Valhalla Post Acute

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility's policies, it was determined the facility failed to ensure that one (1) out of twenty-one (21) sampled residents, Resident (R)5, received proper treatment and care to maintain mobility and good foot health by failing to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s). The findings included:Review of the facility's policy titled, Wound Care, dated 10/2010, revealed that the purpose of the policy was to provide guidelines for the care of wounds to promote healing. Further review revealed that staff should verify the physicians order prior to wound care. Per the policy, documentation of wound care should be recorded in the resident's medical record.Review of R5's Face Sheet revealed that he was admitted to the facility on [DATE] with diagnoses including tobacco use, hypertension, diabetes mellitus type II with hyperglycemia (high blood sugar) and neuropathy, as well as history of venous thrombosis and embolism. Review of R5's Quarterly Minimum Data Set (MDS), dated 06/30/2025, revealed that R5 was assessed as having a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Further review of R5's Quarterly MDS revealed that the resident did not display rejection of care behaviors during the assessment period, had diabetic foot ulcers, and took hypoglycemic medications, including insulin. Review of R5's Comprehensive Care Plan, initiated 03/15/2024 revealed that he was care planned for diabetes putting him at risk for complications such as diabetic nephropathy, hyperglycemia, and skin breakdown. Further review of R5's CCP revealed that he was also care planned for the focus of skin-diabetic foot ulcers and was at risk for complications related to delayed healing, further skin breakdown, infection, and pain and discomfort due to refusing in house wound care consultation, left diabetic foot ulcer, amputation of great toe, surgical debridement of wound with skin staples applied, chronic changes to third or fourth metatarsals, fourth metatarsal had osteoarthritis and septic arthritis, diabetic wounds to left second and fourth toes, right medial first toe, right distal first toe, right second toe, and right distal lateral foot. The care plan noted the resident makes false claims related to wound care being done and was care planned due to refusing care and services of the in-house wound evaluations. Per the CCP, R5 was seen by outside wound care, and had interventions including administering treatments as ordered. Review of R5's current Physician Orders, revealed that he had an order for podiatry care as needed both dated 03/03/2025. R5 also had the following orders: a. Anasept External Liquid 0.057% Solution apply to right distal lateral foot topically every day shift for diabetic wound. Clean with normal saline, pat dry, Anasept and collagen powder and cover with a border gauze daily and PRN (as needed), 05/01/2025. b. Betadine Swabsticks External Swab 10% (Povidone-Iodine) every shift for left fourth toe, bilateral second toes, and right distal and lateral first toe and leave open to air those toes dated 05/05/2025. Review of R5's Treatment Administration Record (TAR) revealed that for the month of 07/2025, treatments were not provided as ordered on 07/05/2025, 07/06/2025, 07/07/2025, 07/12/2025, 07/13/2025, 07/22/2025, 07/23/2025, 07/24/2025, 07/30/2025, and 07/31/2025. These treatments included:a. One treatment that was not given for wound care of the Anasept with collagen powder. b. One treatment of painting with betadine missed for the left second toe. c. Ten treatments of painting the left fourth toe with betadine missed.d. Ten treatments of painting of the right second toe topically with betadine.e. Ten missed betadine treatments for the right distal first toe.f. Ten missed betadine treatments for the right medial first toe. Review of the 06/2025 TAR revealed treatments were not provided as ordered on 06/12/2025, 06/20/2025, 06/29/205, and 06/30/2025. These treatments included:a. Two missed treatments for wound care of the Anasept with collagen powder. b. Two treatments of painting with betadine missed for the left second toe.c. Four treatments of painting the left fourth toe with betadine missed.d. Four missed treatments of painting of the right second toe topically with betadine.e. Four missed betadine treatments for the right distal first toe.f. Four missed betadine treatments for the right medial first toe. Review of the 04/2025 TAR revealed two treatments of the second left toe with the Betadine swab stick were missed. In addition, four treatments for the left first toe and left fourth toe, two treatments for the right distal lateral foot, and three treatments for the right medial first toe were also missed. Review of the 03/2025 TAR revealed a total of 13 treatments were missed. No treatments were missing for the month of 02/2025; however, per the 01/2025 TAR, a total of six treatment were missed, while the 12/2024 TAR revealed that two treatments were missed. Observation of R5's right foot on 08/05/2025 at 9:55 AM revealed that it was wrapped in an ACE bandage that was clean, dry, and intact. There were serosanguinous (wound drainage that is a mix of serous fluid and blood) stains on the pillow upon which it was propped. Interview with R5 on 08/05/2025 at 9:55 AM, revealed he was a diabetic and that his blood glucose was regulated with medications and insulin. He stated that from 12/01/2025 through present, he counted at least 61 instances that the wound care on his feet was not done. He stated that he sometimes does care for the wound because the drainage from the wound soaks the dressing. R5 stated that once last month, he had a conversation with the Assistant Director of Nursing (ADON), and she stated she would talk with the nursing staff and make sure his dressings on his diabetic foot ulcers were changed daily. However, no one came and changed it for the following three days after this conversation. R5 stated that he currently was seeing podiatry at a local hospital and did not see the wound doctor that came to the facility. In an interview on 08/05/2025 at 10:03 AM with State Registered Nurse Aide (SRNA)18 she stated that R5 was not a resident who refused care and was compliant with his medications and treatments. Interview on 08/05/2025 at 4:23 PM with LPN5 revealed that R5 went to his outside podiatry where they did his wound care for the day. Observation at this time revealed that the survey team could not observe the wound as the resident returned from the podiatrist in a cast. In an interview on 08/07/2025 at 2:31 PM with Associate Director of Nursing (ADON) 1, she stated that it was her expectation that wound care be done exactly as ordered by the physician because wound care not done so by the orders could result in worsening of the wound and could contribute to an infection. In an interview on 08/07/2025 at 2:42 PM with ADON2, he stated that R5 went out to an outside facility for wound care for his feet and refused to let the in house wound care physician treat him. ADON2 stated that R5 had complained in the past about not getting his wound care done as ordered and it had been several months since ADON2 investigated the matter. He stated he found there were instances that the wound care was not documented in the TAR. ADON2 stated this was most likely because the facility used a lot of agency nurses in the past and many had difficulty getting access to the facility's electronic medical record (EMR). He stated that this issue was fixed, and he was not sure why the instances of missed wound care increased in the last two months. He stated that if the wound care treatment was not documented in the TAR, it was considered as not performed. He stated that failure to provide wound care as ordered could cause infection and worsening of the wound. ADON2 noted stated that R5 was a diabetic, a smoker, and liked to go outside frequently, exposing his wounds to the elements; all of which contributed to issues with his diabetic foot ulcers and their healing. In an interview on 08/07/2025 at 2:54 PM with the Director of Nursing (DON), she stated it was her expectation that staff follow wound care orders as ordered and report any changes of the wound immediately to the physician. Per the DON, if wound care treatments were done, it was her expectation that they should be marked off on the TAR. If staff forgot to mark off the treatment as done on the TAR, they should go back and do a late entry once they remembered. The DON stated she had called agency staff to ask if treatments were done and had them come and have them mark off their treatments if they forgot; however, it was difficult to get agency staff to return and do this after the fact. She stated that if the treatment was not marked off, it did not necessarily mean it was not done, just that it was not documented. However, she was unable to provide evidence that the missing treatments, which were described by the resident and corroborated by facility documentation, were completed. Further interview with the DON revealed that if wound care was not done as ordered, the wound could worsen. In an interview on 08/07/2025 at 3:05 PM with the Administrator, he stated wound care should be done as ordered. Per the Administrator, if the treatments were not being done, the DON should investigate why and try and come up with a solution to fix this. The Administrator stated that if wound care was not done as ordered, the resident's wound could worsen, and it could lead to sepsis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDEDBased on observation, interview, and review of the facilities policy the facility failed to store and prepare food in accordance with professional standards for food service safety which had the potential to affect 144 residents who consumed food from the kitchen. The findings include:Review of the facility's policy titled, [NAME] Corporate Dieticians Policy 152-Food Storage, revised 07/11/2024, revealed opened products should be placed in seamless plastic or glass containers with tight fitting lids and labeled and dated. Also to rotate stock utilizing first in and first out rotation. Further inquiry revealed no further policies on food handling. Observation on 05/11/2025 at 5:00 PM revealed in a walk-in refrigerator an opened container of a 2-pound roast beef with no epiration date. Further observations revealed a ham labelled as cheese wrapped in plastic wrap and dated 05/08/2025; pepperoni in plastic wrap undated and opened Two pieces of melon, wrapped separately in plastic wrap but undated and unlabeled. A blue plastic bin of tuna unlabeled and undated and a metal pan of tuna covered with foil and unlabeled and undated. A bucket of mushrooms dated 4/16 that appeared slimy and malodorous. 2 angel food cakes and 2 bags of chicken all frozen and unlabeled. In an interview with [NAME] #4 on 05/11/2025 at 5:15 PM she stated she would not serve outdated food items. In an interview with Dietary Aide #3 on 05/11/2025 at 6:00 PM she stated she would not eat something if she did not know how old it was and that residents could possibly get sick if served old food.

Based on interview, record review, and facility policy review, the facility failed to ensure a performance review was completed for every Certified Nursing Assistant (CNA) at least once every 12 months for four out of five CNA's personnel records reviewed, CNA7, CNA8, CNA9, and CNA10.
The finding include:
Review of the facility's policy, titled, Performance Evaluations, revised, September 2020, revealed, The job performance of each employee shall be reviewed and evaluated at least annually. Additionally, the policy stated, A performance evaluation will be completed on each employee at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review. Furthermore, the policy indicated performance evaluations may be used to improve the quality of the employee's work performance.
Review of CNA7's personnel file revealed a hire date of 12/07/2023. For dates of 12/07/2023-12/07/2024, there was a completed paper packet of annual training for 13 hours. However, there was no documentation for a performance evaluation in that 12-month period.
Review of CNA8's personnel file revealed a hire date of 01/21/2020. For dates of 01/21/24-01/21/25, there was a completed paper packet of annual training for 13 hours. However, there was no documentation for a performance evaluation in that 12-month period.
Review of CNA9's personnel file revealed a hire date of 01/04/2024. For dates of 01/04/2024-01/04/2025, there was a completed paper packet of annual training for 13 hours. However, there was no documentation for a performance evaluation in that 12-month period.
Review of CNA10's personnel file revealed a hire date of 05/17/2023. For dates of 05/17/2023-05/17/2024, there was a completed paper packet of annual training for 13 hours. However, there was no documentation for a performance evaluation in that 12-month period.
Interview with the Director of Nursing (DON) on 05/14/2025 at 4:00 PM revealed performance evaluations should be done annually. Further a possible negative outcome could be not knowing how staff are performing.
In an interview with the Administrator on 05/14/2025 at 4:12 PM he stated performance evaluations should be done yearly. The Administrator indicated a possible negative outcome if annual evaluations were not completed may be staff members unsure of the job expectations and their performance. There could be misunderstandings and confusion, as well as, missed opportunities in finding areas to improve.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide a safe environment for residents. The facility's deficient practice had the potential to affect 24 of 24 residents who resided on the English Oak Terrace Unit. On 05/01/2024 a staff member was arrested under suspicion of arson after a fire occurred in Resident (R14) and R466's room.
The facility failed to protect residents when a staff member, the Social Services Assistant (SSA), voiced frustration and threatened Resident (R) 14. On 05/01/2024 at approximately 4:45 PM, the Social Services Assistant (SSA) exited an elevator and stated to Certified Nursing Assistant (CNA) 2 he was going to get rid of R14. Subsequently, on 05/01/2024 the SSA was arrested for suspicion of arson after a fire occurred in the room of R14 and R466. Additionally, the fire was set while R14's roommate was in the room, R466.
It was determined the facility's non-compliance with one or more requirements of participation caused or was likely to cause serious harm, serious impairment and/or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care were identified at 483.25 Free of Accidents, Hazards, or Supervision, F689.
The IJ was identified on 05/10/2024 and was determined to exist on 05/01/2024 at approximately 4:45 PM when the SSA threatened to harm R14.
The facility was notified of the IJ and provided a copy of the IJ template on 05/10/2024 at 5:34 PM. An amended IJ template was delivered to the facility on [DATE] at 4:03 PM. An acceptable IJ Removal Plan was received on 05/16/2024. The State Agency validated removal of the IJ on 05/17/2024 at 5:00 PM following the facility's plan for removal of the IJ.
The findings include:
Review of facility policy Safety and Supervision of Residents, revised July 2017, revealed the facility made resident safety, supervision, and assistance priorities.
Review of facility policy Accidents and Incidents, dated July 2017, revealed it was the facility's responsibility to monitor its employees to ensure the safety of its residents.
Review of the facility's Kentucky Handbook, revised July 2020, revealed in Section 1.4 General Safety and Security Policy, all company employees are responsible to maintain a healthy and safe work environment. Additionally, employees were to advise their supervisor of any known or potential security risks and/or suspicious conduct of employees, customers, or guests.
Review of the Long Term Care Facility - Self-Reported Incident Form initial report to the State Survey Agency, received on 05/01/2024, revealed a fire occurred on 05/01/2024 at 4:57 PM, in the room of Residents (R) 14 and R466. Resident 14 was not in the facility when the fire occurred and R466 was in the room. Resident 466 required total assistance for mobility and ambulation. Continued review of the report revealed the facility's fire alarm was activated, the fire extinguished, and R466 was removed from the room and was evaluated by an emergency medical technician with no injury identified.
Review of the facility's Long Term Care Facility - Self-Reported Incident Form final report/5-day follow-up revealed the fire department personnel initially stated the fire began from a power-wheel chair cord; but, upon further inspection discovered suspicious items in the room and contacted a fire investigator who cleared all facility personnel from the room and secured the room. After the investigation, the local police were notified. The local police then arrested the SSA on 05/01/2024, and charged him with arson. Further review of the facility's final report/5-day follow-up revealed immediately prior to the fire, Certified Nursing Assistant 2 noted suspicious behavior from the SSA, including SSA entering and exiting the room where the fire occurred.
Review of the facility's video footage of the incident revealed on 05/01/2024, the SSA entered R14 and R466's room at 4:59:20 PM and exited the room at 5:00:18 PM. The SSA was in the resident room for approximately 58 seconds, and after exiting the room, the SSA walked away from the room, turned around and walked past the closed door and glanced at the residents' door at 5:00:52 PM. The fire alarm then sounded at 5:01:33, approximately 41 seconds later.
Review of the facility's admission Record revealed the facility admitted Resident (R) 14 on 06/28/2023 with diagnoses including generalized anxiety disorder, schizophrenia, adjustment disorder with mixed anxiety and depressed mood, and post-traumatic stress disorder, unspecified. The facility assessed R14 on the quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) 03/19/2024, as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. Additionally, the facility's functional assessment from the facility's MDS revealed R14 was independent regarding mobility with use of a motorized scooter.
Review of the facility's admission Record revealed the facility admitted R466 on 06/20/2023 with a diagnosis of stroke, hemiparesis and hemiplegia on left side, and unspecified dementia. Review of R466's quarterly MDS, with an ARD of 03/29/2024, revealed the facility assessed him with a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. Review of the facility's functional assessment from the facility's MDS of R466 revealed he was dependent on care regarding turning, repositioning, toileting, hygiene, and mobility.
Review of the facility investigation form Investigation Interview Question and Responses (Employee), (IIQR) undated, revealed Certified Nursing Assistant (CNA) 2, noted on 05/01/2024 at approximately 4:45 PM, she observed the SSA getting out of the elevator and per CNA2, the SSA stated I'm going to get rid of this old fucker. When CNA2 asked the SSA to clarify who, the SSA stated [R14].
Review of the IIQR for Licensed Practical Nurse (LPN) #4, dated 05/02/2024, revealed R14 approached her earlier in the day upset as the SSA had not yet taken R14 to an area store. Additionally, LPN #4 stated when she informed the SSA about R14 waiting for the SSA to take him to the store, the SSA responded by displaying his middle finger and saying fuck [R14] and cussed profusely.
Observation of the room of R14 and R466, on 05/09/2024 at approximately 8:20 AM, revealed no discernable effects of a fire other than fire extinguisher residue.
Interview with R14, on 05/09/2024 at 9:01 AM, revealed on the morning of 05/01/2024, R14 asked the SSA to escort him to the store and the SSA agreed; however, the SSA did not show. R14 then stated he asked the SSA again and the SSA responded he had an emergency and was not able. Further interview revealed R14 stated maybe he [the SSA] got tired of me asking to do this, the [store] thing.
Interview with CNA1, on 05/09/2024 at 10:31 AM, revealed approximately two to three weeks prior to the fire the SSA asked her which residents had cameras in their rooms. CNA1 stated she then escorted the SSA to the room of R14/R466 and pointed out the four cameras installed in the room. CNA1 stated she thought this was an odd question to ask but gave it no further thought.
Interview with CNA2, on 05/08/2024 at 10:40 AM, revealed she observed the SSA enter and exit R14's room and shut the door a few minutes prior to the fire alarm sounding.
Interview with Certified Medication Technician (CMT) 3 on 05/09/2024 at 11:17 AM, revealed that during the immediate aftermath of the fire, the SSA told her not to worry about R14 as the SSA had a feeling [R14] won't be around here much longer. CMT3 further stated she thought the comment odd but did not question it further.
Interview with the Administrator in Training (AIT), on 05/09/2024 at 3:00 PM, revealed he could not recall when the SSA informed him that R14 was getting on him a lot about going to the store. Additionally, he stated the SSA told him that R14 was driving him crazy and the SSA could not get his work done because of assisting R14.
Interview with the Administrator, on 05/08/2024 at 2:34 PM, revealed the facility was responsible for keeping residents safe, but it was difficult to predict when an employee may start a fire. Further, the Administrator stated he did not have a formal type of staff monitoring in place, prior to this incident (the fire on 05/01/2024). Since this incident, however, he stated he has provided education to all staff, including agency staff, regarding being aware of their surroundings and suspicious behaviors, from a resident or fellow staff member. Further, staff were provided education related to reporting any suspicious behaviors.
In an additional interview with the Administrator on 05/09/2024 at 12:47 PM, he stated he was not present at the time of the fire on 05/01/2024. Further, he stated local law enforcement had already taken the SSA into custody by the time he returned to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide a safe environment for residents. One sampled resident (Resident (R) 57) was not assessed for smoking, in accordance with facility policy. This non-smoking facility failed to ensure that incendiary devices (lighters) were not accessible to R57, who was involved in two separate instances of fire in his room. R57 was found to be in possession of cigarettes and a lighter after a fire in his bathroom on 04/15/2024. The following day, 04/16/2024, R57 had a fire in his closet. This failure to assure lighters were secured had the potential to affect six additional sampled residents (R40, R503, R14, R87, R504, and R506) as well as up to 58 residents who resided on one of four units (English Oak Terrace (EOT)) which was evacuated due to the fires, out of a total census of 150 residents.
The findings include:
Review of the facility's policy, Smoking Policy - Residents, revised 02/28/2024, revealed that prior to, and upon admission, residents were informed of the facility's policy to remain a smoke free environment. Per the policy, smoking was not permitted on facility property and smoking was not allowed inside the facility under any circumstances. Continued review of the policy revealed the resident's smoking status was evaluated upon admission. Per the policy, the facility maintained the right to confiscate smoking items found in violation of their smoking policies. The policy did not detail storing residents' lighters or other smoking paraphernalia.
Review of the facility's undated Prohibited Items document, included in the facility's Welcome Packet, revealed that, to keep residents safe and to stay in compliance with State and Federal regulations, the following items are prohibited in patient rooms or patient care areas any item that produced open flames including lighters and matches, also tobacco products (including smokeless).
1. Review of R57's history and physical (H & P) from the local hospital, dated 11/01/2022, revealed he was admitted to the Intensive Care Unit (ICU) after he underwent a thrombectomy (procedure to remove blood clots from the blood vessel) secondary to occlusion in the M1 (proximal) section of the middle cerebral artery. Further review of the H & P revealed R57 was a smoker.
Review of R57's admission Record revealed the facility admitted him to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis on one side of the body) following a cerebral infarction affecting the right dominant side, aphasia (a language disorder caused by damage to the brain) following cerebral infarction, chronic obstructive pulmonary disease (COPD) and noncompliance with other medical treatment and regimen due to unspecified reason.
Review of R57's admission Agreement, originally dated 11/15/2022, and signed with the resident's name but identified as his brother and responsible party, on 11/25/2022, revealed the tobacco policy was such that the resident and resident's guests agreed to follow facility rules and regulations regarding smoking within the facility and may smoke only in designated areas, if any, under appropriate staff supervision.
Review of the admission Minimum Data Set (MDS), with a date of 11/23/2022, included results of his Brief Interview for Mental Status (BIMS). Review of the BIMS revealed a score of 0/15, indicating severe cognitive impairment. Review of a quarterly MDS assessment, dated 12/16/2023, revealed a BIMS score of 10/15, indicating moderate cognitive impairment. Review of the most recent MDS, a quarterly assessment dated [DATE], revealed no BIMS summary score was calculated, instead, a Staff Assessment for Mental Status documented the resident's short- and long-term memory was okay, that he could recall current season and the location of own room and that he was independent in decisions regarding tasks of daily life with no acute onset mental status change. The 03/17/2024 MDS documented no behaviors directed towards himself or others. However, per Progress Notes, the resident did display behaviors after this MDS assessment, including cornering a staff member and swinging his first at her (03/28/2024), purposely running his wheelchair into staff, and attempting to leave the building on 04/02/2024.
Review of R57's complete history of clinical assessments since admission revealed no Smoking Assessment was completed, per facility policy, until 04/17/2024, after the resident sustained two fires in his room (on 04/15/2024 and 04/16/2024.) Review of the Smoking Assessment, dated 04/17/2024, revealed R57 smoked one - two times per day at various times. Further review revealed R57 had no cognitive loss, visual deficits, dexterity problems and could light his own cigarette but the assessment did not indicate if the resident could smoke with, or without, supervision.
In an interview with the Admissions Director on 04/20/2024 at 9:20 AM, she was not aware of when a smoking assessment was completed for a resident. During interview with Licensed Practical Nurse (LPN)16 on 04/17/2024 at 12:54 PM, she stated a smoking assessment was part of the admission assessment, and there was no recurrent smoking assessment completed after the admission assessment.
After failure to assess R57 for smoking, the resident was involved in two separate fires in his room.
Review of an Initial Report to the State Survey Agency, (SSA) dated 04/15/2024, revealed that there was a fire at the facility that day. Per the report, staff smelled cigarette smoke and went into R57's room. R57 was coming out of the bathroom, going back to his bed. Staff found a lighter next to the resident's bed. Staff were interviewing the resident about smoking, which he denied, when they noticed smoke coming from the bathroom at approximately 11:52 AM. Staff evacuated the room, extinguished the fire, and advised the Administrator of the incident. The hallway was evacuated, and the fire department arrived. R57 continued to deny smoking and was placed on 15-minute checks. Both a cigarette and a lighter were found in the resident's room after the event.
Observation of the facility lobby on 04/16/2024 at 12:08 PM revealed an alarm sounding, which proved to be a genuine fire alarm and not a drill. The survey team exited the conference room and observed that staff evacuated 16 residents who were present on the EOT unit where the fire started, in about seven minutes. There was a copious amount of smoke in the hall when the door was opened to allow evacuation of the residents from the unit to the lobby area.
Observation of the EOT unit on 04/16/2024 at 1:42 PM revealed R57's room, a semiprivate room, had sustained a fire in the closet, as evidenced by fire extinguisher residue and water as well as blackened dry wall. There was copious amounts of water in the closet, R57's room, hallway, and surrounding resident rooms, as well as saturated ceiling tiles that had fallen to the floor, plus particles that appeared to be insulation from above the tiles or residue from the sprinklers. ServePro, a business specializing in fire and water damage restoration, was already in the facility, and had begun water extraction.
Review of R57's record revealed he was transferred to the hospital on [DATE], after the second fire, for evaluation. Review of the hospital records, dated 04/19/2024, revealed the resident suffered from severe expressive aphasia and only responded yes or no to closed ended questions during interview. Upon evaluation, R57 indicated he did not set the fire intentionally, knew the facility was nonsmoking, and that he knew it was wrong to dissipate [sic] the rules.
During interview with the Social Services Assistant (SSA) on 04/18/2024 at 8:22 AM, he stated he usually rounds on R57 and his roommate to help with managing behaviors. He stated he was in the hall of EOT on 04/15/2024 around noon and smelled smoke. He stated he alerted the Unit Manager (UM) who dispatched a Certified Nurse Aide (CNA) to accompany him to locate the source of the smoke smell. He stated they went to R57's room and could smell smoke but could not determine the source. He stated that R57, who was present in the room at this time, denied he was smoking. Upon the UM's entrance, they searched surfaces, looking for smoking materials. The SSA stated he opened the bathroom door and smoke was coming from the linen closet, specifically from a hamper that contained clothing items. He stated he kicked it into the shower and turned on the water to extinguish the fire. He further stated nurses evacuated the residents while he stayed in the bathroom until the fire department came.
During the interview on 04/18/2024 at 8:22 AM, the Social Services Assistant stated that after the fire on 04/15/2024, R57 stayed at the nurses' desk in the EOT most of the day after everything was resolved, and the resident was placed on 15-minute checks. The SSA stated that on the following day, 04/16/2024 at approximately 12:05 PM, he was doing rounds on EOT and went to talk to the UM about another resident. He stated another staff member then alerted him to a smell and he went to check its source. He went into R57's room with the UM, and asked R57 if he was smoking, which he denied loudly. The SSA stated they then turned around and observed smoke coming from the closet. The SSA stated they shouted for an alarm to be sounded and for a fire extinguisher, which was brought quickly. He stated he opened the door and used the extinguisher to put out the flame. Subsequently, the SSA closed the door, the Administrator took R57 out of the room while he (the SSA) carried the roommate out, followed by evacuation for the rest of the unit.
During interview with the EOT UM on 04/17/2024 at 4:45 PM, she stated the SSA was coming down the hall on 04/15/2024, smelled smoke and went in R57's room. The UM stated the SSA looked around the room, saw a lighter and confiscated it. The UM stated she came to the room when the SSA brought the lighter. They both smelled cigarette smoke and thought something was on fire. The UM confirmed that the SSA opened the bathroom, found a trash can on fire in the bathroom closet which he kicked to the shower, and then extinguished the fire with water. The UM stated that in response, the unit was completely evacuated and R57 was placed on 15-minute checks. During continued interview, the UM stated the fire situation on 04/16/2024 was identical to the previous day, with the SSA in hallway, who then came for the UM and went in R57's room. She stated they asked R57 if he was smoking, and he denied it. When exiting the room, the UM stated she told the SSA she smelled something burning, and both sniffed for the location. She stated the SSA opened the closet door and fire whooshed out, such that they had to jump back. The UM stated they yelled for the fire alarm and a fire extinguisher. She confirmed the SSA put the fire out, and residents were evacuated. Further interview with the UM revealed she was told R140 may have provided a lighter and cigarette to R57 but there was no way to confirm this, and they did not really know where the lighters were coming from.
During telephone interview with Certified Nursing Assistant (CNA) 37 on 04/19/2024 at 5:09 PM, she stated she knew R140 and R14 smoked and believed R57 used to smoke, saying that R57 went out with others in the past. She stated she was aware that R140 kept a lighter in their jacket pocket, and that it was found when she or others picked up the jacket and it fell from the pocket. CNA37 stated she confiscated this lighter when she found it and reported it but was not sure if R140 continued carrying a lighter and was not sure of the date this incident had occurred. She stated problems with smoking started when several residents transferred from a facility that closed, and many of those residents from the closed facility smoked and just continued to do it at this facility. She stated at least two residents were caught smoking in their room, though neither was currently in the facility. CNA37 stated it was kind of a chain reaction after residents who moved in smoked, as other residents now wanted to smoke as well. CNA37 stated that those residents who could sign out independently, could go off property and smoke. She stated lighters were not supposed to be on property, that R140 was supposed to keep their lighter and cigarettes at the nurses' desk, and staff were expected to confiscate any smoking materials found and report it. After the fire on 04/15/2024, she stated R57 indicated R140 had given him the cigarette and lighter. She further stated that, upon questioning R140, he did not deny giving R57 a lighter, and stated Well, they should have let him go out to smoke.
During interview with the SSA on 04/18/2024 at 8:22 AM. the SSA identified additional smokers in the facility (besides R140) included R503, R14, R87, R504, and R506. He further stated R140 was no longer in the facility at this time and was not available for interview.
a. During interview with R503 on 04/17/2024 at 3:28 PM, he stated he smokes and kept his cigarettes and lighter locked up in his bedside table drawer.
During interview with the EOG UM on 04/17/2024 at 3:42 PM, she acknowledged R503 was able to go out and smoke, away from the building. She stated she understood cigarettes and lighters were kept at the front desk by the receptionist. In further interview, she stated she was unaware that the resident was keeping a lighter or cigarettes in his room and indicated the need to follow up.
In interview with the SSA on 04/18/2024 at 8:22 AM, the SSA stated he confiscated a lighter from R503 the previous afternoon. He stated he had taken R503 to an appointment yesterday and R503 had smoked while they were waiting. He stated he had observed that R503 had cigarettes and two lighters but since R503 was independent in his wheelchair, he did not escort R503 to his room. When he passed the desk, he noted the receptionist had the cigarettes and only one lighter, thus came to R503's room. He stated he told R503 he knew he had the lighter and R503 gave it up.
b. Interview with R504 on 04/19/2024 at 5:25 PM, revealed that prior to the two fire events, he kept his cigarettes and lighter in his top drawer and had no key to keep these items secured. He stated he believed that staff knew he smoked, as some of the staff had seen him smoke off the property and nobody asked him for his cigarette or lighter when he returned to the building. He voiced irritation because, after the fire, staff searched his room. During an additional interview with R504 on 04/20/2024 at 9:31 AM, he stated his lighter and cigarettes were not confiscated until after the second fire.
c. During interview with R14 on 04/20/2024 at 9:25 AM, he stated before the fire he kept his lighter and cigarettes in his room, and believed staff knew he smoked. He stated his lighter and cigarettes were confiscated after the fire but was not sure whether it was after the first or second fire.
d. An attempted interview with R87 on 04/20/2024 at 9:36 AM, was unsuccessful, as when the survey team asked about smoking, he shut his eyes tightly and would not answer questions.
e. During interview with R506 on 04/20/2024 at 10:26 AM, he stated that when he smoked, he got a light from one of the other residents who smoked.
During interview with LPN16 on 04/17/2024 at 12:54 PM, she stated the facility was strictly non-smoking, but lately they have had residents who go off premises to smoke. She stated she did not know where smoking materials were stored.
Observation on 04/17/2024 at 3:52 PM revealed Main Entrance Receptionist 1 demonstrated how she secured smoking materials, including lighters, in a locked box with a key. The lockbox currently contained two packs of cigarettes, each with a lighter as well as a vape. During interview at the same time, the receptionist she stated they used to keep lighters/smoking materials in this manner but got away from this process and was not sure why. When asked when the facility restarted this process of keeping all smoking materials, including lighters, locked up, the receptionist whispered Today, (after the initiation of the survey and the two fires in the facility).
In an interview with Main Entrance Receptionist 2 (who worked on the weekends) on 04/20/2024 at 11:10 AM, he stated that to smoke, the resident required an escort off the property, had a sign in/out on their personal sheet, he then unlocked the lock box and provided the resident with cigarettes and one lighter. He then double checked the checklist and ensured everything was completed prior to the resident exiting the building. The same process was followed when the resident returned. The receptionist stated when his shift was over at 8:00 PM, the lock box was placed in another locked cabinet for the night and the key was placed in a secret location. He said he followed this process for the six months he worked at the facility.
During interview with the Social Services Director on 04/19/2024 at 1:04 PM, she stated she has worked at the facility since 2018 and has always been under the impression this was a smoke free facility. She stated there were policies for smokers, such as a resident can only smoke if they leave the campus, and the Nurse Practitioner (APRN) had to sign off for it. She stated they have to keep the cigarettes/lighter at the front desk but have not always had to do this.
In an interview with the Admissions Director on 04/20/2024 at 9:20 AM, she stated her assistant met with potential residents prior to admission and discussed all the requirements for admission. She said the residents/family were informed at that time that the facility was nonsmoking. She said a Welcome Packet was left in the resident's room and a CNA was supposed to go to the room and orient the resident on their first day. The Admissions Director said at this time, the resident was informed of prohibited items (which included lighters). She stated that when residents were identified as smokers, they were told they had to leave their cigarettes and lighter at the front desk. The items were placed in a bag with the resident's name on it. She stated this process was for cigarettes and all other tobacco related products, such as lighters, matches, and vapes. The Admissions Director stated there would be no way for staff to know if a resident had a lighter hidden in the room, unless the resident left it out in plain sight, dropped it or it fell out of the resident's pocket.
In an interview with CNA17 on 04/20/2024 at 11:00 AM, she was presented a welcome packet and asked to walk through it as if she was welcoming a resident for the first time. She went through each page and explained what she said to a new resident; however, she skipped the page with prohibited items (including lighters) listed on it. When asked about the prohibited items section of the packet. she said she thought the nurses usually went over that part of the packet with the resident. CNA17 stated she had not been educated on welcoming new residents.
In an interview with CNA22 on 04/20/2024 at 11:20 AM, she was conducting a new admission. The CNA said she was not aware of the welcome process, and had not seen the packet, with the prohibited item list, before. CNA22 did not recall the welcome process being discussed in orientation.
During interview with the Assistant Director of Nursing (ADON) on 04/19/2024 at 4:14 PM, she stated they had not had issues until the facility received residents who transferred here after a building closure. She stated that with the arrival of the new residents, they had a lot of noncompliance with smoking, and a lot of the residents already in the building were questioning why others could smoke, so when socializing outside, they might get cigarettes from others. The ADON stated they now have a log where there was an effort to track smoking materials and residents were now expected to keep materials at the front desk. However, she acknowledged they did not have a formal method to track possession of smoking materials, including lighters, as of 04/15/2024 when the first fire occurred.
During interview with the Director of Nursing (DON) on 04/20/2024 at 11:53 AM, she stated when she came to this job almost a year ago, it was a non-smoking campus. She stated that if a resident smoked, he or she would have to go off the campus. The DON stated the resident would have to be assessed to be safe to leave the property independently, and then, if they smoked when they go off the property, that was their right. She stated that when a resident who signed out returned, they had to sign back into the facility, but the facility did not ask everybody if they were smoking or if they have prohibited items such as a lighter. The DON stated the expectation was if staff observed something different with a resident, such as appearing impaired, or if a resident smelled like cigarette smoke, they must report it to the DON. She stated that if they did ask residents if they had lighters and/or cigarettes or other tobacco products, they had to depend on the residents to be honest that they did not have any prohibited items in their room or on their body. The DON stated they did not place R57 on one-to-one supervision after the first fire because his room had been searched and no other lighter (besides the one the SSA confiscated) was found. The DON further stated residents were notified of prohibited items at admission from the admissions staff, and that the welcome packet in their rooms included the list of prohibited items. During this interview, the DON added that the administrative staff do Angel Rounds, on a weekly basis where staff go to each resident's room and assess a variety of issues. During these rounds, the DON stated, staff also look for prohibited items. However, review of the Guardian Angel Rounds form used during these checks revealed that it did not indicate that staff were to check for prohibited items, including lighters.
In an interview with the Administrator on 04/20/2024 at 1:15 PM, he indicated there was a gas station across the parking lot, where residents who went off the property would have the ability to buy smoking materials, including lighters. He stated the facility had a system in place for each resident who was identified as a smoker and they were to sign their cigarettes and lighter in and out each time they went out to smoke. The Administrator stated the facility would have no way of knowing if a resident purchased another lighter at the gas station, other than having the receptionist asked if they had any other lighters. If a resident said no, they had to take them at their word unless there was a reason not to. The Administrator said residents had rights and could not be searched without their permission. The Administrator stated he worked with the management team and staff to ensure no lighters were getting through by checking rooms for any obvious signs of smoking and had not found any.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility alleged removal of the immediacy of the IJ on 01/01/2022 as follows:
1. On 05/10/2021, Resident #112 was assessed using the Elopement Risk Assessment by Licensed Practical Nurse (LPN) #9. The resident was placed on 15-minute checks until he/she went to the hospital on [DATE]. The resident ' s care plan was updated. The resident has not had further elopements since 05/09/2021.
2. On 05/09/2021, the facility reviewed the State Operations Manual (SOM) and again on 02/03/2023, to go over the definition of elopement. The Interdisciplinary team (IDT), Administrator, Assistant Director of Nursing, Nurse Mangers, and Social Services reviewed the Wander Risk Assessment. Residents that were assessed to require a Wander-guard bracelet were placed in the binder located at each nursing station and front desk. Further, the residents assessed to be an elopement risk, care plans were updated.
3. On 05/10/2021, education began with all the facility staff. The Director of Nursing (DON) provided the education, and it was ongoing. Further, education was provided during all staff meetings on 09/2021 through 11/2021 after the Assistant Regional Director of Services identified potential issues and/or concerns during onsite visits through resident medical record audits and observations. Education that was included was on the Elopement Policy, Wandering, resident/resident representative expectations of signing out prior to resident leaving the facility, and missing resident protocol by the Administrator, DON, Nurse Managers, Social Workers, Admissions Staff, and Supervisors.
4. On 07/02/2021 through 07/27/2021, the Assistant Regional Director of Clinical Services assigned the Director of Clinical Services assigned the DON, Nurse Managers, Charge Nurses, and nurse supervisors, after completion of an onsite audit, to conduct an audit on wandering risk assessments. All residents were verified to have an updated risk assessment in their medical record.
5. On 07/02/2021, the Assistant Director of Clinical Services re-educated the DON and Administrator regarding their roles and responsibilities for following the facility's policies which included but was not limited to discharging against medical advice, elopement, and wandering oversight and supervision, QA process and QAPI Program.
6. On 07/29/2021 and 09/24/2021, the Quality Assurance and Performance Improvement meeting was held to review the facility's protocol and policy for elopement. The attendees included the Administrator, Medical Director, Director of Nursing, Assistant Regional Director of Clinical Services, Medical Records, Assistant Director of Nursing, Therapy, Housekeeping, and Activity Director.
7. On 07/29/2021 and 09/24/2021, the facility assessment was reviewed in the Quality Assurance Performance Improvement Committee to review the results of the audits and no changes were needed. Further, the QAPI committee reviewed any discharges or unplanned dischargers from 06/2021 through 12/2021, no concerns were identified.
8. On 08/01/2021, the DON, Nurse Manager, Supervisor or Charge Nurse evaluated all new admissions/re-admissions residents on admission to determine if a resident was triggered to be an elopement risk. The residents who triggered to be at risk for elopement would have a comprehensive person-centered care plan developed and implemented by the Minimum Data Set (MDS) nurse and IDT team, that included the resident's risk for elopement. If concerns were identified, it was discussed in the daily Interdisciplinary Plan of Care Meeting and the DON would report the concerns to the QAPI committee.
9. During the month of August of 2021, the Assistant Regional Director of Clinical Services assigned the Director of Nursing and Administrator to conduct elopement drills. A total of 2 element drills were completed. All elopement drills were reviewed with the Assistant Director of Clinical Services, the Director of Nursing and Administrator. The Emergency Plan for locating a missing resident was reviewed by the Assistant Regional Director of Nursing and the Administrator on 09/24/2021, with no changes indicated.
10. On 11/17/2021, the Governing Body (Regional [NAME] President) received verbal education per the Regional Director of Clinical Services regarding expectations of self-reportable incidents including but not limited to elopements and elopement versus against medical advice. The Assistant Regional Director of Clinical Services and Assistant Regional Director of Clinical Services increased onsite facility visits to 2-3 days per week to ensure that facility Administration and staff were following the Elopement Policy and Procedures.
11. On 12/01/2021 through 12/31/2021, annual competencies were completed, which included but was not limited to elopements. All the new staff received Elopement training upon hire, during new hire orientation, by the staff development coordinator. Staff who had not received the training, to include the agency staff, prior to 12/31/2021 received training prior to the start of their shift by the nursing scheduler, staff development coordinator, nurse management team, or supervisor prior to the start of their shift. Further, self-reportable incidents was reviewed by the Regional Director of Clinical Services and/or Assistant Regional Director of Clinical services on site no later than 72 hours following the incident. The Assistant Regional Director of Clinical Services kept a log of all the self-reportable incidents and was reviewed monthly by the Administrator and the Regional [NAME] President.
The State Agency validated the IJ Removal Plan as follows:
1. Review of Resident #112 Admission/Readmission Assessment revealed the resident was accompanied by the paramedics, by ambulance on 05/10/2021. Further review revealed the resident refused to be checked by staff for a skin assessment. Review of the resident's Baseline care plan revealed the resident's care plan was revised to include 15-minute checks and the care plan included the resident was at risk for elopement.
2. Review of the SOM documentation, dated 2021, revealed the facility reviewed the definition of elopement. Review of the elopement binder revealed the facility had placed all residents to be an elopement risk in the binder.
3. Review of the facilities education, provided by the facility revealed education was provided to all staff from 05/2021 to 11/2021. Education provided included Abuse, Wandering Residents, Behaviors, Customer Service, and Infection Control. Review of the facility's Wandering and Elopement policy, revised on 05/17/2020, revealed the facility defined elopement as an unsafe wandering and the facility strived to prevent harm while maintaining at the least restrictive environment for the residents.
4. Review of the QA Audit-Wander guard Tool, dated 07/02/2021, revealed the residents were audited to ensure the residents that were assessed as an elopement risk had an MD order, Wander guard Bracelet, updated care plan, TAR, and were in the elopement book/binder. No concerns were identified. Review of the Care Planning Audit Tool, dated 07/27/2021, revealed the residents who were assessed as an elopement risk care plan was assessed to include the following: Had the comprehensive care plan been developed; Did the residents care plan identify and include areas that pertain to the residents diagnosis; Did the care plan match the resident ' s needs; Were assistive devices in place per the residents plan of care; Was there evidence that the care plan reflected an interdisciplinary approach to the development of the care plan; Did the care plan identify the residents individualized goals, preferences and choices; Did the care plan clearly show a description of the action to be taken and by whom; Did the care plan contain some evidence of supporting or encouraging the individual to self-care/manage their well-being; Was there evidence that the care plan had been reviewed; Did the care and services provided reflect the residents current functioning status; Did the Kardex reflect the resident specific assistance needed to ensure care and services were provided? Continued review of the Audit tool revealed it was signed off and reviewed on 07/29/2021.
5. Review of facility's document, dated 07/02/2021, revealed the ARDCS went over the roles and responsibilities with the Administrator and DON. Further, the ARDCS went over the facility's goals, leadership, and management expectations. The QA Process and QAPI Program and audits were discussed. Continued review revealed the Administrator, DON, and ARDCS, signed the document on 07/02/2021.
6. Review of the Quality Assurance Committee Meeting Minutes, dated 07/29/2021 and 09/24/2021, revealed the committee reviewed elopement drills with no concerns identified. Review of the sign-in sheet revealed the Administrator, DON, Medical Director, ADON, Social Service, Dietary manager, Dietitian, Therapy, Maintenance, Environmental Services, Activities, Admissions, and MDS attended the meeting.
7. Review of the Facility Assessment revealed the QA Committee revealed the results of the audits. There were no changes on concerns identified.
8. Review of the New admission worksheet revealed the residents were assessed to be an elopement risk and was care planned based on assessment. No concerns were identified.
9. Review of the Emergency Plan and Elopement Drills, dated 07/29/2021 and 09/24/2021, revealed no concerns identified.
10. Review of the document, dated 11/17/2021, revealed the Regional Director of Clinical Services met with the Regional [NAME] President to review the self-reportable incidents from the region. The Regional Director of Clinical Services advised that the DON and Administrator was expected to report any allegations to the Regional Director of Clinical and the Regional [NAME] President to meet regulations related to reporting. Further review of the document revealed the Regional [NAME] President and Regional Director of Clinical Services signed off on the document on 11/17/2021.
11 Review of the annual competencies form revealed the facility checked the competency of each staff in areas which included: resident rights, abuse, skin/wound care, medication management, and disaster planning. Continued review revealed staff were checked prior to the start of their shift.
During an interview with the ARDCS, on 02/05/2024 at approximately 6:30 PM, she stated she reviewed the incident related to Resident #112's elopement and determined the facility needed additional training on the definition of elopement. She stated she retrained the Administrator, who left in November of 2021, and the DON. Further, she stated she put a Plan of Correction in place to address the concerns, with auditing the residents for changes in behaviors, assessing the residents to be an elopement risk, and updated the resident's care plans. Per the interview, she stated she audited the concern until the end of December. She further stated she had not had concerns with Resident #112 leaving the facility without staff supervision since 2021.
Based on interviews, record reviews, and facility document and policy review, it was determined that the facility failed to provide supervision to prevent accidents related to elopement for one (1) of three (3) sampled residents, (Resident #112). Specifically, Resident #112, whom the facility assessed to have moderately impaired cognition and developed a care plan that directed staff to supervise as needed, left the facility without notifying staff on 05/09/2021.
The facility failed to notify the police that the Resident was missing until approximately 18 hours after Resident #112 left the facility. On 05/10/2021 at approximately 10:00 AM, Resident #112 was found on the side of a highway, and the resident, who reported walking around all night, was transported by local Emergency Medical Services (EMS) to a local hospital for cold exposure.
It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified at 483.25, Free of Accidents Hazards and Supervision,F689. Additional IJ deficiencies were identified at 483.70 Administration, F835 and F837.
The IJ began on 05/09/2021 at approximately 6:00 PM when Resident #112 exited the facility without the staff's knowledge.
The facility was notified of the IJ and provided a copy of the IJ template on 02/02/2024 at 5:12 PM. An acceptable IJ Removal Plan was received on 02/05/2024. The IJ was determined to be to past, effective 01/01/2022.
1. A review of an undated facility policy titled, Emergency Procedure - Missing Resident, revealed, Resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed, 2. Staff will implement the protocol for a missing resident upon discovering that a resident cannot be located. Further review of the policy revealed when a resident was missing 1. Announce a Code Pink with the resident's room/unit number. 2. Note the time that the resident was discovered missing. 3. Report to the nursing station to see if the resident was signed out. 4. Notify the Administrator, Director of Maintenance, and Director of Nursing if not on the premises. 5. Report to the resident's unit for briefing and instruction. 6. Initiate a thorough search by staff members to locate the resident. 7. If the search is unsuccessful after a period of ten (10) minutes, call the police to report the resident missing. The policy revealed, 11. Complete an incident report and follow the facility's incident reporting process. 12. Document the incident and events objectively in the resident record, including: a. Circumstances and precipitating factors.
A review of an undated facility policy titled Discharging a Resident without a Physician's Approval revealed, A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice. The policy revealed, 3. If the resident or representative (sponsor) requests discharge or leaves the facility on their own accord without the approval of the attending physician, the resident and/or representative (sponsor) will be asked to sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. 4. If a resident wishes to be discharged to a setting that does not appear to meet his/her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will: a. discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b. document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; c. document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; and d. determine if a referral to Adult Protective Services or other State entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge.
A review of Resident #112's admission Record indicated the facility admitted the resident on 04/01/2021 with diagnoses that included acute kidney failure, stage 3 chronic kidney failure, cerebral infarction (stroke), muscle weakness, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, varicose veins of the left lower extremity with an ulcer to the lower leg, essential hypertension, and heart failure. The admission Record revealed the facility discharged Resident #112 on 05/09/2021 at 6:00 PM. The discharged to, Signature, and Personal Effects Sent With, sections of the form were not completed.
A review of Resident #112's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required extensive assistance of one (1)staff member with dressing, toilet use, and personal hygiene; and required extensive assistance of two (2) or more staff members with transfers. The MDS revealed that Resident #112 required limited assistance (staff provide guided maneuvering of limbs or other non-weight bearing assistance) with locomotion off the unit. Further review revealed Resident #112's balance was not steady. The MDS revealed the resident was not steady and only able to stabilize with staff assistance when transferring from surface to surface. The MDS revealed the resident utilized a walker or wheelchair for mobility. Continued review of the MDS revealed the resident's overall expectation was to remain at the facility.
A review of Resident #112's Care Plan revealed a Focus area initiated on 04/12/2021 that indicated the resident had cognitive impairment related to cognitive communication deficit. The facility developed interventions that directed staff to cue, re-orient, and supervise the resident as needed. Further review of Resident #112's Care Plan revealed a Focus area initiated on 04/02/2021 that indicated the resident needed assistance with activities of daily living (ADL) related to weakness. The facility developed interventions that directed staff to assist the resident with ambulation, locomotion, toileting, and transfers. The Care Plan revealed Focus areas initiated on 04/02/2021 related to pain; a wound to the left lower extremity that was at risk for developing infection and/or deterioration; risk for falls related to weakness; diagnosis of diabetes and risk of complications; risk for bleeding and bruising related to Plavix (a blood thinner) medication use; and risk for cardiac issues related to heart failure, hyperlipidemia, and hypertension. A review of Resident #112's Care Plan revealed no documented evidence the facility planned for the resident to leave the facility nor go to a local store without staff supervision.
A review of Resident #112's Progress Notes dated 05/09/2021 at 6:36 PM, electronically signed by Licensed Practical Nurse (LPN) #2 (a charge nurse), revealed Resident #112 walked past LPN #2 in the hallway heading back to their room, LPN #2 called out the resident's name, and LPN #2 witnessed the resident leave through double doors. The note revealed LPN #2 called the receptionist at the front desk and asked if Resident #112 left the building. The note revealed the receptionist reported she saw a resident leave the building. The note revealed LPN #2 notified the weekend supervisor, Registered Nurse (RN) #3 and checked the parking lot for the resident. The note revealed LPN #2 then walked to the grocery store next door to the facility to check for the resident. The note revealed LPN #2 witnessed Resident #112 checking out with the cashier at the grocery store and encouraged the resident to return to the facility. Continued review revealed the resident looked at LPN #2 but did not respond. LPN #2 walked out to the front of the store while on the phone with Resident #112's Responsible Party (RP) and another family member, and the resident was following behind. The note revealed LPN #2 turned around to check on the resident, and the resident was missing. According to the note, LPN #2 re-checked the grocery store and parking lot and could not locate Resident #112. The note revealed the nurse returned to the facility to look for the resident and met RN #3 at the front door. RN #3 asked about the resident, and LPN #2 explained what she had witnessed. The note revealed RN #3 went to check the grocery store. Further review of the note revealed LPN #2 was on the phone with the resident's family during the entire search. The note revealed the resident's family had also attempted to reach the resident on a cellular phone, but they were unable to reach the resident. The note also revealed RN #3, the Director of Nursing (DON), and the Administrator were notified.
A review of Resident #112's Progress Notes dated 05/09/2021 at 7:47 PM revealed DON #27, a previous DON, documented that the family notified the facility that Resident #112 had discharged AMA (against medical advice), which the family expected. The note revealed the family was in the process of locating the resident by calling the resident's friends. DON #27's documentation revealed a discharge form would be given to a family member. According to the note, the resident's physician was notified of the discharge.
A review of Resident #112's Progress Notes dated 05/10/2021 at 10:31 AM, titled Interdisciplinary Note, revealed Administrator #54, a previous Administrator, documented that Nurse Practitioner (NP) #38 was present during a discussion of Resident #112's AMA discharge the day before. According to the note, NP #38 stated she was not surprised by the resident's discharge because the resident told her the resident had been homeless in the past and was used to going out on their own.
A review of an undated facility document titled Initial revealed Adult Protective Services (APS) was at the facility on 05/11/2021 (two days after the resident left the facility without staff knowledge) related to Resident #112's AMA discharge over the past weekend. The report revealed the facility notified APS that, per the resident's family, this was normal behavior for the resident and that the resident used to live on the streets. According to the document, the resident was alert and oriented and was their own responsible party with BIMS of 10. The document revealed the resident was readmitted to the facility on [DATE], and a family member was working to get power of attorney. Continued review revealed the facility placed the resident on 15-minute checks to make sure the resident settled back into the facility. The document revealed a care plan conference would be set up with the resident and their family member to discuss not leaving AMA in the future.
A review of an undated facility document titled 5-Day revealed the resident's elopement risk assessment indicated the resident was at low risk for elopement (score of 2 of 23) and a Wanderguard bracelet (a bracelet placed on a resident that alerts staff when a resident exits a door equipped with a Wanderguard system) was not placed because the resident's cognition was intact. The document revealed on 05/09/2021, Resident #112 went to a store and bought snacks at approximately 5:45 PM; when the resident did not immediately return, the weekend supervisor (RN #3) went to check on the resident. The report revealed that when RN #3 did not find the resident at the store, she notified the DON, who called the Administrator at approximately 6:04 PM. The document revealed that the Administrator drove along the road looking for the resident but did not find the resident. The facility document revealed the facility contacted the resident's family and notified them the resident had left. The document revealed the Administrator verified with the store's video footage that Resident #112 entered the store at approximately 5:45 PM and left at approximately 5:56 PM with a bag of groceries. The document revealed the resident was wearing a baseball cap and a jacket. According to the document, the resident's family member did not want to file a police report as they considered this normal resident behavior. The document revealed that on 05/10/2021 at 11:24 AM, approximately 18 hours after Resident #112 left the facility, the police were called, and a missing person report was filed. The document revealed that at 12:02 PM on 05/10/2021, the resident's family arrived at the facility and notified them that the resident had been found and was in the emergency room (ER). The document revealed that the facility concluded that Resident #112 went to a store and decided to go visit a friend who lived nearby. The document revealed the resident stated they had always come and gone as they pleased and didn't have to tell anyone what they were doing or where they were going. The document revealed the resident stated they did not tell anyone where they were going because they did not want to, and they had originally planned to come back to the facility after buying snacks. There was no documented evidence the facility followed their Emergency Procedure - Missing Resident protocol that required staff to Initiate a thorough search for the resident and contact the police if the resident was not found within ten minutes.
A review of Google Maps revealed the store was a four-minute walk, or 0.2 miles from the facility.
A review of an untitled and undated facility document revealed DON (Director of Nursing) #27, the previous DON, signed a statement that LPN (Licensed Practical Nurse) #2 reported Resident #112 told them that they were going to the store. However, according to the statement, LPN #2 also called the receptionist about the resident, and the receptionist stated the resident went out the door as a visitor was entering the facility. The statement indicated the nurse followed the resident who was at a store across the street; the resident was getting items at the store and agreed to return to the facility when they were finished. The statement revealed that DON #27 verified with the nurse that the resident was alert, oriented, and able to make their own decisions. Further review revealed the resident was also their own responsible party. DON #27's statement revealed that when the resident did not return, LPN #2 went back to the store, and the resident had left. The nurse notified Resident #112's RP, who stated they were expecting this.
A review of an untitled facility document dated 05/12/2021 revealed Administrator #54, a previous Administrator, signed a statement that revealed LPN #2 reported that on 05/09/2021, Resident #112 left the facility to go to the store. However, the statement also revealed LPN #2 observed the resident walk past the front part of the unit, which prompted her to call the receptionist. Further review revealed LPN #2 stated the receptionist informed her that while she was talking with a family member at the desk, Resident #112 had went through the front doors. The statement revealed that LPN #2 walked to the store, made contact with the resident, and waited by the side door for the resident to exit. The resident did not exit the store, so LPN #2 entered the store and observed that the resident had left. The statement indicated LPN #2 contacted the resident's family.
A review of another untitled facility document dated 05/12/2021 revealed Administrator #54, a previous Administrator, signed a statement that revealed RN #3, the weekend supervisor, went to the store after LPN #2 returned without the resident. After several minutes at the store, RN #3 was unsuccessful at determining where the resident went and notified the DON.
A review of Resident #112's AMA Release Form revealed two (2 ) forms dated 05/09/2021 that were electronically signed by DON #27, the former DON. One of the AMA forms was dated 05/09/2021 at 8:13 PM and revealed Resident #112's RP's name was typed in the section of the form for the Resident/Responsible Party Signature and dated 05/09/2021. The second AMA form for Resident #112 was dated 05/09/2021 at 8:42 PM and revealed an N was documented for the Resident/Responsible Party Signature and for witness one's and two's signatures sections of the form. A statement on the AMA Release Forms revealed 1. This document serves to certify that the above named resident at the above named facility, am leaving against the advice of the attending physician. I acknowledge that I have been informed of the risks involved and hereby release the attending physician and the facility from all responsibility from all ill effects which may result from such discharge.
A review of Resident #112's Emergency Department Encounter note dated 05/10/2021 at 11:18 AM, revealed the resident presented to the Emergency Department (ED) via EMS with cold exposure. The note revealed the resident left the facility the night before at approximately 7:30 PM to go to the store without informing staff. The resident got lost when trying to get back and ended up on the expressway. The note revealed EMS found the resident that morning and stated the resident was out in the cold all night. Continued review revealed the first documented body temperature for Resident #112 was taken on 05/10/2021 at 2:45 PM, and the resident's body temperature was 99.2 degrees Fahrenheit (F). The ED record revealed the resident's diagnoses were chronic confusion, medically noncompliant, and non-intractable vomiting with nausea.
A review of Resident #112's ED Laboratory Results report dated 05/10/2021 revealed the resident's blood glucose level was 250 milligrams per deciliter (mg/dL) and was documented as high. The report reference range for blood glucose was 74-99 mg/dL.
A review of Resident #112's hospital Discharge Plan Update dated 05/10/2021 at 12:50 PM revealed the hospital Social Worker documented Resident #112 had confusion, and the Social Worker spoke with the resident's family about discharge from the hospital.
A review of The Weather Channel's weather history for the area where the facility was located revealed the lowest temperature from 5:56 PM on 05/09/2021 through 11:56 AM on 05/10/2021 was 43 degrees F with no precipitation.
During a telephone interview on 01/31/2024 at 12:04 PM, LPN #2, the Charge Nurse stated Resident #112 was due for blood glucose testing at 6:00 PM on 05/09/2021; however, the resident was not in their room. She stated the resident was ambulatory and went throughout the facility, visiting with residents and staff. LPN #2 stated when she could not find the resident, she went to the receptionist at the front desk. LPN #2 stated the regular/routine receptionist was not at the front desk; there was a new person at the desk. She stated she described the resident to the new receptionist, and the receptionist remembered pushing the button to open the front doors for the resident to exit the facility. LPN #2 stated the receptionist told her she thought the resident was a visitor. LPN #2 stated she walked out the front door to see if Resident #112 was in the parking lot. She stated she did not see the resident, so she notified her supervisor, RN #3 because she was not sure what she should do. LPN #2 stated RN #3 told her to return to her duties on the floor. LPN #2 stated that RN #3 stated she would walk to the store to see if the resident was there. LPN #2 stated RN #3 returned to the facility and stated the resident was not in the store, and she had notified Administrator #54, who stated they were to create a report that indicated the resident had notified the staff the resident was going to the store. LPN #2 stated the resident had not told her they were going to the store; she did not know where the resident had gone. She stated the facility did not ask her to write a statement. She stated she had spoken to the family when she noticed the resident was missing. She stated the family attempted to call the resident on their cell phone, and the resident did not answer. The LPN stated she wrote a lengthy progress note describing the elopement and told the family the res[TRUNCATED]

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure staff administered tube feeding formula at the rate prescribed by the physician. The facility also failed to accurately and consistently monitor the amount of tube feeding formula infused each shift to ensure one (Resident #135) of two (2) sampled residents reviewed for tube feedings consistently received the amount of tube feeding formula recommended by the Registered Dietitian (RD) and as ordered by the physician.
The findings included:
A review of the facility's policy titled Enteral Nutrition, revised in November 2018, revealed, Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation 1. The interdisciplinary team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The policy further indicated, 3. The dietitian, with input from the provider and nurse: a. Estimates calorie, protein, nutrient and fluid needs; b. Determines whether the resident's current intake is adequate to meet his or her nutritional needs; c. Recommends special food formulations; and d. Calculates fluids to be provided (beyond free fluids in formula). 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. The policy also specified, 9. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition.
A review of Resident #135's admission Record revealed the facility admitted Resident #135 on 08/18/2022 with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing) following unspecified cerebrovascular disease, and gastrostomy (a surgically placed opening into the stomach from the abdominal wall) status.
Review of Resident #135's Care Plan revealed a Focus area, initiated on 08/19/2022 and revised on 09/12/2023, that indicated the resident had a feeding tube to meet all nutritional needs and was at risk for complications. Interventions dated 08/19/2022 indicated the resident was to receive nothing by mouth (nil per os; NPO) and directed staff to provide tube feeding and water flushes per physician's orders. Another intervention dated 08/19/2022 indicated the RD would evaluate the resident at least quarterly and as needed to monitor caloric intake, estimate caloric needs, and make recommendations for changes in tube feedings as needed.
A review of Resident #135's Order Summary Report, listing active orders as of 01/31/2024, revealed an order dated 08/18/2022 for the resident to be NPO and an order dated 09/05/2022 for Jevity 1.2 at 70 milliliters per hour (ml/hr) continuously.
A review of Resident #135's Dietary Note dated 11/29/2023 at 8:26 AM revealed a Quarterly Nutrition Assessment that indicated Jevity 1.2 at 70 ml/hr continuously, 150 ml water flushes every six hours, and 200 ml water flushes with medication pass three times a day provided Resident #135 with 1848 calories, 85 grams of protein, and 2,647 ml of fluids every 24 hours. Resident #135's nutritional needs were recorded as 1600 to 1900 calories, 64 to 76 grams of protein, and 1600 to 1900 milliliters of fluids every 24 hours.
A review of the manufacturer's information for Jevity 1.2 revealed the resident's ordered tube feeding formula provided 1.2 calories for every ml infused, indicating that in order for Resident #135 to receive the amount of daily calories recommended by the RD, the resident would need to receive between 1,333 ml and 1,583 ml of tube feeding formula per day.
A review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2023, revealed a Staff Assessment for Mental Status (SAMS) determined Resident #135 had severely impaired cognitive skills for daily decision making. According to the MDS, the resident weighed 166 pounds at the time of the assessment, had not experienced a weight loss or gain of 5 percent (%) or more in the last month or 10 % or more in the last six months, and had a feeding tube while a resident of the facility. The MDS indicated Resident #135 received 51% or more of their total calories through parenteral or tube feeding and an average fluid intake of 501 cubic centimeters (cc) or more per day intravenously or by tube feeding.
A review of Resident #135's Order Summary Report, listing active orders as of 01/31/2024, revealed an order dated 12/04/2023 that directed staff to monitor the resident's tube feeding twice a day by documenting the total amount of formula infused at the end of each shift, then clearing the volume on the tube feeding pump.
A review of Resident #135's December 2023 and January 2024 Medication Administration Record (MAR) revealed documentation of tube feeding monitoring, including recording the total amount of formula infused each shift and clearing the tube feeding pump, was initiated on 12/04/2023 at 6:00 PM. However, the MAR revealed that staff did not begin recording the amount of tube feeding formula infused each shift on the MAR until 6:00 PM on 12/28/2023. The MAR revealed that prior to 12/28/2023, staff only initialed the MAR to indicate they completed the order or initialed and referred to the resident's progress notes. Staff documentation on the MAR revealed that the resident did not receive at least 1,333 ml of tube feeding formula daily to meet the amount of daily calories recommended by the RD on the following dates: 01/01/2024, 01/03/2024, 01/06/2024, 01/07/2024, 01/11/2024, 01/12/2024, 01/14/2024, 01/18/2024, 01/20/2024, 01/26/2024, and 01/27/2024.
A review of Resident #135's Progress Notes for the timeframe from 12/04/2023 to 12/28/2023, for which the MAR referenced the Progress Notes, revealed the following:
- A Nurse's Note dated 12/06/2023 at 6:40 AM that reflected the resident had received 244 ml of tube feeding formula on 12/05/2023 at 8:00 PM and 925 ml of tube feeding formula on 12/06/2023 at 6:35 AM;
- A Nurse's Note dated 12/07/2023 at 6:02 AM that indicated the resident had received 0 ml of tube feeding formula on 12/06/2023 at 8:45 PM and 626 ml of tube feeding formula on 12/07/2023 at 6:00 AM;
- A Nurse's Note dated 12/08/2023 at 6:26 AM that indicated the resident had received 618 ml of tube feeding formula on 12/08/2023 at 6:15 AM, and the pump was cleared to 0 ml for the oncoming nurse;
- A Medication Administration Note dated 12/13/2023 at 5:27 PM that reflected the resident had received a total of 901 ml of tube feeding formula during the shift;
- A Medication Administration Note dated 12/14/2023 at 5:27 PM that indicated the resident had received a total of 686 ml of tube feeding formula during the shift, and the tube feeding pump was cleared;
- A Medication Administration Note dated 12/20/2023 at 5:47 PM that indicated the resident had received a total of 741 ml tube feeding formula during the shift, and the tube feeding pump was cleared;
- An EMAR [electronic medication administration record]- Orders Administration Note dated 12/22/2023 at 5:54 PM that indicated the resident had received 684 ml of tube feeding formula during the shift; and
- A Medication Administration Note dated 12/26/2023 at 5:43 PM that indicated the resident had received a total of 867 ml tube feeding formula during the shift, and the tube feeding pump was cleared.
There were no other documented entries during this timeframe reflecting that staff were consistently monitoring and recording the amount of tube feeding formula the resident received each shift to ensure the resident was receiving the amounts recommended by the RD and as ordered by the physician.
During an interview on 01/31/2024 at 8:26 AM, Licensed Practical Nurse (LPN) #16 stated Resident #135's tube feeding was hung on 01/31/2023 at 6:00 AM and was infusing at a rate of 70 ml/hr. However, LPN #16 said the tube feeding pump reflected the resident had received 981 ml of tube feeding formula because the night shift did not clear the pump. LPN #16 said when recording the amount of tube feeding formula the resident received each shift, she based it on a rate of 70 ml/hr but said it was just a guestimate.
During an observation on 02/04/2024 at 10:35 AM, Resident #135's Jevity 1.2 was labeled as being hung on 02/04/2024 at 6:00 AM, and a water flush bag was labeled as being hung on 02/04/2024 at 8:00 AM. The tube feeding formula was infusing at a rate of 80 ml/hr. The tube feeding pump reflected that 150 ml of water flush and 1094 ml of the tube feeding formula had been infused since the pump was last cleared.
On 02/04/2024 at 10:40 AM, LPN #16 accompanied the surveyor to Resident #135's room to observe the tube feeding pump. LPN #16 confirmed the resident's tube feeding formula was infusing at a rate of 80 ml/hr and said the pump reflected the resident had received 150 ml water flush and 1097 ml of tube feeding formula. After reviewing Resident #135's orders, LPN #16 said the resident's Jevity 1.2 should be administered at a rate of 70 ml/hr, and nursing staff should be recording the amount of tube feeding formula infused each shift, then clearing out the tube feeding pump.
During an interview on 02/05/2024 at 3:11 PM, the RD stated he felt the information documented regarding the amount of tube feeding formula received by Resident #135 was a clerical error because the resident had not lost any weight. The RD said this was likely due to staff not clearing out the tube feeding pump each shift so that they could determine an accurate amount of tube feeding formula infused.
During an interview on 02/06/2024 at 12:04 PM, Nurse Practitioner (NP) #38 stated if nursing staff were not monitoring the amount of tube feeding formula infused and clearing the pump each shift, they were not obtaining accurate information. NP #38 stated this could eventually lead to a negative outcome for the resident, such as significant weight loss, wounds, or low protein levels.
During an interview on 02/06/2024 at 2:00 PM, the Administrator stated he was going to defer questions about tube feedings to nursing staff; however, he stated he expected staff to follow the facility's policies and physician's orders.
During an interview on 02/06/2024 at 2:35 PM, the Director of Nursing stated she expected nurses to infuse tube feeding formula per the physician's orders because if they did not, it could result in weight loss or the development of wounds.

Based on observations, interviews, and facility policy review it was determined that the facility failed to ensure staff stored, prepared, and served foods for 152 of 152 residents in a sanitary manner.
Kitchen staff failed to implement proper hand hygiene practices during meal service to prevent potential contamination. Staff failed to ensure food items were not contaminated during food preparation when staff used a knife while handling raw meat, then without sanitizing, used the same knife to slice cooked meatloaf.
In addition, staff should ensure that personal jewelry should not touch resident's food. Furthermore, staff should ensure that all food stored in the nourishment room refrigerators are properly labeled and dated and discarded if expired.
The findings include:
1. Review of the facility's policy titled, Food Preparation and Service, revised in November 2022, revealed 7. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use.
On 02/01/2024 at 12:22 PM, Dietary Aide #8 was observed serving residents' meal trays. During meal service, Dietary Aide #8 touched her forehead with her gloved right hand, then continued serving trays without changing gloves or washing her hands.
During an interview on 02/01/2024 at 1:47 PM, Dietary Aide #8 stated she had worked at the facility for eight (8) months and had been trained on food preparation and hygiene practices. Dietary Aide #8 stated she was expected to change gloves and wash her hands between every task.
During an interview on 02/04/2024 at 11:45 AM, the Dietary Director stated he expected staff to change gloves and wash their hands after they touched parts of their body.
During an interview on 02/05/2024 at 12:56 PM, [NAME] #24 stated she had been the Assistant Dietary Manager for a year. [NAME] #24 stated staff were expected to change gloves and wash their hands after every task and after they touched parts of their body to avoid cross contamination.
2. Review of the facility's policy titled, Food Preparation and Service, revised in November 2022, revealed the section titled Food Preparation Area specified, 4. Appropriate measures are used to prevent cross contamination. These include: a. storing raw meat separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigerator; b. preparing potentially hazardous foods away from other foods; c. sanitizing towels and cloths used for wiping surfaces in containers filled with approved sanitizing solution; and d. cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines.
On 01/31/2024 at 11:30 AM, [NAME] #7 was observed with a knife that was not cleaned nor sanitized, with particles of raw meat on it, begun to slice prepared meatloaf on the holding steam table.
During an interview on 02/02/2024 at 2:44 PM, [NAME] #7 stated she was expected to sanitize equipment before use.
During an interview on 02/04/2024 at 11:45 AM, the Dietary Director stated he expected staff to sanitize equipment after handling raw meat.
During an interview on 02/05/2024 at 12:56 PM, [NAME] #24 stated she had been the Assistant Dietary Manager for one (1) year. She further stated she expected staff to sanitize equipment after use.
3. Review of the facility's policy titled, Food Preparation and Service, revised in November 2022, revealed 9. Food and nutrition services staff keep fingernails trimmed and clean. Jewelry is worn minimally and hand jewelry is covered with gloves.
On 01/31/2024 at 10:31 AM, [NAME] #7 was observed handling prepared meatloaf with a bracelet on her left wrist. The bracelet came into contact with the meatloaf as she sliced it into individual servings.
During an interview on 02/02/2024 at 2:44 PM, [NAME] #7 stated she should not have worn a bracelet while preparing food, because it could lead to cross-contamination.
During an interview on 02/05/2024 at 12:56 PM, [NAME] #24/the Assistant Dietary Manager stated dietary staff were not permitted to wear jewelry, other than a wedding ring. [NAME] #24 further stated if a staff member's bracelet came into contact with meatloaf as they were preparing it, it risked cross-contamination.
During an interview on 02/06/2024 at 12:10 PM, the Dietary Director stated dietary staff should not wear jewelry while preparing food because it could result in cross-contamination.
4. Review of the facility's policy titled, Food Preparation and Service, revised in November 2022, revealed, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.
On 01/31/2024 at 1:57 PM, observation of the nourishment room refrigerator revealed one (1) container of opened thickened water with no date and one (1) an undated pitcher of orange juice.
On 01/31/2024 at 2:12 PM, observation of the nourishment room refrigerator in the English Oak Terrace revealed an opened containers of zero calorie sweet tea, nectar thickened tea, nectar thickened apple juice, and nectar thickened lemon water. These opened containers were not dated. In addition, the refrigerator contained an opened carton of tomato soup and a sandwich wrapped in plastic wrap labeled as extra that were not dated.
On 01/31/2024 at 2:26 PM, observation of the nourishment room refrigerator in the Chestnut Oak Garden hall revealed an opened tub of cottage cheese, a pitcher of orange juice, and an opened container of honey thickened lemon water.
On 02/01/2024 at 9:11 AM, observation of the Chestnut Oak Terrace nourishment room refrigerator revealed a sign that specified, When using thickened liquid containers, label the day you opened the bottle.
On 02/01/2024 at 11:43 AM, observation of Chestnut Oak Garden Hall nourishment room refrigerator contained three (3) expired half-and-half packets. In addition, there was one (1) undated, opened tub of cottage cheese and one (1) undated pitcher of orange juice in the refrigerator.
On 02/03/2024 at 9:52 AM, observation on English Oak Terrace nourishment room refrigerator contained two (2) undated, opened containers of nectar thickened tea, two (2) undated, opened containers of nectar thickened orange juice, and undated, opened containers of honey thickened orange juice. were observed in the English Oak Terrace nourishment room refrigerator. In addition, the refrigerator also contained an opened container of smoked ham, labeled with a date of 1/29, and one (1) undated, opened box of creamy tomato soup.
During an interview on 02/01/2024 at 1:47 PM, Dietary Aide #8 stated the dietary department was expected to maintain the nourishment rooms on each unit, including discarding unlabeled and undated food items.
During an interview on 02/04/2024 at 11:45 AM, the Dietary Director stated he expected dietary staff to maintain the nourishment rooms, including discarding any expired, undated, or unlabeled food items daily.
During an interview on 02/05/2024 at 11:56 PM, [NAME] #24/the Assistant Dietary Manager stated dietary staff should check the nourishment room refrigerators to make sure food items were in date and nothing was stored beyond three (3) days.
During an interview on 02/06/2024 at 1:31 PM, the Director of Nursing (DON) stated any opened and undated items in the nourishment rooms should be discarded. The DON further stated thickened liquids should be labeled when they were opened, and then discarded after three (3) days.

Based on observations, interviews, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code it was determined the facility failed to ensure 3 of 3 dumpsters were closed and the area around them was free of trash, and the elimination of debris prevented the potential for vermin and pest attraction. This had the potential to affect all 155 of 155 residents who resided in the facility.
The facility failed to provide dumpters.
The findings included:
Review of Chapter 5. Water, Plumbing, and Waste, section 5-5 Refuse, Recyclables, and Returnables of the U.S. FDA 2022 Food Code, dated 01/18/2023, revealed, 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit.
On 01/31/2024 at 1:36 PM, observation of the facility's dumpsters revealed there were three (3) dumpsters. The left dumpster was opened on both sides. This dumpster was identified as cardboard only, but it had a bag of rubbish that hung from the left side. The right dumpster was opened on both sides, as well as the lid. The rear dumpster was also opened on both sides. Additionally, there was debris and rubbish littered about the dumpster area, to include gloves, cigarette butts, one bottle of clinical cleanser, pieces of wood, pieces of cardboard, and pieces of plastic.
On 02/01/2024 at 11:27 AM, observation of the facility's dumpsters revealed the left dumpster's lid was opened and although labeled cardboard only, contained trash. The right dumpster's lid was also opened, and the door on the left side was partially opened. The rear dumpster's left door was opened, and two (2) gloves were on the ground by the dumpsters.
On 02/05/2024 at 11:00 AM, observation of the facility's dumpsters revealed the left dumpster's right door and lid were opened. The right dumpster's left door and lid were opened. The rear dumpster's left door was opened. The back dumpster lid was closed, but a bag of rubbish hung from the top of the dumpster, wedged between the dumpster and its lid. Additionally, there was rubbish littered around the dumpsters, including three (3) gloves, a soda can, a creamer packet, jam and peanut butter packets, and a plastic bag.
During an interview on 02/05/2024 at 12:56 PM, [NAME] #24/Assistant Dietary Manager stated dietary staff were responsible for maintaining the dumpsters. [NAME] #24 stated trash should not be on the ground around the dumpsters, and the dumpster doors should be closed to prevent vermin from getting into the rubbish.
During an interview on 02/06/2024 at 12:10 PM, the Dietary Director stated the dumpsters were the responsibility of the dietary department, but the Maintenance Director usually handled that responsibility. The Dietary Director confirmed the dumpster area should be clean from rubbish, and the dumpsters should be closed so as not to attract vermin.
During an interview on 02/06/2024 at 12:36 PM, the Maintenance Director confirmed the dietary department was responsible for maintaining the dumpsters, but he thought it should be a responsibility of the maintenance department.
During an interview on 02/06/2024 at 1:31 PM, the Director of Nursing (DON) stated that she did not know who was responsible for maintaining the dumpsters. The DON stated that opened dumpsters carried the risk of attracting animals.
During an interview on 02/06/2024 at 3:38 PM, the Administrator stated the maintenance of the dumpsters was a responsibility of the dietary department, but maintenance and housekeeping staff were also at the dumpsters frequently. The Administrator stated the primary concern if the dumpsters were left opened was that they could attract animals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility document and policy review, it was determined the facility failed to ensure that the Administrator of the facility took proper measures to ensure the safety of a resident for 1 (Resident #112) of three (3) sampled residents reviewed for elopement. Specifically, Resident #112, whom the facility assessed to have moderately impaired cognition and developed a care plan that directed staff to supervise the resident as needed, left the facility without notifying staff on 05/09/2021. The facility failed to notify the police that the resident was missing until approximately 18 hours after the resident left the facility. On 05/10/2021 at approximately 10:00 AM, Resident #112 was found on the side of a highway. It was reported that Resident #112, who had been walking around all night, was transported by local Emergency Medical Services (EMS) to a local hospital for cold exposure.
It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d) Accidents, at a scope and severity of J.
The IJ began on 05/09/2021 at approximately 6:00 PM when Resident #112 exited the facility without the staff's knowledge.
The facility was notified of the IJ and provided a copy of the IJ template on 02/02/2024 at 5:12 PM. An acceptable IJ Removal Plan was received on 02/05/2024. The IJ was determined to be to past, effective 01/01/2022.
The findings included:
A review of the facility's policy titled Administrator, dated March 2021, revealed, A licensed Administrator is responsible for the day-to-day functions of the facility. The policy revealed, The Administrator is responsible for, but not limited to: d. implementing established resident care policies, personnel policies, safety and security policies and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long term care facilities; and e. serving as liaison to the governing to the governing board, medical staff, and other professional and supervisory staff.
A review of an undated facility policy titled, Emergency Procedure - Missing Resident revealed, Resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed, 2. Staff will implement the protocol for missing resident upon discovering that a resident cannot be located. The policy revealed, 6. Initiate a thorough search by staff members to locate the resident. 7. If the search is unsuccessful after a period of ten minutes, call the police to report the resident missing.
A review of Resident #112's admission Record indicated the facility admitted the resident on 04/01/2021 with diagnoses that included acute kidney failure, stage 3 chronic kidney failure, cerebral infarction (stroke), muscle weakness, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, varicose veins of the left lower extremity with an ulcer to the lower leg, essential hypertension, and heart failure. The admission Record revealed the facility discharged Resident #112 on 05/09/2021 at 6:00 PM. The discharged to, Signature, and Personal Effects Sent With, sections of the form were not completed.
A review of Resident #112's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required extensive assistance of two or more staff members with transfers. Resident #112's balance was not steady, but was able to stabilize when walking or turning around. Resident #112 utilized a walker or wheelchair for mobility. Review of the MDS revealed the resident's overall expectation was to remain at the facility.
A review of Resident #112's Care Plan revealed a Focus area initiated on 04/12/2021 that indicated the resident had cognitive impairment related to cognitive communication deficit. The facility developed interventions that directed staff to cue, re-orient, and supervise the resident as needed. Further review of Resident #112's Care Plan revealed a Focus area initiated on 04/02/2021 that indicated the resident needed assistance with activities of daily living (ADL) related to weakness. The facility developed interventions that directed staff to assist the resident with ambulation, locomotion, toileting, and transfers. A review of Resident #112's Care Plan revealed no documented evidence the facility planned for the resident to leave the facility or go to a local store without staff supervision.
A review of Resident #112's Progress Notes dated 05/09/2021 at 6:36 PM, electronically signed by Licensed Practical Nurse (LPN) #2 (a charge nurse), revealed Resident #112 walked past LPN #2 in the hallway heading back to their room. The note revealed the receptionist reported she saw a resident leave the building. Continued review revealed LPN #2 notified the weekend supervisor (Registered Nurse (RN) #3) and checked the parking lot for the resident. The note also revealed RN #3, the Director of Nursing (DON), and the Administrator were notified.
A review of Resident #112's Progress Notes dated 05/09/2021 at 7:47 PM revealed DON #27, a previous DON, documented that the family notified the facility that Resident #112 had discharged AMA (against medical advice), which the family expected. DON #27's documentation revealed a discharge form would be given to a family member. According to the note, the resident's physician was notified of the discharge.
A review of Resident #112's Progress Notes dated 05/10/2021 at 10:31 AM, titled Interdisciplinary Note, revealed Administrator #54, a previous Administrator, documented that Nurse Practitioner (NP) #38 was present during a discussion of Resident #112's AMA discharge the day before. According to the note, NP #38 stated she was not surprised by the resident's discharge because the resident told her the resident had been homeless in the past and was used to going out on their own.
However, during an interview on 02/02/2024 at 11:27 AM, NP #38 stated Administrator #54 misquoted her in the Progress Notes dated 05/10/2021, which indicated she was not surprised that the resident had left AMA. She stated she had notified Administrator #54 that she did not make the statement and told him to remove that note from the Progress Notes. She stated she did not see Resident #112 on 05/09/2021, 05/10/2021, or 05/11/2021. She stated she saw the resident on 05/06/2021, prior to the resident leaving the facility, and the resident did not voice anything about leaving the facility. NP #38 stated usually, when a resident left AMA, the resident voiced that they were leaving and not coming back. She stated she thought DON #27, the former DON, notified her that Resident #112 had left AMA, but later, she was told the resident had eloped. She stated she would have called the family and police and would have looked for the resident. She stated the facility should have done more. NP #38 stated the resident could have been seriously injured and was in danger.
A review of an undated facility document titled Initial revealed Adult Protective Services (APS) was at the facility on 05/11/2021 (two days after the resident left the facility without staff knowledge) related to Resident #112's AMA discharge over the past weekend.
A review of an undated facility document titled 5-Day revealed on 05/09/2021, Resident #112 went to a store and bought snacks at approximately 5:45 PM. However, the resident did not immediately return. The facility document revealed the facility contacted the resident's family and notified them the resident had left. The document revealed the Administrator verified with the store's video footage that Resident #112 entered the store at approximately 5:45 PM and left at approximately 5:56 PM with a bag of groceries. However, further review revealed that not until 05/10/2021 at 11:24 AM, approximately 18 hours after Resident #112 left the facility, was the police called, and a missing person report was filed. The document revealed that at 12:02 PM on 05/10/2021, the resident's family arrived at the facility and notified them that the resident had been found and was in the emergency room (ER). There was no documented evidence the facility followed their Emergency Procedure - Missing Resident protocol that required staff to Initiate a thorough search for the resident and contact the police if the resident was not found within ten minutes.
A review of Resident #112's Emergency Department Encounter note dated 05/10/2021 at 11:18 AM revealed the resident presented to the Emergency Department (ED) via EMS with cold exposure. The note revealed the resident got lost when trying to get back and ended up on the expressway. The note revealed EMS found the resident that morning and stated the resident was out in the cold all night.with nausea.
A review of The Weather Channel's weather history for the area where the facility was located revealed the lowest temperature from 5:56 PM on 05/09/2021 through 11:56 AM on 05/10/2021 was 43 degrees F with no precipitation.
During a telephone interview on 01/31/2024 at 12:04 PM, LPN #2, the Charge Nurse stated Resident #112 was due for blood glucose testing at 6:00 PM on 05/09/2021; however, the resident was not in their room. She did not see the resident, so she notified her supervisor (RN #3) because she was not sure what she should do. LPN #2 stated RN #3 returned from the store and stated the resident was not in the store, and she had notified Administrator #54, who stated they were to create a report that indicated the resident had notified the staff the resident was going to the store. LPN #2 stated the resident had not told her they were going to the store; she did not know where the resident had gone. She stated she wrote a lengthy progress note describing the elopement and told the family the resident had eloped. She stated she considered it an elopement because no one knew where Resident #112 was located. LPN #2 stated she had never known Resident #112 to leave the facility unattended before.
During a follow-up interview by phone on 02/01/2024 at 5:43 PM, LPN #2 stated the Progress Notes dated 05/09/2021 at 6:36 PM, with her electronic signature, were inaccurate. She stated the resident did not notify her that they were going to the store, as documented in the note. She stated she would have told the resident not to go. She stated she also did not see the resident leave through the double doors; again, she would have tried to stop the resident. LPN #2 also stated she did not go to the store looking for the resident. She stated she would not have left the residents on her unit without a nurse. LPN #2 stated she did not speak to the resident at the store because she was not there. She stated if she had been at the store and the resident was behind her, the resident could not have disappeared quickly, as stated in the Progress Notes. She explained the resident was ambulatory, but the resident walked very slowly because both of the lower legs were wrapped with dressings.
During an interview on 01/29/2024 at 11:56 AM, Resident #112 stated prior to admission to the facility, the resident had a stroke and had mini-strokes. Resident #112 stated they walked to the gas station, and when they exited the store, the resident went the wrong way. Resident #112 stated they thought they knew the area and where their friend lived, but they could not find the friend's house. Resident #112 stated they did not plan on leaving the facility permanently. Resident #112 stated they did not sleep anywhere that night; they just walked around. Resident #112 stated the next morning, someone found them on the side of the highway. Resident #112 stated they had never gone to the store before and would never do that again.
During a telephone interview on 02/01/2024 at 3:28 PM, Resident #112's RP stated the former Administrator (Administrator #54) called them and reported the resident had gone to the store and had not returned. Resident #112's RP stated Administrator #54 asked them to call the police. Resident #112's RP stated they told Administrator #54 that the facility should call the police, but the Administrator refused. Resident #112's RP stated they ended up calling the police; however, they lived in another state, and due to jurisdiction issues, the police told them they needed to go to the facility/facility area to make the report. Resident #112's RP stated that before they arrived at the facility on the morning of 05/10/2021, the police found the resident. Resident #112's RP stated Administrator #54 had tried to get them to sign a waiver indicating the resident had left the facility AMA; however, they refused to sign the form and told Administrator #54 the resident was confused and was not capable of making a decision to leave AMA. Resident #112's RP stated the resident's mind was not right, and the resident did not understand what was going on.
During a telephone interview on 02/01/2024 at 1:48 PM, Administrator #54, the former Administrator stated the resident was alert, oriented, and their own POA and was allowed to leave. According to Administrator #54, the facility was not a prison. He stated he notified the family, who stated that before entering the facility, the resident would leave without telling anyone. He stated the resident's family notified him the next day that the resident was in the hospital. He stated he visited the resident in the hospital, and the resident stated they had wanted to visit with friends. He stated he also did not know whether the facility had assessed the resident's ability to go to the store because [the resident] left AMA. Administrator #54 further stated he did not remember whether the facility had a policy related to determining whether a resident was capable of going to the store. He stated if the resident was alert and oriented and their own POA, they had the right to go, we cannot stop them. He added he did not remember anything else.
During an interview on 02/06/2024 at 9:46 PM, the Administrator stated he was not at the facility when the incident occurred and did not know what happened; however, he stated the incident with Resident #112 should have been investigated if the resident eloped. The Administrator stated the facility's policy should have been followed, and it should have been investigated a long time ago.
The facility alleged removal of the immediacy of the IJ on 01/01/2022 as follows:
1. On 05/10/2021, Resident #112 was assessed using the Elopement Risk Assessment by Licensed Practical Nurse (LPN) #9. The resident was placed on 15-minute checks until he/she went to the hospital on [DATE]. The resident ' s care plan was updated. The resident has not had further elopements since 05/09/2021.
2. On 05/09/2021, the facility reviewed the State Operations Manual (SOM) and again on 02/03/2023, to go over the definition of elopement. The Interdisciplinary team (IDT), Administrator, Assistant Director of Nursing, Nurse Mangers, and Social Services reviewed the Wander Risk Assessment. Residents that were assessed to require a Wander-guard bracelet were placed in the binder located at each nursing station and front desk. Further, the residents assessed to be an elopement risk, care plans were updated.
3. On 05/10/2021, education began with all the facility staff. The Director of Nursing (DON) provided the education, and it was ongoing. Further, education was provided during all staff meetings on 09/2021 through 11/2021 after the Assistant Regional Director of Services identified potential issues and/or concerns during onsite visits through resident medical record audits and observations. Education that was included was on the Elopement Policy, Wandering, resident/resident representative expectations of signing out prior to resident leaving the facility, and missing resident protocol by the Administrator, DON, Nurse Managers, Social Workers, Admissions Staff, and Supervisors.
4. On 07/02/2021 through 07/27/2021, the Assistant Regional Director of Clinical Services assigned the Director of Clinical Services assigned the DON, Nurse Managers, Charge Nurses, and nurse supervisors, after completion of an onsite audit, to conduct an audit on wandering risk assessments. All residents were verified to have an updated risk assessment in their medical record.
5. On 07/02/2021, the Assistant Director of Clinical Services re-educated the DON and Administrator regarding their roles and responsibilities for following the facility's policies which included but was not limited to discharging against medical advice, elopement, and wandering oversight and supervision, QA process and QAPI Program.
6. On 07/29/2021 and 09/24/2021, the Quality Assurance and Performance Improvement meeting was held to review the facility's protocol and policy for elopement. The attendees included the Administrator, Medical Director, Director of Nursing, Assistant Regional Director of Clinical Services, Medical Records, Assistant Director of Nursing, Therapy, Housekeeping, and Activity Director.
7. On 07/29/2021 and 09/24/2021, the facility assessment was reviewed in the Quality Assurance Performance Improvement Committee to review the results of the audits and no changes were needed. Further, the QAPI committee reviewed any discharges or unplanned dischargers from 06/2021 through 12/2021, no concerns were identified.
8. On 08/01/2021, the DON, Nurse Manager, Supervisor or Charge Nurse evaluated all new admissions/re-admissions residents on admission to determine if a resident was triggered to be an elopement risk. The residents who triggered to be at risk for elopement would have a comprehensive person-centered care plan developed and implemented by the Minimum Data Set (MDS) nurse and IDT team, that included the resident's risk for elopement. If concerns were identified, it was discussed in the daily Interdisciplinary Plan of Care Meeting and the DON would report the concerns to the QAPI committee.
9. During the month of August of 2021, the Assistant Regional Director of Clinical Services assigned the Director of Nursing and Administrator to conduct elopement drills. A total of 2 element drills were completed. All elopement drills were reviewed with the Assistant Director of Clinical Services, the Director of Nursing and Administrator. The Emergency Plan for locating a missing resident was reviewed by the Assistant Regional Director of Nursing and the Administrator on 09/24/2021, with no changes indicated.
10. On 11/17/2021, the Governing Body (Regional [NAME] President) received verbal education per the Regional Director of Clinical Services regarding expectations of self-reportable incidents including but not limited to elopements and elopement versus against medical advice. The Assistant Regional Director of Clinical Services and Assistant Regional Director of Clinical Services increased onsite facility visits to 2-3 days per week to ensure that facility Administration and staff were following the Elopement Policy and Procedures.
11. On 12/01/2021 through 12/31/2021, annual competencies were completed, which included but was not limited to elopements. All the new staff received Elopement training upon hire, during new hire orientation, by the staff development coordinator. Staff who had not received the training, to include the agency staff, prior to 12/31/2021 received training prior to the start of their shift by the nursing scheduler, staff development coordinator, nurse management team, or supervisor prior to the start of their shift. Further, self-reportable incidents was reviewed by the Regional Director of Clinical Services and/or Assistant Regional Director of Clinical services on site no later than 72 hours following the incident. The Assistant Regional Director of Clinical Services kept a log of all the self-reportable incidents and was reviewed monthly by the Administrator and the Regional [NAME] President.
The State Agency validated the IJ Removal Plan as follows:
1. Review of Resident #112 Admission/Readmission Assessment revealed the resident was accompanied by the paramedics, by ambulance on 05/10/2021. Further review revealed the resident refused to be checked by staff for a skin assessment. Review of the resident's Baseline care plan revealed the resident's care plan was revised to include 15-minute checks and the care plan included the resident was at risk for elopement.
2. Review of the SOM documentation, dated 2021, revealed the facility reviewed the definition of elopement. Review of the elopement binder revealed the facility had placed all residents to be an elopement risk in the binder.
3. Review of the facilities education, provided by the facility revealed education was provided to all staff from 05/2021 to 11/2021. Education provided included Abuse, Wandering Residents, Behaviors, Customer Service, and Infection Control. Review of the facility's Wandering and Elopement policy, revised on 05/17/2020, revealed the facility defined elopement as an unsafe wandering and the facility strived to prevent harm while maintaining at the least restrictive environment for the residents.
4. Review of the QA Audit-Wander guard Tool, dated 07/02/2021, revealed the residents were audited to ensure the residents that were assessed as an elopement risk had an MD order, Wander guard Bracelet, updated care plan, TAR, and were in the elopement book/binder. No concerns were identified. Review of the Care Planning Audit Tool, dated 07/27/2021, revealed the residents who were assessed as an elopement risk care plan was assessed to include the following: Had the comprehensive care plan been developed; Did the residents care plan identify and include areas that pertain to the residents diagnosis; Did the care plan match the resident ' s needs; Were assistive devices in place per the residents plan of care; Was there evidence that the care plan reflected an interdisciplinary approach to the development of the care plan; Did the care plan identify the residents individualized goals, preferences and choices; Did the care plan clearly show a description of the action to be taken and by whom; Did the care plan contain some evidence of supporting or encouraging the individual to self-care/manage their well-being; Was there evidence that the care plan had been reviewed; Did the care and services provided reflect the residents current functioning status; Did the [NAME] reflect the resident specific assistance needed to ensure care and services were provided? Continued review of the Audit tool revealed it was signed off and reviewed on 07/29/2021.
5. Review of facility's document, dated 07/02/2021, revealed the ARDCS went over the roles and responsibilities with the Administrator and DON. Further, the ARDCS went over the facility's goals, leadership, and management expectations. The QA Process and QAPI Program and audits were discussed. Continued review revealed the Administrator, DON, and ARDCS, signed the document on 07/02/2021.
6. Review of the Quality Assurance Committee Meeting Minutes, dated 07/29/2021 and 09/24/2021, revealed the committee reviewed elopement drills with no concerns identified. Review of the sign-in sheet revealed the Administrator, DON, Medical Director, ADON, Social Service, Dietary manager, Dietitian, Therapy, Maintenance, Environmental Services, Activities, Admissions, and MDS attended the meeting.
7. Review of the Facility Assessment revealed the QA Committee revealed the results of the audits. There were no changes on concerns identified.
8. Review of the New admission worksheet revealed the residents were assessed to be an elopement risk and was care planned based on assessment. No concerns were identified.
9. Review of the Emergency Plan and Elopement Drills, dated 07/29/2021 and 09/24/2021, revealed no concerns identified.
10. Review of the document, dated 11/17/2021, revealed the Regional Director of Clinical Services met with the Regional [NAME] President to review the self-reportable incidents from the region. The Regional Director of Clinical Services advised that the DON and Administrator was expected to report any allegations to the Regional Director of Clinical and the Regional [NAME] President to meet regulations related to reporting. Further review of the document revealed the Regional [NAME] President and Regional Director of Clinical Services signed off on the document on 11/17/2021.
11 Review of the annual competencies form revealed the facility checked the competency of each staff in areas which included: resident rights, abuse, skin/wound care, medication management, and disaster planning. Continued review revealed staff were checked prior to the start of their shift.
During an interview with the ARDCS, on 02/05/2024 at approximately 6:30 PM, she stated she reviewed the incident related to Resident #112's elopement and determined the facility needed additional training on the definition of elopement. She stated she retrained the Administrator, who left in November of 2021, and the DON. Further, she stated she put a Plan of Correction in place to address the concerns, with auditing the residents for changes in behaviors, assessing the residents to be an elopement risk, and updated the resident's care plans. Per the interview, she stated she audited the concern until the end of December. She further stated she had not had concerns with Resident #112 leaving the facility without staff supervision since 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility document and policy review, it was determined the facility's governing body failed to ensure policies regarding the management and operation of the facility were implemented. The governing body was aware that on 05/09/2021, at approximately 6:00 PM, a resident whom the facility assessed to have moderate cognitive impairment left the facility and was missing. The facility failed to implement its missing resident protocol and notify the police of the missing resident. The governing body was aware that the facility concluded Resident #112 left against medical advice (AMA) and took no further action to find the resident. The police found Resident #112 along a highway (unknown location) on 05/10/2021 at approximately 10:00 AM, approximately eighteen (18) hours after the resident left the facility. Emergency Medical Services (EMS) transported Resident #112 to a local hospital for cold exposure.
It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care were identified at 483.25, Free of Accidents Hazards and Supervision/F689. Additional IJ deficiencies were identified at 483.70 Administration; F835 and F837.
The IJ began on 05/09/2021 at approximately 6:00 PM when Resident #112 exited the facility without the staff's knowledge.
The facility was notified of the IJ and provided a copy of the IJ template on 02/02/2024 at 5:12 PM. A Removal Plan was requested.
The findings include:
A review of the facility's policy titled, Administrative Management (Governing Board), dated October 2017, revealed The governing board shall be responsible for the management and operation of the facility. 1. The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility. The policy revealed, 3. The governing board is responsible for, but not limited to: a. Oversight of facility care and services in accordance with professional standards of practice and principles; and d. Establishment and ongoing review of all administrative programs governing facility management and operations, including: (3) Quality Assurance and Performance Improvement; and j. Establishment of a system whereby the Administrator reports to the governing body, including: (5) How the Administrator will be held accountable for facility management and operations.
A review of an undated facility policy titled Emergency Procedure - Missing Resident, revealed, Resident elopement resulting in a missing resident is considered a facility emergency. The policy revealed, 2. Staff will implement the protocol for missing resident upon discovering that a resident cannot be located. Further review of the policy revealed when a resident was missing 6. Initiate a thorough search by staff members to locate the resident. 7. If the search is unsuccessful after a period of ten (10) minutes, call the police to report the resident missing. The policy revealed, 11. Complete an incident report and follow the facility's incident reporting process. 12. Document the incident and events objectively in the resident record, including: a. Circumstances and precipitating factors.
A review of Resident #112's admission Record indicated the facility admitted the resident on 04/01/2021 with diagnoses that included acute kidney failure, stage 3 chronic kidney failure, cerebral infarction (stroke), muscle weakness, type 2 diabetes mellitus, cognitive communication deficit, major depressive disorder, varicose veins of the left lower extremity with an ulcer to the lower leg, essential hypertension, and heart failure. The admission Record revealed the facility discharged Resident #112 on 05/09/2021 at 6:00 PM. The discharged to, Signature, and Personal Effects Sent With, sections of the form were not completed.
A review of Resident #112's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required extensive assistance of one (1) staff member with dressing, toilet use, and personal hygiene; and required extensive assistance of two (2) or more staff members with transfers. The MDS revealed the resident was not steady and only able to stabilize with staff assistance when transferring from surface to surface and moving on and off the toilet. The MDS revealed the resident utilized a walker or wheelchair for mobility. A continued review of the MDS revealed the resident's overall expectation was to remain at the facility.
A review of Resident #112's Care Plan revealed a Focus area initiated on 04/12/2021 that indicated the resident had cognitive impairment related to cognitive communication deficit. The facility developed interventions that directed staff to cue, re-orient, and supervise the resident as needed. Further review of Resident #112's Care Plan revealed a Focus area initiated on 04/02/2021 that indicated the resident needed assistance with activities of daily living (ADL) related to weakness. The facility developed interventions that directed staff to assist the resident with ambulation, locomotion, toileting, and transfers. A review of Resident #112's Care Plan revealed no documented evidence the facility planned for the resident to leave the facility or go to a local store without staff supervision.
A review of an undated facility document titled 5-Day revealed on 05/09/2021, Resident #112 went to a store and bought snacks at approximately 5:45 PM; when the resident did not immediately return, the weekend supervisor Registered Nurse (RN) #3 went to check on the resident. The report revealed that when RN #3 did not find the resident at the store, she notified the DON, who called the Administrator at approximately 6:04 PM. The facility document revealed the facility contacted the resident's family and notified them the resident had left. The document revealed the Administrator verified with the store's video footage that Resident #112 entered the store at approximately 5:45 PM and left at approximately 5:56 PM with a bag of groceries. According to the document, the resident's family member did not want to file a police report as they considered this normal resident behavior. The document revealed that on 05/10/2021 at 11:24 AM, approximately 18 hours after Resident #112 left the facility, the police were called, and a missing person report was filed. The document revealed that on 05/10/2021 at 12:02 PM, the resident's family arrived at the facility and notified them that the resident had been found and was in the emergency room (ER). There was no documented evidence the facility followed their Emergency Procedure - Missing Resident protocol that required staff to Initiate a thorough search for the resident and contact the police if the resident was not found within 10 minutes.
A review of Resident #112's Emergency Department Encounter note dated 05/10/2021 at 11:18 AM revealed the resident presented to the Emergency Department (ED) via EMS with cold exposure. The note revealed the resident left the facility the night before at approximately 7:30 PM to go to the store without informing staff. The note revealed the resident got lost when trying to get back and ended up on the expressway. Continued review of the note revealed EMS found the resident that morning and stated the resident was out in the cold all night. The note revealed the first documented body temperature for Resident #112 was taken on 05/10/2021 at 2:45 PM, and the resident's body temperature was 99.2 degrees Fahrenheit (F). The ED record revealed the resident's diagnoses were chronic confusion, medically noncompliant, and non-intractable vomiting with nausea.
A review of Resident #112's ED Laboratory Results report dated 05/10/2021 revealed the resident's blood glucose level was 250 milligrams per deciliter (mg/dL) and was documented as high. The report reference range for blood glucose was 74-99 mg/dL.
During an interview with the Regional [NAME] President of Operations (RVPO) on 01/30/2024 at 11:56 AM, the RVPO stated they did not consider the 05/09/2021 incident as an elopement because Resident #112 was their own POA and was alert and oriented. He stated Resident #112 walked to a store located near the facility. The RVPO stated if a resident was alert, oriented, and responsible for themselves they were allowed to go to the store unsupervised. The RVPO stated when it was observed the resident was not in the facility, a staff member walked to the store to escort Resident #112 back to the facility; however, the resident refused to return to the facility. The RVPO stated the staff member waited at the door of the store for the resident, but the resident exited the store through a different door and left the grounds. The RVPO stated that since the resident had refused to return to the facility, they considered the resident to have left AMA. The RVPO stated they immediately notified the family and reported to the state agency on 05/11/2021 or 05/12/2021 that the resident left AMA, after an Adult Protective Services (APS) visit on 05/11/2021.
During a follow-up interview on 02/02/2024 at 5:18 PM, the RVPO stated Resident #112 had a right to leave and stated the facility even went to the store to check on the resident. The RVPO stated they did not check on every resident who went to the store. The RVPO shook his head and stated he did not know why they checked on Resident #112.
The facility alleged removal of the immediacy of the IJ on 01/01/2022 as follows:
1. On 05/10/2021, Resident #112 was assessed using the Elopement Risk Assessment by Licensed Practical Nurse (LPN) #9. The resident was placed on 15-minute checks until he/she went to the hospital on [DATE]. The resident ' s care plan was updated. The resident has not had further elopements since 05/09/2021.
2. On 05/09/2021, the facility reviewed the State Operations Manual (SOM) and again on 02/03/2023, to go over the definition of elopement. The Interdisciplinary team (IDT), Administrator, Assistant Director of Nursing, Nurse Mangers, and Social Services reviewed the Wander Risk Assessment. Residents that were assessed to require a Wander-guard bracelet were placed in the binder located at each nursing station and front desk. Further, the residents assessed to be an elopement risk, care plans were updated.
3. On 05/10/2021, education began with all the facility staff. The Director of Nursing (DON) provided the education, and it was ongoing. Further, education was provided during all staff meetings on 09/2021 through 11/2021 after the Assistant Regional Director of Services identified potential issues and/or concerns during onsite visits through resident medical record audits and observations. Education that was included was on the Elopement Policy, Wandering, resident/resident representative expectations of signing out prior to resident leaving the facility, and missing resident protocol by the Administrator, DON, Nurse Managers, Social Workers, Admissions Staff, and Supervisors.
4. On 07/02/2021 through 07/27/2021, the Assistant Regional Director of Clinical Services assigned the Director of Clinical Services assigned the DON, Nurse Managers, Charge Nurses, and nurse supervisors, after completion of an onsite audit, to conduct an audit on wandering risk assessments. All residents were verified to have an updated risk assessment in their medical record.
5. On 07/02/2021, the Assistant Director of Clinical Services re-educated the DON and Administrator regarding their roles and responsibilities for following the facility's policies which included but was not limited to discharging against medical advice, elopement, and wandering oversight and supervision, QA process and QAPI Program.
6. On 07/29/2021 and 09/24/2021, the Quality Assurance and Performance Improvement meeting was held to review the facility's protocol and policy for elopement. The attendees included the Administrator, Medical Director, Director of Nursing, Assistant Regional Director of Clinical Services, Medical Records, Assistant Director of Nursing, Therapy, Housekeeping, and Activity Director.
7. On 07/29/2021 and 09/24/2021, the facility assessment was reviewed in the Quality Assurance Performance Improvement Committee to review the results of the audits and no changes were needed. Further, the QAPI committee reviewed any discharges or unplanned dischargers from 06/2021 through 12/2021, no concerns were identified.
8. On 08/01/2021, the DON, Nurse Manager, Supervisor or Charge Nurse evaluated all new admissions/re-admissions residents on admission to determine if a resident was triggered to be an elopement risk. The residents who triggered to be at risk for elopement would have a comprehensive person-centered care plan developed and implemented by the Minimum Data Set (MDS) nurse and IDT team, that included the resident's risk for elopement. If concerns were identified, it was discussed in the daily Interdisciplinary Plan of Care Meeting and the DON would report the concerns to the QAPI committee.
9. During the month of August of 2021, the Assistant Regional Director of Clinical Services assigned the Director of Nursing and Administrator to conduct elopement drills. A total of 2 element drills were completed. All elopement drills were reviewed with the Assistant Director of Clinical Services, the Director of Nursing and Administrator. The Emergency Plan for locating a missing resident was reviewed by the Assistant Regional Director of Nursing and the Administrator on 09/24/2021, with no changes indicated.
10. On 11/17/2021, the Governing Body (Regional [NAME] President) received verbal education per the Regional Director of Clinical Services regarding expectations of self-reportable incidents including but not limited to elopements and elopement versus against medical advice. The Assistant Regional Director of Clinical Services and Assistant Regional Director of Clinical Services increased onsite facility visits to 2-3 days per week to ensure that facility Administration and staff were following the Elopement Policy and Procedures.
11. On 12/01/2021 through 12/31/2021, annual competencies were completed, which included but was not limited to elopements. All the new staff received Elopement training upon hire, during new hire orientation, by the staff development coordinator. Staff who had not received the training, to include the agency staff, prior to 12/31/2021 received training prior to the start of their shift by the nursing scheduler, staff development coordinator, nurse management team, or supervisor prior to the start of their shift. Further, self-reportable incidents was reviewed by the Regional Director of Clinical Services and/or Assistant Regional Director of Clinical services on site no later than 72 hours following the incident. The Assistant Regional Director of Clinical Services kept a log of all the self-reportable incidents and was reviewed monthly by the Administrator and the Regional [NAME] President.
The State Agency validated the IJ Removal Plan as follows:
1. Review of Resident #112 Admission/Readmission Assessment revealed the resident was accompanied by the paramedics, by ambulance on 05/10/2021. Further review revealed the resident refused to be checked by staff for a skin assessment. Review of the resident's Baseline care plan revealed the resident's care plan was revised to include 15-minute checks and the care plan included the resident was at risk for elopement.
2. Review of the SOM documentation, dated 2021, revealed the facility reviewed the definition of elopement. Review of the elopement binder revealed the facility had placed all residents to be an elopement risk in the binder.
3. Review of the facilities education, provided by the facility revealed education was provided to all staff from 05/2021 to 11/2021. Education provided included Abuse, Wandering Residents, Behaviors, Customer Service, and Infection Control. Review of the facility's Wandering and Elopement policy, revised on 05/17/2020, revealed the facility defined elopement as an unsafe wandering and the facility strived to prevent harm while maintaining at the least restrictive environment for the residents.
4. Review of the QA Audit-Wander guard Tool, dated 07/02/2021, revealed the residents were audited to ensure the residents that were assessed as an elopement risk had an MD order, Wander guard Bracelet, updated care plan, TAR, and were in the elopement book/binder. No concerns were identified. Review of the Care Planning Audit Tool, dated 07/27/2021, revealed the residents who were assessed as an elopement risk care plan was assessed to include the following: Had the comprehensive care plan been developed; Did the residents care plan identify and include areas that pertain to the residents diagnosis; Did the care plan match the resident ' s needs; Were assistive devices in place per the residents plan of care; Was there evidence that the care plan reflected an interdisciplinary approach to the development of the care plan; Did the care plan identify the residents individualized goals, preferences and choices; Did the care plan clearly show a description of the action to be taken and by whom; Did the care plan contain some evidence of supporting or encouraging the individual to self-care/manage their well-being; Was there evidence that the care plan had been reviewed; Did the care and services provided reflect the residents current functioning status; Did the [NAME] reflect the resident specific assistance needed to ensure care and services were provided? Continued review of the Audit tool revealed it was signed off and reviewed on 07/29/2021.
5. Review of facility's document, dated 07/02/2021, revealed the ARDCS went over the roles and responsibilities with the Administrator and DON. Further, the ARDCS went over the facility's goals, leadership, and management expectations. The QA Process and QAPI Program and audits were discussed. Continued review revealed the Administrator, DON, and ARDCS, signed the document on 07/02/2021.
6. Review of the Quality Assurance Committee Meeting Minutes, dated 07/29/2021 and 09/24/2021, revealed the committee reviewed elopement drills with no concerns identified. Review of the sign-in sheet revealed the Administrator, DON, Medical Director, ADON, Social Service, Dietary manager, Dietitian, Therapy, Maintenance, Environmental Services, Activities, Admissions, and MDS attended the meeting.
7. Review of the Facility Assessment revealed the QA Committee revealed the results of the audits. There were no changes on concerns identified.
8. Review of the New admission worksheet revealed the residents were assessed to be an elopement risk and was care planned based on assessment. No concerns were identified.
9. Review of the Emergency Plan and Elopement Drills, dated 07/29/2021 and 09/24/2021, revealed no concerns identified.
10. Review of the document, dated 11/17/2021, revealed the Regional Director of Clinical Services met with the Regional [NAME] President to review the self-reportable incidents from the region. The Regional Director of Clinical Services advised that the DON and Administrator was expected to report any allegations to the Regional Director of Clinical and the Regional [NAME] President to meet regulations related to reporting. Further review of the document revealed the Regional [NAME] President and Regional Director of Clinical Services signed off on the document on 11/17/2021.
11 Review of the annual competencies form revealed the facility checked the competency of each staff in areas which included: resident rights, abuse, skin/wound care, medication management, and disaster planning. Continued review revealed staff were checked prior to the start of their shift.
During an interview with the ARDCS, on 02/05/2024 at approximately 6:30 PM, she stated she reviewed the incident related to Resident #112's elopement and determined the facility needed additional training on the definition of elopement. She stated she retrained the Administrator, who left in November of 2021, and the DON. Further, she stated she put a Plan of Correction in place to address the concerns, with auditing the residents for changes in behaviors, assessing the residents to be an elopement risk, and updated the resident's care plans. Per the interview, she stated she audited the concern until the end of December. She further stated she had not had concerns with Resident #112 leaving the facility without staff supervision since 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure proper respiratory care was provided to three (3) of five (5) sampled residents (Residents #62, #127, and #57) reviewed for respiratory care.
The findings include:
1. A review of a facility policy titled Tracheostomy Care, revised in October 2023, revealed, The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. The policy further revealed, A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. The policy revealed the Procedure Guidelines for Preparation and Assessment included Check the physician order. The policy revealed it did not specifically address the proper storage of respiratory equipment, to include a suction machine.
A review of Resident #62's admission Record revealed the facility admitted the resident on 09/24/2018, with diagnoses that included tracheostomy (trach) status, atelectasis (complete or partial collapse of a lung), and severe morbid obesity with alveolar hypoventilation.
A review of Resident #62's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2024, revealed a Brief Interview for Mental Status (BIMS) of fifteen (15), which indicated the resident was cognitively intact. In addition, the MDS assessment revealed Resident #62 received tracheostomy care.
A review of Resident #62's care plan revealed a Focus area, revised on 05/31/2024, that indicated Resident #62 had a tracheostomy related to chronic obstructive pulmonary disease (COPD), atelectasis, obstructive sleep apnea (OSA), simple chronic bronchitis, a history of pulmonary embolism, and indicated the resident had a #8 [NAME] Trach (a stainless-steel tracheostomy tube).
A review of Resident #62's physician orders revealed an Active order for Trach Size, with a revision date of 04/21/2021. The order revealed there was no size specified in the order. Further review of Resident #62's physician orders revealed an Active order for an Ambu bag, supplemental oxygen, suction canister, and catheters to be in the resident's room at all times, with a start date of 07/18/2023. The orders also included an Active order to suction the trach as needed every six (6) hours, with a start date of 07/18/2023. Further review revealed an Active order for humidified oxygen at twenty-eight (28) percent (%) to trach, as needed, with a start date of 10/01/2021.
On 01/31/2024 at 9:48 AM, an observation was made in Resident #62's room, which revealed one (1) extra tracheostomy tube taped to a wall.
During an interview on 01/31/2024 at 2:01 PM with Licensed Practical Nurse (LPN) #45, she stated Resident #62 had an additional tracheostomy tube hanging on the wall by the resident's bed in case the current one came out, and additional tracheostomy supplies were in a central supply room.
On 01/31/2024 at 2:06 PM, the Central Supply (CS)/Certified Medication Technician (CMT) was asked to provide the additional tracheostomy tube used for a backup supply. The CS/CMT was observed looking around, and after approximately 60 seconds, the CS/CMT asked LPN #45 what size the tracheostomy tube was. LPN #45 stated that she was not sure and started helping the CS/CMT look at the supplies that were available. The CS/CMT stated she had ordered some supplies for Resident #62, but the resident had their tracheostomy tube changed recently, and the staff had used up the available supplies that she had. The CS/CMT stated that the only extra tracheostomy tube for Resident #62 that the facility had was the one that was taped to Resident #62's room wall. The CS/CMT stated she had ordered more. A copy of the invoice was requested but not received prior to exit.
During an observation and interview on 02/02/2024 at 8:20 AM, in Resident #62's room, LPN #45 stated the suction machine should be covered up with plastic, and it was not; she stated that it was covered in a lot of dust, and she did not see the tubing for it. LPN #45 stated she was not sure how it was supposed to work. She stated she was not sure how long it had been in the resident's room or exactly why it was in there. She also verified there was no supplemental oxygen available in the room and had not been for quite some time.
During an interview on 02/02/2024 at 8:27 AM, LPN #83 stated that when she worked with Resident #62, she only cleaned the inner cannula and around the opening and had never changed out the outer cannula. She stated that if the tracheostomy tube came out, she would call for help and have her supervisor come and do it because the outside was not supposed to come out. She stated an extra tracheostomy tube was hanging by the resident's bed. She further stated she had tracheostomy training during orientation but did not remember if she had to do a return demonstration.
During an interview on 02/02/2024 at 11:55 AM, Nurse Practitioner (NP) #38 stated she was unfamiliar with tracheostomy care and could not say what supplies should have been kept at Resident #62's bedside. She stated suction equipment should be present but was unsure of the facility policy. NP #38 further stated that in an emergency, the staff would use the extra tracheostomy tube hanging on the resident's room wall. She stated that she was unsure how staff could order supplies without the tracheostomy tube size in the physician's order. NP #38 stated without the tracheostomy tube size in the order, if there was not an extra one at the bedside, Resident #62 could potentially die without the correct supplies. During the interview, NP #38 called Respiratory Therapist (RT) #26, who had come to the facility to care for Resident #62. During the phone interview, RT #26 stated Resident #62 started with a Shiley tracheostomy tube, then changed to a [NAME] tracheostomy tube, which was metal and caused the resident discomfort, so he had changed it to the current one, which had been in place for the last couple of years. RT #26 stated that Resident #26's outer cannula did not have to be replaced due to the age of the resident's tracheostomy. RT #26 stated the inner cannula had to be changed, and it should have been changed at least daily. RT #26 stated the suction machine in the resident's room should have been kept clean and ready to be used at all times.
During an interview on 02/06/2024 at 2:35 PM, the Director of Nursing stated she noticed for Resident #62 that there was no size in the physician order. She stated she did not know how the size of the tracheostomy tube was not on the order for so long, and they did not catch it. She stated that she wanted the nurses to clean the suction machine, cover it when not in use, and keep the supplies accessible at the resident's bedside. She also stated they were lucky Resident #62's tracheostomy was stable, and they had not had any problems thus far, because no one, including herself, knew what size the resident's tracheostomy tube was.
During an interview on 02/02/2024 at 2:00 PM, with the Administrator, he stated he would defer to nursing staff for respiratory care; however, he would expect them to follow their policies and physician's orders.
2. A review of a facility policy titled CPAP [continuous positive airway pressure]/BiPAP [bilevel positive airway pressure] Support, revised in March 2015, revealed General Guidelines for Cleaning included 4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Humidifier (if used): a. Use clean, distilled water only in the humidifier chamber. b. Clean humidifier weekly and air dry. 6. Filter cleaning; [sic] a. Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. 7. Mask, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. 8. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry.
A review of a facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer, revised in October 2010, revealed, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The policy revealed it did not include the proper cleaning or storing of nebulizer equipment.
A review of Resident #127's admission Record revealed the facility admitted the resident on 06/13/2022 with diagnoses that included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA) (disruption of breathing during sleep).
A review of Resident #127's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2023, revealed Resident #127 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses including COPD and OSA. The MDS revealed the resident received respiratory treatments, including oxygen therapy and a non-invasive mechanical ventilator.
A review of Resident #127's care plan revealed a Focus area initiated on 06/14/2022, that indicated the resident was at risk for respiratory complications related to COPD, sleep apnea, and a cough. The care plan revealed interventions included instructions for staff to use a CPAP machine (a type of non-invasive mechanical ventilator) as ordered, see a nurse for supplemental oxygen, use ear protectors on oxygen tubing, check placement of oxygen tubing every shift, elevate the head of the bed to decrease difficulty breathing and administer medication per physician orders. Further review revealed interventions included instructions for staff to observe, document, and report symptoms of respiratory distress and monitor, document, and report any signs and symptoms of respiratory infection to the physician as needed.
A review of Resident #127's Order Summary Report for Active Orders As Of: 02/05/2024 revealed an order with a start date of 06/10/2023 for supplemental oxygen at four (4) liters per minute (LPM) via a nasal cannula continuous per concentrator/tank; and indicated that the resident may wear ear protectors if the resident preferred. Further review of the report revealed an order, dated 03/23/2023, that directed staff to change and date all respiratory supplies and tubing weekly on Sunday; if the oxygen concentrator is present, clean the filter every Sunday during the night shift.
A review of Resident #127's Order Details revealed an order dated 06/16/2022 that directed staff to clean the resident's CPAP/BiPAP mask with a moist wipe every day shift.
A review of Resident #127's Order Details revealed an order dated 08/03/2022 that directed staff to clean the resident's CPAP/BiPAP with one-part white vinegar and three parts distilled water. The order directed staff to clean all parts, tubing, mask parts, the shell, pillows, and swivels, soak for 15 minutes, and rinse after disinfection. The order specified that the CPAP/BiPAP cleaning was to be completed every day shift starting on the 10th and ending on the 11th of every month.
A review of Resident #127's Order Details revealed an order dated 06/16/2022 that instructed staff to fill the resident's CPAP/BiPAP with distilled water every Sunday on the night shift.
A review of Resident #127's treatment administration record (TAR) for 01/01/2024 through 01/31/2024 revealed a transcription of an order for the use of a CPAP/BiPAP machine every night shift for sleep apnea. The TAR revealed staff documented that the CPAP/BiPAP machine was used all but one night (01/25/2024). The TAR revealed staff documented that they cleaned the CPAP/BiPAP on 01/10/2024 and 01/11/2024. The TAR revealed staff documented that the CPAP/BiPAP machine was filled with distilled water on 01/07/2024, 01/14/2024, 01/21/2024, and 01/28/2024. The TAR revealed staff documented that the CPAP/BiPAP mask was cleaned with a moist wipe all but one day (01/24/2024). Further review of the TAR revealed staff documented that all respiratory supplies and tubing were changed and dated on 01/07/2024, 01/14/2024, 01/21/2024, and 01/28/2024.
A review of Resident #127's TAR for 02/01/2024 through 02/03/2024 revealed that staff documented that the resident's CPAP/BiPAP mask was cleaned with a moist wipe daily. The TAR revealed that staff documented the resident used their CPAP/BiPAP machine on the night shift on 02/01/2024 and 02/03/2024. The TAR revealed that staff documented that the resident received supplemental oxygen at 4 Liters Per Minute (LPM) via a nasal cannula continuous per concentrator/tank daily.
An observation on 02/02/2024 at 1:39 PM revealed Resident #127 was lying in bed receiving supplemental oxygen; the concentrator was set at 2.5 LPM. The oxygen tubing was not dated.
During an observation and interview on 02/03/2024 at 2:49 PM with Certified Nursing Assistant (CNA) #12, she confirmed that the resident's oxygen concentrator was set at 2.5 LPM. She stated she did not adjust the oxygen setting; she only applied the nasal cannula when needed. She stated she did not do anything with the resident's nebulizer machine and confirmed that the date on the tubing was 07/30/2023. CNA #12 stated she did not know how often the tubing should be changed.
During an observation and interview on 02/03/2024 at 2:56 PM, LPN #39 confirmed that Resident #127's oxygen concentrator was set at 2.5 LPM. She stated she was unsure what it was supposed to be set at without looking at the physician's orders. LPN #39 confirmed the date on the nebulizer tubing was dated 07/30/2023. She stated the tubing and masks were supposed to be changed out weekly.
During an observation on 02/04/2024 at 11:44 AM, Medication Aide (MA) #58 entered Resident #127's room to look for the resident's CPAP/BiPAP machine. MA #58 searched through all the nightstand drawers and found several CPAP/BiPAP masks but no tubing or the machine. MA #58 found the CPAP/BiPAP machine in the bottom of the resident's closet, with the tubing and mask still attached and covered in a thick layer of dust.
During an observation and interview on 02/04/2024 at 11:49 PM, LPN #39 stated she was not aware Resident #127 had a CPAP/BiPAP machine and stated that she thought it might have been discontinued or the resident was refusing it. After observing the condition of the machine, covered in dust, she stated it was not acceptable. She confirmed that the use of the CPAP/BiPAP machine and other orders related to the CPAP/BiPAP were being documented as though it was being used.
During an interview on 02/06/2024 at 11:45 AM, the Director of Nursing (DON) stated nebulizer equipment should be wiped down and covered per the manufacturer's instructions; the mouthpiece should be rinsed, air-dried, and stored in a bag. She stated the equipment should be changed weekly. She stated that when a CPAP/BiPAP machine was not in use, the machine should be covered, and the mask should be wiped down and stored in a bag. The DON stated that Resident #127's CPAP/BiPAP had obviously not been in use. She stated, after speaking with the nurse, the CPAP/BiPAP should have been discontinued since the resident was not wearing it.
During an interview on 02/06/2024 at 2:01 PM, the DON indicated that she expected staff to follow physician orders and check oxygen concentrator settings every shift.
During an interview on 02/06/2024 at 12:15 PM, the Administrator stated he expected the staff to follow the facility's policy and procedures regarding respiratory care. He stated that staff should not be documenting that they were doing something if they were not.
During a follow-up interview on 02/06/2024 at 12:50 PM, the Administrator indicated that he expected staff to follow physician orders.
3. A review of Resident #57's admission Record revealed the facility admitted the resident on 11/15/2022, with diagnoses that included acute respiratory failure with hypoxia (lack of oxygen), chronic obstructive pulmonary disease (COPD) with acute exacerbation (sudden worsening of symptoms), and obstructive sleep apnea (OSA).
A review of Resident #57's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2023, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident's diagnoses included COPD and respiratory failure. The MDS revealed no respiratory treatments were performed during the assessment period.
A review of Resident #57's care plan revealed a Focus area, with a revision date of 01/24/2023, that revealed the resident was at risk for respiratory complications related to COPD, sleep apnea, and shortness of air (SOA). The care plan revealed interventions included instructions for staff to elevate the head of the resident's bed to decrease difficulty breathing, administer medication per orders, observe, document, and report symptoms of respiratory distress, and monitor, document, and report to the physician any signs or symptoms of respiratory infection.
A review of Resident #57's Order Details revealed an order dated 11/22/2022 for ipratropium-albuterol solution 0.5-2.5 (3) milligrams (mg) per 3 milliliters (ml), inhale 3 ml orally four (4) times a day for COPD.
An observation on 01/29/2024 at 12:29 PM revealed a nebulizer machine on Resident #57's nightstand with a nebulizer mask lying on top of the nightstand, and a plastic storage bag was lying next to it.
An observation on 01/30/2024 at 10:47 AM revealed the nebulizer machine was on the nightstand with the mask lying on top of the storage bag. Dried debris was inside the mask, and fluid was observed in the medication chamber.
An observation on 01/31/2024 at 9:26 AM revealed the resident's nebulizer machine was on the nightstand with the mask lying on top of the storage bag. Dried debris was in the mask, and fluid was in the medication chamber.
An observation on 02/01/2024 at 10:24 AM revealed the resident's nebulizer machine was on the nightstand with the mask lying on top of the plastic storage bag. There was debris observed in the mask, and fluid was in the medication chamber.
An observation on 02/02/2024 at 1:39 PM revealed the nebulizer machine was on the nightstand and the mask was lying on top of the plastic storage bag. Fluid was observed in the mask's medication chamber, debris was observed in the mask, and the tubing was not dated.
During an observation and interview on 02/03/2024 at 2:49 PM, in Resident #57's room, CNA #12 confirmed that Resident #57's nebulizer equipment was not stored in a plastic bag.
During an observation and interview on 02/03/2024, in Resident #57's room, LPN #39 stated that nebulizer equipment was supposed to be changed weekly, dated, and stored in a plastic bag when not in use. She confirmed that Resident #57's mask was not stored in a plastic bag.
During an interview on 02/06/2024 at 11:45 AM, the Director of Nursing stated that a nebulizer machine should be wiped down and covered per the manufacturer. She indicated that nebulizer equipment should be rinsed, air-dried, and stored in a bag. She stated the equipment should be changed weekly.
During an interview on 02/06/2024 at 12:15 PM, the Administrator stated he expected the staff to follow the facility's policy and procedures regarding respiratory care.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure Medication Aide (MA) #58 did not allow two (2) of three (3) residents (Resident #96 and Resident #18)observed during medication administration to self-administer their own medications. There were no physicians' orders and interdisciplinary team assessments to determine if the residents were able to safely do so.
The findings include:
A review of a facility policy titled Administering Medications, revised in April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy also specified, 27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.
1. Review of Resident #96's admission Record revealed the facility admitted the resident on 10/07/2021. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and unspecified dementia.
Review of Resident #96's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2023, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15. This score indicated the resident was cognitively intact. According to the MDS, the resident was independent with activities of daily living and had no range of motion impairments.
A review of Resident #96's Order Summary Report, listing active orders as of 01/31/2024, revealed an order dated 01/20/2024 for Flonase allergy relief nasal suspension 50 micrograms per actuation (mcg/act), two sprays in each nostril one time a day for sinus congestions. The Order Summary Report did not reveal any orders for Resident #96 to self-administer their own medications.
During medication administration observations on 01/31/2024 at 7:36 AM, MA #58 handed Resident #96 their Flonase nasal suspension, and the resident sprayed five sprays in their right nostril and four sprays in their left nostril.
During an interview on 02/04/2024 at 12:35 PM, MA #58 reviewed Resident #96's physician's orders and verified there was no order for the resident to self-administer their Flonase nasal spray. MA #58 confirmed the resident administered five sprays in their right nostril and four sprays in their left nostril.
2. A review of Resident #18's admission Record revealed the facility admitted the resident on 08/01/2017. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia and chronic obstructive pulmonary disease (COPD).
A review of Resident #18's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 14. This score indicated the resident was cognitively intact.
A review of Resident #18's Order Summary Report, listing active orders as of 01/31/2024, revealed an order dated 01/20/2024 for Incruse Ellipta Inhalation Aerosol Powder-Breath Activated 62.5 micrograms per actuation (mcg/act), inhale one puff one time a day for COPD. The Order Summary Report did not reveal any orders for Resident #18 to self-administer their own medications.
During medication administration observations on 01/31/2024 at 7:45 AM, MA #58 handed Resident #18 their Incruse inhaler and Resident #18 self-administered one puff of the inhaler.
During an interview on 02/04/2024 at 12:35 PM, MA #58 reviewed Resident #18's physician's orders and verified the resident did not have an order to self-administer their Incruse inhaler.
During an interview on 02/06/2024 at 2:00 PM, the Administrator stated he expected nursing staff to follow the physician's orders and to follow the facility's policies. He stated for questions specific to medication administration, he would defer to the nursing department.
During an interview on 02/06/2024 at 2:35 PM, the Director of Nursing stated she expected staff to administer medications per physician's orders. She further stated allowing Resident #96 and Resident #18 to self-administer their medications was an error.

Based on record review, document reviews, video camera footage, interviews, and facility policy review, it was determined the facility failed to ensure (one) 1 of seven (7) sampled residents, Resident #311, reviewed for abuse was free from physical abuse.
On 09/13/2022 at approximately 3:30 PM, Resident #311's Power of Attorney (POA) met with Administrator #77 and alleged Certified Nursing Assistant (CNA) #74 smacked at the resident's legs while care was being provided. The POA also alleged that another CNA ate food that was on the resident's meal tray and another CNA handled the resident roughly while care was being provided. Per the initial report, the three (3) staff identified were CNA #74, CNA #75, and CNA #76. The facility provided video coverage of the incident for State Survey Agency (SSA) Surveyor review.
The findings include:
A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised in April 2021, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.
A review of Resident #311's admission Record revealed the facility admitted the resident on 08/30/2019, with diagnoses to include major depressive disorder, need for assistance with personal care, unspecified dementia with behavioral disturbance, and anxiety disorder.
A review of Resident #311's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, out of a possible fifteen (15), which indicated the resident had severe cognitive impairment, and was not interviewable. Per the MDS, the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene.
A review of Resident #311's comprehensive care plan, initiated on 09/11/2019, revealed the resident needed assistance with their (his/her) activities for daily living related to limited range of motion.
Review of the facility's initial report, revealed on 09/13/2022 at approximately 3:30 PM, Resident #311's Power of Attorney (POA) met with Administrator #77 and alleged Certified Nursing Assistant (CNA) #74 smacked at the resident's legs while care was being provided. The POA also alleged that another CNA ate food that was on the resident's meal tray and another CNA handled the resident roughly while care was being provided. Per the initial report, the three (3) staff identified were CNA #74, CNA #75, and CNA #76. The initial report revealed an investigation was started, the appropriate agencies were notified, and the staff involved were placed on administrative leave.
A review of the facility final report, dated 09/19/2022, revealed a nurse completed a full body assessment of the resident and found no areas of discoloration or any other concerns. Per the final report, Resident #311 was not able to be interviewed and psychosocial visits were conducted with the resident on 09/14/2022, 09/15/2022, and 09/16/2022 and the staff did not note any distress or concerns with the resident. The final report revealed, CNA #74 and CNA #75 were interviewed by way of telephone and denied any inappropriate interactions with the resident. Per the final report, CNA #76 did not respond to the facility's request for an interview. According to the final report, upon completion of the investigation, the facility terminated the employment of CNA #74 and CNA #75, and since CNA #76 failed to respond to multiple interview attempts, their employment with the facility was terminated.
On 01/31/2024 at 6:06 PM, the surveyor attempted a telephone interview with CNA #74, but there was no answer, and the surveyor was unable to leave a message. On 02/01/2024 at 7:40 PM, the surveyor attempted a telephone interview with CNA #74; a female answered and stated she was not CNA #74 and told the surveyor to not call the telephone number again.
On 01/31/2024 at 6:09 PM and 02/01/2024 at 7:42 PM, the surveyor attempted a telephone interview with CNA #75; the telephone recording indicated the mailbox was invalid.
During a telephone interview on 02/04/2024 at 8:27 PM, Administrator #77 stated he did remember the incident which involved Resident #311 but not a lot of specifics. Per Administrator #77, the resident's family member (FM) came to him with some concerns and he and either the Director of Nursing (DON) or the Assistant DON listened to the FM's concerns, watched the videos to determine the staff involved, removed the staff from resident care, and contacted the Regional [NAME] President of Operations (RVPO) and the Regional Director of Clinical Services (RDCS) for guidance, who then took over the investigation.
During the survey, the facility provided the surveyor video camera footage of the incidents. In one (1) 30-second, undated and untimed video, a male staff member was noted to forcefully roll Resident #311 to their right side to the point the resident's right leg hung off the edge of the bed, all while the resident yelled quit and nurse repeatedly and a female staff member, who was also in the room, laughed. In another 30-second undated and untimed video, a female staff member entered Resident #311's room. The staff member greeted the resident by saying, good morning then pulled back the cover on the resident's bed and asked the resident if he/she was wet. Per the video, when the resident resisted, the staff member used their left hand and smacked the resident on their (his/her) right leg 3 times.
In a telephone interview on 02/05/2024 at 8:21 PM, the RVPO stated he did remember the incident that involved Resident #311. Per the RVPO, Administrator #77 contacted him after a meeting with the resident's family, where concerns were voiced. The RVPO stated he informed Administrator #77 to start an investigation and report the allegation to the state. The RVPO stated he believed a pretty thorough investigation into the allegations was done. The RVPO acknowledged the staff members were suspended pending the investigation and once the investigation was concluded, the staff members were terminated.
In a telephone interview on 02/06/2024 at 1:21 PM, CNA #76 stated she did nothing wrong and for the surveyor to stop calling. The surveyor had previously attempted to interview CNA #76 on 01/31/2024 at 6:15 PM and 02/01/2024 at 7:44 PM; there was no answer, and a voicemail message was left each time.
During an interview on 02/06/2024 at 1:43 PM, the RDCS stated she received a call from Administrator #77 on the day the resident's family sent the concern to Administrator #77. The RDCS stated she immediately ensured the staff members were suspended pending the investigation, the resident was safe, and a skin assessment was completed. The RDCS stated when she was in the facility the next day, and she helped with the investigation. Per the RDCS, two (2) staff were terminated for failure to meet the expectation in the facility's code of conduct and one (1) staff was terminated due to failure to participate in the investigation.
During an interview on 02/06/2024 at 2:45 PM, the Administrator stated he did not tolerate abuse and did not want it to occur in the facility.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure proper placement of a stability boot for one (1) of thirty-one (31) sampled residents, Resident #68.
The findings include:
A review of a facility policy titled, Medication and Treatment Order, revised in July 2016, revealed Orders for medications and treatments will be consistent with principles of safe and effective order writing.
A review of Resident #68's admission Record revealed the facility admitted the resident on 06/15/2022. The admission Record revealed the resident had diagnoses to include a fracture of the right fibula, fracture of the lateral malleolus (bone on the outside of the ankle) of the right fibula, and displaced fracture of medial malleolus of the right tibia.
A review of Resident #68's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/03/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required extensive assistance with personal hygiene.
A review of an emergency department Encounter Summary, dated 12/26/2023 at 7:50 PM, revealed Resident #68 was seen for right foot pain/swelling. The Encounter Summary revealed a boot was placed on the resident.
A review of Resident #68 Order Summary Report for active Orders as of 02/01/2024, revealed an order dated 12/27/2023, to remove the resident's boot every shift and check skin integrity.
During an observation on 02/01/2024 at 1:26 PM, Certified Nursing Assistant (CNA) #36 and CNA #37 took Resident #68 into his/her room and pulled the resident's privacy curtain. CNA #36 pulled the resident's blanket back which exposed the resident's legs. The resident had a stabilizing boot on his/her left foot and no boot on their right foot. CNA #37 immediately identified the resident's boot was on the wrong foot. Once the staff transferred the resident back to bed, they placed the boot on the resident's right foot.
During an interview 02/02/24 12:07 PM, Nurse Practitioner (NP) #38 stated the resident had a fracture of his/her right lower ankle and always wore the boot. NP #38 stated that she was made aware that staff had placed the boot on the resident's left foot. NP #38 stated that staff should ensure the boot was on the correct foot. She stated that the boot was for stabilization.
During an interview on 02/06/2024 at 11:13 AM, Licensed Practical Nurse (LPN) #23 stated the nurse on the hall was responsible to make sure durable medical equipment (DME) was applied appropriately.
During an interview on 02/06/2024 at 11:52 AM, LPN #42 stated she believed Resident #68's physician orders instructed staff to remove the boot to check for skin integrity and indicated that it was the nurses' responsibility, not CNAs.
During an interview on 02/06/2024 at 3:43 PM, the Director of Nursing stated when a resident had DME that required an order, the nurse needed to check every shift at least for skin integrity and placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure one (Resident #463) of five (5) sampled residents reviewed for advance directors, with physician's orders that accurately reflected the resident's code status.
The findings included:
A review of the facility's policy titled, Do Not Resuscitate Order, revised in [DATE], revealed, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect.
A review of Resident #463's admission Record revealed the facility admitted the resident on [DATE], with diagnoses that included metabolic encephalopathy, cognitive communication deficit, and unspecified dementia.
A review of Resident #463's Resuscitation Designation Form dated [DATE], revealed the resident had the code of do not resuscitate and wished for cardiopulmonary resuscitation (CPR) not to be initiated in the event they were found without a pulse or respiration.
A review of Resident #463's Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order, dated [DATE] and discussed with Resident #463's Power of Attorney (POA) and witnessed by two (2) individuals, revealed the resident wished not to be resuscitated.
A review of Resident #463's Order Summary Report, for the time period [DATE] to [DATE], revealed an order dated [DATE], for the resident to have full code status (if a person's heart stopped beating and/or they stopped breathing, CPR should be initiated).
A review of Resident #463's care plan, initiated on [DATE], revealed the resident had full code status.
During an interview on [DATE] at 11;34 AM, Resident #463's POA stated the resident's code status was DNR.
During an interview on [DATE] at 2:00 PM, the Administrator stated he deferred all questions regarding a resident's code status to nursing.
During an interview on [DATE] at 2:35 PM, the Director of Nursing (DON) stated there should not be a discrepancy in Resident #463's code status. Per the DON, the physician's order, care plan, and designation form should all indicate the same information. The DON stated it was important to not have a discrepancy as in the event of an emergency, staff needed to know how to honor the resident's wishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review it was determined the facility failed to ensure one (1) of forty-five (45) residents (Resident #54) received the care and services to prevent complications with the administration of oxygen. Observation revealed the resident's water bottle lacked label and dates, the facility failed to provide a bag to maintain a clean tube and cannula when not in use, and the tube laid on the floor when not in use. Interview revealed staff did not provide a bag or provide education on infection control since admission on [DATE].
The findings include:
Review of policy, Departmental (Respiratory Therapy) Prevention of Infection, undated, revealed staff dated and initialed bottles of water when opened with any use with respiratory therapy. Infection control included to place cannula and tubing into a bag when not in use. Furthermore, nebulizer circuits storage, when not in use, included placement into a bag with the date and resident name between uses.
Review of Resident #54's clinical chart revealed the facility admitted the resident on 12/06/19 with the diagnoses of Acute Respiratory Failure, Pneumonia due to infectious organisms, and Congestive Heart Failure.
Review of Resident #54's admission Minimum Data Set (MDS), dated [DATE], revealed the facility completed a Brief Interview for Mental Status (BIMS) for cognition. The facility determined the resident as interviewable with a score of thirteen (13) out of a score of fifteen (15).
Review of Resident #54 Physician Orders, dated 12/05/19, revealed the facility provided five (5) liters of oxygen every shift. Further review revealed the facility provided a respiratory inhaled medication every four (4) hours as needed for wheezing delivered through a nebulizer system.
Observation, on 01/27/2020 at 3:57 PM, revealed the humidified water bottle for the resident's oxygen did not have a date or initials on the bottle, and the oxygen tube for the portable oxygen hung over the residents wheelchair.
Observation on 01/28/2020 at 10:31 AM, revealed the residents oxygen tubing hung over and around the flow meter without placement into a bag. The water bottle for humidified air lacked a date and initial of when and whom placed the bottle.
Interview with Family #2, on 01/28/2020 at 10:31 AM, revealed the cause of Resident #54's admission included low oxygen due to pneumonia. She stated the resident became unresponsive after days of decline at home and spent three (3) days unresponsive with respiratory support in the intensive care unit. She further stated the resident's excessive fluid and lung disease caused long-term use of oxygen.
Interview with Licensed Practical Nurse (LPN) #14, on 01/29/2020 at 3:57 PM, revealed newly admitted resident's supplies for the use of oxygen included a bag to place the tube. She stated staff dated the bag and changed the bag weekly. She stated the floor contained everything from the facility and tubing laid on the floor required an immediate change due to contamination. She stated nebulizer units required a bag as well to keep the inhale unit clean. She further stated water used to humidify oxygen required an open date with staff's initials. She stated staff followed infection control protocols for oxygen, which included bags, initials, and dates. She stated staff followed these basics of care to prevent bacteria growth and helped to prevent a respiratory infection.
Interview with LPN #15, on 01/29/2020 at 3:40 PM, revealed the facility expected staff to label and date all equipment used with oxygen therapy. She stated labeled water prevented bacteria growth, which occurred after twenty-four (24) hours. She stated staff provided bags to resident rooms with oxygen to provide a clean environment when not in use. She stated germs and bacteria laid on floors and rugs of the facility and the floors were not the place for an oxygen tube to lay. She stated the facility risked the development of a respiratory infection with residents on oxygen with poor infection control.
Observation, on 01/30/2020 at 8:21 AM, revealed Resident' #54's oxygen tube and nasal cannula laid on the rug on the floor of the resident's room.
Interview with Resident #54, on 01/30/20 at 8:21 AM, revealed the facility did not provide a bag, since admission, for the nasal cannula/tube and for the nebulizer unit to keep the items clean to decrease the risk of infection. The resident further stated staff did not provide education to prevent the nose piece/tube from contact with the floor to decrease the risk of a respiratory infection or any other education.
Interview with LPN #6, on 01/30/2020 at 8:33 AM, revealed staff provided residents with oxygen signage at the door, labeled and dated all items and placed a bag in the room to store the tubing when not in use to keep clean. She stated staff immediately changed oxygen tubing found on the floor due to whatever germs walked in with visitors or staff contaminated the tube. She stated resident's developed respiratory infections when breaches of infection control occurred.
Interview with the SDC, on 01/30/2020 at 9:39 AM, revealed she provided staff with orientation, annual education, skill check off, and in services for topics and skills to care for and prevent infections with residents. She stated when she walked the units she conducted audits of staff and residents. She stated the facility provided the education so she expected staff to ensure tubing did not lay on the floors, provided a bag with instructions to the resident to keep clean and monitor, and label and date any bottles or treatments. She stated the concerns of not following protocol included the risk of increased for respiratory infections with residents.
Interview with the Assistant Director of Nursing (ADON), on 01/30/2020 at 11:30 AM, revealed the facility audited residents with oxygen. She stated the facility used an audit sheet to check for signage, bags, dated humidifiers, and tubes. She stated the facility completed the audits with new admissions. She stated staff's responsibility included to ensure residents with oxygen received care, which included prevention of infection. She stated the concern with residents with respiratory issues included the high risk of infection.
Interview with the Director of Nursing (DON), on 01/30/2020 at 10:20 AM, revealed she expected staff to provide respiratory care to residents with oxygen, which included dating and signing the water bottle, a bag for the oxygen, signage, and tubes on the floor meant lack of education to the resident and provision of a bag. She stated the concern for residents included the safety and risk for residents with respiratory conditions or previous treatments for pneumonia.
Interview with the Administrator, on 01/30/2020 at 5:30 PM, revealed the facility did not previously identify infection control concerns with residents on oxygen. She stated the staff responsibilities included following policy and procedure and her role included to ensure staff received education and skills to provide the care to the residents.

Based on observation, interview, record review, and the review of facility policy it was determined the facility failed to have an effective Infection Prevention and Control Program (IPCP) for the prevention and control of transmission of disease to residents and staff of the facility for one (1) of forty-five (45) residents, Resident #81. Wound care observation revealed staff placed the removed wound dressing bag onto the residents bare mattress, used a clear bag for heavily soaked wound dressings, placed bags onto the floors with bloody drainage, and placed the unmarked, clear waste bag of the heavily soiled dressings into an unmarked gray bin.
The finding include:
Review of the policy, Dressings, Soiled/Contaminated, undated, revealed secured dressing which contained exudate, saturated blood, body fluids or infectious material required disposal into the designated biohazard container.
Review of the policy, Biomedical Waste Disposal, undated, revealed the facility provided rigid, puncture resistant containers to prevent tearing or the ability to burst open when handled normally, and must be sealed in a secure manner. Any untreated waste required a red plastic bag for disposal into an inner package and placed into a container, which required an identified label or symbol for biohazard waste.
Review of www.cdc.gov/mrsa/healthcare, dated 02/28/19, revealed the spread of MRSA occurred with direct contact of an infected wound, contaminated hands of the healthcare provider, and indirect contact from a contaminated object or surface.
Review of Wound Source, Principal of a Truly Clean Dressing Technique, 12/24/14, revealed heavily soiled dressings removed from a wound contained potential bacteria which required placement into a red bag and disposed into a red marked bin for biohazard material to prevent further spread of infection(s).
Review of Resident #81's clinical chart revealed the facility admitted the resident, on 06/12/19, with the diagnoses of Paraplegia, Diabetes, and Stage three (3) kidney disease. Review of Resident #81's admission assessment revealed the facility admitted the resident with known sacral, hip and heel pressure wounds.
Review of Resident #81's Minimum Data Set (MDS) admission assessment, dated 06/19/19, revealed the facility assessed the resident with six (6) stage four pressure ulcers, and one (1) undetermined pressure ulcer with admission.
Review of Resident #81's Lab Result, dated 08/24/18, revealed a sampled wound culture of an infected wound identified Methicillin Resistant Staphylococcus Aureus (MRSA) colonized in the wound.
Observation, on 01/28/2020 at 2:19 PM, revealed Licensed Practical Nurse (LPN) #14 completed the daily wound care treatment for Resident #81. The LPN placed an open clear bag at the end of the resident's bed, onto the bare mattress, and proceeded to fill the bag with saturated dressings, and materials used to clean wounds,which became stacked six (6) inches above the bag and hung out the sides of the bag.
Observation, on 01/28/2020 at 3:17 PM, revealed the Quality Assurance (QA) nurse removed the bag with the saturated dressings, bagged the bloody linen from Resident #81 bed, and laid the bags onto the floor rug. After hand hygiene and new glove placement, the QA nurse removed the bags from the room, placed the unlabeled dressing bag into a gray bin and the bagged linen into a white bin located in the dirty utility room across from the resident's room.
Interview with the QA nurse, on 01/29/2020 at 9:04 AM, revealed she observed saturated dressings with heavy bloody drainage from Resident #81 wounds. She stated she removed Resident #81's packed gauze from the wounds, which bled heavily onto the linen. She stated she placed the bagged bloody linen into the white linen bin and placed the unmarked clear bag of wound dressings into the gray trash bin. She stated all utility rooms contained red biohazard bins. She stated the facility did not place residents contaminated material when residents have colonized MRSA into a red bag and red bin. She stated the facility found MRSA colonization infectious enough to put into isolation, which then the facility utilized the bags and biohazard bin. She further stated the facility placed saturated dressing in the regular trash. She further stated when staff did not follow infection control practices standards, residents risks included infections, which lead to negative results. She further stated as the QA nurse of the facility her responsibilities included education to staff, trending of infections, audits of staff performance, and reported to the Director of Nursing (DON).
Interview with LPN #15, on 01/29/2020 at 3:40 PM, revealed heavily soiled dressings required placement into a red biohazard bag with the bag placed into a trashcan to provide stability. She stated a red bag required placement into the red biohazard bin. She further stated when staff placed soiled bloody linen into a red bag the laundry staff easily identified the bag as an increased hazard which helped to protect the staff. She stated the facility provided education on infection control to ensure residents and staff remained safe from infections. She further stated as an agency nurse, the facility expected good infection control prevention practices.
Interview with LPN #14, on 01/29/2020 at 3:57 PM, revealed she placed did not place the waste disposal bags into a bin on a flat steady surface of the floor. She stated when a dressing contained heavily saturated blood or matter staff utilized a red bag. She stated staff placed the red bag into the red bin in the utility room. She stated the red bin identified potential hazardous material and required special disposal by the facility. She stated she placed the waste bag onto the end of the resident's mattress and waste overflowed up and out of the bag. She stated the facility provided education with infection control to ensure residents and staff remained safe from infection.
Observations, on 01/30/2020 at 8:43 AM, revealed LPN #6 opened the door to the utility room across from Resident #81's door. The LPN stated a gray and white bin sat in the room. The LPN stated when a resident on the hall required isolation staff obtained a red biohazard bin to place into the room. The LPN stated the room never contained the red bin for disposal for heavy saturated or potentially infectious waste. The LPN stated she did not identify any resident in the unit with MRSA or wound care with heavily soaked dressings, which the facility wanted to contain for infection control. She stated heavily soiled dressings required a red bag and placement into the red bin. She stated the gray bin bag ripped easily, and for the safety of laundry staff if blood saturated linen placement into a red bag made the sheet easy to identify as an increased biohazard potential. She stated proper containment of saturated linen and waste protected staff and residents from the spread of potential infection.
Interview with the Staff Development Coordinator (SDC), on 01/30/2020 at 9:39 AM, revealed the SDC provided education and in-services for Infection control/wound care, contact pre-cautions, videos which talked about infection prevention in health care settings and when to discard material into biohazard bins. She stated she expected staff to place a can with a liner on the floor, and double bag the waste with heavily soiled waste. She stated staff used the regular trash bins to throw heavily soiled wound dressing away. She stated staff utilized red bins only when residents required isolation. She further stated all utility rooms in the facility contained a red biohazard bin.
Interview with the Assistant Director of Nursing (ADON), on 01/30/2020 at 11:30 AM, revealed she expected staff not to place waste bags for removed wound dressings on the bed. She stated she expected staff to place heavily soiled waste in a red bag and placed into the red bin. She stated as the wound nurse for the facility, infection control with wound care started from the time staff went into the room and ended with the proper disposal of trash.
Interview with the Director of Nursing (DON), on 01/30/2020 at 10:20 AM, revealed disposal of heavily saturated waste from a wound required the use of a red bag and placement into the red bin in the dirty utility room. She stated she expected immediate removal of a soiled bag of linen and bagged wound dressings to the proper bins and not on the floor. She stated this was a potential for contamination. She stated the facility dirty utility rooms contained red bins for biohazard material. She stated bags, which contained heavily soiled matter from wounds required placement into the red bin. She further stated the concern of improper disposal put the facility at risk for cross contamination, which may lead to infections. She stated residents with infections acquired through cross contamination increased the potential for further complications
Interview with the Administrator, on 01/30/2020 at 4:30 PM, revealed she expected staff to place soaked or bloody dressing in a red bag and placed into the red bin. She stated cans with liners with wound care prevented contamination to resident beds and provided stability of the bag.

Based on record review, interview, and review of facility policy, it was determined the facility failed to maintain a complete and accurate clinical record for one (1) of forty-five (45) residents, Resident #81. Record review revealed the facility failed to measure and document the condition and progress and/or lack of progress in the healing of Resident #81's multiple pressure ulcers in his/her medical record.
The findings include:
Review of the facility policy, Wound Care, revealed staff were to document in a resident's medical record all assessment data. Per the policy, all documentation for pressure ulcers or other wounds was to include the following assessment data: wound bed; color; size; drainage; and treatment obtained during the inspection of wounds.
Review of the facility policy, Pressure Ulcers Skin Breakdown Clinical Protocol, undated, revealed the nurses' responsibilities included to describe and document a full assessment of a pressure sore/ulcer. Continued review revealed the documentation was to include the location, stage, depth, width, and length, the presence of exudate or eschar (dead tissue). Further review revealed staff were to include with the pressure sore assessment the following: a pain evaluation; mobility status; current treatment; support surfaces; and all active diagnoses.
Review of the facility's clinical chart for Resident #81 revealed the facility admitted the resident on 06/12/2019, with diagnoses which included Paraplegia, Diabetes, and Stage III kidney disease. Continued review revealed the nurse admission assessment noted Resident #81 had six (6) Stage IV pressure ulcers on the buttocks area, and one (1) Stage IV pressure ulcer to his/her heel. Further review revealed wound assessments and measurements were last performed on 11/17/2019 in Resident #81's clinical record. However, additional review revealed no documented evidence nurses had measured the pressure ulcers or noted the condition of the wounds from 11/08/2019 through 01/28/2020.
Review of the facility's Nurse's Notes for Resident #81 dated 11/08/2019 to 01/27/2020, revealed staff had not documented wound measurements, conditions or stage of pressure ulcers/wounds for the daily wound care. Further review revealed staff had not documented the assessment data and completion of wound care performed daily.
Review of the facility's Assistant Director of Nursing's (ADON) spreadsheet, used for weekly wound measurement documentation, dated 01/24/2020, revealed Resident #81 had been assessed to have eight (8) wounds present on his/her body. Continued review revealed the ADON had documented under the comments data section the wound documentation included the following: Eschar, Deep Tissue Injury (DTI), pressure or areas of undermining of the resident's wounds. However, further review of Resident #81's clinical chart revealed no documented evidence of the ADON's spreadsheet documentation of the resident's wounds entered into the record.
Review of Resident 81's Wound Provider Summaries revealed the facility scanned the Physician's summary of office visits into the resident's clinical chart. However, further review of the Wound Provider Summaries for visits completed in December 2019 and January 2020 revealed no documented evidence the summary included the measurements or descriptive conditions for each of Resident #81's wounds.
Interview with the Minimum Data Set (MDS) Coordinator on 1/30/2020 at 03:12 PM, revealed when she had completed Resident #81's Quarterly MDS Assessment, she used the spreadsheet previously provided by the ADON. She stated the information she acquired for residents' MDS Assessments included the following: resident medical record; assessments; notes; and staff or other interviews. Continued interview revealed she or the ADON neither one scanned Resident #81's wound measurements into his/her medical record. Per interview, she used the ADON's wound spreadsheet as an audit tool, a guide, and used Nurse's Notes and Physician Notes for accurate information. Furthermore, she stated the medical record contained Resident #81's medical information, care, treatments, and it was okay if the medical record did not include the scanned ADON wound spreadsheets.
Interview with the ADON, on 01/28/2020 at 12:00 PM, revealed she completed weekly wound assessments and measurements of Resident #81's wounds. Per interview however, she kept the information on the spreadsheets, and did not include it in the resident's electronic medical record (EMR). She stated she did not scan her spreadsheets into Resident #81's medical record either. According to the ADON, she provided her spreadsheet to the MDS Assessment Nurse for her reference. The ADON revealed the spreadsheet was not part of the resident's record, and the medical staff did not have the information to review for progression of the wounds. Continued interview revealed the ADON measured wounds for the facility, and therefore, it was her responsibility to include the documentation of the wounds in the resident's medical record. Review of Resident #81's medical record with the ADON, revealed she stated on 11/07/2019 the resident's wound measurements and condition assessment was posted under assessments. She further stated the previous ADON had not instructed her to record the weekly findings of her assessment into residents' clinical charts. Further interview revealed the medical record of a resident contained the legal documentation for review by all staff and other outside entities. In addition, she stated the lack of wound documentation could negatively affect Resident #81 if or when a change of condition occurred. She stated the information on the wound spreadsheets not being scanned or included in the resident's clinical record meant the record was incomplete.
Interview with the Director of Nursing (DON), on 01/30/2020 at 10:20 AM, revealed the ADON completed weekly wound assessments and discussed her results with the weekly Wound and Nutrition team in their meeting. She stated the documentation of the assessments was documented in residents' clinical charts. However, further interview revealed she was not aware wound documentation had stopped in November 2019, for Resident #81's wound assessments.
Interview with the Administrator, on 01/30/2020 at 4:46 PM, revealed the facility's EMR provided documentation of wounds measurements and condition. Per interview, the ADON completed her assessment weekly, and she expected the information from the assessments to be documented in residents' medical records. According to the Administrator, the facility did not audit resident medical records to determine whether completed documentation existed in the electronic medical record. Further interview revealed if documentation did not exist in the clinical chart, it might not have completed.

Based on observation, interview and facility policy review, it was determined the facility failed to ensure food was stored, prepared and distributed under sanitary conditions. Review of the facility's Census and Condition, dated 01/26/2020, revealed one hundred and twenty two (122) residents received meals from the kitchen. Observations, on 01/26/2020 through 01/29/2020, revealed staff did not restrain beards and hair with nets, a cook handled residents' food with gloved hands after having pulled up the back of their pants with gloved hands. Further observations revealed numerous unlabeled boxes and cans in the refrigerators, freezers, and dry storage with stored boxes on floors. Observation of sanitation revealed after dishwashing occurred the resident cups remained dirty.
The findings include:
Review of facility policy, Dietary Staff Sanitation, undated, revealed dietary staff shall wear hat, hairnet, hair coverings, beard guards and clothing that was effective in keeping hair from contacting exposed food.
Review of facility policy, Handwashing/Hand Hygiene, undated, revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Perform hand hygiene before and after removing gloves, before and after handling food, and after conducting personal hygiene.
Review of facility policy, Sanitation/Infection Control, undated, revealed the Dietary Manager (DM) had the responsibility to supervise all sanitation and housekeeping within the Dietary Department. This included the daily, weekly and monthly cleaning schedule, properly in-service staff on procedures for washing and sanitizing all kitchen silverware, china, and glasses, and along with working services, utensils and equipment per the manufacturer's recommendations after each use. In addition, the DM also had the responsibility to ensure Dietary staff were supervised and trained on proper sanitation procedures for storing, preparing and serving foods.
Review of facility policy, Food Storage, undated, revealed dry foods were stored at an appropriate temperature and by methods designed to prevent contamination. This included but not limited to dry food was stored at a minimum of six (6) inches off the floor and eighteen (18) below the sprinkler heads. In addition, stored dry pantry items opened and not individually wrapped and remaining in the pantry were dated with the open date as well as the stocking date. All foods in the pantry was in closed containers.
Observations during the initial tour of the kitchen, on 01/26/2020 at 7:42 PM, revealed a sanitation worker had a thick beard and mustache over two (2) inches with no hairnet nor beard guard. Continued observation revealed [NAME] #1 acquired food and placed foods for storage with no beard and hair net in place. Further observation revealed on the clean side of the sanitation dish area a glove and a straw floated in water. In addition, the three (3)-compartment plate warmer contained heavily layered white and brown products to all three-bottom areas, and the sides to all compartments contained dripped white and brown substances and appeared with a slick appearance. Observations of the refrigerators, freezers, and dry storage room revealed copious boxes, cans, and products lacked received or open dates. Continued observation of the dry storage area revealed stored boxes on the floor and stacked onto one another.
Interview with Sanitation worker, on 01/26/2020 at 7:42 PM, revealed his job duties included sanitizing the kitchen at night, which included the walk-in refrigerator. He stated responsibilities in the kitchen included to wear a beard and hair net when in the kitchen to prevent hairs from falling onto food.
Observation during Lunch Services, on 01/28/2020 at 11:45 AM, revealed [NAME] #1 plated food onto the resident's plates with gloved hands. The cook took the gloved hands, grabbed the back of the pants, and pulled the pants upward. [NAME] #1 continued to plate food with the same gloves, and picked up food with the gloves, which dropped of plates and put food back onto the resident's plates.
Interview with family #9, on 01/29/2020 at 08:58 AM, revealed kitchen utensils, plates, and cups contained dried foods and sediment. The family member provided a coffee cup, which she pulled from the day's breakfast tray. The cup contained heavy brown sediment to the rim and the family member slightly rubbed a finger into the cup and stated the cup felt greasy and it contained coffee sediment.
Observation, on 01/29/2020 at 12:25 PM, revealed the Dietary Manager (DM) stated staff rinsed out coffee cups prior to the dishwasher and the facility soaked the cups once a week. Review of a rack of previously cleaned dried cups readied for the residents lunch meals revealed the DM picked up numerous cups to find thick sediment in cups. The DM placed her finger into the bottom and lower sides of the cups, stated the cups were greasy and the sediment on her finger contained old coffee. She further stated she would not want to drink from the cup therefore; she did not want residents to drink from the cup. Further observations with the DM revealed she stated the plate warmer contained sediment and drippings to all sides and all bottoms. She stated the kitchen schedule for cleaning needed revision and she had not completed it. Review of the past cleaning schedule revealed the list did not contain the plate warmer for staff to clean on a schedule.
Interview with [NAME] #1, on 01/29/2020 at 12:45 PM, revealed the facility expected staff to wear hair and beard restrains at all times in the kitchen. Delivered boxes and foods required an immediate date upon arrival of the product to ensure freshness of the foods. He stated stored boxes went onto shelves and not onto the floors. He stated when staff plated foods; staff washed hands, and donned clean gloves prior to the start of the service. Furthermore, if the gloves became contaminated, staff removed gloves, washed hands, and donned clean gloves to continue. He stated when contaminated gloves touched resident foods, the germs or bacteria on the gloves transferred to resident foods, which may make the resident sick. He stated the facility provided education and training included safety, cleaning and preparations of foods to prevent of cross contamination of resident foods.
Interview with Dietary Aide (DA) #1, on 01/29/2020 at 01:00 PM, revealed the facility required nets to cover the entire head of hair for women and for men, including beards. She stated the sight of hair in food made people lose their appetites. She stated the kitchen staff was to label all containers received at delivery to ensure staff knew what to use first, which prevented spoilage. She stated shelves provided storage for the boxes, not the floors. She stated rodents accessed boxes better on the floor than on shelves. She stated staff washed their hands upon entry to the kitchen, and put on clean gloves. She stated if staff touches, hair, skin, or clothing the gloves became contaminated. She stated continued use of contaminated gloves passed the germs to residents' food, which caused residents to become ill. She stated with sanitation of residents' kitchenware, staff rinsed the cups and used a scrubber on the inside if sediment existed. Review of a previously cleaned cup revealed the DA stated the inside of the cup contained a greasy sediment, which smelled like coffee. She further stated clean cups meant no sediment inside. She further said her nor the residents would want to drink from a dirty cup. She further stated the kitchen soaked cups once a week, and cleaned daily. However, she stated the kitchen did not have a schedule, which provided a schedule for daily, weekly or month tasks.
Interview with [NAME] #2, on 01/29/2020 at 1:15 PM, revealed when staff entered the kitchen the staff placed hair and beard nets before they entered. She stated this prevented hairs dropping into food. She stated the cooks' responsibility included to receive the food shipment, label, date the boxes, and store the boxes in the appropriate areas. She stated this ensured the kitchen used the oldest food first and proper storage prevented contamination. All boxes required placement off the floor. She stated all staff labeled and dated left over foods prior to the placement into the refrigerator. She stated if found undated the staff threw items away to prevent food borne illness from old food. She stated the facility expected staff to maintain proper hand hygiene with food preparation and service to prevent cross contamination. She stated the manipulation of clothing contaminated gloves. She further stated although the kitchen soaked resident cups weekly, she observed cups with thick residue and sediment. She stated the kitchen staff responsibilities included to maintain good practices with food prep, storage, and sanitation to prevent food borne illness to the residents. She further stated staff cleaned the kitchen daily but a weekly and monthly schedule did not exist. She stated she not know when staff cleaned the plate warmer.
Interview with the DM, on 01/30/2020 at 10:02 AM, revealed she expected all staff to wear beard guards and hairnets before they entered the kitchen. She stated she expected staff to label and date leftovers before storage to prevent food borne illness. The Cook's responsibilities included to label, date all boxes or cans, and to store them off the floor and rotate with the existing boxes. She stated use of undated foods caused illness to residents and unlabeled items made it impossible to ensure which box to use first. She stated the schedule to clean equipment provided staff with known tasks to complete to ensure the kitchen was clean. She stated the cook kept the gloved hands to the front of the body away from clothes and contact with clothes contaminated the gloves. She stated the cups required further attention. She stated she expected staff to remove objects such as the glove and straw in the sanitation room to ensure the clean side was clean with active sanitation. Additionally, she stated staff practiced all infection control techniques to prevent cross contamination therefore prevented the illness to residents,
Interview with the Director of Nursing (DON), on 01/30/2020 at 10:20 AM, revealed the importance of proper nutrition for residents concerned all nurses. She stated concerns included food borne illness from the kitchen with improper storage, prep, sanitation, or other unwanted practices. She further stated proper food preparation was necessary resident for nutrition, hydration provided calories, and nutrients to ensure residents healed and remained healthy.
Interview with the Administrator, on 01/30/2020 at 4:30 PM, revealed she expected staff to follow policies to ensure residents remained safe and healthy. She stated the facility had not identified issues during monthly review.