Allen Oaks Nursing And Rehab Center

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles. This deficient practice has the potential to affect all 72 residents residing in the facility. The facility failed to:
1.
Ensure expired medications were not available for administration to residents in 1 (Med Room B) of 2 (Med Room A and Med Room B) medication rooms.
2.
Ensure controlled substances were properly stored in a permanently affixed compartment and had restricted access until destroyed appropriately.
Findings:
Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Controlled Substances revised on 12/2012 revealed the following in part .The facility shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances.
Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Storage of Medications revised on 04/2007 revealed the following in part .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Discarding and Destroying Medications revised on 10/2014 revealed the following in part . Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of.
1.
On 07/01/2025 at 8:20 a.m., an observation of Med Room B was conducted accompanied by S4 LPN and revealed the following items in the medication room for use:
1. One opened and used tube of Hydrocortisone cream with an expiration date of 04/15/2025.
2. One opened and used tube of Clobetasol Propionate 0.05% cream with an expiration date of 04/22/2025.
At the time of observation, S4 LPN confirmed both creams were expired and should have been disposed of properly, but were not.
In an interview on 07/01/2025 at 8:35 a.m., S2 DON confirmed that Med Room B should not have any expired medications available for usage.
2.
Observation on 07/01/2025 at 11:08 a.m. of the facility's narcotic destruction locked box, accompanied by S10 ADON, revealed the box was located on a shelf in S10 ADON's shared office. Interview with S10 ADON at the time of observation confirmed that the locked box was not permanently affixed to any surface. S10 ADON was observed unlocking the narcotic box which revealed the box contained multiple medication cards and bottles of controlled substances. S10 ADON confirmed the narcotics destruction locked box did have controlled medication inside, was not permanently affixed to any surface, and that two other employees had access to the shared office space where the box was stored. S10 ADON revealed she was responsible for the controlled substance destruction process, which included storing, handling, documentation, and destroying of narcotics.

Based on interview, observations, and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life by failing to apply a privacy cover to an indwelling catheter urinary drainage bag for 1 (#61) of 1 residents reviewed for dignity.
Findings:
Review of Resident #61's medical record revealed an admission date of 04/04/2025, with diagnoses that included in part . Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct; Hypospadias, Penile; Encounter for Palliative Care; Presence of Urogenital Implants; Neuromuscular Dysfunction of Bladder; and Retention of Urine.
Review of Resident #61's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/25/2025 revealed a BIMS score of 14, which indicated intact cognition. Resident #61 used an indwelling urinary catheter for urine elimination.
Review of Resident #61's current clinical physician's orders revealed an order date of 04/24/2025-catheter care every shift: to keep Foley catheter clean to prevent infection related to Presence of Urogenital Implants.
On 06/30/2025 at 9:59 a.m., Resident #61 was observed lying in bed with the door closed. Upon entrance into Resident #61's bedroom, Resident #61's indwelling catheter urinary drainage bag was observed with 200-300ml (milliliters) of yellow urine in the collection bag and without a privacy cover.
On 06/30/2025 at 3:44 p.m., Resident #61 was observed sitting up in bed watching television. Upon entrance into Resident #61's bedroom, Resident #61's indwelling catheter urinary drainage bag was observed with about 150ml of yellow urine in the collection bag and without a privacy cover.
On 06/30/2025 at 3:52 p.m., in an interview and observation with S5 LPN to Resident #61's bedroom, S5 LPN stated Resident #61's urine output is monitored and flushed every 2 hours. S5 LPN confirmed Resident #61's indwelling catheter urinary drainage bag should have a privacy cover, but had not. S5 LPN stated I'll go look for one right now.

Based on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to have an assistive device accessible to 1 (Resident #45) of 26 sampled residents.
Findings:
On 07/2/2025 at 1:50 p.m., review of the facility policy titled. Assistive Devices and Equipment, with a revision date of July 2017, revealed in part . Our facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These include, but are not limited to, walkers. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' plan of care.
Review of Resident #45's electronic medical record revealed an admit date of 12/26/2024 with diagnoses that included but not limited to: Malignant Neoplasm of Prostate, Secondary and Unspecified Malignant Neoplasm of Lymph Nodes of Head, Neck, and face, Heart Failure, Acquired Absence of other Right Toes, Cognitive Communication Deficit, Difficulty Walking, Not elsewhere Specified, Other Lack of Coordination, Unspecified Dementia.
On 07/01/2025 at 1:43 p.m., review of Resident #45's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 04/04/2025, revealed a BIMS Score of 6, indicating severe cognitive impairment. Resident #45 utilized a walker.
On 07/01/2025 at 1:28 p.m., review of Resident #45's care plan with start date of 04/21/2025 revealed Resident #45 was a fall risk and had two previous falls on 04/03/2025 and 04/11/2025. Interventions included in part . encourage the resident to use a walker and wear shoes, call for assistance to ambulate due to dizziness and weakness, and ensure the resident has assistive devices and understands how to properly use them.
On 06/30/2025 at 09:50 a.m., observation revealed Resident #45 ambulating throughout his room without supervision or an assistive device. Resident #45's gait was shuffled. Resident #45 walker was not present in the room.
On 07/01/2025 at 11:37 a.m., observation revealed Resident #45 was lying in his bed awake, alert, and confused. Resident #45's walker was not present in the room.
On 07/01/2025 at 11:40 a.m. S5 LPN accompanied the surveyor to Resident #45's room. S5 LPN confirmed Resident #45's walker was not present in the room. S5 LPN stated she worked the day prior and did not see the resident ambulate with a walker. S5 LPN stated the last time she could recall Resident #45 ambulating with a walker was the week prior, and was unsure where Resident #45's walker was located. S5 LPN confirmed Resident #45 required a walker to ambulate safely and should have had a walker present in the room with him, but did not.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure a resident received enteral feedings as ordered by the physician for 1 (#65) of 1 residents reviewed for tube feeding. Total sample size 26.
Findings:
Review of Resident #65's Clinical Record revealed an admit date of 07/10/2024 with diagnoses which included: Pneumonitis due to Inhalation of Food and Vomit; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation; Heart Failure; Anxiety; Cerebral Infarction; Hyperlipidemia; Aphasia; Hypertension; Dysarthria and Anarthria.
Review of Resident #65's Annual MDS with an ARD of 05/24/2025 revealed a BIMS score of 0 indicating Resident #65 rarely/never understood. Resident #65 was dependent for bed mobility, transfers, eating, and toileting.
Review of Resident #65's Physician Orders revealed the following, in part:
06/27/2025-Enteral feedings: Osmolite 1.2 at 40 milliliters (ml) /hour via pump
Review of Resident #65's Care Plan dated 04/28/2025 read in part: Resident #65 requires tube feeding related to diagnoses of Dysphagia following a Cerebral Vascular Accident. Interventions included: Osmolite 1.2 at a rate of 40 ml/hour with a 30 ml/ hour water flush.
An observation on 06/30/2025 at 10:49 a.m. revealed tube feeding Osmolite 1.2 infusing at 50 ml/ hour continuous via pump.
Interview on 06/30/2025 at 03:48 p.m. with S4 LPN confirmed Osmolite 1.2 should have been infusing at 40 ml/hour as ordered by the physician and was not.
Interview on 07/01/2025 at 02:10 p.m. with S10 ADON confirmed that physician decreased tube feeding rate during rounds on 06/27/2025. S10 ADON confirmed that Resident #65 should have received Osmolite 1.2 at 40 ml/hour starting on 06/27/2025.
Interview on 07/01/2025 at 02:13 p.m. with S2 DON confirmed Osmolite 1.2 should have been infusing at 40 ml/ hour as ordered by the physician and was not.

Based on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (#55) of 2 (#14 and #55) residents reviewed for respiratory care.
Findings:
Review of the facility's policy titled Oxygen Administration, with a revised date of 10/2010 revealed the following in part, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 4. All assessment data obtained before, during, and after the procedure.
Review of Resident #55's medical record revealed an admission date of 10/15/2024 with diagnoses that included in part, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (COPD), Other Disorders of Lung, Dependence on Supplemental Oxygen, and Dyspnea.
Review of current Physician Orders for Resident #55 revealed continuous O2 (oxygen) at 2 liters per minute via nasal cannula, every day and night shift related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation with an order date of 11/18/2024.
Review of Resident #55's Quarterly Minimum Data Set (MDS) with an ARD (Assessment Reference Date) dated 08/27/2025 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Further review revealed Resident #55 requires oxygen therapy.
Review of Resident #55's Care Plan revealed in part, Resident #55 has oxygen therapy related to ineffective gas exchange, respiratory illness (COPD, Dyspnea, Pneumonia: reoccurring frequently). Interventions to include: Continuous oxygen at all times, give medications as ordered by physician.
Observation on 06/30/2025 at 9:35 a.m., revealed Resident #55 sitting up in a chair in her bedroom. Resident #55 observed with oxygen in progress at 3.5 liters/minute via nasal cannula per oxygen concentrator. Resident #55 stated she wears oxygen via nasal cannula continuously.
Observation on 07/01/2025 at 8:39 a.m., revealed Resident #55 sitting up in her recliner with oxygen in progress at 3.5 liters/minute via nasal cannula. Resident #55 stated no one comes to check to see how many liters of oxygen she is on.
Observation on 07/01/2025 at 1:37 p.m., revealed Resident #55 sitting up in her recliner with oxygen in progress at 3.5 liters/minute via nasal cannula.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate disposition and/or administration of medications to meet the needs of each resident. The facility failed to:
1.
Ensure proper nursing procedures and documentation were completed at the time of wasting/destroying narcotics on 1 (Med Cart 1) of 2 (Med Cart 1 and Med Cart 2) medication carts for Resident #26.
2.
Ensure proper nursing procedures for wasting of controlled substances were completed when Resident #60's controlled medication was not administered.
Findings:
Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Discarding and Destroying Medications revised on 10/2014 revealed the following part . Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 6. for unused, non-hazardous controlled substances that are not disposed of by an authorized collector, c. dispose with the solid waste in the presence of two witnesses. e. include the signature(s) of at least two witnesses. 7. destruction of a controlled substance must render it non-retrievable, meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted.
Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Controlled Substances revised on 12/2012 revealed the following in part .The facility shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances. 8. When a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container.
1.
On 07/01/2025 at 9:38 a.m. a controlled medications reconciliation was conducted with S5 LPN of Med Cart 1. Review of Resident #26's document titled, Controlled Substance Count Sheet for Tramadol 50mg tablets revealed one entry on 06/13/2025 at 8:00 a.m. where one tablet was documented as wasted by a nurse. Further review of the document revealed no evidence of a destruction witness signature for the waste entry. S5 LPN confirmed there should had been a witness/second signature when Resident #26's Tramadol tablet was wasted on 06/13/2025, but there was not.
2.
On 07/01/2025 at 9:38 a.m. a controlled medications reconciliation was conducted with S5 LPN on Med Cart 1. Review of Resident #60's blister medication card package for Hydrocodone/APAP 5mg-325mg tablets revealed that tablet #41 was opened/popped and the back of the packaging was taped with clear tape. Further review revealed a white pill was placed back into tablet #41's packaging of the medication card. S5 LPN confirmed that Resident #60's Hydrocodone/APAP 5mg-325mg blister package should never have medications taped back into the package after it has been popped or opened. S5 LPN confirmed tablet #41 should have been wasted appropriately and not placed back into the packaging, but was not.
In an interview on 07/01/2025 at 11:43 a.m., S2 DON revealed that the floor nurses are aware of the proper procedures for wasting of controlled substances/narcotics. S2 DON stated there should always be two nurses to witness any wasting/destruction of controlled substances and both nurses are to document in the clinical record. S2 DON confirmed the nurse failed to follow proper nursing procedures for wasting Resident #26's narcotic medications on 06/13/2025. S2 DON revealed that the nurses are never to tape the back of a blister medication package and place a tablet back into the packaging. S2 DON confirmed the nurse failed to follow proper nursing procedures for wasting Resident #60's controlled medications by placing the tablet back into the packaging.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by:
1. Failing to store clean unused resident care items in a sanitary manner on Hall Z
2. Failing to ensure opened resident care items were not stored on the clean linen cart on Hall Z after use
3. Failing to practice Enhanced Barrier Precautions for Resident #63.
Findings:
1.
Observation on 07/02/2025 at 10:18 a.m., of the dirty soiled linen closet on Hall Z accompanied with S6 Laundry revealed 6 clean water basins stored on the top shelf, un-bagged. Observation revealed a large yellow barrel overflowed with dirty and soiled linen next to the shelf. S6 Laundry stated staff brings dirty and soiled linen in this closet to be stored and then washed. S6 Laundry confirmed the 6 water basins were clean, used for resident use, should be bagged, and not stored in this closet on Hall Z. S6 Laundry stated its cross-contamination.
2.
Observation on 07/02/2025 at 10:40 a.m., of the clean linen cart on Hall Z with S11 CNA Supervisor revealed 1 pack of opened wipes used for resident care and 2 pink denture cups, which contained baby powder. S11 CNA Supervisor stated anytime staff uses resident care items such as wipes or baby powder it is to be left in the resident's room. S11 CNA Supervisor confirmed the 1 pack of opened wipes and 2 pink denture cups of baby powder should not have been left on the clean linen cart.
Observation on 07/02/2025 at 12:20 p.m., of the clean linen cart on Hall Z with S12 CNA stated she gathers resident care items such as wash, wipes, adult briefs, and resident linen from the clean linen cart and places them in a clear bag. S12 CNA stated these items are to remain in the resident's room since all rooms are now private. S12 CNA stated some staff have a habit of using these items, bringing them back out of a resident's room, and placing them back on the clean linen cart. S12 CNA confirmed the 1 bottle of skin and hair cleanser was used for resident care and shouldn't have been placed back on the clean linen cart.
3.
Resident #63
On 07/1/2025 at 3:07 p.m., review of facility policy titled, Enhanced Barrier Precautions, dated 05/01/2024, revealed in part . Facility shall ensure that Enhanced Barrier Precautions (EBP) are utilized in the infection control program. Enhanced Barrier Precautions is used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROS to staff hands and clothing. EBP are indicated for residents with any of the following .Indwelling medical devices . even if the resident is not known to be infected or colonized with Multi-drug Resistant Organism (MDRO). Indwelling medical devices include central lines.
Review of Resident #63's electronic medical record revealed an admit date of 12/13/2024 with diagnosis that included but not limited to: End Stage Renal Disease, Hypotension, Moyamoya Disease, Paroxysmal Atrial Fibrillation, Presence of other vascular implants and grafts, Encounter for fitting and adjustment of Extracorporeal Dialysis Catheter, Dependence of Renal Dialysis.
On 07/01/2025 at 9:33 a.m., review of Resident #63's Significant Change MDS with ARD of 06/21/2025 revealed a BIMS Score of 8, indicating moderate cognitive impairment.
On 07/01/2025 at 9:28 a.m., review of Resident #63's July 2025 Physican's Orders revealed an active order for Enhanced Barrier Precautions with initiation date of 12/24/2024.
On 07/01/2025 at 9:45 a.m., review of Resident #63's care plan with initiation date of 12/15/2024 revealed Resident #63 was on enhanced barrier precautions for dialysis catheter access with interventions that included: Enhanced Barrier Precautions will be used for dialysis catheter and EBP as instructed, hanging outside of door.
On 07/01/2025 at 12:03 p.m., observation of the interior and exterior of Resident #63's room revealed no EBP signage or caddy with appropriate PPE for enhanced barrier precautions.
During an interview on 07/01/2025 at 11:37 a.m. Resident #63 stated that staff only applied gloves when caring for him. Resident #63 denied staff wore gowns when caring for him.
During an interview on 07/01/2025 at 12:12 p.m., S9 CNA revealed she had been employed at the facility since 2018 and was familiar with the care Resident #63 required. S9 CNA stated Resident #63 did not require any special precautions. S9 CNA confirmed she applied only gloves before caring for Resident #63.
On 07/01/2025 at 12:20 p.m., an interview with S4 LPN revealed she has been employed at the facility for about 2 years and was familiar with Resident #63 and the care he required. S4 LPN stated Resident #63 was not on EBP. Resident #63's active orders and care plan were reviewed with S4 LPN during the interview. S4 LPN confirmed Resident #63 had an active order for enhanced barrier precautions.
On 07/01/2025 at 12:25 p.m., S4 LPN accompanied the surveyor to Resident #63's room. S4 LPN confirmed enhanced barrier precautions were not in place for Resident #63 and should have been.
On 07/01/2025 at 2:30 p.m., S2 DON and S10 ADON acknowledged that Resident #63 should have had enhanced barrier precautions in place and did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 72 residents who resided in the facility. The facility failed to ensure:
1. Food items in the refrigerators and freezers were labeled and dated;
2. Dry food items were labeled with an open date and stored in a sealed container;
3. Dishware was clean and stored under sanitary conditions;
4. Staff were wearing hair restraints, including beard restraints, to prevent hair from contacting food.
Findings:
On 07/01/2025 at 9:50 a.m., review of facility policy titled, Food Receiving and Storage, with revision date of July 2014, revealed in part . Food shall be received and stored in a manner that complies with safe food handling and practices. All food stored in the refrigerator or freezer will be covered, labeled, and dated.
1.
On 06/30/2025 at 8:47 a.m., observation of the freezer in the kitchen food prep area with S3 Dietary Manager revealed one 1-gallon Ziploc bag of chicken nuggets open and undated. S3 Dietary manager confirmed the 1-gallon bag of chicken nuggets was not sealed and dated, and should have been.
On 06/30/2025 at 9:10 a.m., observation of the outdoor walk-in refrigerator with S3 Dietary Manager revealed one 1-gallon tub of mayonnaise open and undated. S3 Dietary manager confirmed the 1 gallon tub of mayonnaise was open and undated, and should not have been.
2.
On 06/30/2025 at 8:52 a.m., observation of a flour container in the food prep area with S3 Dietary Manager revealed a scoop stored in the flour container. S3 Dietary Manager confirmed the scoop was stored in the flour container and should not have been.
On 06/30/2025 at 9:04 a.m., observation of the pantry with S3 Dietary Manager revealed one 50-pound bag of pinto beans open. S3 Dietary Manager confirmed that pinto beans should have been stored in a sealed container, but were not.
On 06/30/2025 at 10:10 a.m., observation of Dining room [ROOM NUMBER] serving area with S3 Dietary Manager revealed one small bag of powdered substance not labeled and undated. S3 Dietary Manager stated that the powder was powdered creamer. S3 Dietary Manager confirmed that powdered creamer should have been labeled, dated, and in a sealed container, and it was not.
3.
On 06/30/2025 at 8:50 a.m., observation of open shelving that stored clean dishware revealed all dishware plates stored face up, 3 visibly dirty plates, and 1 plate visibly dirty with 3 paperclips in the plate. S3 Dietary Manager was present and confirmed 3 dishware plates stored on clean dishware shelving were dirty and should not have been. S3 Dietary Manager confirmed there were paperclips on clean dishware plates and should not have been. S3 Dietary Manager confirmed clean dishware should be stored facedown, and it was not.
4.
On 06/30/2025 at 9:00 a.m., observation revealed S8 Dietary Aide was present in the kitchen with facial hair not contained by a hairnet. S3 Dietary Manager confirmed S8 Dietary Aide should have had a hairnet containing facial hair, and did not.

Based on observation, interview, and record review, the facility failed to meet the nutritional needs for residents in accordance with established national guidelines. The facility failed to follow the menu for all residents receiving puree diet. 5 residents in the facility received a puree diet.
Findings:
On 06/30/2025 at 3:25 p.m., review of facility undated policy titled, Puree Diet, revealed in part . the puree diet is based on the regular diet, therefore, all the same guidelines apply with alterations being made only to allow for ease and chewing and swallowing.
On 07/01/2025 at 9:15 a.m., review of facility policy titled, Menus, with revision date of October 2017 revealed in part, Menus meet the nutritional needs of residents in accordance with recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). If a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs.
On 06/30/2025 at 10:00 a.m., observation of the menu posted revealed lunch menu for 06/30/2025 included: meatloaf, black eyed peas, cauliflower and cheese, dinner roll, and lemon glazed cake.
On 06/30/2025 at 10:30 a.m., observation revealed S7 [NAME] prepare meatloaf, black-eyed peas, and cauliflower and cheese puree.
On 06/30/2025 at 10:52 a.m., an interview with S7 cook confirmed she did not puree glazed cake because pudding was being provided as an alternative for all puree diets. S7 [NAME] confirmed she did not puree dinner rolls for any of the residents who received puree diets.
During an interview on 06/30/2025 at 3:52 p.m., S3 Dietary Manager revealed facility cooks did not puree bread and did not provide an alternate for bread when bread is served. S3 Dietary Manager confirmed S7 [NAME] did not follow the menu for all residents that received a puree diet, and should have.

Based on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from flies. The deficient practice had the potential to affect 72 residents who resided in the facility.
Findings:
On 07/01/2025 11:00 a.m., review of facility policy titled Pest Control with revision date of May 2008 revealed in part . Our facility shall maintain an effective pest control program.
This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.
Observation of the facility's kitchen on 06/30/2025 at 9:06 a.m., accompanied by S3 Dietary Manager, revealed multiple flies observed throughout the kitchen area, with flies landing on the food being prepared and the food prep area.
On 06/30/2025 at 10:25 a.m., during a return trip to the kitchen, multiple flies were observed in the kitchen food prep area.
On 06/30/2025 at 3:50 p.m., during a return trip to the kitchen area for an interview with S3 Dietary Manager, multiple flies were observed in the kitchen area. S3 Dietary Manager confirmed the kitchen area had a fly problem. S3 Dietary Manager confirmed the kitchen area should be free of pests, but it was not.
On 07/01/2025 at 8:00 a.m., observation revealed multiple flies present in Room A.
On 07/02/2025 10:04 a.m., observation revealed multiple flies present in Room A.
On 07/02/2025 at 12:16 p.m., S1 Admin acknowledged the facility had a current issue with flies in the building.

Based on interview and record review the facility failed to ensure each resident had a comprehensive person-centered care plan developed and implemented to meet his or her goals and address the resident's medical, physical, mental, and psychosocial needs for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
Review of Resident #2's medical record revealed an admit date of 07/18/2024 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting right non-dominant side, Other Muscle Spasms, Major Depressive Disorder, Insomnia, and Type 2 Diabetes Mellitus.
Review of Resident #2's Admission/OSA MDS with an ARD of 07/24/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2's MDS revealed she required extensive assistance with 2 plus persons for bed mobility, transfers, and toilet use.
Review of Resident #2's Care Plan with a Target Date of 10/18/2024 revealed in part . History of Drug Abuse. Date initiated 07/22/2024. Intervention: Resident noted to be lethargic, slurred speech, unable to perform ADL's at her normal capacity, found to have container of synthetic THC gummies, container taken to the nurses' station. Date initiated 08/22/2024.
Interview on 09/03/2024 at 2:31 p.m. with S6 LPN MDS revealed Resident #2 had a history of drug abuse on admission. S6 LPN MDS confirmed Resident #2's Care Plan should have had interventions in place other than the intervention initiated on 08/22/2024.

Based on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem and to attain the highest practicable mental and psychosocial well-being for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
Review of a facility policy titled Change in a Resident's Condition or Status dated 12/2016 read in part . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): d. significant change in the resident's physical, emotional, mental condition .
Review of Resident #2's medical record revealed an admit date of 07/18/2024 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Non-Dominant Side, Other Muscle Spasms, Major Depressive Disorder, Insomnia, and Type 2 Diabetes Mellitus.
Review of Resident #2's Admission/OSA MDS with an ARD of 07/24/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2's MDS revealed she required extensive assistance with 2 plus persons for bed mobility, transfers, and toilet use.
Review of Resident #2's Care Plan with a Target Date of 10/18/2024 revealed in part . History of Drug Abuse. Intervention: Resident #2 noted to be lethargic, slurred speech, unable to perform ADL's at her normal capacity, found to have container of synthetic THC gummies, container taken to the nurses' station. Diagnosis of Depression. Interventions: 08/22/2024 Resident #2 reported suicidal ideations to nurse, PEC per Psychiatrist to inpatient psych hospital. Administer medications as ordered. Consult to see Psychiatrist for medication management. Encourage Resident #2 to express feelings (anger, sadness, guilt) and come up with alternative ways to handle feelings. Monitor for any signs and symptoms of depression: feelings of guilt, helplessness, or hopelessness, poor concentration, sleep disturbances, lethargy, appetite loss or weight gain, anhedonia, loss of mood reactivity, and thoughts of death. Mood and behavior monitored every shift.
Review of Resident #2's Progress Notes revealed in part .
08/21/2024 6:30 p.m. Resident #2 on the outside on patio, saying she wanted to speak to someone, anyone, staff says that she was just talking about a lot of nothing, until she replied, that she wanted to kill herself and those around her, writer was inside the building .when Resident #2 did come inside passed me .she went to her room, and did not wait nor ask for anything. By: S4 LPN
08/22/2024 12:00 a.m. Resident remains up in wheelchair in room .her speech is slurred, and she appeared to be intoxicated, staff .finds gummies in an opened container, with a few missing .she has torn the room up, items on the floor, food, and other items, when Resident #2 came back in, she was asked what else did she have beside the prescribed medicine that she received at facility, she replied nothing . By: S4 LPN
08/22/2024 9:30 a.m. Resident #2 noted to be agitated this am. Yelling out help me from room. Stated that she wanted to kill herself to the night time nurse. Psychiatrist here on rounds .PEC filled out for transfer to facility for psych evaluation. Send to local hospital for evaluation r/t verbal threats to harm self. By: S5 LPN
08/23/2024 3:01 p.m. On 08/22/2024 at 10:21 a.m., I was notified by nursing staff that Resident #2 was verbalizing threats to harm herself and that she was being sent out to the local ER for psychiatric evaluation .On 08/23/2024 at 10:07 a.m. I spoke with S2 DON on the phone. S2 DON stated .Resident #2 asked him to pick up some THC gummies from the gas station earlier this week and he did so. I was not notified until after this occurred. I did not give an order for them .I told him that he shouldn't have given Resident #2 gummies . By: Physician
Review of Resident #2's PEC dated 08/22/2024 at 1:00 p.m. revealed in part .stating she wants to kill herself, not sleeping. Mental condition: depressed, anxious, crying, not sleeping, not cooperative. Suicidal. Dangerous to self. Unwilling. Signed by: Psychiatrist
Review of a Disciplinary Warning Notice for S4 LPN Dated 08/23/2024 revealed in part .
Resident #2 stated she wanted to kill herself and S4 LPN did not put Resident #2 on one on one or notify the physician . Signed by: S3 ADON and S2 DON
Interview on 08/27/2024 11:07 a.m. with S1 ADM revealed Resident #2 was depressed about being in a nursing home after having a massive stroke and her boyfriend recently broke up with her. S1 ADM revealed when S2 DON talked to Resident #2, she asked him to get her marijuana and S2 DON told her he could not. S1 ADM reported S2 DON asked her if he could get THC gummies for Resident #2 and she told him he could. S1 ADM revealed S2 DON bought THC-P gummies and gave the can of 10 gummies to Resident #2. S1 ADM revealed she did not consider the complications of allowing S2 DON to purchase THC gummies, and confirmed she should have called the doctor prior to allowing the S2 DON to purchase the gummies for Resident #2.
Interview on 08/27/2024 at 2:53 p.m. with S2 DON revealed on 08/20/2024 he heard and saw Resident #2 crying on the patio. S2 DON revealed he went out to speak with Resident #2 and when he asked her what was wrong, she said Nothing, It's Nothing. S2 DON reported Resident #2 then asked him for a marijuana joint and he told her he could not do that, but he could see about getting her THC gummies. S2 DON revealed he spoke to S1 ADM and S1 ADM told him it was legal and he could get it for Resident #2. S2 DON revealed Resident #2 asked about the THC gummies on 08/21/2024 and he went that afternoon and got them for her. S2 DON reported he got a container that had 10 gummies and gave Resident #2 the whole container.
Interview on 08/29/2024 at 1:58 p.m. with S2 DON confirmed he did not call Resident #2's physician prior to buying the THC gummies and giving them to her, but he should have. S2 DON revealed it was reported to him on 08/22/2024 that Resident #2 had behaviors the night before of wanting to kill herself and others, and S4 LPN did not follow policy and procedure. S2 DON reported once he found out Resident #2 had threatened to kill herself and others, she was immediately placed on 1:1 and he got a PEC from the psychiatrist to send her to a psych facility. S2 DON reported they could not find placement therefore, Resident #2 was sent to a local hospital, and then was eventually transferred to a behavioral hospital. S2 DON reported S4 LPN should have taken immediate action, the physician should have been called, and Resident #2 should have been on 1:1 for close monitoring to ensure her safety as well as others in the facility.
Telephone interview on 08/30/2024 at 9:07 a.m. with S4 LPN revealed during her medication pass on 08/21/2024, staff notified her Resident #2 voiced she wanted to kill herself and those around her. S4 LPN revealed she could not recall the time or name of the staff. S4 LPN reported she told the staff to monitor Resident #2 when she went into her room. S4 LPN revealed she could not recall if she notified the Resident #2's physician. S4 LPN revealed when passing Resident #2's room she saw it was in disarray and she went in. S4 LPN reported she found food on the floor and some blue THC gummies in a tin can with 8 gummies remaining in the can.
Interview on 08/30/2024 at 12:55 p.m. with Resident #2's physician revealed he was notified by S5 LPN on 08/22/2024 around 10:00 a.m. that Resident #2 was suicidal and was being sent to the local ER. He reported about an hour later, around 11:00 a.m., he received a message from S2 DON saying the resident needed a PEC. He revealed S2 DON told him Resident #2 was suicidal and threatened to kill herself and everyone else at the nursing home. He revealed he was told Resident #2 was already placed on 1:1 and he said he would write the PEC. He reported he wrote the PEC and S2 DON came by his clinic and picked it up. He revealed he found out that the psychiatrist had gone to see Resident #2 and had also written a PEC for Resident #2 and was helping with trying to find placement at an inpatient psychiatric hospital. He revealed he was made aware by S1 ADM and S3 ADON on 08/29/2024 that Resident #2 was suicidal on 08/21/2024 and he was not notified by staff until 08/22/2024. He reported Resident #2 should have gone straight to the local ER if she was suicidal and threatening to harm others. He revealed he heard S2 DON had given Resident #2 THC gummies, he said he was not notified, and would have never agreed to it. He revealed he was never made aware Resident #2 was asking staff about marijuana, nor did any staff speak to him about THC gummies, until after they were given to Resident #2 and she was in the hospital.
Interview on 08/30/2024 at 2:11 p.m. with S5 LPN revealed on 08/22/2024 S4 LPN informed her during report for her 6:00 a.m. to 6:00 p.m. shift, THC gummies were found in Resident #2's purse. S5 LPN revealed Resident #2 woke up screaming and hollering for S3 ADON because S4 LPN had called S3 ADON on the 6:00 p.m. to 6:00 a.m. shift to let her know about Resident #2's behaviors. S5 LPN reported the psychiatrist saw Resident #2 and wrote a PEC. S5 LPN revealed Resident #2 went out around 2:00 p.m. to the local ER. S5 LPN reported she was not instructed to have staff sit 1:1 with Resident #2. S5 LPN reported from 6:00 a.m. to around 2:00 p.m. when Resident #2 went to the hospital, whenever she went in the room to provide care, Resident #2 was alone. S5 LPN revealed when the psychiatrist came, she woke up and starting screaming, and then was screaming again right before she went to the hospital.
Interview on 09/03/2024 at 11:04 a.m. with S3 ADON revealed Resident #2 reported to staff on 08/21/2024 around 6:20 p.m. that she wanted to kill herself and others. S3 ADON reported Resident #2's physician was not notified until around 9:30 a.m. to 10:00 a.m. the following morning on 08/22/2024. S3 ADON reported she got a call at around 12:30 a.m. on 08/22/2024 notifying her Resident #2 was yelling out, they found THC gummies in her room, and her room was a mess. S3 ADON reported they did not tell her Resident #2 voiced wanting to kill herself and others. S3 ADON confirmed the resident was not placed on 1:1, but should have been.
Interview on 09/03/2024 at 3:00 p.m. with Resident #2 revealed she just returned to the facility today after being treated at a behavioral hospital. Resident #2 reported she does not recall exactly what happened on 08/21/2024 or what she said to staff because she was in and out of it. Resident #2 reported she just knows she was very depressed. Resident #2 revealed she had taken THC gummies in the past prior to being admitted to the facility. Resident #2 reported the THC gummies that were purchased by S2 DON were stronger and she did not like the way they made her feel.

Based on interview and record review, the facility failed to ensure services were provided to meet professional standards of quality for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by providing Resident #2 with THC gummies without consulting the resident's physician.
Findings:
Review of Resident #2's medical record revealed an admit date of 07/18/2024 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Non-Dominant Side, Other Muscle Spasms, Major Depressive Disorder, Insomnia, and Type 2 Diabetes Mellitus.
Review of Resident #2's Admission/OSA MDS with an ARD of 07/24/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2's MDS revealed she required extensive assistance with 2 plus persons for bed mobility, transfers, and toilet use.
Review of Resident #2's Care Plan with a Target Date of 10/18/2024 revealed in part . History of Drug Abuse. Intervention: Resident #2 noted to be lethargic, slurred speech, unable to perform ADL's at her normal capacity, found to have container of synthetic THC gummies, container taken to the nurses' station. Diagnosis of Depression. Interventions: 08/22/2024 Resident #2 reported suicidal ideations to nurse, PEC per Psychiatrist to inpatient psych hospital. Administer medications as ordered. Consult to see Psychiatrist for medication management. Encourage Resident #2 to express feelings (anger, sadness, guilt) and come up with alternative ways to handle feelings. Monitor for any signs and symptoms of depression: feelings of guilt, helplessness, or hopelessness, poor concentration, sleep disturbances, lethargy, appetite loss or weight gain, anhedonia, loss of mood reactivity, and thoughts of death. Mood and behavior monitored every shift.
Review of Resident #2's Progress Notes revealed in part .
08/22/2024 12:00 a.m. Resident remains up in wheelchair in room .her speech is slurred, and she appeared to be intoxicated, staff .finds gummies in an opened container, with a few missing .she has torn the room up, items on the floor, food, and other items, when Resident #2 came back in, she was asked what else did she have beside the prescribed medicine that she received at facility, she replied nothing . By: S4 LPN
08/23/2024 3:01 p.m. On 08/22/2024 at 10:21 a.m., I was notified by nursing staff that Resident #2 was verbalizing threats to harm herself and that she was being sent out to the local ER for psychiatric evaluation .On 08/23/2024 at 10:07 a.m. I spoke with S2 DON on the phone. S2 DON stated .Resident #2 asked him to pick up some THC gummies from the gas station earlier this week and he did so. I was not notified until after this occurred. I did not give an order for them .I told him that he shouldn't have given Resident #2 gummies . By: Physician
Review of a Disciplinary Warning Notice for S2 DON dated 08/26/2024 revealed in part .
This is a record showing S2 DON and S1 ADM had a meeting regarding that THC gummies will no longer be allowed at the nursing home .
Interview on 08/27/2024 11:07 a.m. with S1 ADM revealed Resident #2 was depressed about being in a nursing home after having a massive stroke and her boyfriend recently broke up with her. S1 ADM revealed when S2 DON talked to Resident #2, she asked him to get her marijuana and S2 DON told her he could not. S1 ADM reported S2 DON asked her if he could get THC gummies for Resident #2 and she told him he could. S1 ADM revealed S2 DON bought THC-P gummies and gave the can of 10 gummies to Resident #2. S1 ADM revealed she did not consider the complications of allowing S2 DON to purchase THC gummies, and confirmed she should have called the doctor prior to allowing the S2 DON to purchase the gummies for Resident #2.
Interview on 08/27/2024 at 2:53 p.m. with S2 DON revealed on 08/20/2024 he heard and saw Resident #2 crying on the patio. S2 DON revealed he went out to speak with Resident #2 and when he asked her what was wrong, she said Nothing, It's Nothing. S2 DON reported Resident #2 then asked him for a marijuana joint and he told her he could not do that, but he could see about getting her THC gummies. S2 DON revealed he spoke to S1 ADM and S1 ADM told him it was legal and he could get it for Resident #2. S2 DON revealed Resident #2 asked about the THC gummies on 08/21/2024 and he went that afternoon and got them for her. S2 DON reported he got a container that had 10 gummies and gave Resident #2 the whole container.
Interview on 08/29/2024 at 1:58 p.m. with S2 DON confirmed he did not call Resident #2's physician prior to buying the THC gummies and giving them to her, but he should have.
Telephone interview on 08/30/2024 at 9:07 a.m. with S4 LPN revealed during her medication pass on 08/21/2024, staff notified her Resident #2 voiced she wanted to kill herself and those around her. S4 LPN revealed she could not recall the time or name of the staff. S4 LPN reported she told the staff to monitor Resident #2 when she went into her room. S4 LPN revealed she could not recall if she notified the Resident #2's physician. S4 LPN revealed when passing Resident #2's room she saw it was in disarray and she went in. S4 LPN reported she found food on the floor and some blue THC gummies in a tin can with 8 gummies remaining in the can.
Interview on 08/30/2024 at 12:55 p.m. with Resident #2's physician revealed he heard S2 DON had given Resident #2 THC gummies, he said he was not notified, and would have never agreed to it. He revealed he was never made aware Resident #2 was asking staff about marijuana, nor did any staff speak to him about THC gummies, until after they were given to Resident #2 and she was in the hospital.
Interview on 09/03/2024 at 3:00 p.m. with Resident #2 revealed she just returned to the facility today after being treated at a behavioral hospital. Resident #2 reported she does not recall exactly what happened on 08/21/2024 or what she said to staff because she was in and out of it. Resident #2 reported she just knows she was very depressed. Resident #2 revealed she had taken THC gummies in the past prior to being admitted to the facility. Resident #2 reported the THC gummies that were purchased by S2 DON were stronger and she did not like the way they made her feel.

Based on interview and record review, the facility failed to ensure a resident's right to be free from verbal and mental abuse by staff for 1 (Resident #1) of 12 (Resident #1, Resident #2, Resident #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9) sampled residents.
This failed practice resulted in an actual harm situation for Resident #1 on 07/23/2024 on the 6:00 p.m. to 6:00 a.m. shift when Resident #1, who was severely impaired cognitively, and had diagnoses of Dementia and Major Depressive Disorder, was verbally and mentally abused by S3 CNA. Review of Resident #1's video camera footage revealed on 07/23/2024 at 7:54 p.m., S3 CNA while in Resident #1's room stated to Resident #1 You old meanie. At 11:00 p.m., while S3 CNA and S4 CNA were providing ADL assistance to Resident #1, S3 CNA stated to Resident #1 Why you gotta be like that man? Resident #1 replied I love Jesus. S3 CNA stated If you loved Jesus, you wouldn't be ugly every time someone came in here. That's not loving Jesus, that's loving the Devil. At 11:07 p.m., S3 CNA and S4 CNA were in Resident #1's room. S3 CNA stated to Resident #1, You act a F****** animal.
A reasonable person in Resident #1's situation would have experienced severe psychosocial harm and humiliation as a result of this verbal and mental abuse.
Findings:
Review of the facility's policy titled Abuse and Neglect - Clinical Protocol dated 07/2017, read in part .1. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .
Review of Resident #1's medical record revealed an admit date on 03/24/2021, with diagnoses that included: Altered Mental Status, Dementia, Pseudobulbar Affect, Muscle Weakness, Difficulty in Walking, Anxiety Disorder, and Major Depressive Disorder.
Review of Resident #1's Significant Change MDS with an ARD of 05/01/2024, revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #1's MDS revealed she had the ability to express her ideas and wants which could be understood. Resident #1's MDS stated she required moderate assistance with upper body dressing, lower body dressing and personal hygiene; maximal assistance with bathing; and she was dependent on staff for toileting hygiene.
Review of Resident #1's Care Plan with a Target Date of 08/30/2024 revealed in part .Communication problem related to dementia. Interventions: Anticipate and meet needs. Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, ask yes/no questions if appropriate, use simple brief consistent words/cues, use alternative communication tools as needed. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed. ADL self-care performance. Interventions: Camera in room provided per family. Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care.
Review of video camera footage of Resident #1's room dated 07/23/2024 at approximately 7:54 p.m., revealed Resident #1 lying in bed with S3 CNA standing near the head of the bed. S3 CNA stated You old meanie to Resident #1, while adjusting the foot of the electric bed.
Review on 08/12/2024 of video camera footage of Resident #1's room, dated 07/23/2024 at approximately 11:00 p.m., revealed Resident #1 in bed, and S3 CNA and S4 CNA changing her gown. As S3 CNA was removing her gown, she stated Why you gotta be like that man? Resident #1 responded I love Jesus. S3 CNA then stated If you loved Jesus you wouldn't be ugly every time someone came in here. That's not loving Jesus, that's loving the Devil.
Review on 08/12/2024 of video camera footage of Resident #1's room, dated 07/23/2024 at approximately 11:07 p.m., revealed S3 CNA near Resident #1's bed, and S4 CNA present in the room. As S3 CNA was adjusting Resident #1's gown, she stated to her You act a F****** animal.
The video camera footage of Resident #1's room, dated 07/23/2024 at 7:54 p.m., 11:00 p.m., and 11:07 p.m. was reviewed with S1 ADM and S2 DON on 08/15/2024 at 2:15 p.m. S1 ADM confirmed the above statements were made to Resident #1 by S3 CNA. S1 ADM confirmed verbal and mental abuse of Resident #1 by S3 CNA was evident in the camera footage.
Review of S4 CNA's, undated, written statement provided by S1 ADM on 08/15/2024 read in part .To my knowledge, S3 CNA and I went into Resident #1's room .While in there providing care, S3 CNA did make some comments that were not appropriate to Resident #1 and mishandled her. I was in shock .All I could do was be quiet and try the best to give her care. After all of this, I did inform the nurse about what took place that night.
Telephone interview on 08/16/2024 at 11:50 a.m. with S4 CNA revealed she worked with S3 CNA on 07/23/2024. S4 CNA reported when they provided care to Resident #1 together, S3 CNA was going off. S4 CNA revealed S3 CNA was not speaking to Resident #1 the way she should. S4 CNA reported Resident #1 was scared because of the way S3 CNA was talking to her. S4 CNA reported she could recall S3 CNA saying something along the lines of If you hit me, I don't know what my reflexes might do, but could not recall everything else she said. S4 CNA stated she was unsure of the number times S3 CNA acted like that throughout that night.
Telephone interview on 08/16/2024 at 2:26 p.m. with Resident #1's daughter revealed Resident #1 had always listened to Christian music. She revealed she was Pentecostal, and raised her and her sisters Pentecostal. She reported prior to being in the nursing home, Resident #1 went to church services faithfully on Wednesdays and Sundays. She reported Resident #1, prior to having dementia, would have been mad and upset by the way S3 CNA cursed at her, and called her names. She reported Resident #1 would have responded in a Christian manner even if she was mad and upset. Resident #1's daughter stated it would have hurt Resident #1's feelings, upset her, and she would have felt extremely disrespected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the care plan for 1 Resident (#R7), of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9). The facility failed to revise the comprehensive person centered care plan to include new interventions following two elopements. Findings:
Review of Resident #R7's medical record revealed she was admitted to the facility on [DATE]. Resident #R7 had diagnoses that included in part . Alzheimer's Disease, Schizoaffective Disorder, Generalized Muscle Weakness, Major Depressive Disorder, Unspecified Behavioral and Emotional Disorders, Anxiety Disorder, and Bipolar Disorder.
Review of Resident #R7's Quarterly Wandering Risk Scale dated 05/23/2024, completed by S13LPN, revealed a score of 13, which indicated she was at high risk to wander.
Review of Resident #R7's Quarterly MDS with an ARD of 05/23/2024, revealed a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #R7 used a wander/elopement alarm daily.
Review of Resident #R7's current comprehensive plan of care with a target date of 08/21/2024, revealed Resident #R7 was at risk for elopement; initiated on 04/17/2023. Interventions included in part .04/19/2023 - Coded locks on doors and gates to prevent elopement of residents, gates are kept closed; 04/19/2023 - Monitor every 1 hour to prevent elopement; and 04/19/2023 - Signs are posted for visitors to not let residents out without staff approval, and keep gates closed after entry, and 06/25/2024 - Went outside behind a visitor, wander guard in place, resident seen, and brought back inside by staff. Further review revealed no new interventions were put into place after the 06/25/2024 or 08/03/2024 elopements.
Interview on 08/16/2024 at 2:15 p.m. with S2 DON revealed Resident #R7 went out the X Hall front door, unsupervised by staff on 06/25/2024 and 08/03/2024.
Interview on 08/16/2024 at 2:25 p.m. with S2 DON revealed the facility had not implemented any further interventions to Resident #R7's plan of care following elopements on 06/25/2024 and 08/03/2024.
Interview on 08/16/2024 at 6:50 p.m. with S1 ADM revealed she was aware of Resident #R7's elopements that occurred on 06/25/2024 and 08/03/2024. S1 ADM confirmed the facility had not updated Resident #R7's plan of care with further interventions following elopements to prevent the likelihood of elopement, but should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 (Resident #1) of 12 (Resident #1, Resident #2, Resident #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9) sampled residents. The facility failed to create and sustain an environment which humanized Resident #1's quality of life when:
1. Resident #1 was abruptly transferred to her geri-chair.
2. Resident #1 was pulled up in bed with S3 CNA standing on her bed.
Findings:
Review of Resident #1's medical record revealed an admit date on 03/24/2021 with diagnoses which included: Altered Mental Status, Dementia, Pseudobulbar Affect, Muscle Weakness, Difficulty in Walking, Anxiety Disorder, and Major Depressive Disorder.
Review of Resident #1's Significant Change/OSA MDS with an ARD of 05/01/2024 revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #1's MDS revealed she had the ability to express her ideas and wants which could be understood. Resident #1's MDS stated she required moderate assistance with upper body dressing, lower body dressing and personal hygiene; maximal assistance with bathing; and she was dependent on staff for toileting hygiene. Resident #1's MDS revealed she required extensive 2+ person physical assistance with bed mobility and transfer was coded as did not occur.
Review of Resident #1's Care Plan with a Target Date of 08/30/2024 revealed in part .Communication problem related to dementia. Interventions: Anticipate and meet needs. Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, ask yes/no questions if appropriate, use simple brief consistent words/cues, use alternative communication tools as needed. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed . ADL self-care performance. Interventions: Camera in room provided per family. Geri-chair as tolerated. Mattress at bedside, may place two mattresses if needed. Extensive to total care with ADLs and mobility. Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care.
1. Review of a facility incident investigation for Resident #1 documented by S1 ADM dated 06/11/2024 revealed in part .
On the morning of 06/11/2024, DON of local hospice stated that one of her nurses was visiting Resident #1. When she was visiting, Resident #1's daughter was visiting her mother.
The hospice nurse stated Resident #1's daughter had a video of two facility CNAs putting Resident #1 in a geri-chair in a rough manner. She stated that there were 2 CNAs as per protocol but that it seemed that they just plopped her mother into the geri-chair instead of placing her gently. Hospice DON also stated that the family has the incident on video and that the family showed the video to the hospice nurse.
The CNAs should have removed one of the mattresses and moved the geri-chair closer to Resident #1 when getting her up. The mattresses on the floor make the CNAs footing very unsteady and they often hurriedly place the resident in the chair or bed without taking extra time .this is an improper transfer.
Review of S5 CNA's written statement signed and dated 07/11/2024 at 12:30 p.m. read in part .me and my coworker found Resident #1 on the mattresses they have laid out on the floor. We picked her up and transferred her to her chair.
Review of S6 CNA's written statement signed and dated 06/11/2024 at 1:00 p.m. read in part . me and my coworker found Resident #1 on the floor. We both picked her up under her arms and transferred her to her chair.
Interview on 08/12/2024 at 10:45 a.m. with S1 ADM and S2 DON revealed they had received video footage of Resident #1's room on 06/11/2024. S1 ADM reported S5 CNA and S6 CNA transferred Resident #1 from the mattress in between her bed and the other mattress on the floor to a geri-chair that was on the other side of the end mattress. S1 ADM and S2 DON revealed S5 CNA and S6 CNA could have done a proper transfer. S1 ADM confirmed they should have moved the mattress and placed the geri-chair closer to the mattress that Resident #1 was on to prepare for a safe, proper transfer.
Review on 08/12/2024 at 3:17 p.m. of undated video camera footage of Resident #1's room which was provided to S1 ADM on 06/11/2024 revealed Resident #1 sitting on the mattress that was in between her bed and the other mattress on the floor. There was a geri-chair on the side of the mattress farthest from the bed. S5 CNA and S6 CNA go to lift Resident #1 off the mattress and one CNA can be heard stating to Resident #1 You can lock up all you want. S5 CNA and S6 CNA lift Resident #1 from under both of her arms and drag her backwards across the other mattress making a dragging sound with her heels. The geri-chair was unlocked as it was seen moving around as S5 CNA and S6 CNA abruptly sit Resident #1 in her geri-chair. As Resident #1 was seated, a 'ding' sound can be heard and the foot rest of the chair kicks up approximately a foot.
Telephone interview on 08/13/2024 at 2:26 p.m. with S5 CNA revealed she worked 6:00 p.m. to 6:00 a.m. and remembers she transferred Resident #1 with S6 CNA but could not recall the exact date. S5 CNA reported they picked Resident #1 up from under hers arms and moved her across the second mattress to put her in the geri-chair. S5 CNA stated Why would you move the mattresses? I don't know why they have them there anyway. I just don't understand that.
Telephone interview on 08/13/2024 at 2:40 p.m. with S6 CNA revealed she recalled a video of a transfer she did with another CNA for Resident #1 but could not recall the date or the name of the other CNA. S6 CNA reported Resident #1 was on the mattress next to her bed and she and the other CNA lifted her from under her arms and transferred her to the geri-chair. S6 CNA revealed she did not move the other mattress because they were trying to get her up quickly but could not remember why they had to do it quickly.
2. Review on 08/12/2024 of video camera footage of Resident #1's room dated 07/23/2024 at 7:52 p.m. revealed S3 CNA climbing onto Resident #1's bed and standing on her mattress at the head of her bed. S3 CNA pulled Resident #1 up in bed to where Resident #1's head was underneath her and in between her legs. S3 CNA then climbed over Resident #1 to the side of her mattress and placed her hands on Resident #1's knees to get down from the bed. As S3 CNA had her hands on Resident #1's knees to get down from the bed, Resident #1 stated Oww.
Interview on 08/09/2024 at 2:53 p.m. with S11 ADON revealed she received a video from the hospice DON on 07/26/2024. S11 ADON reported in the video footage, S3 CNA was standing in the bed with Resident #1 as she pulled her up in bed.
Interview on 08/12/2024 at 9:13 a.m. with S17 CNA Supervisor revealed she was notified on 07/26/2024 by S11 ADON that S3 CNA had stood in Resident #1's bed to pull her up. S17 CNA Supervisor reported she performed an improper lifting technique because Resident #1 required 2 staff to be pulled up in bed and S3 CNA did it alone.
Interview on 08/12/2024 at 10:45 a.m. with S1 ADM revealed Resident #1's family came to the facility on [DATE] and spoke with S11 ADON. S1 ADM reported she received the video on 07/29/2024 where S3 CNA got on Resident #1's bed to pull her up in bed. S1 ADM revealed Resident #1 was a 2 person assist and S3 CNA should have called for another staff member to assist her. S1 ADM confirmed S3 CNA should have never stood on Resident #1's bed. S1 ADM revealed S3 CNA reported she did not want to have to pick up the floor mattress and raise the bed to pull her up.
Interview on 08/12/2024 at 12:30 p.m. with S2 DON revealed in the video in which S3 CNA was standing on the bed, the bed was shaking and not a stable surface for S3 CNA to have proper footing to move Resident #1. S2 DON reported there was potential for injury to Resident #1 and staff.
Telephone interview on 08/15/2024 at 10:52 a.m. with S3 CNA revealed Resident #1 required 1 or 2 staff for bed mobility and incontinent care. S3 CNA revealed she would have had to move the mattress next to Resident #1's bed and lower the bed but she was in a rush. S3 CNA confirmed she should not have stood on Resident #1's bed to pull her up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure a cognitively impaired resident who had a history of wandering, was adequately supervised and not allowed to exit the building without staff knowledge, for 1 Resident (#R7) of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9).
This deficient practice resulted in an Immediate Jeopardy situation on 06/25/2024 at 3:59 p.m., when Resident #R7, a severely cognitively impaired resident who had a history of wandering, followed visitors out of the building via the front entrance door, and walked into the parking lot unsupervised on 06/25/2024 and 08/03/2024.
S1 ADM was notified of the Immediate Jeopardy on 08/16/2024 at 6:50 p.m.
The Immediate Jeopardy was removed on 08/19/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Review of the facility's policy titled, Elopements, dated 12/2007, revealed in part . Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing.
Review of Resident #R7's medical record revealed she was admitted to the facility on [DATE]. Resident #R7 had diagnoses that included in part . Alzheimer's Disease, Schizoaffective Disorder, Generalized Muscle Weakness, Major Depressive Disorder, Unspecified Behavioral and Emotional Disorders, Anxiety Disorder, and Bipolar Disorder.
Review of Resident #R7's Quarterly Wandering Risk Scale dated 05/23/2024, completed by S13LPN, revealed a score of 13, which indicated she was at high risk to wander.
Review of Resident #R7's Quarterly MDS with an ARD of 05/23/2024, revealed a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #R7 used a wander/elopement alarm daily.
Review of Resident #R7's current comprehensive plan of care with a target date of 08/21/2024, revealed Resident #R7 was at risk for elopement; initiated on 04/17/2023. Interventions included in part .04/19/2023 - Coded locks on doors and gates to prevent elopement of residents, gates are kept closed; 04/19/2023 - Monitor every 1 hour to prevent elopement; and 04/19/2023 - Signs are posted for visitors to not let residents out without staff approval, and keep gates closed after entry, and 06/25/2024 - Went outside behind a visitor, wander guard in place, resident seen, and brought back inside by staff. Further review revealed no new interventions were put into place after the 06/25/2024 or 08/03/2024 elopements.
Review of Resident #R7's Elopement Risk Evaluation dated 06/26/2024, and completed by S11ADON, revealed the following:
Elopement Score: 4.0 (At Risk)
BIMS Score: 3
History of elopement while at home: Yes.
History of attempting to leave the facility without informing staff: Yes.
Verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door: Yes.
Wanders: No.
Wandering behavior a pattern or goal-directed: Yes.
Review of Resident #R7's current 08/2024 physician orders revealed in part .
07/31/2024: Wanderguard to ankle for elopement risk every shift.
07/31/2024: Monitor every hour due to elopement attempts.
Review of Resident #R7's record revealed no evidence of hourly monitoring.
Review of Resident #R7's Departmental Progress Notes revealed the following in part .
06/16/2024 11:13 a.m., documented by S10LPN, read in part . Behavior issues noted this shift. Resident pacing in hallways, attempting to get out of doors when someone enters or exit.
6/20/2024 3:16 p.m., documented by S10LPN, read in part . Attempting to exit facility, went to north reception screaming and cursing pushing on front door.
08/04/2024 17:34 p.m., documented by S8LPN, read in part . Resident walks in hallways independently, Resident often asking when she can go home, re direction difficult at times. Active exit seeker. Safety maintained.
Review of Departmental Progress Notes dated 05/2024 - 08/2024 revealed no documentation of Resident #R7's elopements on 06/25/2024 and 08/03/2024.
Telephone interview on 08/16/2024 at 9:07 a.m., with S8LPN revealed she was assigned care of Resident #R7 on 08/03/2024. S8LPN revealed she was seated at the nurse's station charting when she heard a wanderguard alarm go off at the X Hall front door. S8LPN revealed Resident #R7 went out the front door without staff, and ambulated a few feet, before a CNA was able to get to Resident #R7. S8LPN revealed #R7 was outside for about 1 minute, and was located in the facility's driveway when staff responded. S8LPN revealed staff immediately brought Resident #R7 back into the facility. S8LPN revealed Resident #R7 was able to get out the X Hall front door, unsupervised by staff, due to a visitor entering the facility and allowing #R7 outside. S8LPN confirmed #R7 had active exit seeking behaviors, wore a wanderguard, and staff were to monitor Resident #R7 every 1 hour. S8LPN was unable to recall the last time she had visually seen Resident #R7 prior to the elopement. S8LPN revealed Resident #R7 had another elopement on 06/25/2024, but she was unable to recall details of that incident.
Observation on 08/16/2024 at 12:40 p.m., revealed there was no signage posted at the front entrance of X Hall side of facility, that instructed that visitors were not to let residents out without staff approval, as noted in Resident #R7's care plan.
Observation on 08/16/2024 at 1:56 p.m., revealed there was no signage posted at the front entrance of Z Hall side of facility, that instructed that visitors were not to let residents out without staff approval, as noted in Resident #R7's care plan.
Observation on 08/16/2024 at 1:59 p.m. revealed Resident #R7 was ambulating on X Hall, and had a wanderguard device located on her left ankle.
Interview on 08/16/2024 at 2:04 p.m. with Resident #R7 revealed she stated I want to go home so bad, I can taste it! Resident #R7 stated Can you do something for me? Can you call my son? I want to see my kids so bad, I got to go! If you have kids you understand what I'm saying.
Interview on 08/16/2024 at 2:15 p.m. with S2DON, revealed Resident #R7 went out the X Hall front door, unsupervised by staff on 06/25/2024 and 08/03/2024.
Review of the facility's video camera footage on 08/16/2024, revealed on 06/25/2024 at 3:59:36 p.m., a group of visitors entered the access code to unlock the X Hall front door. Before the door closed, Resident #R7 was seen ambulating briskly behind the group of visitors, unsupervised by staff, and quickly ambulated down the sidewalk towards a high traffic road adjacent to the front side of facility. Observation revealed there was no staff present in the X Hall lobby at the time Resident #R7 exited the facility. S14CNA was observed running to respond to the wandergaurd alarm, and on 06/25/2024 at 4:00:36 p.m., S14CNA brought Resident #R7 back into the facility.
Review of the facility's video camera footage on 08/16/2024, revealed on 08/03/2024 at 1:39:17 p.m., Resident #R7 was observed ambulating from X Hall, and continued to walk towards the X Hall front door. Observation revealed there was no staff present in the X Hall lobby at the time Resident #R7 was in the lobby. At that time, a visitor was seen entering the access code to unlock the front door. As the visitor walked in, Resident #R7 walked out of the facility door unsupervised, and briskly ambulated into the parking lot walking towards a high traffic road adjacent to the front side of facility. S15CNA was observed running out X Hall front door at 1:39:39 p.m. to respond to the wanderguard alarm. S15CNA, S16CNA, and S8LPN were observed speaking to Resident #R7 in the facility's parking lot, and was able to get Resident #R7 back into the facility at 1:40:07p.m.
Interview on 08/16/2024 at 2:25 p.m. with S2DON, following review of video camera footage, revealed he was unsure of the last time staff had visually monitored Resident #R7 before she exited the facility unsupervised, as every 1 hour monitoring had not been documented by staff. S2DON revealed Resident #R7 was able to ambulate very quickly. S2DON revealed the facility had not implemented any further interventions to #R7's plan of care following elopements on 06/25/2024 and 08/03/2024. S2DON reported no new in-services related to elopement were done as a result of Resident #R7's elopements. S2DON reported he did not consider these incidents as elopements because Resident #R7 did not leave the facility grounds, and that was why the facility had not implemented further interventions or investigate.
Interview on 08/16/2024 at 6:50 p.m. with S1ADM, revealed she was aware of Resident #R7's elopements that occurred on 06/25/2024 and 08/03/2024, and the facility did not feel the incidents were elopements. S1ADM revealed Resident #R7 was able to ambulate very quickly, and stated She's fast! S1ADM revealed the facility did not have 1 hour monitoring documentation for Resident #R7 as ordered and care planned. S1ADM confirmed the facility had not updated Resident #R7's plan of care with further interventions following Resident #R7's elopements, to prevent the likelihood of further elopements by Resident #R7, but should have.

Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development of communicable diseases and infections for 1 (Resident #1) of 12 (Resident #1, Resident #2, Resident #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9) sampled residents. The facility failed to ensure the following:
1. Staff provided proper perineal care for Resident #1.
2. Staff did not stand on Resident #1's mattresses to provide care.
3. Proper disposal of soiled linens and briefs in Resident #1's room.
Findings:
Review of the facility's policy titled Perineal Care dated 02/2018 read in part .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. b. Wash perineal area, wiping from front to back. e. Wash the rectal area thoroughly, wiping from the base of the labia towards extending over the buttocks. 9. Discard disposable items into designated containers.
Review of Resident #1's medical record revealed an admit date on 03/24/2021 with diagnoses which included: Altered Mental Status, Dementia, Pseudobulbar Affect, Muscle Weakness, Difficulty in Walking, Anxiety Disorder, and Major Depressive Disorder.
Review of Resident #1's Significant Change MDS with an ARD of 05/01/2024 revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #1's MDS revealed she had the ability to express her ideas and wants which could be understood. Resident #1's MDS stated she required moderate assistance with upper body dressing, lower body dressing and personal hygiene; maximal assistance with bathing; and she was dependent on staff for toileting hygiene.
Review of Resident #1's Care Plan with a Target Date of 08/30/2024 revealed in part . ADL self-care performance. Interventions: Camera in room provided per family. Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care.
Review on 08/12/2024 of video camera footage of Resident #1's room dated 07/19/2024 at 1:47 a.m. revealed S3 CNA providing perineal care to Resident #1 while standing on the mattress that is on the floor by the side of Resident #1's bed. S3 CNA turned Resident #1, removed the disposable incontinent brief from under her, and put it on the mattress on the side of Resident #1's bed.
Review on 08/12/2024 of video camera footage of Resident #1's room dated 07/23/2024 at 7:52 p.m. revealed S3 CNA standing on the mattress on the floor next to Resident #1's bed. The mattress has areas that were wet where S3 CNA is standing. S3 CNA then climbed into Resident #1's bed and stood on the mattress at the head of the bed to pull her up. S3 CNA then walked on the mattress to get off of the bed.
Review on 08/12/2024 of video camera footage of Resident #1's room dated 07/23/2024 at 11:02 p.m. revealed S3 CNA and S4 CNA were providing perineal care to Resident #1. S3 CNA and S4 CNA rolled Resident #1 on her left side and S3 CNA cleansed from her buttocks downward to her labia. S4 CNA grabbed the disposable incontinent brief from under Resident #1 and tossed it on the floor.
Interview on 08/12/2024 at 10:45 a.m. with S1 ADM revealed she reviewed video video footage on 07/29/2024 where S3 CNA got on Resident #1's bed to pull her up in bed. S1 ADM confirmed S3 CNA should have never stood on Resident #1's bed. S1 ADM revealed S3 CNA reported she did not want to have to pick up the floor mattress and raise the bed to pull her up.
Telephone interview on 08/15/2024 at 10:52 a.m. with S3 CNA revealed she would have had to move the mattress next to Resident #1's bed and lower the bed but she was in a rush. S3 CNA confirmed she should not have stood on Resident #1's bed to pull her up.

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 Resident (#R7), of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9).
The facility failed to:
1. Have an effective system in place to ensure Resident #R7 was adequately supervised to prevent her from exiting the building unsupervised on 06/25/2024 and 08/03/2024;
2. Complete an incident report and/or thoroughly investigate Resident #R7's elopements on 06/25/2024 and 08/03/2024; and
3. Update Resident #R7's care plan to include new interventions to prevent the resident from exiting the building unsupervised after two previous elopements.
This deficient practice resulted in an Immediate Jeopardy situation on 06/25/2024 at 3:59 p.m. when Resident #R7, a severely cognitively impaired resident who had a history of wandering, followed visitors out of the building via the front entrance door, and walked into the parking lot unsupervised on 06/25/2024 and 08/03/2024.
S1 ADM was notified of the Immediate Jeopardy on 08/16/2024 at 6:50 p.m.
The Immediate Jeopardy was removed on 08/19/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Cross Reference to F689
Review of the facility's policy titled, Elopements dated 12/2007 revealed in part . Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse of Director of Nursing.
Review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting dated 07/2017 revealed in part . All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator.
Interview on 08/16/2024 at 2:15 p.m. with S2 DON revealed Resident #R7 went out the X Hall front door, unsupervised by staff on 06/25/2024 and 08/03/2024. S2 DON confirmed the facility did not complete an incident report on 06/25/2024. S2 DON revealed the facility had not investigated Resident #R7's elopement incidents as there was no incident to investigate.
Interview on 08/16/2024 at 2:25 p.m. with S2 DON revealed the facility had not implemented any further interventions to Resident #R7's plan of care following elopements on 06/25/2024 and 08/03/2024. S2 DON revealed no new in-services related to elopement were done as a result of Resident #R7's elopements. S2 DON revealed he did not consider these incidents an elopement because Resident #R7 did not leave the facility grounds.
Interview on 08/16/2024 at 3:19 p.m. with S2 DON revealed the facility did not have a policy related to training staff on risk for elopement, how to respond after an elopement, or a policy specific to Elopement/Wandering Assessments.
Interview on 08/16/2024 at 6:50 p.m. with S1 ADM revealed she was aware of Resident #R7's elopements that occurred on 06/25/2024 and 08/03/2024, and the facility did not complete incident reports or in-servicing because the facility did not feel the incidents were elopements. S1 ADM confirmed the facility had not updated Resident #R7's plan of care with further interventions following elopements to prevent the likelihood of elopement, but should have.

Based on record review and interview, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner which promotes enhancement of his or her own quality of life for 1 (Resident #1) of 12 (Resident #1, Resident #2, Resident #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9) sampled residents.
Findings:
Review of the facility's policy titled Quality of Life - Dignity dated 08/2009 read in part .Each resident will be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents will be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 8. Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed .
Review of Resident #1's medical record revealed an admit date on 03/24/2021 with diagnoses which included: Altered Mental Status, Dementia, Pseudobulbar Affect, Muscle Weakness, Difficulty in Walking, Anxiety Disorder, and Major Depressive Disorder.
Review of Resident #1's Significant Change MDS with an ARD of 05/01/2024 revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #1's MDS revealed she had the ability to express her ideas and wants which could be understood. Resident #1's MDS stated she required moderate assistance with upper body dressing, lower body dressing and personal hygiene; maximal assistance with bathing; and she was dependent on staff for toileting hygiene.
Review of Resident #1's Care Plan with a Target Date of 08/30/2024 revealed in part .Communication problem related to dementia. Interventions: Anticipate and meet needs. Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, ask yes/no questions if appropriate, use simple brief consistent words/cues, use alternative communication tools as needed. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed. ADL self-care performance. Interventions: Camera in room provided per family. Extensive assistance to total care with ADL's and mobility. Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care.
Review on 08/09/2024 of video camera footage of Resident #1's room dated 07/23/2024 at 11:07 p.m. revealed S3 CNA providing care to Resident #1. While adjusting Resident #1's gown, S3 CNA roughly turned her, let go of her, and let fall back on the mattress.
Review on 08/09/2024 of video camera footage of Resident #1's room dated 07/19/2024 at 1:43 a.m. through 1:54 a.m. revealed S3 CNA in the room providing care to Resident #1. Christian music could be heard playing on Resident #1's radio in the room. S3 CNA was on her cellphone throughout the video talking to a female on speaker phone. Resident #1 tried to speak to S3 CNA while she was providing care. S3 CNA did not acknowledge Resident #1 when Resident #1 spoke to her and she continued with her cell phone conversation.
Interview on 08/12/2024 at 9:13 a.m. with S17 CNA Supervisor revealed there was video footage of S3 CNA on her cell phone while providing care to Resident #1. S17 CNA stated she should not have been on the phone while providing care to Resident #1.
Telephone interview on 08/15/2024 at 10:52 a.m. with S3 CNA confirmed she used her cell phone on speaker while providing care to Resident #1, but should not have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by failing to assess, obtain, and implement services for the behavioral health care needs for 1 of 1 (#21) residents reviewed for behavioral health services.
Findings:
Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring read in part
Cause Identification:
1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify cause, and address any modifiable factors that may have contributed to the residents change in condition.
Management:
1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm.
Review of Resident #21's medical record revealed an admit date of [DATE], with diagnoses that included: Opioid Abuse, Psychoactive Substance Abuse with Psychoactive Substance induced Psychotic Disorder with Delusions, Unspecified Mood Disorder, Alcohol Use, and Anxiety Disorder.
Review of the Quarterly MDS with an ARD of [DATE], revealed Resident #21 had a BIMS of 15, which indicated he was cognitively intact.
Review of Resident #21's Physician Orders dated 04/2024 revealed the following:
Document behaviors every shift - 1. Delusion, 2. Combative, 3.Crying out, 4. Hallucinations, 5. Other.
Suboxone sublingual film 8 - 2mg - Give 0.5 film sublingual 2 times a day, related to Psychoactive Substance Abuse with Psychoactive Substance Induced Delusions.
Suboxone sublingual film 8 - 2mg - Give 0.5 film sublingual at bedtime, related to Psychoactive Substance Abuse with Psychoactive Substance Induced Delusions.
Review of the Resident #21's medical records revealed no documentation that he was assessed by a psychiatric provider, or received psychiatric services from 01/2024 through 04/2024.
Review of Resident #21's Care plan with target date [DATE] read in part .
1. Resident #21 has a history of Polysubstance drug abuse (methamphetamine/Opiate) with psychosis, delusions and hallucinations.
[DATE] - Suspected of drug use.
[DATE] - Suspected of stimulant use causing paranoia.
[DATE] - Set up appointment for Saboxone clinic per MD.
2. Resident #21 has a mood problem related to history of Polysubstance drug abuse.
[DATE] - Resident #21 went out of facility, and returned with altered mental status and violent behaviors. A Physician's Emergency Certificate was signed.
Monitor/record/report to MD any risk for harming others: increased anger, liable mood and agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons.
Observation on [DATE] at 9:45 a.m. revealed a box cutter was observed lying on Resident #21's wheelchair seat as he removed the wheelchair cushion. Resident #21 stated he had the box cutter in case anyone came into his room late at night, and he needed it for his protection.
Interview on [DATE] at 9:55 a.m. with S1 Administrator revealed she was unaware Resident #21 had a box cutter in his possession. S1 Administrator stated approximately a month ago a contract worker notified her that Resident #21 was harassing a fellow contract worker about the nonexistent relation between her and a fellow resident's family member, and that Resident #21 had told the contract worker to watch her back. S1 Administrator stated she had a conversation with Resident #21 and asked him to stop. S1 Administrator stated the next day the contract worker notified her that Resident #21 had a knife under his wheelchair. S1 Administrator stated the knife was a paring knife she believed he had gotten from the kitchen. S1 Administrator stated she did not ask Resident #21 why he had a knife hidden under his wheelchair. S1 Administrator stated she had not been notified that any resident or staff had been fearful or threatened by Resident #21.
During an interview on [DATE] at 11:20 a.m., S5 Speech Therapist stated Resident #21 started asking her for a picture of herself, saying inappropriate things to her, and would follow her around the facility. S5 Speech Therapist stated she had notified S6 Therapy manager of how uncomfortable Resident #21 was making her feel, but could not recall exactly when. S5 Speech Therapist stated approximately 1 month ago, Resident #21 was waiting outside by the gate as she was leaving the facility, and told her she needed to watch her back. S5 Speech Therapist stated she immediately notified the S6 Therapy Director of the incident. S5 Speech Therapist stated she did not feel that Resident #21 would hurt her but made her feel uncomfortable.
Interview on [DATE] at 11:31 a.m. with S6 Therapy Director revealed approximately 1 month ago, (unable to remember exact date), he observed a knife handle coming out from under Resident #21's wheelchair cushion. S6 Therapy Director asked Resident #21 why he had the knife, and he told him he was too old to fight, and needed some protection. S6 Therapy Director stated he notified S1 Administrator immediately of the knife, and informed S1 Administrator on a date prior to his observations of the knife (unable to remember the exact date), that S5 Speech Therapist notified him that Resident #21 was making her feel uncomfortable by following her around, staying in the therapy gym more often, asking/telling her inappropriate things, and once told her to watch her back, as she was leaving the facility. S6 Therapy Director stated he reported these incidents to S1 Administrator approximately 1 month ago.
An interview on [DATE] at 11:37 a.m. with S1 Administrator, confirmed there was no documentation in Resident #21's medical records that addressed Resident #21 had a hidden knife in his possession, or that he was harassing S5 Speech Therapist after she was notified by S6 Therapy Director. S1 Administrator confirmed the MD was not contacted, and Resident #21 was not seen by psychiatric services after she was informed of Resident #21 behaviors because she felt as though the situation was remedied. After the surveyor discussed these findings with S1 Administrator, Resident #21 was put on 1:1 supervision and was PEC'd to a Behavioral hospital on [DATE].

Based on record reviews and interviews, the facility failed to ensure that 1 (#57) of 1 sampled residents who required dialysis received such services, consistent with professional standards of practice as evidenced by failing to ensure there was ongoing communication, coordination and collaboration with the dialysis facility regarding dialysis care and services.
Findings:
Review of Resident #57's medical record revealed a readmit date of 02/23/2024 with diagnoses that included: End Stage Renal Disease, Dependence on Renal Dialysis, and Heart Failure.
Review of Resident #57's 04/2024 physician's orders revealed an order to receive dialysis three days per week on Monday, Wednesday, and Friday.
Review of Resident #57's dialysis communication sheets for 04/2024 revealed two dialysis communication sheets, which had the pre-dialysis information section filled out by the nursing facility only. In an interview on 04/16/2024 at 4:12 p.m., S2 DON confirmed the communication sheets dated 04/08/2024 and 04/15/2024 were the only communications sheets that could located for Resident #57 and the dialysis communication sheets were not completed by the dialysis facility.
Interview on 04/16/2024 at 10:00 a.m., with S3 LPN revealed Resident #57 returns from dialysis on the shift she works. S3 LPN stated the dialysis communication sheets should return to the facility with Resident #57 from dialysis but she had not received any back from dialysis.
Telephone interview on 04/16/2024 at 10:20 a.m. with the dialysis facility RN in charge of Resident #57's care revealed the nursing facility did not send communication sheets with Resident #57 to be filled out by dialysis staff for ongoing coordination of care. The dialysis RN stated if the facility would send a communication sheet, it would be filled out at each dialysis appointment but had not been sent.
Interview on 04/16/2024 at 10:35 a.m. with S2 DON confirmed the dialysis communication sheets were not being completed by nursing staff prior to Resident #57 being sent to dialysis, Resident #57 did not return to the facility with communication sheets filled out by the dialysis center, and nursing staff did not contact the dialysis nurse to communicate dialysis care received. S2 DON reported it should have been completed with each Monday, Wednesday, and Friday dialysis visit, but it was not.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #5) of 1 residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly changed, labeled and stored.
Findings:
Review of Resident #5's medical record revealed an admit date of 11/09/2023 with a BIMS score of 5 (indicating severe cognitive impairment), and diagnoses which included: Alzheimer's disease, Chronic Obstructive Pulmonary Disease, Sarcopenia and Sleep Apnea.
Review of Resident #5's Physician's Orders dated 04/2024 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (breathing treatment) -1 application inhale orally every 6 hours as needed for SOB/Congestion.
Review of Resident #5's Care Plan with a target of 05/19/2024 revealed a problem for Chronic Obstructive Pulmonary Disease with interventions that included in part .Administer medications and nebulizers as ordered for cough and congestion. Give Nebulizers or inhalers as ordered. Monitor/document any side effects/effectiveness.
Observation on 04/14/2024 at 11:06 a.m. revealed Resident #5's nebulizer mouthpiece was lying on her bedside table in a Ziploc bag undated. The nebulizer mouthpiece was also undated. Interview with Resident #5 revealed she used the nebulizer for her breathing treatments.
Observation on 04/15/2024 at 10:00 a.m. revealed Resident #5's nebulizer mouthpiece was lying on her bedside table in a Ziploc bag undated. The nebulizer mouthpiece was also undated.
Observation and interview on 04/15/2024 at 10:06 a.m. with S3 LPN revealed Resident #5's nebulizer mouthpiece lying on her bedside table in a Ziploc bag undated. The nebulizer mouthpiece was also undated. S3 LPN confirmed the above findings and stated the nebulizer mouthpiece and Ziploc bag should have been dated and were not. S3 LPN revealed the weekend ward clerk was responsible for dating/labeling oxygen equipment weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications of enteral feeding by failing to check placement and gastric residual volume (GRV) for 1 (#45) of 2 (#34, and #45) residents reviewed for Tube Feeding. Findings:
Review of the facility's current policy titled Confirming Placement of Feeding Tubes dated 03/2015 read in part . The purpose of this procedure is to ensure proper placement of the feeding tube to prevent aspiration during feedings. If feeding has been interrupted for a few hours, observe and check the pH of aspirate.
Review of the facility's current policy titled Checking Gastric Residual Volume (GRV) dated 03/2015 read in part .The purpose of this procedure is to assess tolerance of enteral feeding and minimize the potential for aspiration. Check the position of the feeding tube before the initiation of each feeding. Measure GRV with at least a 60 mL syringe.
Review of Resident #45's Medical Record revealed Resident #45 was admitted to the facility on [DATE] and had diagnoses that included in part . Cerebral Infarction, Heart Failure, Epilepsy, Dementia, Acute Necrotizing Hemorrhagic Encephalopathy, Gastrostomy Status, Type 2 Diabetes Mellitus, Gastroesophageal Reflux Disease, and Chronic Kidney Disease.
Review of Resident #45's Quarterly MDS with ARD of 01/23/2024 revealed Resident #45 had a BIMS score of 02 (severe cognitive impairment). Resident #45 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene.
Interview on 04/14/2024 at 1:20 p.m. with Resident #45's RP in room revealed Resident #45 had been out of the facility on pass since approximately 9:30 a.m. on this day, and he had notified staff that Resident#45 needed to be connected back to her tube feeding. Observation at this time revealed Resident #45 was disconnected from her tube feeding. Observation also revealed the feeding was set at 40ml/hr. continuously, and flush was set for 40ml/hr. continuously via pump.
Observation on 04/14/2024 at 1:40 p.m. revealed S5 LPN entered Resident #45's room donned gloves, cleaned feeding tube connection with an alcohol wipe, then connected the tubing to Resident #45's PEG and placed the pump to run.
Interview on 04/14/2024 at 1:57 p.m. with S5 LPN confirmed she did not check for placement or residual prior to administering Resident #45's enteral feeding, but should have.
Interview on 04/15/2024 at 10:30 a.m. with S2 DON to discuss above finding revealed S5 LPN should have checked placement prior to initiating Resident #45's enteral feeding.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to:
1. Implement Enhanced Barrier Precautions (EBP) for residents whom EBP are indicated.
2. Maintain a water management program, to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system.
This deficient practice had the potential to affect all residents who reside in the facility. The total resident census was 76. Findings:
1. Observation on 04/14/2024 at 1:20p.m. revealed there were no Enhanced Barrier Precautions implemented for Residents throughout the facility as indicated.
Observation on 04/15/2024 at 9:44 a.m. revealed there were no Enhanced Barrier Precautions implemented for Residents throughout the facility as indicated.
Interview on 04/15/2024 at 4:30p.m. with S2 DON confirmed the facility did not have a policy or procedure for Enhanced Barrier Precautions. S2 DON confirmed there were currently no Resident's placed on EBP as indicated.
2. Interview on 04/16/2024 at 12:48 p.m. with S1 Administrator revealed the facility did not have a plan for when control limits are not met, and/or control measures are not effective, and documentation of water management program. S1 Administrator stated the facility's maintenance staff were responsible for checking the water for Legionella, and confirmed the facility had failed to do so.

Based on interview and record review the facility failed to ensure their grievance policy and procedure was followed. The facility failed to inform the resident/resident's RP (responsible party) of investigation findings and actions taken to correct the identified problems for 1 (#1) of 7(#1, #2, #3, #4, #5, #R1, and #R2) sampled residents. Findings:
Review of the facility policy titled Resident Rights read in part . Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to: Have the facility respond to his or her grievances.
Review of the facility policy titled Investigating Grievances/Complaints read in part .Our Facility investigates all grievances and complaints filed with this facility. The Resident Grievance/Complaint Investigation Report Form must be filed with the administrator within two (2) working days of the receipt of the grievance or complaint form. The resident, or person acting in behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ten (10) working days of the filing of the grievance or complaint. A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Investigation Report Form and filed in the business office. Copies of all reports must be signed and will be made available to the resident or person acting in behalf of the resident.
Review of the facility's Grievance Log dated 01/2023-01/2024 revealed no grievances on file for Resident #1.
Interview on 01/29/2024 at 9:51 a.m. with Resident #1's RP revealed she had concerns about the meals her mother (Resident #1) and the other residents at facility were receiving. Resident #1's RP stated herself, Resident #1, and her sister have made numerous complaints to S1 ADMIN, S2 DM, and S3 SW regarding food service. Resident #1's RP stated she specifically asked S3 SW to document her concerns as a formal complaint on December 18, 2023 when she brought to S1 ADMIN's attention via text that her mother had received 2 inadequate meals on this specific day. Resident #1's RP stated a follow up had not been provided regarding the complaint.
Interview on 01/29/2024 at 12:51 p.m. with Resident #1 revealed she had concerns regarding the food served at facility, and that she and her family had brought the concerns to staff on multiple occasions and felt nothing had been taken care of.
Interview on 01/29/2024 at 1:13 p.m. with S4 CNA stated Resident #1 had voiced concerns about food quality several times, and Resident #1's daughter would bring Resident #1 something to eat on those days. S4 CNA stated she had multiple residents complain about food quality since the change in food providers, but felt administration was aware of these concerns, and addressing it.
Interview on 01/29/2024 at 3:04 p.m. with S3 SW revealed she had received a complaint from Resident #1's daughter in December 2023, but did not document it. S3 SW confirmed she should have documented the concerns when she received them.
Interview on 01/29/2024 at 3:15 p.m. with S1 ADMIN and S2 DM revealed they had received dietary concerns from Resident #1's family on different occasions, but felt they had addressed the concerns. S1 ADMIN stated she had received a text on 12/18/2023 from Resident #1's RP regarding food concerns, and a picture that S1 ADMIN described as terrible. S1 ADMIN stated she had dietary staff fix sandwiches to remedy that situation. S1 ADMIN confirmed she should have documented the concerns and followed the facility's policy for grievances. S2 DM stated she had received concerns from Resident #1's RP on a separate date, but could not recall the exact date. S2 DM provided surveyor with a photo of meal, and a copy of menu for the meal in which the complaint was about. The menu for meal consisted of chef's salad and potato soup. S2 DM stated the meal served on that day was insufficient for Residents. Observation of the photo revealed residents were served 1 cookie, a small portion of a green salad on plate, and a side of potato soup that appeared very thin in consistency. S2 DM confirmed this meal was insufficient to meet the needs of residents, and she was not sure who followed up with Resident #1's RP regarding the concerns.

Based on interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines by failing to:
1)
follow the approved menu in regard to meals served
2)
record and archive deviations/substitutions of menu
3)
post menus in at least 2 resident areas
This deficient practice had the potential to affect the 68 Residents who receive meals prepared by the facility kitchen. Findings:
Review of the facility's policy titled Menus read in part . Menus are developed and prepared to meet resident's choices including religious, cultural and ethnic needs while following established national guideline for nutritional adequacy. Deviations from posted menus are recorded (including the reason for the substation and/or deviation) and archived. Copies of the menus (as served, including substitutions) are kept on file. Copies of menus are posted in at least two (2) resident areas, in positions and in print large enough for residents to read them.
Review of the facility's policy titles Substitutions read in part . All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitution must include the reason for the substitution.
Observation on 01/29/2024 at 8:55 a.m. of Dining Room A revealed there was no postings of current menu.
Observation on 01/29/2024 at 8:58 a.m. of Dining Room B revealed there was no postings of current menu.
Interview on 01/29/2024 at 9:00 a.m. with S2 DM revealed approximately 4 months ago the facility switched menus and food service provider, and she had received multiple concerns from residents in regards to this. S2 DM stated she was instructed by S1 ADMIN to use the new menus for 1 full cycle, and if revisions were needed, they would make changes following the completed cycle. S2 DM stated in November 2023, herself, S1 ADMIN, and the Registered Dietician met with the facility's Resident Council group to discuss the concerns and menu changes. S2 DM stated she had made several changes to meals on the previously approved new menus. S2 DM confirmed she did not have the substitutions to the menu recorded, and was not able to provide surveyor with the revised served menu. S2 DM confirmed she should have documented the changes on the menu, and had Registered Dietician sign off on the revised menu.
Interview on 01/29/2024 at 10:36 a.m. with S1 ADMIN revealed she was aware that multiple residents at the facility had food concerns. S1 ADMIN stated the facility recently switched food service providers, and they began using new menus. S1 ADMIN stated S2 DM had made changes to the menu due to the resident's preferences, and confirmed S2 DM should have a documented copy of the revised served menus.
Interview on 01/29/2024 at 2:50 p.m. with S1 ADMIN revealed S2 DM had informed her that the dietary cooks had been deviating from the approved menus. S1 ADMIN confirmed dietary staff were to utilize the menu as it was written and approved, and should not have deviated from it.
Interview on 01/29/2024 at 3:15 p.m. with S1 ADMIN and S2 DM revealed October 12, 2023 was the beginning date for utilizing the newly approved menus. S1 ADMIN confirmed at time of interview the facility did not post menus in the dining rooms, or in at least 2 resident areas.

Based on observation, record review and interview, the facility failed to ensure food served to residents was palatable, attractive, and at an appetizing temperature for 3(#1, #2, #5) of 7(#1, #2, #3, #4, #5, #R1, and #R2) sampled resident's. This deficient practice had the potential to affect all 68 residents who received meals served by the facility kitchen. Findings:
Review of the facility's policy titled Food and Nutrition Services) read in part . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Reasonable efforts will be made to accommodate resident choices and preferences. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.
Resident #1
Review of Resident #1's medical record revealed she was admitted to facility on 08/01/2023. Resident #1 had diagnoses that included in part . Unspecified Dementia, Generalized Muscle Weakness, Cognitive Communication Deficit, Diabetes Mellitus, and Chronic Kidney Disease.
Review of Resident #1's Quarterly MDS with ARD of 11/01/2023 revealed she had a BIMS of 15(Cognition intact).
Interview on 01/29/2024 at 9:51 a.m. with Resident #1's RP revealed she had concerns about the meals her mother (Resident #1) and the other residents at facility were receiving. Resident #1's RP stated food was undercooked, and meals were not nutritionally balanced and appealing to Residents. Resident #1's RP presented surveyor with multiple photos of the meals Resident #1 was served.
Interview on 12/29/2024 at 12:51 p.m. with Resident #1 revealed she had concerns regarding the food served at facility, and that she and her family had brought the concerns to staff on multiple occasions. Resident #1 stated her daughter's usually had to bring her meals when she was served things that were inedible, or she snacked on items in her room. Resident #1's lunch tray was observed with what appeared to be, one bite taken from meal. Resident #1 stated the ham was hard, she didn't like greens, and the potatoes were not good. Resident #1 stated she was unaware she could ask for something else, and did not know the facility had an alternate menu to choose from. Resident #1 stated she did not know what was served until she received the meal. During interview with Resident #1, S5 CNA presented to room, asked Resident #1 if she was done with meal, stated you didn't eat very much to Resident #1, and proceeded out of room with tray without offering a substitution.
Interview on 01/29/2024 at 1:09 p.m. with S5 CNA revealed she typically did not work the hall Resident #1 resided on, so she did not know how Resident #1 did with meal intakes. S5 CNA stated she did not think to offer Resident #1 anything else to eat.
Interview on 01/29/2024 at 1:13 p.m. with S4 CNA revealed Resident #1 ate well, but only for the meals she liked. S4 CNA stated Resident #1 had voiced concerns about food quality several times, and Resident #1's daughter would bring Resident #1 something to eat on those days. S4 CNA stated she had multiple residents complain about food quality since the change in food providers, but felt administration was aware of these concerns, and addressing it.
Interview on 01/29/2024 at 3:15 p.m. with S1 ADMIN and S2 DM revealed they had received dietary concerns from Resident #1's family on different occasions, but felt they had addressed the concerns. S1 ADMIN stated she had received a text on 12/18/2023 from Resident #1's RP regarding food concerns, and a picture that S1 ADMIN described as terrible. S1 ADMIN stated she had dietary staff fix sandwiches to remedy that situation. S2 DM stated she had received concerns from Resident #1's RP on a separate date, but could not recall the exact date. S2 DM provided surveyor with a photo of meal, and a copy of menu for the meal in which the complaint was about. The menu for meal consisted of chef's salad and potato soup. S2 DM stated the meal served on that day was insufficient for Residents. Observation of the photo revealed residents were served 1 cookie, a small portion of a green salad on plate, and a side of potato soup that appeared very thin in consistency. S2 DM confirmed this meal was insufficient to meet the needs of residents.
Resident #2
Review of Resident #2's medical record revealed she was admitted to facility on 01/22/2020. Resident #2 had diagnoses that included in part . Generalized Muscle Weakness, Diabetes Mellitus, Peptic Ulcer Disease, Guillan Barre Syndrome, and Rheumatoid Arthritis.
Review of Resident #2's Annual MDS with ARD of 11/17/2023 revealed she had a BIMS of 15(Cognition intact).
Interview on 01/29/2024 at 3:32 p.m. with Resident #2 revealed she had concerns about dietary services. Resident #2 stated she had been served meals that were inedible and cold at times. Resident #2 stated in Resident Council meetings, Residents had consistently voiced dietary concerns every month since the change in food service providers. Resident #2 stated on 11/08/2023, S1 ADMIN and S2 DM met with the Resident Council, and discussed the concerns, and necessary menu changes.
Resident #5
Review of Resident #5's medical record revealed Resident #5 was admitted to facility on 03/11/2022. Resident #5 had diagnoses that included in part . Dependence on Supplemental Oxygen, Chronic Obstructive Pulmonary Disease, Generalized Muscle Weakness, Anxiety Disorder, and Unspecified Protein Calorie Malnutrition.
Review of Resident #5's Quarterly MDS with ARD of 12/27/2023 revealed she had BIMS of 14 (Cognition intact).
Interview on 01/29/2024 at 3:35 p.m. with Resident #5 revealed she had concerns about the food served at facility. Resident #5 stated she did not like many of the meals served, especially since the change in food service provider. Resident #5 stated many times she did not eat because of the food served being cold, uncooked, or just not good. Resident #5 stated she was not aware the facility had an alternate menu that she could select food from, and staff never offered her any substitutions.

Based on record review, observation, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to properly log temperatures daily for 1(Refrigerator A) of 2 (Refrigerator A, Refrigerator B) Refrigeration units observed. This deficient practice had the potential to affect the 68 Residents that received meals prepared by the kitchen. Findings:
Review of the Facility's Policy & Procedure titled Refrigerators and Freezers read in part . This Facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.
Observation of Refrigerator A on 01/29/2024 at 11:47 a.m. accompanied by S2 DM revealed a review of Refrigerator A's 01/2024 daily temperature log did not include daily recorded temperatures on the following dates: 01/09/2024, 01/15/2024, 01/21/2024, 01/27/2024, and 01/28/2024.
Interview on 01/29/2024 at 11:48 a.m. with S2 DM confirmed temperature checks for Refrigerator A are required to be completed daily, but had not been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an alleged injury of unknown origin was reported immediately, but not later than two (2) hours after the allegation was made to the State Survey Agency for 1 (#2) out of 3 (#1, #2, #3) sampled residents. The deficient practice had the potential to affect a total census of 70 residents.
Findings:
A review of the facility's policy title,d Abuse/Neglect and Reporting, revealed in part: An alleged violation of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.
Resident #2 was admitted to the facility on [DATE]. She had diagnoses that included in part: Cerebral Vascular Accident, Hemiplegia of Left Side and Osteoarthritis.
A review of Resident #2's latest Minimum Data Set (MDS) assessment for a Significant Change with an Assessment Reference Date (ARD) of 11/22/2023 revealed she had a Brief Interview for Mental Status (BIMS) score of 05 that indicated severe cognitive impairment.
A review of Resident #2's electronic health record revealed a nurse note on 11/16/23 at 1:06 a.m. that read in part: The resident stated staff stood her up and now she has intermittent pain to her left outer ankle with pain scale of 9. No discoloration, deformity or injury noted. She intermittently moved her foot up and down while crying in pain that radiated up into her hip. Pain medication was administered and her leg was propped on pillows for comfort.
A review of Resident #2's Incident/Accident Report revealed the incident occurred 11/15/23 at 3:30 p.m. in the beauty shop. She was transferred by 2 therapists from a Geri-chair to a wash chair. During the transfer, the resident stated ouch my foot. After she was transferred, she did not complain and there was no bruising or swelling noted. An x-ray was completed on 11/16/2023. The physician and responsible party was notified on 11/16/2023 at 9:00 a.m.
A review of the state agency incident report #157147 for Resident #2 revealed the report was related to an injury of unknown origin with a fracture. The report was entered on 11/20/2023 at 12:59 p.m. Further review of the report revealed the incident occurred on 11/15/2023 at 3:30 p.m. and was discovered on 11/16/2023 at 5:00 p.m.
A review of Resident #2's Radiology Interpretation for left ankle x-ray complete 3 view on 11/16/2023 read: Impression: non-displaced fracture of the distal fibula, acute.
On 12/12/2023 at 2:45 p.m., an interview was conducted with S2DON (Director of Nursing). She stated that she was notified by S3ADON (Assistant Director of Nursing) on the night of 11/16/2023 that Resident #2 had a non-displaced fracture of the distal fibula. She confirmed that she should have notified S2ADM (Administrator) immediately.
On 12/12/2023 at 4:00 p.m., an interview was conducted with S1ADM (Administrator). She stated the facility was notified via fax on 11/16/23 at 4:55 p.m. of Resident #2's x-ray results that revealed a non-displaced fracture of the distal fibula. She stated was notified of the fracture on Friday, 11/17/2023 at 8:37 a.m. by S2DON. She confirmed that she should have reported the injury of unknown origin no later than 2 hours of being notified of the fracture.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure: 1) Food preparation equipment was clean. 2) Food preparation spices were stored on the shelves in sanitary conditions and stored in clean storage containers. This deficient practice had the potential to affect all Residents that received meals prepared in the kitchen.
Findings:
Observation of the kitchen on 04/10/2023 at 10:30 a.m. accompanied by S6 DM revealed:
1. Single door convection oven with a thick layer of greasy film of yellow, brown, and black substance. The fan on the back of the convection oven was noted to have a moderate amount of dust and the vents were clogged.
2. A storage shelf contained:
1 32 oz. plastic jar - creole seasoning- seasoning particles caked on the top and outside of the container.
1 32 oz. plastic jar- herb seasoning- seasoning particles caked on the top and outside of the container.
1 24 oz. plastic jar- garlic and herb seasoning- seasoning particles caked on the top and outside of the container.
1 24 oz. plastic jar of rotisserie chicken seasoning- seasoning particles caked on the top and outside of the container.
1 16 oz. glass bottle - red food coloring- a sticky film on the outside and color drippings on the outside.
3. A non-moveable 2 tier wire cart underneath a 12 foot table held the following:
1- 2 quart storage container with grits- side of the container with sticky film and the top was covered with particles of spices.
1- 2 quart storage container with potato flakes- side of the container with sticky film and the top was covered with particles of spices.
1- 2 quart storage container with oat meal- side of the container with sticky film and the top was covered with particles of spices.
4. A 3 drawer rolling plastic storage container was noted with sticky films of white, black and rust colored particles contained the following:
Numerous individual packets of salt, numerous individual packets of Concord grape jelly.
5 ½ -24 oz. bags of brown gravy mix.
6 ½ - 24 oz. bags of peppered old fashion biscuit gravy mix.
5. A 5 pound plastic container of black pepper- top and side of container with sticky substances of granulated particles gray, black and white specks.
Interview on 04/11/2023 at 11:15 a.m. with S6 DM confirmed all of the above findings at the time of the observation. S6 DM stated the convection oven and its fan unit should have been cleaned and wasn't. S6 DM stated all spices, seasoning, and food flavoring containers should have been wiped down before being stored and wasn't. S6 DM stated all storage container should be cleaned and disinfected before storing any food items inside and wasn't.

Based on interview and record review the facility failed to ensure PRN (as needed) orders for psychotropic drugs are limited to 14 days. The facility failed to indicate the duration for the PRN order of psychotropic medication for 1 (Resident #1) of 5 ( Resident #1, Resident #23, Resident #44, Resident #46 and Resident #167 ) Residents reviewed for unnecessary medications.
Findings:
Review of Resident #1's clinical record revealed an admission date of 03/24/2021 with diagnoses that included Schizophrenia, Dementia, Altered Mental Status, Anxiety disorder and Major Depressive Disorder.
Review of Resident #1's Quarterly MDS Assessment with ARD of 01/30/2023 revealed Resident #1 had a BIMS of 00 (severe cognitive impairment) and received antipsychotics on a routine basis.
Review of Resident #1's April 2023 Medication Administration Record revealed an order for Ativan Injection Solution 2mg/ml (Lorazepam) Inject 1ml intramuscularly every 2 hours as needed for target behavior: Aggressiveness-start date 04/26/2022. Review of the record revealed the order for prn Ativan was discontinued on 01/08/2023 when Resident #1 was admitted to a behavioral health hospital.
Review of Resident #1's behavioral health hospital discharge orders and 01/2023 Medication Administration Record revealed Ativan Injection Solution 2mg/ml (Lorazepam) Inject 1ml intramuscularly every 2 hours as needed for target behavior of aggressiveness had been reordered with a start date of 01/25/2023.
Review of Pharmaceutical Consultant reports dated 05/03/2022 revealed a rationale for PRN continuation that stated: Medication is required to manage symptoms/behaviors. Review of the report revealed no duration.
Review of Pharmaceutical Consultant reports dated 11/11/2022 and signed by the physician on 11/16/2022 revealed a rationale for PRN continuation that stated: Medication is required to manage symptoms/behaviors. Review of the report revealed no duration.
Review of Pharmaceutical Consultant reports dated 11/11/2022, and signed by the physician on 03/22/2023 revealed a rationale for PRN continuation that stated: Medication is required to manage symptoms/behaviors. Review of the report revealed no duration.
Review of behavior monitoring for 02/01/2023-02/28/2023 revealed Resident #1 had no behaviors.
Review of behavior monitoring for 03/01/2023-03/31/2023 revealed on 03/01/2023 Resident #1 was combative and on 03/23/2023 exhibited delusions.
Review of behavior monitoring for 04/01/2023-04/11/2023 revealed Resident #1 had no behaviors.
Review of Resident #1's Medication Administration Records revealed Resident #1 did not received prn injections of Ativan (psychotropic medication) during the months of 01/2023 (after return from hospitalization), 02/2023 or 03/2023.
Interview on 04/12/2023 at 2:40 p.m. with S2 DON revealed Resident #1 did not receive the prn IM Ativan after returning from the hospital in January or during the months of February and March of 2023 and the order was not discontinued. S2 DON confirmed the PRN order for Ativan Injection Solution 2mg/ml (Lorazepam) Inject 1ml intramuscularly every 2 hours as needed for target behavior: Aggressiveness had been continued without documented durations from 04/26/2022 through 01/08/2023 and from 01/26/2023 to date of interview.

Based on interview and record review the Facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 2 of 13 weekends. Findings:
Review of the Facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1 2023 (October 1-December 31) revealed the submitted weekend staffing data was excessively low.
Review of a Facility staffing pattern for weekends from Fiscal Year Quarter 1 revealed the Facility was required to provide 164.5 hours on 12/03/2023 and provided 163.5. The Facility was required to provide 171.55 hours on 12/24/2022 and provided 165.5.
Interview on 04/13/2023 at 10:30 a.m. with S1 Administrator confirmed the facility had not provided the minimum required hours on 12/03/2022 and 12/24/2022 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 3
Observation on 04/11/2023 at 12:45 p.m. revealed Resident #3 lying in bed in a grayish gown. Resident #3's hair was dry, loose, and uncombed with a small blue ponytail wrapper sitting inside of loose hair.
Observation on 04/12/2023 at 10:35 a.m., revealed Resident #3 lying in bed in a hospital gown. Resident #3 hair's was loose, uncombed, and dry with a small blue ponytail wrapper noted inside of loose hair. Resident #3 stated she was given a bed bath 04/11/2023 and the CNA did not comb/brush her hair. Resident #3 stated she was unable to brush/comb her own hair.
A review of Resident #3's EHR revealed she was readmitted to the facility on [DATE] with diagnoses that included in part . Hemiplegia and Hemiparesis, Acute Kidney Failure, Type 2 Diabetes Mellitus, and Hypertension.
Review of Resident #3's 5 day admission MDS with an ARD of 01/16/2023 revealed Resident #3 had a BIMS of 13 (cognitively intact). Resident #3 required two person extensive assist for physical transfer, bed mobility, dressing, toilet use, and one person physical assist with locomotion on/off the unit, eating, and personal hygiene.
Review of Resident #3's Care Plan with a target date of 05/06/2023 addressed a deficit in ADLs as related to limited physical mobility- Interventions in part included two person extensive assist with bed mobility, dressing, and toileting, and one person extensive personal hygiene, use Hoyer lift for transfer two person assist.
Interview on 04/12/2023 at 10:45 a.m. with S3 ADON confirmed Resident #3's hair needed to be brushed/combed and should have been done along with her bath and every day as needed or per Resident #3's request and wasn't.
Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#3 and #19) of 4 (#3, #19, #27, and #46) Residents reviewed for ADL's. The facility failed to ensure a Resident (#3) received hair grooming, and failed to ensure a Resident (#19) received a bath on her scheduled bath days. The total sample size was 36.
Findings:
Review of the facility policy titled: Activities of Daily Living (ADL), Supporting read in part .
Appropriate care and services will be provided for Residents who are unable to carry out ADLs independently, with the consent of the Resident and in accordance with the plan of care including: a. Hygiene (bathing, dressing, grooming, and oral care.)
Resident #19
Review of Resident #19's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with an admitting diagnosis of Congestive Heart Failure. Other diagnoses included: Major Depressive Disorder, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Osteoarthritis, Seizures, and Cerebral Infarction.
Review of Resident #19's Quarterly MDS with an ARD date of 02/03/2023 revealed in part . Resident had BIMS of 13 (Cognitively Intact) and required one person physical assist for personal hygiene and bathing.
Review of Resident #19's Care Plan with a target completion date of 05/29/2023 revealed in part ADL self-care deficit related to limited mobility, history of muscle weakness and atrophy. Approaches included: Staff to provide extensive assistance for personal hygiene.
Interview with Resident #19 on 04/11/2023 at 9:00 a.m. revealed she had concerns of staff not bathing her on her scheduled days. Resident #19 stated she was to receive whirlpool baths on Monday, Wednesday, and Friday, but she was not consistently receiving them. Resident #19 stated last month she went 10 days without a bath.
Review of the facility Bath Schedule revealed Resident #19 was scheduled to receive Whirlpool on Mondays, Wednesdays and Friday's at 1:00 p.m.
Review of Resident #19's ADL documentation for previous 30 days revealed Resident #19 did not receive a Whirlpool, or a shower/bed bath on the following scheduled dates: 03/24/2023, 03/27/2023, 03/29/2023, and 03/31/2023.
Interview with S2 DON on 04/12/2023 at 3:12 p.m. revealed Resident #19 was to receive whirlpool baths on Monday, Wednesday, and Friday. S2 DON stated staff are to document when patient is given a bath on the Resident's ADL record. S2 DON stated sometimes staff will document Residents receiving bath on the actual shower schedule, and staff turns that documentation in to S3 ADON. S2 DON reviewed Resident #19's ADL record and confirmed Resident #19 did not have documented baths on 03/24/2023, 03/27/2023, 03/29/2023, and 03/31/2023, but should have. S2 DON confirmed according to Resident #19's whirlpool schedule, Resident #19 had 5 missed scheduled baths, and should not have.
Interview with S3 ADON on 04/12/2023 at 3:15 p.m. revealed there was no shower schedule forms turned in to her between 03/22/2023- 04/3/2023 for Resident #19. S3 ADON confirmed staff did not document or turn in documentation of Resident #19 receiving a bath, but should have.
Interview with S7 CNA on 04/12/2023 at 4:03 p.m. revealed any type of bath given to Resident's should be documented in the Resident's ADL record. S7 CNA stated if staff did not document on the ADL record, they would document on the shower schedule and turn this documentation in to S3 ADON. S7 CNA recalled Resident #19 did miss scheduled whirlpools while she was out last month, but she could not recall the exact dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the Facility failed to ensure a Resident's Person-Centered Plan of Care was reviewed and revised for 1 Resident #46 of 36 sampled Residents. The facility failed to revise Resident #46's care plan to reflect the refusal of ADL's.
Findings:
Observation of Resident #46 on 04/12/2023 at 9:25 a.m. revealed the Resident lying in bed awake and alert. She was dressed in a hospital gown; her teeth were noted with yellow film; her lips were dry/cracking; and her hair was uncombed and dry.
Interview during observation with Resident #46 revealed the Resident was scheduled for a whirlpool bath on Monday, Wednesday and Friday and had not had a bed bath/shower or whirlpool for 2 weeks. Resident #46 stated she was able to brush her teeth but required set-up assistance from the CNAs'.
Interview on 04/12/2023 at 10:20 a.m. with S4 CNA revealed Resident #46 was scheduled for a whirlpool bath on Monday, Wednesday and Friday and often refused to go the whirlpool. S4 CNA stated she reported to the nurse each time that Resident #46 would refuse a whirlpool/shower/bath.
Interview on 04/12/2023 at 10:45 a.m. with S3 ADON revealed Resident #46 would at times, refuse a bath/shower/whirlpool, oral care and grooming. S3 ADON stated Resident #46 signed a refusal for daily shower.
Interview on 04/12/2023 at 11:13 a.m. with S5 LPN revealed she had been employed at the Facility for 2 years and provided care to Resident #46. S5 LPN stated Resident #46 displayed anger and aggression and refused all care at times including ADLs. S5 LPN stated the CNAs would report to her whenever Resident #46 refused care. S5 LPN stated at times she had been able to talk Resident #46 into taking a bath/shower/whirlpool.
Observation on 04/13/2023 at 8:56 a.m. revealed Resident #46 lying in bed dressed in a hospital gown with yellow film on teeth and hair uncombed and dry.
Interview on 04/13/2023 at 8:56 a.m. with Resident #46 revealed on 04/12/2023, the Resident was offered a whirlpool and refused. Resident #46 stated after speaking to S5 LPN, the Resident agreed to a bed bath. Resident #46 stated S5 LPN sent a CNA to give her a bed bath.
Review of a document in Resident #46's clinical record revealed a refusal of daily showering signed/dated 01/25/2023 by Resident #46. The form was witness by S1 Administrator, S2 DON, S3 ADON, S6 Dietary Manager, Social Service Director, Activity Director and, MSD Coordinators.
Review of the bath schedule reviewed from 03/01/2023 - 04/10/2023, revealed Resident #46 was scheduled for and refused a whirlpool bath on 03/26/2023 but had a bed bath on 03/27/2023; refused on 03/28/2023 but received a whirlpool bath on 03/29/2023; refused on 03/31/2023; shower 04/03/2023, and 04/05/2023; and refused on 04/07/2023.
A review of Resident #46's EHR revealed she was readmitted to the facility on [DATE] with diagnoses that included in part . Type 2 Diabetes Mellitus, Major Depressive Disorder, and Anxiety Disorder.
Review of Resident #46's Annual MDS with an ARD of 02/17/2023 revealed Resident #46 had a BIMS of 15 (cognitively intact). Resident #46 required extensive two persons physical assist for transfers and dressing, extensive one person assist with bed mobility, locomotion on/off unit, personal hygiene, total one person physical assist with toilet use, and supervision eating with set-up help. Resident use a wheelchair and has no upper/lower extremity impairment.
Review of Resident #46's Care Plan with target date of 05/18/2023 revealed Resident #46 had a self-care deficit as related to ADL's. Interventions listed in part included extensive assistance one person with bath of choice three times/week bathing/showering, dressing, personal hygiene, extensive one person assist with transfers and one-two persons extensive assist with toilet use.
Resident #46's Care Plan revealed no documentation that Resident was care planned for refusal of ADL care.
Interview on 04/13/2023 at 9:45 a.m. with S3 ADON after reviewing Resident #46's Care Plan, confirmed the Care Plan did not address the refusal of ADL's and should have.