record review of the facility's Care Planning policy and procedure, revised 10/24/22, revealed the following: <BR/>The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 3 residents (Resident #1) reviewed for PASRR.<BR/>The facility failed to ensure Resident #1 was referred for Specialized OT and PT evaluations and services after these were agreed upon during his IDT meeting on 12/11/23. <BR/>This failure placed Resident #1 at risk of decline in functional ADLs. <BR/>Findings included:<BR/>Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included spina bifida (birth defect that occurs when the spine and the spinal cord do not develop completely), abnormal posture, lack of coordination, unsteadiness on feet, malaise (feeling uncomfortable, ill or lack of energy but you cannot explain the cause), need for assistance with personal care, muscle, weakness, mild cognitive impairment of uncertain, ideology, bipolar disorder, major depressive disorder, and anxiety disorder.<BR/>Review of the quarterly MDS assessment for Resident #1 reflected a BIMS score of 15, indicating intact cognition. It also reflected he received 0 minutes of PT or OT and 0 minutes of restorative treatment (range of motion exercises with unskilled staff).<BR/>Review of the care plan for Resident #1 reflected the following: [Resident #1] is PASRR positive for MI/DD and receives specialized services through MHMR. [Resident #1] will receive indicated specialized services as ordered through review date. PT/OT/ST per recommendations.<BR/>Review of the annual PASRR PCSP form for Resident #1 dated 12/11/23 reflected the IDT was composed of Resident #1, the former DON, the LIDDA, a facility RN, the DOR, and the former MDS nurse. It reflected that the following services were agreed upon: specialized assessment for OT and PT, specialized OT and PT.<BR/>Review of OT progress notes for Resident #1 reflected an evaluation for specialized services dated 03/26/24 and a subsequent episode of care.<BR/>Review of PT progress notes for Resident #1 reflected an evaluation for specialized services dated 03/29/24 and a subsequent episode of care.<BR/>Observation and interview on 05/20/24 at 11:30 AM revealed Resident #1 seated in a customized manual wheelchair in the doorway of his room. He had contractures (joint deformity) in both hands and both legs. He stated he was in therapy but he did not want to go that day, because he had a headache. <BR/>During an interview on 05/20/24 at 11:50 AM, the DOR stated she was present at Resident #1's PASRR IDT meeting on 12/11/23, but she had no role in requesting the services they had agreed upon in the portal. She stated her job was to initiate the evaluations and ensure services were provided once they were approved. She stated Resident #1 was receiving specialized habilitative OT and PT.<BR/>During an interview on 05/20/24 at 01:00 PM, the ADM stated the MDSN was responsible for inputting the request for specialized services decided upon by the IDT. He stated the MDS nurse who was part of the IDT for Resident #1 on 12/11/23 no longer worked at the facility, and the current MDSN worked remotely and only worked on nights and weekends. He stated he was new to the facility and not completely sure what role each department head had in the PASRR process. <BR/>During an interview on 05/20/24 at 01:42 PM, the CSM stated he handled social services in the building and coordinated the meetings for the PASRR IDT. He stated beyond that, he had no role in coordination of PASRR services and did not know much about what was involved. <BR/>An attempt was made to contact the MDSN by telephone on 05/20/24 at 02:18 PM and again at 07:35 PM. A voicemail was left but no return contact received. <BR/>During an interview on 05/20/24 at 02:46 PM, the ADM stated he had not developed a procedure for monitoring that PASRR services were requested in a timely manner, because he had only been working at the facility for a week and a half. The ADM stated he had not dug too much into what was previously done for Resident #1, but he knew the services had to be requested right after they were agreed upon and not several months later. He stated a potential negative impact of the failure was residents could decline and experience loss of mobility and freedom. He stated the facility did not have policy specific to PASRR, but they used the RAI manual (handbook for MDS activities).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was unable to conduct activities of daily living independently, received the necessary services to maintain good grooming and personal hygiene for 2 of 4 residents reviewed for quality of life (Resident #3 and Resident #4). <BR/>1. The facility failed to provide scheduled bath/showers for Resident #3. <BR/>2. The facility failed to provide scheduled bath/showers for Resident #4. <BR/>These failures could place residents who required assistance from staff for ADL's at risk of poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.<BR/>Findings included:<BR/>1. Review of Resident #3's face sheet, dated 04/07/2024, reflected a [AGE] year-old female initially admitted on [DATE] with re-admission date of 2/15/24 after a three-day hospitalization, diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain), epilepsy (brain disorder causing seizures).<BR/>Review of Resident #3's MDS, dated [DATE] revealed a BIMS score of 15 indicating no cognition impairments. Section GG, Functional Abilities and Goals, indicated Resident #3 required supervision or touching assistance with bathing. <BR/>Review of Resident #3's Care Plan, revised 08/01/2023, reflected a self- care deficit related to hemiplegia, interventions included to encourage the resident to participate to the fullest extent possible .<BR/>Review of the facility shower schedule, undated, revealed that Resident #3 was scheduled to shower every week on Tuesday, Thursday, and Saturday during the 2:00 PM to 10:00 PM shift. Indicating from Resident #3's readmission date of 2/15/24 through 04/05/2024, if given 3 showers a week, a total of 22 showers scheduled. <BR/>Review of Resident #3's Shower Sheets, request for the dates of 02/15/2024 through 04/05/2024, reflected documentation that Resident #3 received 8 of 22 scheduled showers, on 2/24, 2/29, 3/9, 3/12, 3/16, 3/21, 4/2 and 4/4. <BR/>Review of Resident #3's Progress Noted from 02/15/2024 through 04/05/2024 revealed there was no documentation regarding a shower refusal. <BR/>During an interview on 04/06/2024 at 9:20 AM with Resident #3 revealed when asked about showers she stated she was supposed to get one 3 days a week but usually they did not give her one because there were no towels. She stated a family member brought her washcloths so that she can wash herself, best she can from the bathroom sink, which does not make her feel as clean as a shower would. <BR/>2. Review of Resident #4's face sheet, dated 04/07/2024, reflected a [AGE] year-old female initially admitted on [DATE] with re-admission date of 1/23/24, diagnoses including Cerebral Palsy (a motor disability that causes weakness and/or problems using muscles), Epilepsy (brain disorder causing seizures), unsteadiness on feet and adult failure to thrive.<BR/>Review of Resident #4's MDS, dated [DATE] revealed a BIMS score of 15 indicating no cognition impairments. Section GG, Functional Abilities and Goals, was not completed. <BR/>Review of Resident #4's Care Plan, revised 11/29/2023, reflected a self- care deficit, interventions included the resident required assistance of one staff while bathing/showering. <BR/>Review of the facility shower schedule, undated, revealed that Resident #4 was scheduled to shower every week on Monday, Wednesday, and Friday during the 2:00 PM to 10:00 PM shift. Indicating from readmission date of 1/24/24 thru 04/05/2024, if given 3 showers a week, a total of 30 showers scheduled. <BR/>Review of Resident #4's Shower Sheets, request for the dates of 01/24/2024 through 04/05/2024, reflected documentation that Resident #4 received 4 of 30 scheduled showers on 1/29, 2/09, 2/13 and 3/2. <BR/>Review of Resident #4's Progress Noted from 01/24/2024 through 04/05/2024 revealed there was no documentation regarding the resident refusing a shower. <BR/>During an interview on 04/06/2024 at 10:15 AM, Resident #4 revealed when asked about frequency of showers she stated she had not had a shower in over two weeks. She stated she does not ask anymore she waits for staff to ask her. <BR/>During an interview on 04/06/2024 at 3:01 PM, RN A revealed she knew when a resident was given a shower because the staff gave her a shower sheet. She signs the sheet and puts it in the shower book. RN A stated if she was given a shower sheet with refusal on it, she will talk to the resident. Refusals are sometimes documented in the nurses notes by the nurse. She has not known of a problem with showers being given. <BR/>During an interview on 04/07/2024 at 11AM, CNA E revealed that he only knows of one way to document that a shower was given, he uses the shower sheets, and gives to the nurse. He stated there are residents that refuse a shower, and they make a shower sheet saying that when it happens. CNA E stated he can usually get his showers done because the assignment will be 3 to 4 residents a day . He stated if something happens that they are unable to get a shower done that was scheduled they let the next shift know. <BR/>During an interview on 04/07/2024 at 11:20 AM, CNA F revealed that he gets all his assigned showers completed. He stated he documents on a shower sheet form, there is a section to fill out if refused. All shower sheets are given to the nurse. CNA F stated the only times he does not get a shower completed is when there are no towels. He stated he does not document anywhere when that happens. <BR/>During an interview on 04/07/2024 at 1:26 PM, the facility Administrator revealed the shower sheets provided were how they are keeping track of showers given. There may have been a documentation system with the prior owners, but no longer have that system. Policy states a minimum of one shower a week, but residents are scheduled for three showers a week, scheduled showers should be occurring. <BR/>Record review of the facility's policy titled Showering a Resident, undated, included the purpose of the policy as A shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors.; and Residents are offered a shower at minimum of once weekly and given per resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to prepare food in a form to meet individual needs for 1 of 4 (Resident #5) residents observed for dietary needs.<BR/>The facility failed to provide a mechanical soft diet with pureed meats for Resident #5 and served her chopped meat during lunch and an entire pureed meal for dinner. <BR/>This failure could contribute to causing a resident to choke and poor food intake. <BR/>Findings included: <BR/>Review of Resident #5's face sheet dated 04/06/2024, revealed Resident #5 was a [AGE] year-old female admitted to the facility 07/28/2021 with diagnoses that included: dementia (disorder that causes impairments in thinking, memory and behavior), major depressive disorder, dysphagia (difficulty or discomfort in swallowing), and pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit.<BR/>Review of Resident #5's MDS Assessment updated 11/03/2023, revealed a BIMS score of eight indicating moderately impaired cognitive function. Resident #5 was assessed as independent with eating once the meal was placed in front of her. Resident #5 was noted to have a swallowing disorder of coughing and choking during meals, requiring a mechanically altered diet. <BR/>Review of Resident #5's care plan updated 12/14/2023 revealed Resident #5 nutritional care area triggered related to severe protein-calorie malnutrition, mechanically altered diet. Interventions included LD to evaluate and make diet change recommendations as needed. Serve diet as ordered, monitor intake, and record every meal. <BR/>Review of Resident #5's Speech Therapy Evaluation and plan of Treatment, dated 3/12/24, revealed a recommendation of mechanical soft texture with pureed meat. <BR/>Review of Resident #5's physician's order summary dated 04/06/2024 revealed an active order made on 08/11/2022 for a mechanically soft with pureed meat texture, thin consistency liquids. <BR/>Observation on 04/06/2024 at 12:10 PM in the facility dining room revealed none of the residents had dietary cards with their trays. There were no names or diet orders on the tray. Resident #5 was sitting at the table with a visitor standing behind her. A regular textured tray was being removed by DA A, and Resident #5's visitor told DA A the tray had not been touched because she stopped Resident #5 from eating from the tray as it was not pureed. At 12:12 PM DA A returned with a tray and explained it was mechanical soft, which was the diet ordered. The tray was noted to contain chopped sausage (not pureed), regular textured sauerkraut, potatoes, and strawberry cake. DA A remained at the table to watch Resident #5 take several bites of food. <BR/>Observations on 04/06/2024 from 5:35PM to 6:10 PM, in the facility dining room revealed resident trays now included a dietary card with their name, picture, diet order and allergies. At 5:41PM Resident #5 was given a tray by RN B containing a grilled cheese sandwich, tomato soup, tater tots and gelatin. The surveyor asked RN B if the tray was a mechanical soft diet. RN B stated she did not know; she would ask and took the tray. At 5:50 PM, Resident #5 was given a new tray that was pureed texture. At 5:52 PM observations revealed another resident in the dining room with a diet card that read mechanical soft diet, RN B was cutting up the cheese sandwich into small pieces. <BR/>During an interview on 04/06/202424 at 12:38PM, DA A revealed the company that owned the facility had recently changed. She stated they had used diet cards before but now there were not any. DA A stated currently they handwrote a label that they put on the first of that type of that tray. DA A gave the example, if there were seven pureed trays the first in the cart would say pureed then all others under it are the same until another tray is label a different type. If a resident makes a special request the tray will be labeled with their name. There are no resident names on other trays because the nurse's know what type diets the residents have and can print out a list. DA A have a list in the kitchen of allergies and diet orders that we look at when making the trays, but they knew them by heart now. <BR/>During an interview on 04/06/2024 at 1:33pm, with the facility DM D revealed she has been the DM since January 2024. She stated she had recently handmade cards for each of the residents that contained their diet order and allergies. DM D stated she did not know why the kitchen staff did not use them. DM D stated she was the Manager at another facility but checks in on this facility. She believes that the company is trying to implement the same system they use at her facility. DM D stated she had just called and asked the kitchen staff why they were not using the cards she made and was told they had handwritten cards and put on the trays. <BR/>During an interview on 04/06/2024 at 3:01 PM, with RN A revealed there have not been diet cards on the trays for a couple of months. She stated the nursing staff checked all trays prior to them being passed out to the residents. RN A stated she knows the diet because it is on the residents' profiles. She stated Resident #5's diet is mechanical soft and demonstrated the profile area on her computer at the nurse's station. The page RN A showed the surveyor did contain an order for mechanical soft. RN A was asked if she was aware the diet order was soft mechanical diet with pureed meat, and she stated she had not been aware of the pureed meat. RN A expanded the profile to the entire screen and the pureed meat was included on the profile in the next sentence of the order once the entire screen was visible. RN A confirmed that was the current order.<BR/>During an interview on 04/06/2024 at 4:24 PM, the facility [NAME] revealed with the old system with the previous owners they had diet cards, but all the information was lost when the current company took over. He stated today he got cards to use on the trays with the diet and allergies. Prior to today since about February 2024 they had a piece of paper they could refer to that had the information. <BR/>During an interview on 04/06/2024 at 5:28 PM, CNA C stated there have not been any diet tray cards on the trays prior to today, that the CNAs depend on the nurses to tell them which tray was for which resident. CNA C stated they have most residents diet memorized. When asked how a new or temporary staff would know she stated the nurse will tell them.<BR/>During an interview on 04/06/2024 at 6:03 PM with RN B revealed she was aware of Resident #5's order but was unsure if a grilled cheese was considered mechanical soft. She stated when she asked the kitchen, they said it was but to give her a pureed tray. RN B stated when she asked the DON, he said the sandwich was what they had so give it, but it needed to be cut in small pieces. She did so for the other residents on mechanical soft diets. <BR/>During an interview on 04/07/2024 at 1:26 PM, the facility Administrator revealed they had a system for diet cards but in February 2024, the system was no longer available. She stated prior to observations made by the surveyor on 04/06/2024 they had been using diet cards made by the DM, she did not know what happened to those, why they were not used or where they are now. The Administrator stated they should have been on each residents' tray. She stated new cards had been made yesterday for each resident. <BR/>Review of the undated policy, titled Diet Tray Card, revealed that the purpose of the policy was to ensure that resident receives the proper diet as ordered by the physician. The policy notes that a diet identification card will be completed, by the nutrition services manager, for each resident receiving meals by mouth. The procedures include that a new tray card is to be used at each meal. If reusable tray cards are used, they should be sanitized after each meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 elopement.<BR/>Resident #1 walked out of the facility unattended on 03/15/2024 at about 9:00PM until the police found him at about 10:00 PM from a place approximately 1.5 miles away from the facility. EMS organized by the police to take him to the hospital and at the hospital it was confirmed that resident had hairline fracture above the left eye and cheek with lacerations on left eye lid, left wrist, and lower and upper lips, and abrasions on hands. The facility staff was not aware the resident was missing until the family called the facility. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 4:55 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 03/25/24 at 6:00 PM. While the IJ was removed on 03/27/24, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could affect residents by placing them at risk of physical harm, pain and mental anguish, or emotional distress.<BR/>Findings Included:<BR/>Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged on 03/17/2024. His diagnoses included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), Prostatic Hyperplasia (enlarged prostate gland), Hypothyroidism, Hearing Loss-Left ear, and Abnormal Involuntary Movements. <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. <BR/>Record review of Resident #1's Baseline Care Plan dated 03/10/24 reflected Resident #1 had no history of falls and no elopement risk.<BR/>Record review of Resident #1's Elopement Risk Evaluation dated 03/16/24 reflected a score of 14.00 indicating Resident #1 was at imminent risk for elopement. No Elopement Risk Evaluation completed prior to the elopement. <BR/>Record review of the care plan completed after the incident, dated 03/16/24 reflected , Resident #1 was at risk for elopement related to Elopement Evaluation Risk Score. No care plan was completed prior to the elopement incident. <BR/>Record review of the Weekly Skin Check dated 03/16/24 reflected Resident #1 had lacerations on left eye lid, left wrist and lower and upper lips. <BR/>Record review of Trauma Informed assessment dated [DATE] reflected Resident #1 felt scared, helpless, or horrified related to the sudden event of elopement with fall. <BR/>Record review of facility's incident report to HHSC dated 03/18/24 reflected, on 3/15/2024 the ADM was notified by MDS C that on 03/15/24, Resident #1 was being transported to the hospital for further evaluation and treatment related to fall with injury after found him outside the facility at a place half a mile away. The facility came to know about this incident when the FM of Resident #1 notified the facility over the phone at 10:20PM, that the resident was off the property. She also informed the facility that resident was on his way to the hospital. At the hospital it was revealed that Resident #1 had a hairline fracture above the left eye and the left cheek. Resident also had abrasions on his hands. <BR/>Record review of Nurses Progress Notes for Resident #1 by RN B on 03/16/24 at 6:41 AM, reflected Resident arrived from [Hospital] ER. Resident arrived with acute head injury orbital fracture, lip laceration Zygomatic arch fracture. Wander guard was placed on resident right lower leg. Notified doctor of return. Family is aware of return. Resident is comfortable at this time. <BR/>During an interview over the phone on 03/25/24 at 10:30 AM, Resident #1's FM stated she was out of the state when the incident of the elopement occurred. She stated at about 10:00PM the police called and talked to her over the phone and said that they went and picked Resident #1 up from a place approx. 1.5 miles away from the facility. She said the police reported that they responded to a 911 call from a community member who found Resident #1 with injuries braced on his parked car. She said the police organized EMS and transported him to the nearby hospital for further assessment and treatment. The FM stated the facility was unaware of Resident #1's disappearance from the facility until she called and informed the FR at the facility at about 10:20 PM. FM stated, initially when she asked about Resident #1, the FR stated Resident #1 resides at the 2nd floor and she would transfer FM's call to the 2nd floor nursing station so that FM could request the staff to talk to him. <BR/>During an interview over the phone on 03/25/24 at 11:00 AM, FR stated she worked as the receptionist at the facility from 6:00 PM to 10:30 PM, Monday to Friday. She said, on 03/15/24 at about 10:20 PM she received a phone call from Resident #1's FM asking if Resident #1 was there at the facility. FR said, she replied to FM that Resident #1 was living on the 2nd floor, and she would transfer the call to the nursing station at the 2nd floor so that the FM could talk to the staff there. FR said, FM then reported to FR that she was checking if staff was aware of what was going on and then reported that the police had picked up Resident #1 from a place about 1.5 miles away from the facility at about 10:00 PM and admitted to a hospital nearby due to the injuries he had. FR stated she or anyone at the facility was aware until then that Resident #1 was absconded from the facility. FR said at about 10:00 PM LVN A at the 2nd floor enquired her if she saw Resident #1 at the 1st floor as they could not find him at the 2nd floor. FR stated they were under the impression that Resident #1 was wandering around within the facility until they heard about his elopement from the facility from the FM. FR said, on 03/13/24 Resident #1 was persistently requesting to her to let him leave the facility and made unsuccessful efforts to open the coded front door at two different occasions. FR stated this behavior from him was evident since his admission on [DATE] and LVN A from 2nd floor requested her to have a [NAME] on Resident #1. She stated she also had informed LVN A about his attempts for unauthorized exit. FR stated she had a watch on him whenever he was on 1st floor and ensured that he did not exit through the front door on 03/15/24 as she was the only one who allowed the visitors to come and go from the facility. She stated the front door was secured with code numbers and only the staff members knew the code number. FR said she believed Resident #1 might have exited through the emergency fire exit door situated at the back of the facility. FR added, though the back door secured by code numbers, the lock can be override if the handle of the door holds down for some time. The door will be opened with an alarm though the alarm would not be heard at the reception area. <BR/>During an interview on 03/25/24 at 10:00 AM, MDS C stated she worked at the facility in the morning shift until 5PM. She said, on 03/15/24 at about 10:30PM she received a phone call at home from FR stating Resident#1 eloped from the facility and had a fall. FR reported to her that the police found him about 1.5 miles away from the facility with lacerations on his body and admitted him to a nearby hospital for treatment. MDS C stated, as per her understanding the staff at 2nd floor did not find him there at about 9.45PM and then they informed FR to have a watch on him if he appears at the front door. She stated it appeared the staff came to know his exit out of the facility only after the FM passed on that information<BR/>During a telephone interview on 03/25/24 at 10:30, LVN A stated she worked in the afternoon shift on 03/15/24 with the responsibility of the hall where Resident #1 resided. She said on 03/15/24 Resident #1 accepted his night medication at 9:00PM in his room. At about 9:45PM one of the CNAs noticed that Resident #1 was not in his room and his name tag at the door also was missing. LVN A stated she immediately informed FR to check if he was there at the reception area and by that time the information about his elopement was received from the FM of Resident #1. LVN A stated according to her Resident #1 was not an elopement risk as he mostly stayed in his room. When this investigator asked her about an incident of his two unsuccessful attempts to get out of the facility on 03/13/24 in the evening, reported by FR, LVN A stated those were the only attempts she was aware of. <BR/>During a phone interview on 03/25/24 at 3:00PM, RN B stated she was the night nurse at the facility and was not aware of what was going on with Resident #1 until 10:00 PM as she was not in charge of his hall. RN B stated the staff at the facility came to know through the FM about Resident #1's disappearance and subsequent incident of finding him outside the facility. RN B stated Resident #1 arrived back at the facility on 03/16/24 at about 6:00 AM from the hospital. She said she had a nurse-to-nurse communication from the nurse at the hospital. RN B stated, the nurse from the hospital reported Resident #1 had an acute head injury, orbital fracture, lip laceration and Zygomatic Arch (the most lateral projection of the midface) fracture. She stated she had recorded this in the progress note in the electronic medical record. <BR/>During an interview on 03/26/24 at 10:00 AM, LVN C stated she worked at the facility for more than a year and worked the morning shift. She said she did not work on the hall where Resident #1 resided. LVN C stated the nursing stations at the 2nd floor were equipped with alarms and any attempt to open the doors downstairs trigger the alarm. She added, staff immediately go down to ensure no elopement attempt was made by any residents. LVN C stated she did not know what really happened on that day as the incident occurred on the night shift. <BR/>In an interview and observation walk through with the ADM on 03/25/24 at 3:00 PM, she stated Resident #1 must have exited through the emergency fire exit door at the back, adjacent to the kitchen. ADM stated she believed it was not an elopement since the facility was not a locked facility. She added, stopping anyone from leaving the facility, when they wanted to, was a violation of resident rights. The ADM stated Resident #1 had a BIMS score of 13, indicated intact cognition to make independent decisions. The ADM stated there was residents at the facility who regularly go Out-On-Pass to the community and return within the stipulated time (72 hours). When this investigator asked if Resident #1 left the facility as per the policies and procedures for Out-On-Pass, she stated, he was not. The ADM also stated, Resident #1 neither signed any AMA documents nor declined to sign one and exited without the knowledge of any staff members. Observation of the emergency exit door revealed there was an instruction posted on the door explaining how to override the passcode in case of any emergency however an alarm went off when opened without the passcode. The ADM said since the door was away from the reception it was difficult to hear the alarm from the reception area. Observation of the front door revealed, it was secured by number code and the entrance and exit was controlled by the receptionist. There were no other exit doors at the facility.<BR/>During an interview on 03/26/24 at 12:50 PM, the DON stated he started working at the facility about a week ago, after the elopement incident of Resident #1 occurred. He stated he was well informed about the incident. The DON defined an elopement as, a resident leaving the facility without any notice or knowledge of the facility. The DON stated it appeared there was some shortfall in the security measures at the backdoor as it was believed Resident # 1 accessed the back door for his exit on 03/15/24. The DON stated it seemed the elopement risk evaluation and nursing judgement also was not accurate as there was no management plan, like usage of a wander band in place. The DON stated, when an alarm would be heard at nursing stations, the staff was supposed to go down to the 1st floor and make sure the alarm went off not because of any resident's attempt for an unauthorized exit. <BR/>During an interview on 03/26/24 at 1:10 PM, MDS C stated she did not know how Resident #1 got out of the facility. She stated she was the MDS nurse and was helping the administrator within her scope of practice as an LVN, in the absence of a DON at that time. She stated the act of Resident #1 was elopement if he exited the facility without the knowledge of the staff and without completing Out-On-Pass paperwork or without signing an AMA form. <BR/>Review of undated facility policy Elopement Risk Reduction Approaches reflected. <BR/>Planning:<BR/>As necessary, provide new residents (to the facility, wing, unit ,etc.) with additional staff assistance until they are comfortable in their new environment .<BR/> Ensure that residents are able to move freely, are monitored and remain safe .<BR/> .Training:<BR/>Facility staff needs to know:<BR/> . The resident's propensity to wander and the triggering conditions <BR/> The consequences of unsafe wandering, the protocols to follow to minimize successful exiting and the procedures to follow when resident is lost .<BR/>Promote identification of residents who are at risk of elopement. Ensure that photographs of residents who wander are maintained in an accessible but secure location and that receptionist, activities and clinical staff and others in appropriate positions to help are able to recognize at-risk residents and to assist in redirecting them <BR/> .Environment: <BR/> Ensure that staff alert and elopement alarm/warning systems are the least intrusive and burdensome possible <BR/> After conferring with fire and other appropriate officials, minimize the risk of elopement. <BR/>An Immediate Jeopardy was identified on 03/25/24 at 4:55 PM. The IJ Template was provided to the facility ADM on 03/25/24 at 6:00 PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 03/26/24 at 7:01 PM and indicated the following:<BR/>Plan of Removal <BR/>Immediate Jeopardy <BR/>On 03/25/2024 an abbreviated survey was initiated at the facility. On 03/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: <BR/>F689 - The facility failed to provide an environment free of accident hazards to minimize elopement risk. <BR/>Action: Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>Start Date: 3/17/2024. <BR/>Completion Date: 3/17/2024 <BR/>Action: All residents re-evaluated for risk of elopement via assessment on 3/25/2024. No additional residents were identified based on evaluation. Elopement Binder up to date and remains at reception desk. DON ensured all residents who are imminent risk for elopement are donning a wander guard for safety. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: DON or Designee <BR/>Action: Medical Director notified of IJ on 3/25/2024 <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Administrator <BR/>Action: Physician orders related to residents on wander guard placement reviewed and updated for all residents <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible: Medical Director or Designee <BR/>Action: In-services completed with all staff (facility does not use agency, all staff to include PRN staff) related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). As new employees are hired they will be in-serviced on all protocols in hire process. <BR/>Start Date: 3/25/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: In-service completed with all staff (facility does not use agency, all staff to include PRN staff) that if resident has more than one request to leave that elopement/wandering risk assessment completed and wander guard placed if applicable as intervention for safety. Elopement risk reduction approaches policy reviewed with all staff. As new employees are hired they will be in-serviced on protocol in hire process. <BR/>Start Date: 3/26/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: QAPI meeting held related to IJ. Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT, and Medical Director (via phone) present. <BR/>Start Date: 3/26/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible Administrator <BR/>Action: HR and Administrator in-serviced by Regional Clinical Specialist on all in-services, to include Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON, and Elopement risk reduction. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Regional Clinical Specialist<BR/>The surveyor confirmed the facility implemented their plan of removal sufficiently from 03/25/24 through 03/27/24 to remove the IJ by: <BR/>1. Record review of Resident #1's face sheet confirmed Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>2. Record review of an Inservice to all nursing and CNA staff was completed on 03/27/24 by ADM and HR related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). <BR/>HR and Administrator were in-serviced on the above topics by Regional Clinical Specialist <BR/>3. Record review of the medical records of all the resident at the facility revealed all residents re-evaluated for risk of elopement via assessment on 3/25/2024 and ensured all residents who are an imminent or moderate risk for elopement had wander guards for safety. <BR/>4. Record review of the Elopement Binder revealed it was up to date and remains at reception desk. Copies of them were available at Nursing stations. <BR/>5. Record review on 03/27/24 of the medical records of all residents revealed physician orders related to residents on wander guard placement reviewed and no additional residents added to the existing residents with elopement risk.<BR/>6. Record review of the minutes of the QAPI meeting that was conducted for discussing elopement prevention on 03/26/24 revealed that the medical Director attended via Phone and Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT were physically attended the meeting. <BR/>Interviews conducted with RN C on 03/27/24 at 10:15 AM; LVN A on 03/26/24 at 11:00 AM; LVN C on 03/26/24 at 10:00AM. CNA A on 03/27/24 at 11:15AM, revealed nurses was in serviced on 03/27/24. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, taking mid night census, do head count to make sure no resident missing. <BR/>ADM was notified that while the IJ was removed on 03/27/24 at 00:00, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #1, 2 and 3) of 4 residents and 1 of 1 hallway observed for a clean environment. <BR/>1. The facility failed to ensure Resident #1, #2, and #3's bedroom floor was clean. <BR/>2. The facility failed to ensure the hallway floor was clean and had no foul odors. <BR/>This deficient practices could place residents at risk of a decreased quality of life. <BR/>Findings included: <BR/>During an interview on 02/21/24 at 8:40 a.m., the ADM revealed housekeepers followed the deep clean schedule. The ADM explained housekeepers deep cleaned twice a week and spot checked and cleaned residents' rooms and commonly shared areas daily. The ADM also revealed there were two housekeepers for each shift.<BR/>An observation on 02/21/24 at 10:38 a.m. revealed Resident #1's bedroom floor was sticky. <BR/>During an interview on 02/21/24 at 10:47 a.m., Resident #1 revealed she cleaned her own room. Resident #1 explained the floor was sticky because housekeeping did not mop it. <BR/>During an observation and interview on 02/21/24 at 11:14 a.m., Resident #2 revealed housekeeping cleaned his room daily. Resident #2 explained the floor was sticky because housekeeping had not been in his room that morning.<BR/>During an observation and interview on 02/21/24 at 11:31 a.m., Resident #3 and his family revealed the bedroom floor was sticky. Resident #3 and his family explained housekeeping did not thoroughly clean his room. <BR/>During an interview on 02/21/24 at 2:15 p.m., CNA A revealed housekeepers cleaned residents' rooms daily. CNA A also revealed she never received complaints about residents' rooms not being cleaned.<BR/>An observation on 02/21/24 at 2:31 p.m., revealed the hallway floor was sticky and had a urine and feces odor. <BR/>During an interview on 02/21/24 at 2:33 p.m., HK B revealed she worked at the facility for 15 days. HK B explained she cleaned residents' rooms once daily. HK B further explained she did not document residents' rooms she cleaned. HK B revealed she never received complaints about rooms not being cleaned. HK B also revealed she mopped the floor once a day. HK B explained there were housekeepers who worked at night from 1:00 p.m. through 8:00 p.m. HK B revealed there were no housekeepers who worked at night from 8:00 p.m. through 6:00 a.m. HK B did not know who cleaned from 8:00 p.m. through 6:00 a.m. if a resident had a mess.<BR/>During an interview on 02/21/24 at 2:45 p.m., HK C revealed she worked at the facility for one year. HK C explained she cleaned residents' rooms once daily. HK C further explained she did not document residents' rooms she cleaned. HK C explained she was out of the facility for the last three days. HK C explained housekeepers divided the hallway whenever a housekeeper was absent. HK C further explained housekeepers were assigned to designated sections of the hallway. HK C revealed other housekeepers did not clean their hallway sections. HK C revealed she observed hallway sections were not cleaned. HK C explained she informed HS about the housekeepers who did not do their job. HK C explained HS told her that she also observed that. HK C explained she was told to clean other residents' rooms that she was not assigned to because of the housekeepers not doing their responsibilities. HK C explained sometimes residents spilled beverages on the floor. HK C revealed she was assigned to clean the floor on 02/21/24. HK C revealed the person in charge of the floors mopped twice a week. HK C revealed she always received complaints from residents and families about floors being dirty. HK C explained HS was informed multiple times about the dirty floors. HK C revealed there were no housekeepers who worked from 9:00 p.m. through 6:00 a.m., HK C said she did not know who cleaned during that time.<BR/>During an interview on 02/21/24 at 3:16 p.m., HS revealed she worked at the facility for four weeks. HS said she expected housekeepers to mop residents' rooms and bathrooms twice daily. HS explained five deep cleanings were completed daily. HS further explained there was first shift who worked from 7:00 a.m. through 3:00 p.m. and second shift who worked from 1:00 p.m. through 8:00 p.m. HS revealed there was no third shift because residents were sleeping and lying down from 8:00 p.m. through 7:00 a.m. HS also revealed CNAs helped housekeepers if residents' had spills or rooms were dirty from 8:00 p.m. through 7:00 a.m. HS revealed housekeeping closets were fully stocked and CNAs had access to the closets. HS also revealed she had a daily deep clean and weekly checklist she was preparing that had not taken into effect because she was still finalizing the checklists. HS explained housekeepers used the old checklists for the time being while she finalized the new ones. HS revealed she spot checked to make sure housekeepers cleaned residents' rooms and hallways. HS also revealed she had two housekeepers per shift. HS revealed she in-serviced housekeepers on housekeeping duties on 02/21/24. HS also revealed she observed residents' rooms and hallway floors were sticky. HS explained the former HS let housekeepers slack off. <BR/>During an interview on 02/22/24 at 12:06 p.m., the ADM revealed housekeepers did not have a deep clean log or documentation reflecting they completed their duties. The ADM explained housekeepers had designated areas of the building they were responsible for cleaning.<BR/>Record review of the facility's staff schedule, dated 02/16/24, 02/18/24 and 02/19/24, reflected there were two housekeeping staff who worked from 6:06 a.m. through 2:57 p.m. and three housekeeping staff who worked from 12:31 p.m. through 9:01 p.m. There were no housekeepers who worked from 9:01 p.m. through 6:06 a.m.<BR/>Record review of the facility's housekeeping general policy and procedure, revised 08/20, reflected the following,<BR/>Purpose: To ensure that the Facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors.<BR/>Policy: <BR/>I. The Facility maintains an adequate, qualified Housekeeping Staff to ensure that all areas of the Facility and its furnishings are clean and sanitary at all times.<BR/>IV. All rooms of the Facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents.<BR/>Procedure: <BR/>A. The Housekeeping Department is responsible for completing the daily, weekly, and monthly cleaning procedures.<BR/>A. The Housekeeping Supervisor determines the cleaning schedule by completing the Housekeeping Schedule Form.<BR/>C. The Housekeeping Staffs general duties are to:<BR/>i. Sweep and mop, or vacuum, all floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs for 1 of 13 (Resident #81) residents reviewed for call lights on the 2100 hall in that:<BR/>The facility failed to ensure Residents #81's call light was within reach and placed for easy access.<BR/>The deficient practice could place residents at risk of not receiving care or attention needed and risk of falling. <BR/>The Findings Included:<BR/>Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply blood), bilateral occlusion and stenosis of carotid arteries (blockage of arteries that are on both sides of the next that carry blood to the brain), contractures of left shoulder, left wrist and left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).<BR/>Record review of Resident 81's Baseline Care Plan dated 12/22/2023 and locked date of 12/28/2023 revealed under Section 1, B, 1 - 2. Under Communication Resident #81 can communicate easily with staff and understands the staff.<BR/>Record review of Resident #81's admission MDS with an ARD/Target Date of 12/30/2023 revealed Resident #81 had a BIMS score of 14 indicating the resident had intact cognition response (able to make needs known). <BR/>Record review of Resident #81's comprehensive care plan date initiated 12/22/2023 to 01/08/2024 revealed the care plan did not address the resident's issue with the call light.<BR/>Record review of Resident #81's revised comprehensive care plan dated 01/11/2024 revealed a care plan which addressed Resident #81 frequently repositioning his call light with revision on 01/11/2024. <BR/>Record review of Resident 81's consolidated Physician's Orders dated 01/11/2024 and last order review was 12/27/2023 revealed an order dated 12/22/2023 to admit to the facility under the care of a doctor for hospice care. OT (occupational therapy) splint/brace order for resident to wear on his LUE (left upper extremity) a carrot splint daily or as tolerated dated 01/08/2024. <BR/>Observation on 01/09/2024 at 11:47 a.m. in Resident #81's room revealed the resident lying in his bed and his call light was hanging close to the top of his privacy curtain and not within reach. <BR/>Observation on 01/10/2024 at 9:45 am- revealed Resident #81 was lying in his bed with the call light lying on the floor at the floor of Resident #81's bed and not within reach.<BR/>Interview on 01/10/2024 at 9:48 a.m. with CNA F confirming Resident #81's call light was lying on the floor at the foot of Resident #81's bed and was not within reach of the resident. When asked why the call light was on the floor, CNA F stated Resident #81 will mess with the call light. When asked if you know Resident 81 will mess with the call light what should you do? CNA F stated check on him more often.<BR/>Interview on 01/11/2024 at 9:30 a.m. with the DON concerning Resident #81's call light and where it was observed on 01/09/2024 at 11:47 a.m. close to the top of the resident's privacy curtain and not within reach and 01/10/2024 at 9:45 a.m. on the floor at the foot of Resident #81's bed and was not within reach. The DON stated the call light was to be within the resident's reach and if it was not the resident could not get help when he needed it and could also fall. The DON stated it was everyone's responsibility to make sure the resident has the call light within reach.<BR/>Interview on 01/11/2024 at 10:05 a.m. with LVN U, MDS Coordinator, confirmed the call light for Resident #81 was placed on the care plan on 01/11/2024.<BR/>Request was made for a copy of the facility policy and procedure regarding the resident call lights from the Administrator, however the policy was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 1 residents (Resident # 249) reviewed for oxygen in that:<BR/>Resident #249's oxygen tubing were not changed as ordered.<BR/>This deficient practice could affect residents in the facility ordered to receive oxygen therapy as needed and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.<BR/>The findings were:<BR/>Record review of Resident #249 's face sheet, dated 01/12/024, revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to: Malignant Neoplasm of Prostate (cancer or the prostate), chronic pain, major depressive disorder (more often than not persistent feeling of sadness and loss of interest in activities-interferes with daily life), and Dyspnea (shortness of breath, difficult or labored breathing). <BR/>Record review of Resident #249's Order Summary Report dated 01/11/2024 revealed an order to change respiratory tubing mask bottled water clean filter every 7 days on Sunday night shift, change O2 tubing and date every Sunday the order was listed as active, order dates was 12/16/2023 and the start date was 12/17/2023. <BR/>Observation and interview with Resident #249 on 01/09/2024 at 11:31 a.m. said, I have something to talk to you about, my oxygen, I have been here since 12/15/2023 and they have not changed it one time. At the place I came from and when I was at home it was changed once a week, I don't understand why they have not done anything with it here. Resident #249 stated I have asked the nurse but could not remember the nurse's name and said she looked at me like she did not understand me.<BR/>Observation on 01/11/2024 at 2:16 p.m. Resident #249, while lying in bed and utilizing his oxygen cannulas and tubing dated 12/18/2023, said, my oxygen tubing is still dated 12/18/2023, not one has even looked at it still. <BR/>Observation and interview with Resident #249, LVN S and Administrator while in the residents room viewing the oxygen tubing being utilized by Resident #249 was dated 12/18/2023, LVN S said it should be changed every Sunday since the resident has been here and it has not. LVN S did not further comment. After exiting the room an additional interview was attempted with LVN S who shook her head saying it should have been changed and she had been off two days during the most recent time the oxygen should have been changed, LVN S did not comment further or respond to any additional questioning. <BR/>Interview with the DON on 01/12/2024 at 12:04 p.m. revealed the DON reviewed Resident #249's EHR and stated the resident was admitted on [DATE], the oxygen tubing was changed on 12/18/2023 and the resident remained in the facility with no transfers out since his arrival. The DON stated there was no excuse for the oxygen tubing not being changed and that 6 different nurses who had been in Resident #249's room had changed the oxygen tubing as a result all of those nurses were given what was called a first and final warning after it was discovered the oxygen tubing had not been changed as it should have been according to the physician's order. The DON stated I do not feel the oxygen tubing not being changed affected the resident in anyway, it should have been changed due to manufacturer's recommendations, the physician's order and most importantly so the resident gets the oxygen and care needed. <BR/>Interview with the Administrator on 01/12/2024 at 4:45 p.m., the Administrator stated the DON had already commented on the oxygen tubing used by Resident #249 and felt she had addressed the issue as needed at this time. <BR/>The Oxygen Administration Policy provided by the facility Administrator prior to exit revealed the following: <BR/>III. A. All oxygen tubing, humidifiers, masks and cannulas used to deliver oxygen; ii: will be changed weekly and when visibly soiled, or as indicated by state regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure nurse aides can demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 3 residents (#82) in that:<BR/>1. The facility failed to ensure CNA A cleaned Resident #82's penis by changing wet wipes or folding the wet wipe to change surfaces. <BR/>2. The facility failed to ensure CNA T cleaned Resident #82's using 1 wipe and moving the wet wipe back and forth at the coccyx area without changing surfaces.<BR/>These deficient practices affect residents who require peri care and could result in infection.<BR/>The findings included: <BR/>Record review of Resident #82's face sheet dated 01/12/2024 revealed the [AGE] year-old male resident was admitted initially 03/01/2023. Resident #82's diagnoses included unstable angina, pressure ulcer on sacral region, stage 2 (skin is broken, leaves an open wound, or looks like a pus-filled blister), quadriplegia (paralysis of all four limbs), osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), chronic pain syndrome (Conditions that cause widespread and long-lasting pain), hypertension (high blood pressure) (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), atherosclerosis of coronary artery bypass grafts, congestive heart failure (CHF) ( a serious condition in which the heart doesn't pump blood as efficiently as it should).<BR/>Record review of Resident 82's Annual MDS dated [DATE] revealed the resident has a BIMS of 15 indicating intact cognition responses, requires extensive assistance to total dependence 1 to 2 staff and frequently incontinent of bowel and bladder. <BR/>Record review of Resident #82's comprehensive care plan created on 03/21/2023 and revised on 03/21/2023 revealed the care plan for Resident 82's bowel and bladder with incontinence and increased risk for alteration in skin integrity. One of the interventions was to check Resident #82 frequently for incontinence. Wash, rinse and dry perineum (the region of the body between the pubic symphysis (pubic arch) and the coccyx (tail bone), including the perineal body and surrounding structures).<BR/>Observation on 01/11/2024 at 11:27 a.m. of CNA A and CNA T performed incontinent/peri care for Resident #82 revealing CNA A wiped the shaft of the penis, using 1 wipe and moving from under the head of the penis to the pubic arch back and forth without changing the surfaces or using another wet wipe after each stroke. After Resident #82 was turned to his left side, CNA T began to clean Resident #82 from the rectal area up to the coccyx tossing the wipe after each stroke. The third time CNA T wiped Resident #82 she began at the rectal area, moved up to the coccyx and began to wipe back and forth without changing the surface of the wet wipe. <BR/>Interview on 01/11/2024 at 11:42 a.m. with CNA A, revealed she never changed her gloves or sanitized her hands during or after the incontinent/peri care procedure and while assisting CNA T with repositioning, placing the brief, pull up sheet under Resident #82's, pulling his gown down, pulling the resident up in bed, placing the call light and bed control within reach of Resident #82. CNA A stated she was not aware she had done anything wrong during the incontinent/peri care procedure.<BR/>Interview on 01/11/2024 at 11:42 a.m. with CNA T revealed she had not used hand sanitizer between glove changes or changed gloves after the procedure and while assisting CNA A with repositioning, placing the brief and pull up sheet under Resident #82, also pulling his gown down, pulling the resident up in bed, placing the call light and bed controls within reach of Resident #82. CNA T stated she changed her gloves but, had not used hand sanitizer between glove changes and CNA T was not aware she had wiped back and forth with a wet wipe without changing surfaces during the incontinent/peri care procedure.<BR/>Interview on 01/11/2024 at 11:45 a.m. with CNA A and CNA T when asked what they should do now. CNA A stated I need to go back and go over the procedure manual (facility CNA Manual). CNA T did not comment. When asked about the sanitizing of their hands, CNA T stated we can get the hand sanitizer off the nurse's cart or from the wall dispenser outside the door. CNA T also said she usually went and washed her hands.<BR/>Interview on 01/11/2024 at 11:45 a.m. with CNA A and CNA T together when asked what can happen by not properly providing incontinent/peri care both stated there was an infection control problem and Resident #82 could develop a UTI (urinary tract infection).<BR/>Interview on 01/11/2024 at 12:00 p.m. with the DON stopping this surveyor and asking how the peri care went. This surveyor expressed concerns with handwashing, sanitizing, donning gloves, procedure for incontinent/peri care and availability of hand sanitizer. DON stated they have hand sanitizer they can carry in their pockets. The DON stated CNA A was a newbie (new person just hired). The DON requested to have the incontinent/peri care completed again. <BR/>Review of CNA A and CNA T's Competency for providing incontinent/peri care, hand washing/sanitizing their hands and donning gloves revealed CNA A was hired on 01/03/2024 and had not been given a competency evaluation for handwashing and incontinent/peri care. CNA T'S date of hire was 06/2023 and had a competency evaluation for incontinent/peri care on 09/14/2023 which used the facility Policy and Procedure Perineal Care (incontinent/pericare) revision 06/2020 as the guideline for the competency evaluation for incontinent/peri care. <BR/>Review of the facility Policy and Procedure, Perineal Care (incontinent/peri care), revision date 06/2020 stated in part, Purpose- to maintain cleanliness of the genital area, to reduce odor and prevent infection or skin breakdown. Policy- Perineal care is provided as part of resident's hygienic program XII. Note: Do not touch anything with soiled gloves after the procedure (i.e. curtain, siderails, clean linen, call bell, etc.) NOTE: The facility policy says to wash hands, put on gloves and provide the complete procedure to include turning, removing wet linen, placing dry linens or brief or both under the resident and reposition the resident BEFORE removing the gloves and replacing them and no mention of washing hands or sanitizing hands prior to adding a new pair of gloves.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: <BR/>1. A metal pan covered with white wax style paper covering approximately 6 chicken breasts was placed on a shelf in the bottom of the walk-in cooler, the chicken was removed from the manufacturer's box and was not completely covered or in an enclosed container. <BR/>2. Six loaves of raisin bread with no dates or labeling of any type on the individual loaves and when the raisin bread was removed from the original manufacturer's box, placed on a metal tray with the date it was taken out of the freezer by the Food Service Supervisor.<BR/>These failures could place residents at risk for food-born illness, and food contamination. <BR/>Findings included:<BR/>Observation on 05/09/2023 at 8:45 a.m. in the dry storage room revealed: <BR/>1. Approximately 6 partially chicken breasts in a metal pan partially covered, allowing air to reach the chicken breasts. <BR/>2. Six loaves of raisin bread with no manufacture's dates of any type found on the loaves.<BR/>Interview with the Food Services Supervisor on 01/09/2024 at 10:40 a.m. following the initial tour of the walk-in cooler, the Food Services Supervisor replied when the chicken is covered with the paper it is okay, that is the way we do it. She did not further reply about any questions related to the chicken. When asked about the dates of the raisin bread and how she knew if the bread was fresh, she said we take it out of the box frozen and put a date on the tray. She was unable to provide any other information regarding the bread or locate any type of date on any of the 6 loaves of bread and said that is how we do it here, we throw away the box it comes in. <BR/>Interview on 01/11/2024 at 3:00 p.m., the Dietician stated all items should be stored according to the facility policy and that the Food Services Supervisor had not told her about the observation of the chicken covered by the white wax style paper in the walk-in cooler. The Dietician stated raw chicken should be completely covered when stored in the cooler, it does not sound like it was and said she would talk to the Food Service Supervisor about that to ensure chicken was stored properly. The Dietician stated the observed raisin bread was removed from the manufacturer's box and a label was placed on the metal tray that reflected when the bread was removed from the freezer, however there was no other type of date on the bread. The Dietician stated she did not feel either affected the residents in anyway. <BR/>Review of the facility policy titled Food Storage, Revised 11/2023, revealed the following: II. Frozen Meat/Poultry and Food Guidelines, D. Thawing: Thaw food at 41 degrees or below in a covered container in a refrigerator. <BR/>. <BR/>Record Review Revealed The U.S. Public Health Service, Food Code, dated 2017 revealed the following regarding marking the date of food when prepared and when the original container was opened: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking<BR/>(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: <BR/>(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; <BR/>(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 1 resident (Resident # 7) reviewed for hospice services in that: <BR/>The facility failed to maintain required hospice forms and documentation to ensure residents received adequate end-of-life care. <BR/>This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings were: <BR/>Review of Resident #7's face sheet dated 01/22/2024 revealed a [AGE] year-old resident originally admitted on [DATE] and initially admitted on [DATE] with diagnoses that included but not limited to dementia(progressive persistent loss of intellectual functioning. thinking, remembering, and reasoning); major depressive disorder ( persistent feelings of sadness or loss of interest in activities in general and daily activities) , need for assistance with personal care, obesity (overweight) , chronic kidney disease , spinal stenosis (spinal narrowing) and reduced mobility. <BR/>Review of Resident #7's Order Summary Report dated 01/11/2023, revealed the following order, admit routine home care with hospice. <BR/>Interview on 01/12/2024 at 12:30 p.m. revealed Resident #7 was currently receiving Hospice services at the facility. The DON did not know whose responsibility it was to ensure Hospice documentation or forms was completed at this time. The DON stated she was not familiar with hospice forms and had not been asked to participate in the completion of any of the hospice form completion process. The DON further stated in looking at form # 3074, the form provided directions and appeared to be lacking the signature of the hospice physician and attending physician for the forms in Resident #7's chart. The DON stated she was not aware of the reasons form #3074 should be completed and stated she did not believe the form being incomplete in any way affected the care Resident #7 received. <BR/>Interview on 01/12/2024 at 3:14 p.m. with the Medical Records Clerk, the medical records stated the previous social worker ensured the forms for any resident at the facility receiving hospice services were completed and that social worker had been gone approximately two weeks to a month and went on to say the new social worker just started about a week ago she thought. The medical records clerk said she did not know hospice forms needed to be completed and placed in the chart but would be checking into what needed to be done if anything by medical records to make sure it was taken care of for the residents if she was supposed to be doing that. <BR/>Interview on 1/12/2024 at 4:32 p.m. with the Administrator, the Administrator stated the hospice binders for the most part are handled by the hospice companies and they usually get our physician and their physician to sign and forms necessary, however there seems to have been a breakdown in the system with Resident #7's forms getting signed by either. The previous social worker was helping with that process but she was no longer employed by the facility, but I don't know if that had anything to do with the forms not being signed and in Resident #7's binder. The forms should have been signed by both physicians as indicated by the directions on the form and neither were completed, however I do not believe the forms not being signed affected Resident #7 in any way. <BR/>The Policy, End of Life Care, Revised 8/2020 was provided by the Administrator prior to exit from the facility. Section IV of the policy titled Coordination with Hospice section (B). Social Services staff will coordinate with Hospice Staff to ensure that the resident's needs are communicated to Hospice and section (C). Social Services staff may include the Hospice Team in the resident's IDT conference but makes no mention of any hospice forms.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 3 staff (CNA A, CNA T and LVN S) reviewed for infection control, in that:<BR/>1. CNA A, while providing peri-care to a male resident, did not change her gloves during the whole procedure.<BR/>2. CNA T, while providing peri-care to a male resident, did not sanitize her hands between glove changes.<BR/>3. LVN S, while looking at a catheter bag that was hanging from the bed side bottom bed frame and partially touching the floor, did not use gloves while handling the catheter bag and touched the tubing on Resident #7's bed without practicing hand hygiene. <BR/>These deficient practices could place residents at-risk for infections. <BR/>The findings included: <BR/>1. and 2. During an observation on 01/11/2024 at 11:27 a.m. with CNA A and CNA T providing incontinent/peri care to Resident #82. CNA T asked CNA A if she felt comfortable providing incontinent/peri care and CNA A stated Yes. This surveyor asked CNA A again if she felt she could provide incontinent/peri care to Resident #82 and she again stated Yes. CNA A and CNA T both provided the incontinent/peri care. After CNA A completed incontinent/peri care on Resident #82 in the front, CNA A kept her gloves on. CNA T continued to provide incontinent/peri care to the back side of Resident #82. During the procedure CNA T removed her gloves and without washing or sanitizing her hands donned another pair of clean gloves and folded the soiled brief and soiled wet wipes, and CNA A picked up the trash can and leaned over Resident #82 and CNA T tossed the soiled brief and soiled wet wipes into the trash can. CNA T, keeping the same pair of soiled gloves on, picked up the clean pull up sheet and placed it under the left side of the resident along with the clean brief. CNA T turned Resident #82 over to his back and then to his right side with CNA A's help. CNA A, wearing the same soiled gloves used to clean Resident #82 in the front, pulled the rest of the pull sheet and brief out from under the resident while CNA T held him. After turning the resident to his back, CNA A & CNA T, wearing the same soiled gloves, completed placing the brief on the Resident #82 and pulled down his gown, pulled up the top covers and placed his call light and bed controls within reach of the resident. CNA T then removed her soiled gloves. CNA A continued to wear the same soiled gloves she started out with at the beginning of the incontinent/peri care procedure.<BR/>During an interview on 01/11/2024 at 11:40 a.m. with CNA A, she was asked if she ever removed, sanitized and donned another pair of gloves during the incontinent/peri care procedure? CNA A confirmed she had not changed her gloves or sanitized her hands.<BR/>During an interview on 01/11/2024 at 11:42 a.m. with CNA A and CNA T, both confirmed they never used hand sanitizer or washed their hands while providing incontinent/peri care to Resident #82. When asked what can happen because of not changing gloves, sanitizing their hands and not providing peri care properly? Both stated infection control and Resident #82 could develop a UTI. When asked CNA A and CNA T what should they do now? CNA A stated I need to go back and go over the procedure again in the manual (facility nurse aide manual). CNA T did not say anything. When asked about the sanitizing of their hands CNA T stated we can get the sanitizer off the nurses cart or from the wall dispenser outside. CNA T stated she usually went and washed her hands. <BR/>On 01/11/2024 at 12:00 p.m. As this surveyor was walking down the hall, the DON stopped this surveyor and asked how the peri care went and this surveyor expressed her concerns with handwashing, sanitizing, donning gloves, procedure for incontinent/peri care and availability of hand sanitizer. DON stated they have hand sanitizer they can carry in their pockets. The DON stated CNA A was a newbie (new person just hired).<BR/>On 01/11/2024 at 12:05 p.m. this surveyor went with the DON to Central supply to see where the hand sanitizer was stored. The DON called CNA I who does Central Supply and Transportation to find the hand sanitizer in Central Supply. The DON stated it looks like we are going to have to do some more training. CNA I finally came into Central Supply carrying a bag with small bottles of hand sanitizer. DON asked CNA I where the small bottles of hand sanitizer was that are bigger than the tiny bottles and CNA I stated, we do not have those. The DON left to go check on another hall for the hand sanitizer. <BR/>On 01/11/2024 at 12:15 p.m. this surveyor continued to interview CNA I. when asked by the surveyor when do you know when to order hand sanitizer? CNA I stated when the nurse comes into the Central Supply room and writes on my Communication board, then I will order. <BR/>Review of CNA A and CNA T's Competency for hand washing/sanitizing their hands and donning gloves revealed CNA A was hired on 01/03/2024 and had not been given a competency evaluation for handwashing and incontinent/peri care but, had been a CNA before being hired. CNA T's date of hire was 06/20/2023 and had a competency evaluation for incontinent/peri care on 09/14/2023 which used the facility Policy and Procedure revision 06/2020 as the guideline for the competency evaluation. <BR/>3. During an observation and interview on 01/11/2024 at 1:25 p.m., LVN S looked at Resident #7's catheter bag that was touching the floor and repositioned it without utilizing any gloves and then touched the tubing that was lying on the bed beside the resident. LVN S said it was okay that the catheter bag was touching the floor because it was just the front cover part of the bag when asked by the Resident's daughter that was in the room, she then proceeded to touch the tubing. When this surveyor left the room after the observation and attempted to ask LVN S if she could talk about the catheter she walked off and said she had been off for 10 days, she did not comment further. <BR/>On 01/12/2024 at 11:45 p.m. with the DON, the DON stated no part of the catheter bag should be touching the floor and LVN S should have practiced proper hand hygiene and infection control while touching any part of the catheter. Our Catheter bags have a dignity cover that is permanently attached to them so it is actually one bag, we have a separate bag that should also be used to cover both portions of the bag and to ensure it is kept off of the floor. LVN S should have practiced proper hand hygiene and the catheter bag should not have been on the floor in anyway, no part of it should have been touching the floor. Those types of issues create the potential for infection control problems, I don't think it created an problems for the Resident but it did create potential and that should have never been an issue. <BR/>Review of the facility Policy and Procedure, Perineal Care (peri care/incontinent care), revision date 06/2020 stated in part, Purpose- to maintain cleanliness of the genital area, to reduce odor and prevent infection or skin breakdown. Policy- Perineal care is provided as part of resident's hygienic program XII. Note: Do not touch anything with soiled gloves after the procedure (i.e. curtain, siderails, clean linen, call bell, etc.) NOTE: The facility policy says to wash hands, put on gloves and provide the complete procedure to include turning, removing wet linen, placing dry linens or brief or both under the resident and reposition the resident BEFORE removing the gloves and replacing them and no mention of washing hands or sanitizing hands prior to adding a new pair of gloves.<BR/>Review of the facility Policy and Procedure for their Infection Prevention and Control Program with revision date 06/2020 revealed the following in part: Purpose- To ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements vi. Develop infection orientation and in-service training programs for all levels of Facility Staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (Resident #1 and Resident #2) of three residents reviewed for colostomies, in that: <BR/>The facility failed to:<BR/>- <BR/>Ensure Resident #1 and Resident #2's colostomy pouches were emptied in a timely manner.<BR/>- <BR/>Ensure Resident #2 had orders for an ostomy or for ostomy treatment/care to be provided.<BR/>These failures placed residents with an ostomy at risk of in delay in treatment/care, infection, or a decrease of self-esteem.<BR/>Findings included:<BR/>Record review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including perforation of intestine (ruptured bowel), gastritis (a group of conditions that cause inflammation of the stomach lining), and personal history of other diseases of the digestive system.<BR/>Record review of Resident #1's quarterly care plan, revised 12/12/22, reflected she had an alteration of elimination of bowel requiring a colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) with interventions of emptying and rinsing the ostomy pouch as MD order and PRN.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 12/18/22, reflected a BIMS of 15, indicating no cognitive impairment. Section G (Functional Status) reflected she required one person physical assistance with ADL's. Section H (Bladder and Bowel) reflected the presence of an ostomy . <BR/>Review of Resident #1's physician order, dated 11/17/21, reflected an order for providing ostomy care every shift and PRN for infection control. <BR/>Review of Resident #1's TAR, from 01/01/23 - 01/29/23, reflected documentation that colostomy care had not been provided for eight shifts (out of 87 shifts).<BR/>During an observation and interview on 01/30/23 at 9:30 AM, Resident #1 was lying in bed reading a book. She removed her blanket revealing her colostomy pouch that was full to the edges and emitted a strong feces odor. She stated the staff did not empty it regularly and she had to fight with them to get them to do so. She stated, It hurts! It always hurts when it is full. She stated she felt gross and humiliated because she stunk (pinching her nose and shaking her head) and hated thinking about it. She stated it had not been emptied since the day before (01/29/23) sometime in the afternoon. <BR/>During a telephone interview on 01/30/23 at 9:52 AM with Resident #1's FM, he stated the colostomy pouch issue had been an issue since she was admitted . He stated he felt like the staff thought they should not empty it until it over-flowed or ruptured. He stated he visited Resident #1 the day before (01/29/23) and the pouch was full to the edges. He stated Resident #1 told him it had not been emptied since the night before (01/28/23). He stated it was gross and not right and he hated thinking about her having to lay there with her feces on her stomach. He stated he would constantly beg for assistance from the staff but felt like it made it worse, as in, they would retaliate and wait even longer to empty it. He stated he had spoken to the ADM several times, but nothing had changed.<BR/>Observation on 01/30/23 at 10:36 AM revealed Resident #1's colostomy pouch had not been cared for.<BR/>Observation on 01/30/23 at 11:59 AM revealed Resident #1's colostomy pouch had not been cared for.<BR/>During an interview on 01/30/23 at 12:02 PM with CNA A, she stated she worked on Resident #1's hall. She stated she had not been educated on care and/or emptying colostomy pouches. <BR/>She stated she thought the nurses were responsible for emptying them. She stated she had not told the nurse about Resident #1's pouch being full because she figured she (nurse) would notice when she conducted her rounds. <BR/>Review of Resident #2's undated face sheet reflected a [AGE] year-old make who was admitted to the facility on [DATE] with diagnoses including diverticulitis (inflammation or infection of the pouches formed in the colon) of large intestine and severe protein-calorie malnutrition. <BR/>Review of Resident #2's quarterly MDS assessment, dated 12/09/22, indicating no cognitive impairment. Section G (Functional Status) reflected he required one person physical assistance with ADL's. Section H (Bladder and Bowel) reflected the presence of an ostomy. <BR/>Review of Resident #2's quarterly care plan, revised 12/09/22, reflected he had a colostomy due to removal of perforated large intestine with an intervention of emptying or changing out ostomy pouch PRN.<BR/>Review of Resident #2's physician orders reflected there were no orders for an ostomy or for ostomy treatment/care to be provided.<BR/>During an observation and interview on 01/30/23 at 11:42 AM with Resident #2, he was in his room listening to music. He pulled up his shirt, exposing his colostomy pouch. The pouch was &frac34; full, with no drainage noted. He stated he emptied his own pouch himself when he felt like it needed to be emptied. He stated if he were to wait on the staff to do it, it would only be emptied twice a week. <BR/>During an interview on 01/30/23 at 11:50 AM with LVN B, she stated colostomy pouches should be emptied when they were full, PRN, or when a resident requested it. She stated a negative outcome of them not being emptied timely, could be the pouches could burst which could cause contamination and infection control issues. She stated Resident #2 preferred to empty his own pouch and did not want staff to assist him. She was unaware if Resident #2 had ever had formal training or education regarding colostomy care. She stated she had not been notified by an aide that Resident #1's pouch was full. <BR/>During an interview on 01/30/23 at 12:10 PM with ADON C, he stated colostomy pouches should be emptied PRN, when they were full, or ideally, whenever they contained any fecal matter. He stated a negative outcome of not emptying them timely could be impaction or skin breakdown. <BR/>He stated it was the responsibility of the nurses to ensure this was being done as needed. <BR/>During an interview on 01/30/23 at 12:54 PM with the DON, she stated her expectations were that colostomy pouches be emptied according to state standards - as ordered, PRN, or when &frac34; full. She stated if this was not being done in a timely manner, she would see it as a resident neglect issue. She stated it was the responsibility of the aides to notify the nurses when the pouches needed to be emptied. The DON stated it was the charge nurse's (and ultimately herself) responsibility to ensure this was being done. She stated she had only been employed at the facility a few weeks and was unaware Resident #2 was tending to his own pouch without staff assistance. She stated she was not aware if he had been formally educated on the process. She stated she had noticed earlier in the day that Resident #2 did not have orders for an ostomy or for ostomy treatment/care to be provided, and they had since been entered into his EMR. She stated she was not sure if the aides had any specific training on ostomy care.<BR/>Review of grievance forms, from 10/01/22 - 01/30/23, reflected no documented grievances regarding the lack of ostomy care. <BR/>Review of in-services conducted, from 10/01/22 - 01/30/23, reflected no education was provided regarding ostomy care.<BR/>Review of the facility's Colostomy and Ileostomy Care policy, revised 06/2020, reflected the following:<BR/>Purpose: To maintain resident hygiene, control odor, prevent skin irritation or breakdown, and provide supportive care to the resident.<BR/>Policy: Colostomy and ileostomy care is provided for all residents requiring ostomy care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all residents had the right to request, refuse, and/or discontinue treatment to participate in or refuse to participate in experimental research, and to formulate an advance directive for 5 of 30 residents (Residents #22, #81, #235, and #40) reviewed for advanced directives. <BR/>1. <BR/>The facility failed to ensure Resident # 22's admission face sheet included an accurate advanced directive, as it listed both Full Code and a DNR (Do Not Resuscitate) on file. Resident # 22's care plan included documentation of the DNR on file.<BR/>2. <BR/>The facility failed to ensure Resident # 81 had documentation on file in their records concerning their wishes on their advance directive status.<BR/>3. <BR/>The facility failed to ensure Resident # 235 had documentation of their advanced directive on the admission face sheet, although the care plan included documentation wishing to be a Full Code. No Full Code documentation in Resident # 235 records.<BR/>4. <BR/>The facility failed to ensure Resident #40 had an advanced directive documented on his summary report<BR/>These failures could place residents at risk for not having their end of life wishes honored and incomplete records.<BR/>Findings include:<BR/>1. Record review of Resident #22 admission face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses which included metabolic encephalopathy (brain dysfunction caused by imbalances in the body's chemical processes and systemic illness), acute kidney failure, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), repeated falls, cognitive communication deficit (difficulties in communicating), depression, anxiety disorder, muscle wasting and atrophy, asthma and polyneuropathy. Resident #22 listed as a Full Code under Advance Directives.<BR/>Record review of Resident #22 Comprehensive MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. Section GG functional abilities reflected mobility device of wheelchair, independent for eating, partial to moderate assist for (toileting, dressing, putting on/taking off footwear, and transfers), maximum assist for bathing.<BR/>Record review of Resident #22 care plan, dated [DATE], reflected the resident had a DNR on file. Resident # 22 has an ADL self-care performance deficit related to hemiplegia, limited mobility, and musculoskeletal impairment with interventions of limited assistance with toileting, dressing, and transfers. Extensive assistance required with bathing and extensive assistive device usage with transfers.<BR/>Record review of Resident #22 OOHR-DNR order, dated [DATE], reflected document was complete with signatures of Resident # 22, physician and witnesses.<BR/>2. Record review of Resident #81's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81 had diagnoses which included Cerebral Infarction (an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain), Hyperlipidemia (imbalance of cholesterol in your blood), Hypertensive Heart Disease (conditions caused by high blood pressure), Angina Pectoris (chest pain caused by reduced blood flow to the heart), Myalgia (pain in a muscle or group of muscles), Acute Kidney Failure (illness, infection, or injury damages the kidneys), and Cognitive Communication Deficit (brain injuries that affects a person's ability to communicate effectively).<BR/>Record review of Resident #81's Minimum Data Set Assessment, dated on [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Minimum Data Set Assessment didn't reflect any Full Code or Do Not Resuscitate information.<BR/>Record review of Resident #81's Care Plan, last revised on [DATE], reflected a focus on Resident #81 having Cognitive Communication Deficit, Hypertensive Heart Disease, Angina Pectoris, and Acute Kidney Failure in which there was no form of documentation found reflecting appropriate advanced directive actions for Full Code and or Do Not Resuscitate protocols. <BR/>Record review on of care plan, admission, and Point Click Care documentation for Resident #81 didn't reflect having any documentation for advance directives.<BR/>3. Record review of Resident #235 admission face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 235 had diagnoses which included rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), tremors (a rhythmic involuntary movement of a body part), atrial fibrillation (irregular heart rate), autistic disorder (a lifelong developmental disability that affects how a person communicates, interacts with others, learns, and behaves), obsessive compulsive disorder (excessive thoughts that lead to repetitive behaviors), cerebral palsy (a congenital disorder of movement, muscle tone, or posture), anxiety disorder (persistent and excessive worry that interferes with daily activities) and lack of normal physiological development in childhood. No advance directive documentation was recorded on the admission face sheet.<BR/>Record review of Resident #235 admission MDS, dated [DATE], did not reflect a BIMS score or functional abilities recorded. The Comprehensive MDS was in progress at time of the review.<BR/>Record review of Resident #235 care plan, dated [DATE], reflected Resident #235 was a Full Code status. <BR/> 4. Record review of Resident #40's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), need for assistance with personal care, dementia, acquired absence of right leg below knee, acquired absence of left leg above knee, aphasia (a disorder that affects how you communicate), diabetes mellitus type 2 (a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure), and gastrostomy status (an enteral feeding tube). Resident #40's face sheet did not indicate any Advanced Directives. <BR/>Record review of Resident #40 's Quarterly MDS assessment, dated [DATE], did not reflect a BIMS score. Resident #40 required substantial/maximal assistance for all activities of daily living. <BR/>Record review of Resident #40's Care Plan, dated [DATE], reflected Resident #40 had a Full Code CPR order in place with initial date of [DATE]. The goal was the request for CPR to be initiated would be followed. Interventions included review of Resident #40's medical record to ensure proper documents were signed, consult with nursing staff on changes in health, and counsel with the resident and family regarding any emotional concern arising from the decision. <BR/>Record review of Resident #40's Order Summary Report, dated [DATE], reflected he had an order for Full code may use AED, dated [DATE]. <BR/>In an interview on [DATE] at 3:24 PM with the Social Worker stated the facility is in charge of putting in Full Code and Do Not Resuscitate information into the care plan, but there wasn't a designated person in charge of handling Full Code and Do Not Resuscitate information. The Social Worker stated this information was usually already filled out before they saw the resident. The Do Not Resuscitate or Full Code request was not on the medical face sheet of each client, which meant it's more than likely not within the system electronically and believed this was something entered by the nursing department or a doctor. The Social Worker provided Determination of Life Prolonging Procedures form for Resident #81 in which it didn't specify the information needed as well as it was, dated on [DATE], after the Department discovered it wasn't inputted or documented into the facility's Point Click Care sections for residents for Do Not Resuscitate in which it was not located in the residents face sheet, care plan, or anywhere else. Its important to know what actions need to take place to follow the advance directives. <BR/>In an interview on [DATE] at 2:35 PM with the ADON, she stated the facility had a hard copy of Do Not Resuscitate and it's supposed to be in the resident's care plans. Everything would be in the care plans. She stated the social worker, and the nurses were to check for a Do Not Resuscitate if it's been scanned in. If they didn't have it, they're full code until they could physically see or scan it in. She met the family and asked them what they wanted as well. There's no system in place and couldn't provide a reason for as to why nor who is in charge. At the nurse's station they had a book that had their Do Not Resuscitate status book and were at both nurse's station. She stated it's important to have Do Not Resuscitate or Full Code in resident's charts. It's important because potentially there could be an issue if it's not in the chart for Do Not Resuscitate.<BR/>Record review of the facility's Advance Directives policy, revised 08/2020, reflected: <BR/>Advance Directives Operational Manual - Social Services<BR/>I. At the time of admission, admission Staff or designee will inquire about the existence of an Advance Directive. The admission Staff will inform and provide written information to all adult residents concerning the right to accept or refuse medical treatment.<BR/>II. The Facility will honor resident's Advance Directives and will provide the resident with;-<BR/>information related to Advance Directives upon admission<BR/>III. If no Advance Directive exists, the Facility provides the resident with an opportunity to complete the Advance Directive Form upon resident request.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #1, 2 and 3) of 4 residents and 1 of 1 hallway observed for a clean environment. <BR/>1. The facility failed to ensure Resident #1, #2, and #3's bedroom floor was clean. <BR/>2. The facility failed to ensure the hallway floor was clean and had no foul odors. <BR/>This deficient practices could place residents at risk of a decreased quality of life. <BR/>Findings included: <BR/>During an interview on 02/21/24 at 8:40 a.m., the ADM revealed housekeepers followed the deep clean schedule. The ADM explained housekeepers deep cleaned twice a week and spot checked and cleaned residents' rooms and commonly shared areas daily. The ADM also revealed there were two housekeepers for each shift.<BR/>An observation on 02/21/24 at 10:38 a.m. revealed Resident #1's bedroom floor was sticky. <BR/>During an interview on 02/21/24 at 10:47 a.m., Resident #1 revealed she cleaned her own room. Resident #1 explained the floor was sticky because housekeeping did not mop it. <BR/>During an observation and interview on 02/21/24 at 11:14 a.m., Resident #2 revealed housekeeping cleaned his room daily. Resident #2 explained the floor was sticky because housekeeping had not been in his room that morning.<BR/>During an observation and interview on 02/21/24 at 11:31 a.m., Resident #3 and his family revealed the bedroom floor was sticky. Resident #3 and his family explained housekeeping did not thoroughly clean his room. <BR/>During an interview on 02/21/24 at 2:15 p.m., CNA A revealed housekeepers cleaned residents' rooms daily. CNA A also revealed she never received complaints about residents' rooms not being cleaned.<BR/>An observation on 02/21/24 at 2:31 p.m., revealed the hallway floor was sticky and had a urine and feces odor. <BR/>During an interview on 02/21/24 at 2:33 p.m., HK B revealed she worked at the facility for 15 days. HK B explained she cleaned residents' rooms once daily. HK B further explained she did not document residents' rooms she cleaned. HK B revealed she never received complaints about rooms not being cleaned. HK B also revealed she mopped the floor once a day. HK B explained there were housekeepers who worked at night from 1:00 p.m. through 8:00 p.m. HK B revealed there were no housekeepers who worked at night from 8:00 p.m. through 6:00 a.m. HK B did not know who cleaned from 8:00 p.m. through 6:00 a.m. if a resident had a mess.<BR/>During an interview on 02/21/24 at 2:45 p.m., HK C revealed she worked at the facility for one year. HK C explained she cleaned residents' rooms once daily. HK C further explained she did not document residents' rooms she cleaned. HK C explained she was out of the facility for the last three days. HK C explained housekeepers divided the hallway whenever a housekeeper was absent. HK C further explained housekeepers were assigned to designated sections of the hallway. HK C revealed other housekeepers did not clean their hallway sections. HK C revealed she observed hallway sections were not cleaned. HK C explained she informed HS about the housekeepers who did not do their job. HK C explained HS told her that she also observed that. HK C explained she was told to clean other residents' rooms that she was not assigned to because of the housekeepers not doing their responsibilities. HK C explained sometimes residents spilled beverages on the floor. HK C revealed she was assigned to clean the floor on 02/21/24. HK C revealed the person in charge of the floors mopped twice a week. HK C revealed she always received complaints from residents and families about floors being dirty. HK C explained HS was informed multiple times about the dirty floors. HK C revealed there were no housekeepers who worked from 9:00 p.m. through 6:00 a.m., HK C said she did not know who cleaned during that time.<BR/>During an interview on 02/21/24 at 3:16 p.m., HS revealed she worked at the facility for four weeks. HS said she expected housekeepers to mop residents' rooms and bathrooms twice daily. HS explained five deep cleanings were completed daily. HS further explained there was first shift who worked from 7:00 a.m. through 3:00 p.m. and second shift who worked from 1:00 p.m. through 8:00 p.m. HS revealed there was no third shift because residents were sleeping and lying down from 8:00 p.m. through 7:00 a.m. HS also revealed CNAs helped housekeepers if residents' had spills or rooms were dirty from 8:00 p.m. through 7:00 a.m. HS revealed housekeeping closets were fully stocked and CNAs had access to the closets. HS also revealed she had a daily deep clean and weekly checklist she was preparing that had not taken into effect because she was still finalizing the checklists. HS explained housekeepers used the old checklists for the time being while she finalized the new ones. HS revealed she spot checked to make sure housekeepers cleaned residents' rooms and hallways. HS also revealed she had two housekeepers per shift. HS revealed she in-serviced housekeepers on housekeeping duties on 02/21/24. HS also revealed she observed residents' rooms and hallway floors were sticky. HS explained the former HS let housekeepers slack off. <BR/>During an interview on 02/22/24 at 12:06 p.m., the ADM revealed housekeepers did not have a deep clean log or documentation reflecting they completed their duties. The ADM explained housekeepers had designated areas of the building they were responsible for cleaning.<BR/>Record review of the facility's staff schedule, dated 02/16/24, 02/18/24 and 02/19/24, reflected there were two housekeeping staff who worked from 6:06 a.m. through 2:57 p.m. and three housekeeping staff who worked from 12:31 p.m. through 9:01 p.m. There were no housekeepers who worked from 9:01 p.m. through 6:06 a.m.<BR/>Record review of the facility's housekeeping general policy and procedure, revised 08/20, reflected the following,<BR/>Purpose: To ensure that the Facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors.<BR/>Policy: <BR/>I. The Facility maintains an adequate, qualified Housekeeping Staff to ensure that all areas of the Facility and its furnishings are clean and sanitary at all times.<BR/>IV. All rooms of the Facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents.<BR/>Procedure: <BR/>A. The Housekeeping Department is responsible for completing the daily, weekly, and monthly cleaning procedures.<BR/>A. The Housekeeping Supervisor determines the cleaning schedule by completing the Housekeeping Schedule Form.<BR/>C. The Housekeeping Staffs general duties are to:<BR/>i. Sweep and mop, or vacuum, all floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #81) reviewed for comprehensive care plans in that:<BR/>Resident #81's comprehensive care plan did not address the resident's Hospice services. <BR/>This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.<BR/>The findings included:<BR/>Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply blood), bilateral occlusion and stenosis of carotid arteries (blockage of arteries that are on both sides of the next that carry blood to the brain), contractors of left shoulder, left wrist and left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).<BR/>Record review of Resident 81's Baseline Care Plan dated 12/22/2023 and locked date of 12/28/2023 revealed under Section 1, D, 6. General information and Initial Goals/Daily Preferences that Resident Prefers HOSPICE SERVICES with a hospice company.<BR/>Record review of Resident #81's admission MDS with an ARD/Target Date of 12/30/2023 revealed under Section O0110, Special Treatments, Procedures and Programs, under K1. Hospice care while a resident yes.<BR/>Record review of Resident #81's comprehensive care plan date initiated 12/22/2023 to 01/08/2024 revealed no mention on the care plan to address the resident's issue with hospice services.<BR/>Record review of Resident #81's revised comprehensive care plan dated 01/11/2024 revealed no mention on the care plan found to address Resident #81's hospice services.<BR/>Record review of Resident 81's consolidated Physician's Orders dated 01/11/2024 and last order review was 12/27/2023 revealed an order dated 12/22/2023 to admit to the facility under the care of a doctor for hospice care. OT (occupational therapy) splint/brace order for resident to wear on his LUE (left upper extremity) a carrot splint daily or as tolerated dated 01/08/2024. <BR/>Record review of Resident #81's revised comprehensive care plan dated 01/12/2024 revealed under the care plan of #81's DNR (do not resuscitate) with interventions/tasks the last bullet stated, Social Services to consult with resident and RP (responsible party) regarding their decision to continue DNR, Hospice with revision on 01/12/2024. <BR/>Interview on 01/12/2024 beginning at 8:47 a.m. with LVN U, the MDS Coordinator, revealed Resident #81 had orders for hospice dated 12/22/2023 and on the admission MDS dated [DATE] indicating section O reflects resident on hospice. Further interview with LVN U revealed as soon as they (facility) receive any order the care plan is updated. <BR/>Interview on 01/12/2024 at 9:30 a.m. LVN U stated even though previously during the day this surveyor had interviewed LVN U concerning Resident #81's care plan for Hospice, she had no idea how the word Hospice was added to the social worker's care plan with revision 01/12/2024.<BR/>Interview on 01/12/24 at 2:45 p.m. with the social worker concerning the DNR care plan for Resident #81 showing a revision of the care plan on 01/12/2024 revealed she had started writing Resident #81's care plan on 12/18/2023 for Resident #81's DNR on 12/22/2023 but, she had not made any revisions to the care plan she had no idea who added the word Hospice: on to the care plan.<BR/>A request was made for a copy of the facility policy and procedure regarding resident care plans from the Administrator but, was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 elopement.<BR/>Resident #1 walked out of the facility unattended on 03/15/2024 at about 9:00PM until the police found him at about 10:00 PM from a place approximately 1.5 miles away from the facility. EMS organized by the police to take him to the hospital and at the hospital it was confirmed that resident had hairline fracture above the left eye and cheek with lacerations on left eye lid, left wrist, and lower and upper lips, and abrasions on hands. The facility staff was not aware the resident was missing until the family called the facility. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 4:55 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 03/25/24 at 6:00 PM. While the IJ was removed on 03/27/24, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could affect residents by placing them at risk of physical harm, pain and mental anguish, or emotional distress.<BR/>Findings Included:<BR/>Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged on 03/17/2024. His diagnoses included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), Prostatic Hyperplasia (enlarged prostate gland), Hypothyroidism, Hearing Loss-Left ear, and Abnormal Involuntary Movements. <BR/>Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. <BR/>Record review of Resident #1's Baseline Care Plan dated 03/10/24 reflected Resident #1 had no history of falls and no elopement risk.<BR/>Record review of Resident #1's Elopement Risk Evaluation dated 03/16/24 reflected a score of 14.00 indicating Resident #1 was at imminent risk for elopement. No Elopement Risk Evaluation completed prior to the elopement. <BR/>Record review of the care plan completed after the incident, dated 03/16/24 reflected , Resident #1 was at risk for elopement related to Elopement Evaluation Risk Score. No care plan was completed prior to the elopement incident. <BR/>Record review of the Weekly Skin Check dated 03/16/24 reflected Resident #1 had lacerations on left eye lid, left wrist and lower and upper lips. <BR/>Record review of Trauma Informed assessment dated [DATE] reflected Resident #1 felt scared, helpless, or horrified related to the sudden event of elopement with fall. <BR/>Record review of facility's incident report to HHSC dated 03/18/24 reflected, on 3/15/2024 the ADM was notified by MDS C that on 03/15/24, Resident #1 was being transported to the hospital for further evaluation and treatment related to fall with injury after found him outside the facility at a place half a mile away. The facility came to know about this incident when the FM of Resident #1 notified the facility over the phone at 10:20PM, that the resident was off the property. She also informed the facility that resident was on his way to the hospital. At the hospital it was revealed that Resident #1 had a hairline fracture above the left eye and the left cheek. Resident also had abrasions on his hands. <BR/>Record review of Nurses Progress Notes for Resident #1 by RN B on 03/16/24 at 6:41 AM, reflected Resident arrived from [Hospital] ER. Resident arrived with acute head injury orbital fracture, lip laceration Zygomatic arch fracture. Wander guard was placed on resident right lower leg. Notified doctor of return. Family is aware of return. Resident is comfortable at this time. <BR/>During an interview over the phone on 03/25/24 at 10:30 AM, Resident #1's FM stated she was out of the state when the incident of the elopement occurred. She stated at about 10:00PM the police called and talked to her over the phone and said that they went and picked Resident #1 up from a place approx. 1.5 miles away from the facility. She said the police reported that they responded to a 911 call from a community member who found Resident #1 with injuries braced on his parked car. She said the police organized EMS and transported him to the nearby hospital for further assessment and treatment. The FM stated the facility was unaware of Resident #1's disappearance from the facility until she called and informed the FR at the facility at about 10:20 PM. FM stated, initially when she asked about Resident #1, the FR stated Resident #1 resides at the 2nd floor and she would transfer FM's call to the 2nd floor nursing station so that FM could request the staff to talk to him. <BR/>During an interview over the phone on 03/25/24 at 11:00 AM, FR stated she worked as the receptionist at the facility from 6:00 PM to 10:30 PM, Monday to Friday. She said, on 03/15/24 at about 10:20 PM she received a phone call from Resident #1's FM asking if Resident #1 was there at the facility. FR said, she replied to FM that Resident #1 was living on the 2nd floor, and she would transfer the call to the nursing station at the 2nd floor so that the FM could talk to the staff there. FR said, FM then reported to FR that she was checking if staff was aware of what was going on and then reported that the police had picked up Resident #1 from a place about 1.5 miles away from the facility at about 10:00 PM and admitted to a hospital nearby due to the injuries he had. FR stated she or anyone at the facility was aware until then that Resident #1 was absconded from the facility. FR said at about 10:00 PM LVN A at the 2nd floor enquired her if she saw Resident #1 at the 1st floor as they could not find him at the 2nd floor. FR stated they were under the impression that Resident #1 was wandering around within the facility until they heard about his elopement from the facility from the FM. FR said, on 03/13/24 Resident #1 was persistently requesting to her to let him leave the facility and made unsuccessful efforts to open the coded front door at two different occasions. FR stated this behavior from him was evident since his admission on [DATE] and LVN A from 2nd floor requested her to have a [NAME] on Resident #1. She stated she also had informed LVN A about his attempts for unauthorized exit. FR stated she had a watch on him whenever he was on 1st floor and ensured that he did not exit through the front door on 03/15/24 as she was the only one who allowed the visitors to come and go from the facility. She stated the front door was secured with code numbers and only the staff members knew the code number. FR said she believed Resident #1 might have exited through the emergency fire exit door situated at the back of the facility. FR added, though the back door secured by code numbers, the lock can be override if the handle of the door holds down for some time. The door will be opened with an alarm though the alarm would not be heard at the reception area. <BR/>During an interview on 03/25/24 at 10:00 AM, MDS C stated she worked at the facility in the morning shift until 5PM. She said, on 03/15/24 at about 10:30PM she received a phone call at home from FR stating Resident#1 eloped from the facility and had a fall. FR reported to her that the police found him about 1.5 miles away from the facility with lacerations on his body and admitted him to a nearby hospital for treatment. MDS C stated, as per her understanding the staff at 2nd floor did not find him there at about 9.45PM and then they informed FR to have a watch on him if he appears at the front door. She stated it appeared the staff came to know his exit out of the facility only after the FM passed on that information<BR/>During a telephone interview on 03/25/24 at 10:30, LVN A stated she worked in the afternoon shift on 03/15/24 with the responsibility of the hall where Resident #1 resided. She said on 03/15/24 Resident #1 accepted his night medication at 9:00PM in his room. At about 9:45PM one of the CNAs noticed that Resident #1 was not in his room and his name tag at the door also was missing. LVN A stated she immediately informed FR to check if he was there at the reception area and by that time the information about his elopement was received from the FM of Resident #1. LVN A stated according to her Resident #1 was not an elopement risk as he mostly stayed in his room. When this investigator asked her about an incident of his two unsuccessful attempts to get out of the facility on 03/13/24 in the evening, reported by FR, LVN A stated those were the only attempts she was aware of. <BR/>During a phone interview on 03/25/24 at 3:00PM, RN B stated she was the night nurse at the facility and was not aware of what was going on with Resident #1 until 10:00 PM as she was not in charge of his hall. RN B stated the staff at the facility came to know through the FM about Resident #1's disappearance and subsequent incident of finding him outside the facility. RN B stated Resident #1 arrived back at the facility on 03/16/24 at about 6:00 AM from the hospital. She said she had a nurse-to-nurse communication from the nurse at the hospital. RN B stated, the nurse from the hospital reported Resident #1 had an acute head injury, orbital fracture, lip laceration and Zygomatic Arch (the most lateral projection of the midface) fracture. She stated she had recorded this in the progress note in the electronic medical record. <BR/>During an interview on 03/26/24 at 10:00 AM, LVN C stated she worked at the facility for more than a year and worked the morning shift. She said she did not work on the hall where Resident #1 resided. LVN C stated the nursing stations at the 2nd floor were equipped with alarms and any attempt to open the doors downstairs trigger the alarm. She added, staff immediately go down to ensure no elopement attempt was made by any residents. LVN C stated she did not know what really happened on that day as the incident occurred on the night shift. <BR/>In an interview and observation walk through with the ADM on 03/25/24 at 3:00 PM, she stated Resident #1 must have exited through the emergency fire exit door at the back, adjacent to the kitchen. ADM stated she believed it was not an elopement since the facility was not a locked facility. She added, stopping anyone from leaving the facility, when they wanted to, was a violation of resident rights. The ADM stated Resident #1 had a BIMS score of 13, indicated intact cognition to make independent decisions. The ADM stated there was residents at the facility who regularly go Out-On-Pass to the community and return within the stipulated time (72 hours). When this investigator asked if Resident #1 left the facility as per the policies and procedures for Out-On-Pass, she stated, he was not. The ADM also stated, Resident #1 neither signed any AMA documents nor declined to sign one and exited without the knowledge of any staff members. Observation of the emergency exit door revealed there was an instruction posted on the door explaining how to override the passcode in case of any emergency however an alarm went off when opened without the passcode. The ADM said since the door was away from the reception it was difficult to hear the alarm from the reception area. Observation of the front door revealed, it was secured by number code and the entrance and exit was controlled by the receptionist. There were no other exit doors at the facility.<BR/>During an interview on 03/26/24 at 12:50 PM, the DON stated he started working at the facility about a week ago, after the elopement incident of Resident #1 occurred. He stated he was well informed about the incident. The DON defined an elopement as, a resident leaving the facility without any notice or knowledge of the facility. The DON stated it appeared there was some shortfall in the security measures at the backdoor as it was believed Resident # 1 accessed the back door for his exit on 03/15/24. The DON stated it seemed the elopement risk evaluation and nursing judgement also was not accurate as there was no management plan, like usage of a wander band in place. The DON stated, when an alarm would be heard at nursing stations, the staff was supposed to go down to the 1st floor and make sure the alarm went off not because of any resident's attempt for an unauthorized exit. <BR/>During an interview on 03/26/24 at 1:10 PM, MDS C stated she did not know how Resident #1 got out of the facility. She stated she was the MDS nurse and was helping the administrator within her scope of practice as an LVN, in the absence of a DON at that time. She stated the act of Resident #1 was elopement if he exited the facility without the knowledge of the staff and without completing Out-On-Pass paperwork or without signing an AMA form. <BR/>Review of undated facility policy Elopement Risk Reduction Approaches reflected. <BR/>Planning:<BR/>As necessary, provide new residents (to the facility, wing, unit ,etc.) with additional staff assistance until they are comfortable in their new environment .<BR/> Ensure that residents are able to move freely, are monitored and remain safe .<BR/> .Training:<BR/>Facility staff needs to know:<BR/> . The resident's propensity to wander and the triggering conditions <BR/> The consequences of unsafe wandering, the protocols to follow to minimize successful exiting and the procedures to follow when resident is lost .<BR/>Promote identification of residents who are at risk of elopement. Ensure that photographs of residents who wander are maintained in an accessible but secure location and that receptionist, activities and clinical staff and others in appropriate positions to help are able to recognize at-risk residents and to assist in redirecting them <BR/> .Environment: <BR/> Ensure that staff alert and elopement alarm/warning systems are the least intrusive and burdensome possible <BR/> After conferring with fire and other appropriate officials, minimize the risk of elopement. <BR/>An Immediate Jeopardy was identified on 03/25/24 at 4:55 PM. The IJ Template was provided to the facility ADM on 03/25/24 at 6:00 PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 03/26/24 at 7:01 PM and indicated the following:<BR/>Plan of Removal <BR/>Immediate Jeopardy <BR/>On 03/25/2024 an abbreviated survey was initiated at the facility. On 03/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: <BR/>F689 - The facility failed to provide an environment free of accident hazards to minimize elopement risk. <BR/>Action: Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>Start Date: 3/17/2024. <BR/>Completion Date: 3/17/2024 <BR/>Action: All residents re-evaluated for risk of elopement via assessment on 3/25/2024. No additional residents were identified based on evaluation. Elopement Binder up to date and remains at reception desk. DON ensured all residents who are imminent risk for elopement are donning a wander guard for safety. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: DON or Designee <BR/>Action: Medical Director notified of IJ on 3/25/2024 <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Administrator <BR/>Action: Physician orders related to residents on wander guard placement reviewed and updated for all residents <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible: Medical Director or Designee <BR/>Action: In-services completed with all staff (facility does not use agency, all staff to include PRN staff) related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). As new employees are hired they will be in-serviced on all protocols in hire process. <BR/>Start Date: 3/25/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: In-service completed with all staff (facility does not use agency, all staff to include PRN staff) that if resident has more than one request to leave that elopement/wandering risk assessment completed and wander guard placed if applicable as intervention for safety. Elopement risk reduction approaches policy reviewed with all staff. As new employees are hired they will be in-serviced on protocol in hire process. <BR/>Start Date: 3/26/2024 <BR/>Completion Date: 3/26/2024 <BR/>Responsible Human Resources or Administrator <BR/>Action: QAPI meeting held related to IJ. Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT, and Medical Director (via phone) present. <BR/>Start Date: 3/26/2024. <BR/>Completion Date: 3/26/2024 <BR/>Responsible Administrator <BR/>Action: HR and Administrator in-serviced by Regional Clinical Specialist on all in-services, to include Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON, and Elopement risk reduction. <BR/>Start Date: 3/25/2024. <BR/>Completion Date: 3/25/2024 <BR/>Responsible: Regional Clinical Specialist<BR/>The surveyor confirmed the facility implemented their plan of removal sufficiently from 03/25/24 through 03/27/24 to remove the IJ by: <BR/>1. Record review of Resident #1's face sheet confirmed Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. <BR/>2. Record review of an Inservice to all nursing and CNA staff was completed on 03/27/24 by ADM and HR related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). <BR/>HR and Administrator were in-serviced on the above topics by Regional Clinical Specialist <BR/>3. Record review of the medical records of all the resident at the facility revealed all residents re-evaluated for risk of elopement via assessment on 3/25/2024 and ensured all residents who are an imminent or moderate risk for elopement had wander guards for safety. <BR/>4. Record review of the Elopement Binder revealed it was up to date and remains at reception desk. Copies of them were available at Nursing stations. <BR/>5. Record review on 03/27/24 of the medical records of all residents revealed physician orders related to residents on wander guard placement reviewed and no additional residents added to the existing residents with elopement risk.<BR/>6. Record review of the minutes of the QAPI meeting that was conducted for discussing elopement prevention on 03/26/24 revealed that the medical Director attended via Phone and Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT were physically attended the meeting. <BR/>Interviews conducted with RN C on 03/27/24 at 10:15 AM; LVN A on 03/26/24 at 11:00 AM; LVN C on 03/26/24 at 10:00AM. CNA A on 03/27/24 at 11:15AM, revealed nurses was in serviced on 03/27/24. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, taking mid night census, do head count to make sure no resident missing. <BR/>ADM was notified that while the IJ was removed on 03/27/24 at 00:00, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: <BR/>1. A metal pan covered with white wax style paper covering approximately 6 chicken breasts was placed on a shelf in the bottom of the walk-in cooler, the chicken was removed from the manufacturer's box and was not completely covered or in an enclosed container. <BR/>2. Six loaves of raisin bread with no dates or labeling of any type on the individual loaves and when the raisin bread was removed from the original manufacturer's box, placed on a metal tray with the date it was taken out of the freezer by the Food Service Supervisor.<BR/>These failures could place residents at risk for food-born illness, and food contamination. <BR/>Findings included:<BR/>Observation on 05/09/2023 at 8:45 a.m. in the dry storage room revealed: <BR/>1. Approximately 6 partially chicken breasts in a metal pan partially covered, allowing air to reach the chicken breasts. <BR/>2. Six loaves of raisin bread with no manufacture's dates of any type found on the loaves.<BR/>Interview with the Food Services Supervisor on 01/09/2024 at 10:40 a.m. following the initial tour of the walk-in cooler, the Food Services Supervisor replied when the chicken is covered with the paper it is okay, that is the way we do it. She did not further reply about any questions related to the chicken. When asked about the dates of the raisin bread and how she knew if the bread was fresh, she said we take it out of the box frozen and put a date on the tray. She was unable to provide any other information regarding the bread or locate any type of date on any of the 6 loaves of bread and said that is how we do it here, we throw away the box it comes in. <BR/>Interview on 01/11/2024 at 3:00 p.m., the Dietician stated all items should be stored according to the facility policy and that the Food Services Supervisor had not told her about the observation of the chicken covered by the white wax style paper in the walk-in cooler. The Dietician stated raw chicken should be completely covered when stored in the cooler, it does not sound like it was and said she would talk to the Food Service Supervisor about that to ensure chicken was stored properly. The Dietician stated the observed raisin bread was removed from the manufacturer's box and a label was placed on the metal tray that reflected when the bread was removed from the freezer, however there was no other type of date on the bread. The Dietician stated she did not feel either affected the residents in anyway. <BR/>Review of the facility policy titled Food Storage, Revised 11/2023, revealed the following: II. Frozen Meat/Poultry and Food Guidelines, D. Thawing: Thaw food at 41 degrees or below in a covered container in a refrigerator. <BR/>. <BR/>Record Review Revealed The U.S. Public Health Service, Food Code, dated 2017 revealed the following regarding marking the date of food when prepared and when the original container was opened: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking<BR/>(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: <BR/>(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; <BR/>(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section.

Based on interview and record review, the facility failed to include effective communications as mandatory training for 13 of 16 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, FSS, Act Dir, RN P, LVN Q, and LVN S.)<BR/>The facility failed to provided CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, FSS, Act Dir, RN P, LVN Q, and LVN S with effective communications as mandatory training.<BR/>This failure could place residents at risk of being cared for by untrained staff.<BR/>The findings included:<BR/>Review of CNA F's personnel record had a hire date of 08/23/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of CNA G's personnel record had a hire date of 02/12/20, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of CNA H's personnel record had a hire date of 03/19/20, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of CNA I's personnel record had a hire date of 04/16/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of CNA J's personnel record had a hire date of 08/20/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of CNA K's personnel record had a hire date of 10/08/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of CNA L's personnel record had a hire date of 11/04/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of CNA M's personnel record had a hire date of 09/07/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of the Food Service Supervisors' personnel record had a hire date of 02/15/19, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of Activity Director's personnel record had a hire date of 08/23/20, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of RN P's personnel record had a hire date of 12/22/22, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of LVN Q's personnel record had a hire date of 03/15/21, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>Review of LVN S's personnel record had a hire date of 05/25/23, with annual training in-services provided by the facility that did not include evidence of effective communications as mandatory training.<BR/>During a record review and interview with the HR Personnel on 01/12/24 at 4:00 pm, the HR Personnel revealed each month the corporate office would send a copy of the training topic staff were to complete and the DON or ADON 1 would ensure trainings were completed. The HR Personnel further revealed the organization's orientation set did not include communication as part of that training.<BR/>During an interview with the Administrator on 01/12/24 at 5:30 pm, the Administrator stated she was not aware of any other trainings other than those provided since the corporate office provided the training topics each month so they could be given in person rather than online.

Based on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for for 16 of 21 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that:<BR/>The facility failed to ensure that compliance and ethics training was provided to CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S.<BR/>This failure could place residents at risk for injury or improper care due to a lack of training.<BR/>The findings were:<BR/>Review of CNA F's personnel record had a hire date of 08/23/21 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of CNA G's personnel record had a hire date of 02/12/20 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of CNA H's personnel record had a hire date of 03/19/20 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of CNA I's personnel record had a hire date of 04/16/21 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of CNA J's personnel record had a hire date of 08/23/21 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of CNA K's personnel record had a hire date of 10/08/21 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of CNA L's personnel record had a hire date of 11/04/21 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of CNA M's personnel record had a hire date of 09/07/22 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of LVN N's personnel record had a hire date of 12/07/98 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of LVN O's personnel record had a hire date of 05/07/20 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of FSS's personnel record had a hire date of 02/15/19 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of the Act Dir's personnel record had a hire date of 08/23/20 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of RN P's personnel record had a hire date of 12/22/22 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of LVN Q's personnel record had a hire date of 03/15/21 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of LVN R's personnel record had a hire date of 02/06/23 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>Review of LVN S's personnel record had a hire date of 05/25/23 did not include evidence of communication related to the compliance and ethics program's standards.<BR/>During a record review and interview with the HR Personnel on 01/12/24 at 4:00 pm, the HR Personnel revealed each month the corporate office would send a copy of the training topic staff were to complete and the DON or ADON 1 would ensure trainings were completed. The HR Personnel further revealed the organization's orientation set did not include compliance and ethics as part of that training.<BR/>During an interview with the Administrator on 01/12/24 at 5:30 pm, the Administrator stated she was not aware of any other trainings other than those provided since the corporate office provided the training topics each month so they could be given in person rather than online.

Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 6 of 16 employees (CNA G, CNA J, LVN N, RN P, LVN Q and LVN S) reviewed for training, in that:<BR/>The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA G, CNA J, LVN N, RN P, LVN Q and LVN S.<BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training. <BR/>The findings included:<BR/>Review of CNA G's personnel record had a hire date of 02/12/20, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents.<BR/>Review of CNA J's personnel record had a hire date of 08/20/21, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents.<BR/>Review of LVN N's personnel record had a hire date of 12/07/98, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents.<BR/>Review of RN P's personnel record had a hire date of 12/22/22, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents.<BR/>Review of LVN Q's personnel record had a hire date of 03/15/21, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents.<BR/>Review of LVN S's personnel record had a hire date of 05/25/23, with annual training in-services provided by the facility that did not include evidence of education on the rights of the resident and the responsibilities of a facility to properly care for its residents.<BR/>During a record review and interview with the HR Personnel on 01/12/24 at 4:00 pm, the HR Personnel revealed each month the corporate office would send a copy of the training topic staff were to complete and the DON or ADON 1 would ensure trainings were completed. The HR Personnel further revealed the organization's orientation set did not include resident rights as part of that training.<BR/>During an interview with the Administrator on 01/12/24 at 5:30 pm, the Administrator stated she was not aware of any other trainings other than those provided since the corporate office provided the training topics each month so they could be given in person rather than online.

Based on interview, and record review, the facility failed to provide resident abuse prevention training to 2 of 21 staff reviewed including CNA G and LVN Q.<BR/>The facility failed to ensure that 2 of 21 staff reviewed had completed their mandatory abuse annual training.<BR/>This failure could place residents at risk of being cared for by untrained staff.<BR/>The findings included:<BR/>Record review of the annual training information provided by the HR Personnel revealed that CNA G (hired-02/12/20) and LVN Q (hired-03/15/21) had not completed their mandatory abuse annual training.<BR/>During an interview with the Administrator on 01/12/24 at 5:30 pm, the Administrator stated they provided abuse prevention training as required but she was not aware that the identified staff members had not completed the training.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 2 of 2 facility dumpsters in that: <BR/>1. Dumpster #1 had the side door open making trash placed in the dumpster visible for 3 of 3 observations.<BR/>2. Dumpster #2 had the top lid open making trash placed in the dumpster visible.<BR/>These deficient practices could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents, and expose them to germs and diseases carried by vermin and rodents. <BR/>The findings were: <BR/>Observation on 01/10/2024 beginning at 1:14 p.m. revealed dumpster #1 with the side door open making the trash placed in the dumpster visible. Observation revealed dumpster #2 with one side of the top lid open making trash placed in the dumpster visible. <BR/>Observation on 1/10/24 beginning at 5:25 p.m. revealed dumpster #1 with the side door open making the trash placed in the dumpster visible. Observation revealed dumpster #2 with both sides of the top lid open making trash placed in the dumpster visible. <BR/>Observation on 01/11/2024 beginning at 2:58 p.m. revealed dumpster #1 with the side door open and a bag of trash in a white garbage bag style bag lying in front of the dumpster on the ground. Observation revealed dumpster #2 with both sides of the lid open and cardboard boxes stacked past the top of the dumpster with one white cardboard box (contents unknown) lying on the ground in front of the dumpster. <BR/>During an observation and interview on 1/11/2024 begining at 3:54 p.m. with the Food Service Supervisor, standing in front of dumpster #1 with the side door open and visible trash as well as dumpster #2 with both lids open and trash stacked past the top of the dumpster, the Food Service Supervisor stated the dumpster lids and doors should be closed because them being open could attract insects and rodents. The Food Service Supervisor did not think the dumpsters begin open affected the residents in anyway. <BR/>During and observation and interview with the Administrator on 01/12/2024 beginning at 4:22 p.m., the Administrator stated ensuring the dumpsters are closed and kept as they should be was the responsibility of all staff however the Maintenance Director had been in charge of that task. The Administrator went on to say the Maintenance Director was unavailable for interview because the facility was in between maintenance men at this time. The Administrator stated she was unaware of the conditions of the dumpsters during the survey team observations and the dumpster lids nor doors should be open but did not feel either being open had any affect on the residents at this time. <BR/>The facility's policy Maintenance Services, Operational Manual - Physical Environment with a revision date of 08/2020 was provided by the Administrator prior to exit when she was asked for a policy stating how the facility managed trash. The policy did not specifically address trash or garbage by those use of those terms but did reveal the following: <BR/>I. The Maintenance Department is responsible for maintain the buildings, ground, and equipment in a safe and operable manner at all times. <BR/>A. <BR/>Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #81) reviewed for comprehensive care plans in that:<BR/>Resident #81's comprehensive care plan did not address the resident's Hospice services. <BR/>This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.<BR/>The findings included:<BR/>Record review of Resident #81's face sheet, dated 9/6/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), depression (mood disorder), cerebral vascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply blood), bilateral occlusion and stenosis of carotid arteries (blockage of arteries that are on both sides of the next that carry blood to the brain), contractors of left shoulder, left wrist and left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).<BR/>Record review of Resident 81's Baseline Care Plan dated 12/22/2023 and locked date of 12/28/2023 revealed under Section 1, D, 6. General information and Initial Goals/Daily Preferences that Resident Prefers HOSPICE SERVICES with a hospice company.<BR/>Record review of Resident #81's admission MDS with an ARD/Target Date of 12/30/2023 revealed under Section O0110, Special Treatments, Procedures and Programs, under K1. Hospice care while a resident yes.<BR/>Record review of Resident #81's comprehensive care plan date initiated 12/22/2023 to 01/08/2024 revealed no mention on the care plan to address the resident's issue with hospice services.<BR/>Record review of Resident #81's revised comprehensive care plan dated 01/11/2024 revealed no mention on the care plan found to address Resident #81's hospice services.<BR/>Record review of Resident 81's consolidated Physician's Orders dated 01/11/2024 and last order review was 12/27/2023 revealed an order dated 12/22/2023 to admit to the facility under the care of a doctor for hospice care. OT (occupational therapy) splint/brace order for resident to wear on his LUE (left upper extremity) a carrot splint daily or as tolerated dated 01/08/2024. <BR/>Record review of Resident #81's revised comprehensive care plan dated 01/12/2024 revealed under the care plan of #81's DNR (do not resuscitate) with interventions/tasks the last bullet stated, Social Services to consult with resident and RP (responsible party) regarding their decision to continue DNR, Hospice with revision on 01/12/2024. <BR/>Interview on 01/12/2024 beginning at 8:47 a.m. with LVN U, the MDS Coordinator, revealed Resident #81 had orders for hospice dated 12/22/2023 and on the admission MDS dated [DATE] indicating section O reflects resident on hospice. Further interview with LVN U revealed as soon as they (facility) receive any order the care plan is updated. <BR/>Interview on 01/12/2024 at 9:30 a.m. LVN U stated even though previously during the day this surveyor had interviewed LVN U concerning Resident #81's care plan for Hospice, she had no idea how the word Hospice was added to the social worker's care plan with revision 01/12/2024.<BR/>Interview on 01/12/24 at 2:45 p.m. with the social worker concerning the DNR care plan for Resident #81 showing a revision of the care plan on 01/12/2024 revealed she had started writing Resident #81's care plan on 12/18/2023 for Resident #81's DNR on 12/22/2023 but, she had not made any revisions to the care plan she had no idea who added the word Hospice: on to the care plan.<BR/>A request was made for a copy of the facility policy and procedure regarding resident care plans from the Administrator but, was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, for 2 of 3 medication carts observed, in that:<BR/>1. The Middle Medication Cart 2200 hall contained eighteen loose medication pills. <BR/>2. The Hall Back Medication Cart 2200 hall contained eight loose medication pills. <BR/>These practices could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. <BR/>The findings included: <BR/>1. Observation on 01/10/2024 at 9:10 a.m. of the 2200 Hall Middle Medication Cart revealed there were eighteen loose medication pills inside one of the drawers of the cart. <BR/>During an interview with Nurse T on 01/10/2024 at 9:12 a.m., Nurse T confirmed there were eighteen loose medication pills inside a drawer of the Middle Medication Cart. <BR/>2. Observation on 01/10/2024 at 9:34 a.m. of the 2200 Hall Back Medication Cart revealed there were eight loose medication pills inside one of the drawers of the cart. <BR/>During an interview with Nurse U on 01/10/2024 at 9:38 a.m., Nurse U confirmed there were eight loose medication pills inside a drawer of the 2200 Hall Back Medication Cart.<BR/>During an interview with DON on 1/10/2024 at 10:38 a.m., stated medication carts are the responsibility of the nurse that accepted responsibility for the cart, also the medications carts are supposed to be checked bi-weekly by the ADON's and any loose medications are to be identified, followed by a medication count then cross-checked by residents, then disposed of per facility policy.<BR/>During an interview with the Administrator on 1/11/2024 at 10:09 a.m., stated nurses accept responsibility of the medication carts, she stated that the ADON's should be conducting medication cart check bi-weekly and then follow facility policy for any loose medications that are found.<BR/>Record review of the facility policy titled Storage of Medications, revised 08/2020, revealed, Policy Statement: Medications and biologicals are to be stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Further review revealed, Policy Interpretation and Implementation: 1. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers.

Based on interviews and record review, the facility failed to designate an Infection Preventionist that was qualified by education, training, experience, or certification, and who completed specialized training in infection prevention and control, for one of one facility. <BR/>The facility did not designate a qualified Infection Control Preventionist.<BR/>This failure could place residents at risk for cross contamination and infection.<BR/>Findings included:<BR/>During an interview on 01/30/25 at 1:38 PM the ADON stated she was in charge of infection control but did not have the certificate to be the infection control preventionist. The ADON stated the Administrator and the DON had certification for infection control preventionist. The ADON stated she was working on her certification of being the Infection Control Preventionist .<BR/>During an interview on 01/30/25 at 2:27 pm, the ADM stated the ADON was the designated staff as Infection Control Preventionist. The Administrator stated he had certification to be infection control preventionist but has never done anything in the facility regarding infection control.<BR/>During a phone interview on 01/31/2025 at 09:30 am, the DON stated the ADON was the Infection Control Preventionist. The DON stated the ADON had been working on certification since she was given the position and completed on 01/31/2025 after the State Surveyor asked about it. The DON stated it was important for the Infection Control Preventionist to complete training and be certified because without certification she would not be able to train the staff for infection control prevention.<BR/>Review of document resented by the Administrator reflected the ADON completed Nursing Home Infection Preventionist training course on 01/30/2025.<BR/>Review of the ADON's personnel file reflected the ADON was hired on 07/02/2024.

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 16 of 21 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that:<BR/>The facility failed to ensure that quality assurance and performance improvement training was provided to CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S.<BR/>This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately trained staff and could result in a decline in health and well-being.<BR/>The findings were:<BR/>Review of CNA F's personnel record had a hire date of 08/23/21 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of CNA G's personnel record had a hire date of 02/12/20 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of CNA H's personnel record had a hire date of 03/19/20 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of CNA I's personnel record had a hire date of 04/16/21 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of CNA J's personnel record had a hire date of 08/23/21 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of CNA K's personnel record had a hire date of 10/08/21 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of CNA L's personnel record had a hire date of 11/04/21 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of CNA M's personnel record had a hire date of 09/07/22 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of LVN N's personnel record had a hire date of 12/07/98 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of LVN O's personnel record had a hire date of 05/07/20 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of FSS's personnel record had a hire date of 02/15/19 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of the Act Dir's personnel record had a hire date of 08/23/20 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of RN P's personnel record had a hire date of 12/22/22 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of LVN Q's personnel record had a hire date of 03/15/21 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of LVN R's personnel record had a hire date of 02/06/23 revealed no evidence of QAPI topics within the previous 12 months.<BR/>Review of LVN S's personnel record had a hire date of 05/25/23 revealed no evidence of QAPI topics within the previous 12 months.<BR/>During a record review and interview with the HR Personnel on 01/12/24 at 4:00 pm, the HR Personnel revealed each month the corporate office would send a copy of the training topic staff were to complete and the DON or ADON 1 would ensure trainings were completed. The HR Personnel further revealed the organization's orientation set did not include QAPI as part of that training.<BR/>During an interview with the Administrator on 01/12/24 at 3:40 pm, the Administrator stated that only the Department Managers were part of the QAPI meetings. The Administrator did not explain why other members of the staff were not included in the QAPI process.

Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 7 of 16 staff (CNA G, CNA J, LVN N, RN P, LVN Q, LVN R and LVN S) reviewed for training, in that:<BR/>The facility failed to ensure infection prevention and control training was provided to CNA G, CNA J, LVN N, RN P, LVN Q, LVN R and LVN S.<BR/>This failure could place residents at risk of illness due to lack of staff training. <BR/>The findings were:<BR/>Review of CNA G's personnel record had a hire date of 02/12/20, revealed no evidence of infection control topics within the previous 12 months. <BR/>Review of CNA J's personnel record had a hire date of 08/20/21, revealed no evidence of infection control topics within the previous 12 months. <BR/>Review of LVN N's personnel record had a hire date of 12/07/98 revealed no evidence of infection control topics within the previous 12 months. <BR/>Review of RN P's personnel record had a hire date of 12/22/22, revealed no evidence of infection control topics within the previous 12 months. <BR/>Review of LVN Q's personnel record had a hire date of 03/15/21, revealed no evidence of infection control topics within the previous 12 months. <BR/>Review of LVN R's personnel record had a hire date of 02/06/23 revealed no evidence of infection control topics within the previous 12 months. <BR/>Review of LVN S's personnel record had a hire date of 05/25/23 revealed no evidence of infection control topics within the previous 12 months. <BR/>During a record review and interview with the HR Personnel on 01/12/24 at 4:00 pm, the HR Personnel revealed each month the corporate office would send a copy of the training topic staff were to complete and the DON or ADON 1 would ensure trainings were completed. The HR Personnel further revealed the organization's orientation set did not include communication as part of that training.<BR/>During an interview with the Administrator on 01/12/24 at 5:30 pm, the Administrator stated she was not aware of any other trainings other than those provided since the corporate office provided the training topics each month so they could be given in person rather than online.

Based on observation and interview, the facility failed to post notice of the reports and have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request in a place readily available to resident's, family members, and legal representatives for the facilty's postings reviewed for resident rights. <BR/>1. The facility failed to have the copies of the survey and investigation reports with the plan of corrections available for family members and residents to review.<BR/>2. The facility failed to ensure there was a posted notice saying the location of the survey, investigation, and plan of correction reports. <BR/>These failures place residents and visitors at risk of not being aware of the facility's past deficiencies.<BR/>The findings included:<BR/>During an observation on 11/08/2022 at 9:00 a.m. there did not appear to be any survey results available in the front reception/ entry area of the facility nor a sign indicating where they were located. <BR/>During an observation on 11/09/2022 at 8:30 a.m., there did not appear to be any survey results available in the front/reception entry area of the facility nor a sign indicating where they were located. <BR/>During an observation and interview on 11/09/2022 at 12:26p.m., the Receptionist, explained the survey results were available for review if someone asked for them and they were behind the front counter. When asked exactly where they were kept and if I could see them; she turned to a row of approximately 7 binders and looked through several of the binders, briefly. She located the binder identified as survey results in that row of binders. She then explained the survey results binder, should have been on top of the counter so that it was available for review if the Surveyors come in and ask to see it. There was no sign in the front Reception/Entry way of the facility where she said the facility was supposed to keep the survey results book. The Receptionist stated there was no sign posted. When asked if those items could have possibly been placed in any other area of the facility, the Receptionist answered, No. <BR/>In an interview on 11/11/2022 at 3:45 PM, the Administrator stated he was unaware of the survey results not being available in the survey results binder or a posting indicating their availability. The Administrator stated that he was aware of the requirement of posting the previous 3 years of survey, investigation, and plan-of-correction items within the survey results binder but not of the requirement for posting a notice of the availability and location of the result s. The Administrator stated the risk associated with not having the survey results available and a notice of their availability and location would be visitors, residents, and staff not being aware of the previous survey results.

Based on record review and interviews, the facility failed to maintain record of the required annual in-service recordsensure the required in-service trainings for nurse aides were sufficient to ensure the continuing competences of nurse aides, but must be no less than 12 hours per year and included dementia management training and resident abuse prevention training for 6 of 9 direct care staff CNA F, CNA G, CNA B, RNA H, CNA J, and CNA K records reviewed for staff training.<BR/>The facility failed to provide CNA F, CNA G, CNA B, RNA H, CNA J, and CNA K with HIV, Falls, Restraints, or Dementia management training per year.<BR/>This failure could place residents at risk of being cared for by untrained staff.<BR/>The findings included:<BR/>Record review of training hours for CNA F, CNA G, CNA B, RNA H, CNA J, and CNA K revealed:<BR/>CNA F had a hire date of 08/16/18 with a training transcript that did not include evidence of training in Falls, Restraints, or Dementia Management.<BR/>CNA G had a hire date of 08/30/18 with a training transcript that did not include evidence of training in HIV, Falls, Restraints, or Dementia Management.<BR/>CNA B had a hire date of 02/25/21 with a training transcript that did not include evidence of training in Restraints.<BR/>RNA H had a hire date of 08/26/21 with a training transcript that did not include evidence of training in Falls.<BR/>CNA J had a hire date of 08/13/20 with a training transcript that did not include evidence of training in HIV, Falls, Restraints, or Dementia Management.<BR/>CNA K had a hire date of 08/16/18 with a training transcript that did not include evidence of training in HIV, Restraints, or Dementia Management.<BR/>CNA G had a hire date of 08/13/20 with a training transcript that did not include evidence of training in HIV, Falls, Restraints, or Dementia.<BR/>CNA H had a hire date of 08/16/18 with a training transcript that did not include evidence of training in HIV, restraints, or Dementia.<BR/>In an interview on 11/11/22 at 2:45 PM, the Human Resources Director stated training and in-servicing for care staff was completed by the DON, ADON's, and regional nurses. The Human Resources Director stated it was her own responsibility to keep a record of completed training for staff and ADON A would possibly have additional training in her office. The Human Resources Director stated that she was unaware of why the trainings were unable to be located.<BR/>In an interview on 11/11/22 at 3:15 PM, ADON A stated it was the nursing administration staff such as herself, STAFF E, and the DON's responsibility to complete competency training for direct care staff and all trainings were completed in person with paper sign-in sheets to confirm who was in attendance and how long the trainings took place. ADON A stated training for staff had taken place for all staff but could not affirm the record of training due to the facility only using paper records for training history. <BR/>In an interview on 11/11/22 at 3:30 PM, the DON stated it was her responsibility to complete in-service training for staff at the facility and records the training on paper sign in sheets. The DON stated she was not aware nursing aide staff had incomplete training transcripts and stated the staff had completed the training but could not identify record of the training. The DON stated she was unsure of why the training records were incomplete or lacking evidence of specific training for staff. The DON stated she understood the risks associated with not having a record of staff annual training competencies would be an inability to determine if nursing aid staff would remain competent in their role<BR/>In an interview on 11/11/22 at 3:45 PM, the Administrator stated he was unaware of the incomplete record of staff training for nursing aides. The Administrator stated he understood the risks associated with not having a record of staff annual training competencies would be an inability to determine if nursing aid staff would remain competent in their role.<BR/>Record review of facility training and competencies policy titled Care Standards, dated 06/2020 revealed The DON or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #3) of five residents reviewed for accurate medical records.<BR/>The facility failed to ensure Resident #3's medical chart contained any documented nursing progress notes.<BR/>This deficient practice could result in errors in care and treatment.<BR/>Findings included:<BR/>Review of Resident #3's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes memory loss), hypertension (high blood pressure), seizures, and type II diabetes.<BR/>Review of Resident #3's quarterly MDS assessment, dated 08/15/24, reflected a BIMS of 6, indicating a severe cognitive impairment.<BR/>Review of Resident #3's quarterly care plan, dated 05/30/24, reflected she had an ADL self-care performance deficit with an intervention of requiring staff supervision with transfers and bed mobility. It further reflected she was a moderate risk for falls related to gait/balance problems with an intervention of anticipating/meeting her needs.<BR/>Review of Resident #3's progress notes section in her EMR, on 09/04/24, reflected no documentation since her admission.<BR/>During an interview on 09/04/24 at 11:42 AM, the DON stated her expectations were that nurses document everything that was going on with the resident in their charts such as incidents, new orders, and the progress of the resident. She stated for a resident to not have any progress notes for four months would be unacceptable. She stated documentation was important so all nurses could see any changes in residents or any new interventions. She stated if it was not documented, it did not happen.<BR/>Review of the facility's Nursing Documentation Policy, revised 06/2020, reflected the following:<BR/>Nursing documentation will be concise, clear, pertinent, accurate, and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures.<BR/> .<BR/>K. Documentation will be completed by the end of the assigned shift.

Based on observation and interview the facility failed to post in a location available for all residents, contact information including telephone numbers of the Long-Term Care Ombudsman program for the facility's postings reviewed for resident rights. <BR/>The facility did not have the Ombudsman Program sign posted: <BR/>This failure could place residents at risk of not having access to signs informing them of their rights and resident advocacy groups. <BR/>The findings include: <BR/>Observation on 11/08/2022 at 9:15 a.m. revealed there was no posting for the Long-Term Care Ombudsman visible to residents and vistors. <BR/>On 11/9/2022 during a group meeting at 11:00 a.m., 2 alert and oriented residents, Resident #35 and Resident #53, said they had not seen any posting for the Long-Term Care Ombudsman Program in the facility. Resident #53 did not know the facility had an Ombudsman or the role of the Ombudsman in Long-Term Care Facilities. The residents were given a brief overview of the program, the name of the Ombudsman and was informed that facility management would provide the contact information for the Ombudsman. <BR/>During an interview on 11/09/2022 at 12:35 p.m. the Receptionist confirmed there was no posting for the Long-Term Care Ombudsman in the building, including the entrance area of the facility that was visible to residents or their families. <BR/>During an interview on 11/11/2022 at 9:00 a.m. Resident #35 stated she had to locate the number for the Long Term-Care Ombudsman on the internet, utilizing her personal device as she could not find it anywhere in the facility. She went on to explain she was resourceful but it was really sad for those that live in the facility and are not able to advocate for themselves or may not even know of an Ombudsman's role. <BR/>During an interview on 11/11/2022 at 10:27 a.m. RN C said she thought she had seen a posting for the Long-Term Care Ombudsman somewhere but was unable to locate it. She further stated sometimes the patients take things off of the walls. <BR/>During an interview with the Administrator on 11/11/2022 the Administrator was unable to locate the Ombudsman Posting for the surveyor when asked to do so. The Administrator stated the risk associated with not having the Ombudsman contact information posted would be that resident's would not be able to mediate concerns with the facility effectively and would go potentially unheard. The Administrator stated the facility did not have policy specific to required postings within the facility.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #3) of five residents reviewed for accurate medical records.<BR/>The facility failed to ensure Resident #3's medical chart contained any documented nursing progress notes.<BR/>This deficient practice could result in errors in care and treatment.<BR/>Findings included:<BR/>Review of Resident #3's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes memory loss), hypertension (high blood pressure), seizures, and type II diabetes.<BR/>Review of Resident #3's quarterly MDS assessment, dated 08/15/24, reflected a BIMS of 6, indicating a severe cognitive impairment.<BR/>Review of Resident #3's quarterly care plan, dated 05/30/24, reflected she had an ADL self-care performance deficit with an intervention of requiring staff supervision with transfers and bed mobility. It further reflected she was a moderate risk for falls related to gait/balance problems with an intervention of anticipating/meeting her needs.<BR/>Review of Resident #3's progress notes section in her EMR, on 09/04/24, reflected no documentation since her admission.<BR/>During an interview on 09/04/24 at 11:42 AM, the DON stated her expectations were that nurses document everything that was going on with the resident in their charts such as incidents, new orders, and the progress of the resident. She stated for a resident to not have any progress notes for four months would be unacceptable. She stated documentation was important so all nurses could see any changes in residents or any new interventions. She stated if it was not documented, it did not happen.<BR/>Review of the facility's Nursing Documentation Policy, revised 06/2020, reflected the following:<BR/>Nursing documentation will be concise, clear, pertinent, accurate, and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures.<BR/> .<BR/>K. Documentation will be completed by the end of the assigned shift.

Based on interview and record review, the facility failed to ensure the pharmacist reported any irregularities to the attending physician and the facility's medical director and director of nursing and the reports were acted on for 1 of 3 residents (Resident 53) reviewed for unnecessary medications, <BR/>The facility failed failed to ensure there was documentation for Resident 53's Pharmacist Consultant Recommendations, dated 9/9/2022, was reviewed by anyone at the facility.<BR/>This deficient practice place residents at-risk of not having their pharmacy consultations reviewed.<BR/>The findings were:<BR/>Record review of Resident 35's face sheet dated 11/11/2022, revealed the resident was admitted to the facility on 0715/2022 with the diagnoses which included: personal history of cardiac arrest, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, congestive heart failure, as well as type II diabetes. <BR/>Resident 53's Pharmacist Consultant Recommendations, dated 9/9/2022, stated Suggest amend order for ELIQUIS to include a CMS APPROVED DIAGNOSIS FOR USE. 'For anti-coagulant is not acceptable as a diagnosis. There was not indication on any reviewed documents in the Pharmacy Review for that month nor any documentation in the electronic medical record, that the recommendation had been reviewed by any nurse or physician.<BR/>During an interview on 11/11/2022 at 1:34 p.m., the ADON explained the Pharmacy Consultation for Resident #53 should have been reviewed but it was not, if it had been reviewed there should have been physical documentation that it had been reviewed. She said the former DON should have taken the recommendation to the physician but there was not documentation to show that was done on the Pharmacy Consultation documents or in the electronic health record. She further explained although there was not any negative consequence for Resident #53, not reviewing pharmacy consultations and documenting they had been reviewed and completed could lead to something the patient needed being missed. She stated the facility was aware pharmacy consultations had not been followed up on during the presence of past administration and this one had been missed. <BR/>During an interview on 11/11/2022 at 2:37 p.m. the DON stated, there should have been a diagnosis with the order for Eliquis and explained the pharmacy consultation should have been reviewed and a signature by a nurse or a physician would show that it had been reviewed. She stated Resident #53's pharmacy recommendation did not show that it was ever reviewed. She explained the previous ADON should have ensured the order was amended, as recommended by the pharmacy consultant, the pharmacy consultants are the experts when they make recommendations, they should be followed according to the facility policy and procedure. She said she did not think in this case there was a negative consequence for the Resident.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, for 2 of 3 medication carts observed, in that:<BR/>1. The Middle Medication Cart 2200 hall contained eighteen loose medication pills. <BR/>2. The Hall Back Medication Cart 2200 hall contained eight loose medication pills. <BR/>These practices could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. <BR/>The findings included: <BR/>1. Observation on 01/10/2024 at 9:10 a.m. of the 2200 Hall Middle Medication Cart revealed there were eighteen loose medication pills inside one of the drawers of the cart. <BR/>During an interview with Nurse T on 01/10/2024 at 9:12 a.m., Nurse T confirmed there were eighteen loose medication pills inside a drawer of the Middle Medication Cart. <BR/>2. Observation on 01/10/2024 at 9:34 a.m. of the 2200 Hall Back Medication Cart revealed there were eight loose medication pills inside one of the drawers of the cart. <BR/>During an interview with Nurse U on 01/10/2024 at 9:38 a.m., Nurse U confirmed there were eight loose medication pills inside a drawer of the 2200 Hall Back Medication Cart.<BR/>During an interview with DON on 1/10/2024 at 10:38 a.m., stated medication carts are the responsibility of the nurse that accepted responsibility for the cart, also the medications carts are supposed to be checked bi-weekly by the ADON's and any loose medications are to be identified, followed by a medication count then cross-checked by residents, then disposed of per facility policy.<BR/>During an interview with the Administrator on 1/11/2024 at 10:09 a.m., stated nurses accept responsibility of the medication carts, she stated that the ADON's should be conducting medication cart check bi-weekly and then follow facility policy for any loose medications that are found.<BR/>Record review of the facility policy titled Storage of Medications, revised 08/2020, revealed, Policy Statement: Medications and biologicals are to be stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Further review revealed, Policy Interpretation and Implementation: 1. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers.

Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 16 employees (CNA F, CNA G, CNA J, LVN N, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that: <BR/>The facility failed to ensure effective behavioral health training was provided to CNA F, CNA G, CNA J, LVN N, RN P, LVN Q, LVN R, and LVN S.<BR/>This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. <BR/>The findings included:<BR/>Review of CNA F's personnel record had a hire date of 08/23/21 revealed no evidence of behavioral health training.<BR/>Review of CNA G's personnel record had a hire date of 02/12/20 revealed no evidence of behavioral health training.<BR/>Review of CNA J's personnel record had a hire date of 08/20/21, revealed no evidence of behavioral health training.<BR/>Review of LVN N's personnel record had a hire date of 12/07/98 revealed no evidence of behavioral health training.<BR/>Review of RN P's personnel record had a hire date of 12/22/22 revealed no evidence of behavioral health training.<BR/>Review of LVN Q's personnel record had a hire date of 03/15/21 revealed no evidence of behavioral health training.<BR/>Review of LVN R's personnel record had a hire date of 02/06/23 revealed no evidence of behavioral health training.<BR/>Review of LVN S's personnel record had a hire date of 05/25/23 revealed no evidence of behavioral health training.<BR/>During a record review and interview with the HR Personnel on 01/12/24 at 4:00 pm, the HR Personnel revealed each month the corporate office would send a copy of the training topic staff were to complete and the DON or ADON 1 would ensure trainings were completed. The HR Personnel further revealed the organization's orientation set did not include behavioral health as part of that training.<BR/>During an interview with the Administrator on 01/12/24 at 5:30 pm, the Administrator stated she was not aware of any other trainings other than those provided since the corporate office provided the training topics each month so they could be given in person rather than online.