Calhoun Convalescent Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interview, the facility failed to ensure that Resident (R)1 received appropriate supervision to prevent a successful elopement from the facility on 03/22/26.On 03/30/26 at 2:37 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 03/30/26 at 2:37 PM the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/22/26. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision/Devices. On 03/30/26 at 4:07 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth due diligence in identifying and addressing the non-compliance. The SA is considering this at Past Non-Compliance as of 03/24/26. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include:Review of the facility's policy titled, Elopement revised on 11/01/2017, revealed, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident . Procedures: 1. Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead ______ (insert code name). 2. The DON/designee completes a missing resident profile . 4. The entire search process of the facility and grounds, from the time the patient/resident is missing, will be completed within (30) thirty minutes.Review of R1's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to, dementia, unspecified severity, muscle weakness (generalized), unsteadiness on feet, other abnormities of gait and mobility.Review R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/25, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating R1 suffered from severe cognitive impairment. Further review of the MDS, revealed R1 had no impairments of the upper or lower extremities, at risk for falls, and need partial/moderate assistance for sit to stand mobility, to walk 10 feet and walking 50 feet with two turns as not attempted due to medical condition or safety concerns.Review of R1's Progress Notes dated 03/24/2026 at 9:33 PM, revealed, Resident seen today for follow-up after recent elopement event. Since last evaluation, the patient remains ambulatory with good strength and endurance and continues to exhibit impaired judgment and poor safety awareness in the setting of vascular dementia. Nursing reports ongoing need for close supervision due to continued exit-seeking behaviors. No new elopement episodes reported since implementation of 1:1 supervision. The patient remains pleasantly confused at baseline and is unable to reliably provide history.Review of R1's Care Plan with a problem start date of 10/17/2025, under the category behavioral symptoms, revealed, R1 wanders through out the facility, is a risk for 1. Elopement and has had a recent elopement 2. Increased fall risk.Review of R1's Nursing- Elopement Risk Observation dated 03/20/26, indicated, Does the patient/resident have safe decision-making capabilities? This question is answered as No.Review of R1's PATIENT/RESIDENT INCIDENT/ACCIDENT INVESTIGATION WORKSHEET revealed under NOTIFICATIONS AND TREATMENTS: Transferred to Hospital or emergency room by police. DESCRIBE EXACTLY WHAT HAPPENED: Elopement from facility. Please see timeline/summary.Timeline/Summary of events/incident:5:30-5:40pm: Resident observed by staff in safe environment at ambulating in facility which is baseline in behavior.5:40-6:00pm: Alarm sounded at fire exit near dietary department. re-engaged alarm and returned to kitchen.5:50-6:05pm: [R1's] CNA noticed he wasn't in his room to receive his dinner tray and started to look for him. Census head count initiated.6:08-6:39pm: Employee that was leaving work in his car thought he saw the resident near the Dollar General store. The staff member called the workplace and informed staff he thought he saw [R1]. Staff in facility started a search for the resident.A nurse went to Dollar General in her car to retrieve the resident but he was not at the store when she arrived.Dollar General apparently notified police.Police called facility and validated we were missing a resident. They noted him walking on the corner of [NAME] and Mills. Police stated they would take the resident to the Emergency Department to be checked out.During this process the Administrator and DON (Director of Nursing) were informed.Census headcount completed with all residents except for [R1] account for.6:39pm: Administrator notified Clinical Services Director of incident.6:39pm: Administrator notified Clinical Services Director of incident.6:42pm: SVP notified of incident by CSD.1:1 education completed with identified dietary employee.Re-education started for staff in the facility.Review of the local police department incident report with a dispatched date of 03/22/2026, revealed the following:INCIDENT TYPE. 1. 901 - RUNAWAYDISP DATE: 03/22/2026 DISP. TIME 1821 TIME ARRIVED 1825DATE/TIME OF OFFENSE 03/22/2026. 1821Offenses: RUNAWAYON 03/22/2026, OFFICERS WERE DISPATCHED OUT IN REFERENCE TO LOCATE A SUSPICIOUS PERSON WALKING WITH A HOSPITAL BRACELET ON. OFFICERS CONDUCTED AN AREA SEARCH AND LOCATED THE SUBJECT ON FR [NAME]/ MILL ST. THE SUBJECT APPEA [sic] TO BE IN A DELIRIOUS STATE, DISORIENTED, AND UNABLE TO PROVIDE COHERENT RESPONSES. DUE TO THE SUBJECT'S CONDITIO [sic] EMS WAS REQUESTED TO THE SCENE. EMS ARRIVED AND ASSESSED THE SUBJECT. BASED ON THEIR EVALUATION, THE SUBJECT V [sic] TRANSPORTED TO MUSC ORANGEBURG HOSPITAL FOR FURTHER MEDICAL TREATMENT. DISPATCH WAS CONTACTED BY HOSPITAL PERSONNEL FOR CONFIRMATION OF RESIDENCY. OFFICERS WERE DISPATCHED TO 601 [NAME] ST ([NAME] CONVALESCENT CENTER) TO CONFIRM IF THEY HOUSED A PATIENT BY THE NAME OF [R1]. ONCE CONFIRMED THE FACILITY WAS INFORMED TO CONTACT HOSPITAL PERSONNEL. NO FURTHER INCIDENTS WERE REPORTED AT THIS TIME.During an interview on 03/30/26 at 9:25 AM, R1 revealed that he did not recall exiting the building.During an interview on 03/30/26 at 9:25 AM, Certified Nursing Assistant (CNA)1 revealed that she was assigned for 1:1 care for the resident for the day. CNA1 states that this was her first day working with the resident in this capacity, however she could not confirm how long the resident had been on 1:1 care.During a follow up interview on 03/30/26 at 10:05 AM, CNA1 explained that R1 was on 1:1 care because he had got out of the building.During an interview on 03/30/26 at 10:10 AM, CNA2 revealed that she completed her orientation with the facility on March 17, 2026. CNA2 stated that she had not received any in-service training related to elopements and today was her first time hearing about R1 exiting the building.During an interview on 03/30/26 at 11:15 AM, the [NAME] stated that on the day of the incident, between 5:00 PM and 6:00 PM, the dietary staff heard the alarm of the dining room door going off. Dietary Aide (DA)1 was sent to check the alarm and reported that he looked and did not see anyone. He then shut the alarm off and returned to the kitchen. The [NAME] stated that staff were unaware how long the alarm had been going off before they heard it, as it is difficult to hear in the kitchen.During an interview on 03/30/26 at 11:52 AM, Licensed Practical Nurse (LPN)1 stated that R1 was on thirty-minute checks due to prior wandering behaviors. She reported that R1 was in bed most of the day until about 5:00 PM, when a Certified Nursing Assistant took him to get a shower. Around 5:25 PM-5:30 PM, she last had eyes on R1 and assumed he was doing his usual laps around the facility. LPN1 further stated that around 5:45 PM, after staff noticed that R1 had not received his dinner tray and had not been seen in the halls, a search was initiated and all areas of the building were checked. Shortly after, someone called the facility to report that they thought they had seen R1 down the street at the Dollar General. She then left the facility in her car to go locate R1 but did not see him, and within 10 minutes of her arrival back at the facility, staff were notified that R1 had been picked up by the local police department near the initial sighting at Dollar General and was subsequently taken to the emergency room. LPN1 was unable to state how R1 eloped from the building but noted he was found with his wander guard still in place.During an interview on 03/30/26 at 12:09 PM, the Facility Administrator (FA) stated that on the day of the incident, the alarm to the dining room door was going off. Staff responded, did not see anyone, disarmed the alarm, and returned to work. The FA stated that between 5:50 PM and 5:55 PM, staff noticed R1 was missing and went to look for him. R1 was not located in his room or hallway. Around 6:10 PM-6:15 PM, while heading home, a staff member reported that they thought they saw R1 around Dollar General. LPN1 then left the facility in her car to go locate R1; however, when she arrived at Dollar General, R1 was not there. R1 was later located by the local police department and sent to the emergency room for evaluation. The FA reported that R1 was wearing his wander guard when he was found.During an interview on 03/30/26 at 12:29 PM, the Director of Nursing (DON) stated that she was not working the day R1 eloped. She noted that LPN1 called and informed her that she was headed to Dollar General to locate R1, after someone called to report seeing him there. While still on the phone, LPN1 stated that R1 was not there. The DON then instructed LPN1 to return to the facility. She reported that R1 may have exited through the dining room door, which alarms if pushed and opens after 15 seconds. She stated that staff were unable to tell how long the alarm was going off before hearing it. When they responded, they looked outside, did not see anything, and entered the code to shut the alarm off. The DON stated that R1 was last seen between 5:15 PM and 5:30 PM. In the weeks leading up to the incident, R1 had to be redirected and displayed wandering behaviors. She noted that all doors were checked and were working without issue. The resident was later found by the local police department.During an interview on 03/30/26 at 12:43 PM, DA1 reported that R1 was last seen around 5:25 PM - 5:30 PM. They later learned from nursing staff that R1 was missing and noted that Dollar General is about a 3.5 minute drive away from the facility.During an observation and interview on 03/30/26 at 1:23 PM, the Maintenance Director and the FA, they stated that all doors in the facility were working properly and sounded alarms. The Maintenance Director noted that when a door is opened, it sounds immediately, and a panel at each nurse station lights up showing which door is open. Then, after 15 seconds, the door will open. He demonstrated on the front door and dining room door, holding each door for 15 seconds, and the alarm sounded. The alarm was heard at the nurse stations, and the panel lit up showing the corresponding door. Multiple staff noted the alarm sounding in the halls with no response. The FA stated that staff are to respond to the alarm until the all clear is given.On 03/30/26 at 4:07 PM, the facility provided an acceptable IJ Removal Plan, which included the following:Resident #1 evaluated at emergency room on 3/22/26. No injuries indicated. Resident #1 returned on 3/22/26 and 1:1 supervision initiated and continues.Each Exit door was assessed to validate doors were working properly on 3/23/26 by the Maintenance Staff.Upon Resident return, Elopement Risk Assessment Updated to reflect current status by Licensed Nurse. Care Plan and resident profile updated on 3/22/26 by Licensed Nurse.An elopement drill was completed on 3/23/26 that included:The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill ProcedureThe Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutesIf the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying informationThe Search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radiusWhen the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress.The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative.The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrencesWhen the missing resident is found, an announcement will be made, Code [NAME] all clear.Residents residing in the facility had an Elopement Risk Assessments updated by 3/24/26 by Director of Nursing/Designee. Residents identified as elopement risk were placed in the elopement binder and had care plans and profiles updated by Director of Nursing/Designee on 3/24/26Facility Staff were reeducated by the Director of Nursing/Designee on Elopement Policy, including immediate staff response to the door alarm to verify if resident exited facility, and Abuse, Neglect & Misappropriation Policy by 3/24/26Any staff not receiving this education by 3/24/26 will receive prior to their next scheduled shift.New admission elopement risk assessments are being reviewed in Clinical Morning Meeting Monday - Friday by the Director of Nursing/Designee to validate accuracy and interventions validated if indicated. Quarterly Elopement risk assessments will be reviewed weekly following the MDS schedule to validate accuracy and interventions validated if indicated by the Director of Nursing/Designee.The Maintenance Director/Designee will inspect facility exit doors 3 times weekly for 4 weeks, then weekly for 2 additional months to validate doors are functioning properly.The Administrator will round weekly for 4 weeks then monthly for 2 additional months with the maintenance director validating doors are functioning properly.Ad Hoc QACPI was held on 3/25/26Medical Director was notified of the incident and plan on 3/23/26 and 3/30/26Results of these audits will be presented in the Quality Assurance and Performance Improvement Committee meeting for review and recommendations for 3 months.AOC date: 3/24/26

Based on observation, interview, and record review, the facility failed to ensure Resident (R)7 and R37 were offered and/or assisted with hand hygiene prior to meal service for 2 of 2 residents observed during meal service. Findings include: Review of the facility's policy titled Infection Prevention and Control Policies and Procedures Subject: Hand Hygiene/Handwashing, indicated under the Procedures section that hand hygiene/handwashing is to be performed before eating and before preparing, distributing, handling, or serving food.Review of R7's electronic medical record (EMR) revealed R7 had an admission date of 08/12/25, with diagnoses including but not limited to, vascular dementia, muscle weakness, schizophrenia, bipolar disorder and dysphagia oropharyngeal phase.Review of R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/26, revealed R7 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicates R7 was severely cognitively impaired. Further review of the MDS revealed R7 requires setup or clean-up assistance with eating.Review of R37's EMR revealed R37 had an admission date of 01/14/28, with diagnoses including but not limited to, polyarthritis, hypertensive heart disease with heart failure and muscle weakness.Review of 37's MDS with an ARD of 01/21/26, revealed R37 had a BIMS score of 15 out of 15, which indicates R37 was cognitively intact.During a dining observation on 02/24/26 at 8:30 AM, R7 was not offered hand hygiene before their breakfast was served by Certified Nurse Aide (CNA)1. During a dining observation on 02/24/26 at 8:44AM, R37 was not offered hand hygiene before their breakfast was served by CNA1.During a dining observation on 02/24/26 at 12:26 PM, R7 was not offered hand hygiene before their lunch was served by CNA3. During a dining observation on 02/24/26 at 12:36 PM, R37 was not offered hand hygiene before their lunch was served by CNA2. During an interview on 02/24/26 at 11:00 AM, (R)7, when ask did the aide offer her to clean her hands before she ate breakfast, she shook her head yes.During an interview on 02/24/26 at approximately 12:40 PM, (R)37, when asked did the aide offer her hand hygiene before her lunch was served, she stated No, not today.During an interview on 02/24/26 at approximately 12:43 PM, (R)37's Representative, her son, started he is at the facility every day between 9:15 AM and 3:00 PM, and no one ever offers his mother hand hygiene before her meals.During an interview on 02/24/26 at 1:03 PM, CNA1 revealed she has worked at the facility for almost 2 years. She stated it's procedure and policy to clean resident hands before serving meals. She confirmed that she did not offer hand hygiene today to the residents as she forgot too.During an interview on 02/24/26 at approximately 1:10 PM, CNA2 revealed she has worked at the facility for almost 4 years. She stated it's procedure and policy to clean resident hands before serving meals. She stated R37 usually cleans her hands herself. When asked with what, she stated she has hand sanitizer. When asked did R37 clean them today, she stated No.During an interview on 02/24/26 at approximately 1:42 PM, CNA3 revealed she is unsure of the procedure and policy regarding hand hygiene before serving meals. When asked how she knows any procedures and policy when working at the facility, she revealed that staff will tell her. CNA3 confirmed that she did not offer hand hygiene to any of the residents that she served meals to today.During interview on 02/24/26 at 1:48 PM, the Administratar revealed that she would love staff to offer hand hygiene to each resident before meals. She would like them to have warm clean cloth, and at the very least hand sanitizer. She stated it is her expectation to offer hand hygiene to residents before serving meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interview, the facility failed to update the Care Plan for Resident (R)2, who changed from a Full Code status to a Do Not Resuscitate (DNR) status, for 1 of 1 resident reviewed for Hospice care and services. Specifically, R92 changed from a Full Code status to a DNR status on 11/24/25, and her Care Plan was not updated to reflect this change until 02/24/26. Findings include:Review of the facility policy titled Person-Centered Care Plan with a revision date of 06/09/23, revealed, . Procedures: . 3. The person-centered care plan is interdisciplinary and created to guide facility staff in providing treatment, care, and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care.Review of R92's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, chronic kidney disease, Type 2 diabetes mellitus, heart disease, congestive heart failure, chronic pain syndrome, chronic obstructive pulmonary disease, anxiety disorder, and schizoaffective disorder.Review of R92's Orders revealed an order for Code Status: Do Not Resuscitate dated 11/24/25. Review of R92's Care Plan on 02/22/26 revealed, Problem: [R92] is currently a Full Cardio-Pulmonary Resuscitation-Full Code . The Goal revealed, [R92] will be informed of her right to complete advanced directives to direct her medical care and make her values and treatment goals know. [R92] stated desires through the next review period will be honored . The Approach directed staff to, [R92] has completed the following advanced directives and copies are in the medical record: Full Code. The problem and goal start dates were 03/12/25. The problem and goal were both edited on 02/20/26 with no changes. The approach was started and last edited on 03/17/25. During an interview on 02/24/26 at 2:30 PM, the Social Services (SS) Director revealed, When someone changes their advanced directives, either me or the Nurse Assessment Coordinator (NAC) will change the Care Plan. We usually learn about it in the Clinical Meeting as a change in condition. I've already changed her Care Plan today to show she is a DNR.During an interview on 02/24/26 at approximately 3:45 PM, the Director of Nursing (DON) revealed, Our NAC nurse left in December, so we had a gap of having no NAC nurse. I only started in this position officially in December.During an interview on 02/24/26 at approximately 4:15 PM, the Administrator revealed, Our NAC nurse was out the first few weeks of January. The care plan not being changed when [R92] changed to a DNR status was probably due to this. Our NAC nurse was out from 01/09/26 through 01/26/26, and she resigned on 01/27/26.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interview, the facility failed to perform Abnormal Involuntary Movement Scale (AIMS) assessments every three months as ordered by the provider for 3 out of 3 residents reviewed for psychotropic medications (Resident (R)41, R92, R97). This failure to complete AIMS assessments as ordered put residents at risk for harm due to the potential of adverse effects from psychotropic medications not being recognized in a timely manner. Findings include:Review of the facility policy titled Medication Management with a revision date of 04/17/25, revealed, . 9. The facility will monitor and document the resident's response to psychotropic medication for efficacy and adverse consequences. Monitoring will include: . F. AIMS (Abnormal Involuntary Movement Scale) testing should be completed as a baseline on admission or re-admission with an enduring antipsychotic medication, on initiation of an anti-psychotic medication, and at least every six months and with dosage changes.1. Review of R41's Face Sheet revealed he was admitted to the facility most recently on 03/31/25, with diagnoses including, but not limited to, severe bipolar disorder with psychotic features, major depressive disorder, generalized anxiety disorder, and dementia. Review of R41's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/26, revealed he had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he had no cognitive deficits. R41 showed no indicators of hallucinations or delusions and exhibited no behavioral symptoms towards himself or others. His medications included antipsychotic medication. Review of R41's Care Plan revealed, [R41] is currently taking an antipsychotic r/t bipolar disorder, unspecified . The goal revealed, [R41] will receive therapeutic treatment from medication with no complications through next review. Interventions directed staff to, Licensed nurse will monitor for adverse side effects and report to physician.Review of R41's Orders revealed he was prescribed Aripiprazole 30 mg every night at bedtime. On 06/20/25, R41 had an order for an AIMS assessment to be completed every three months on the 22nd of March, June, September, and December. Review of R41's Observation History from 01/24/25 - 02/23/26, revealed an AIMS assessment was completed on 03/31/25, 12/12/25, and 01/26/26. No AIMS assessment was found for the months of 06/2025 and 09/2025, as ordered. 2. Review of R92's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, borderline personality disorder, anxiety disorder, and schizoaffective disorder. Review of R92's Annual MDS with an ARD of 02/17/26, revealed she had a BIMS score of 15 out of 15, indicating she had no cognitive deficits. R92 had no indicators of hallucinations or delusions and exhibited no behavioral symptoms towards herself or others. Her medications included antipsychotic medication. Review of R92's Care Plan revealed, [R92] is at risk for adverse consequences r/t receiving psychotropic medication for treatment of anxiety/schizoaffective disorder, bipolar. This problem was identified on 02/20/26. The goal revealed, [92R] will not exhibit sign of drug related side effects or adverse drug reactions during review period. Interventions directed staff to, Assess if the resident's behavioral symptoms present a danger to the resident and/or others. and Pharmacy consultant review. The care plan also revealed, [R92] . is having mood and behavior needs as evidenced by periods of (being) physically aggressive. This problem was identified on 03/17/25. The goal revealed, [R92] will have a reduction in unwanted mood or behaviors. Interventions directed staff to, Give medications as ordered. Monitor for side effects and effectiveness. Notify physician of changes or concerns.Review of R92's Orders revealed she was prescribed Saphris (asenapine maleate) 10 mg under her tongue twice a day. On 03/20/25, she had an order to have an AIMS assessment completed every three months on the 20th day in March, June, September, and December. Review of R92's Observation History from 01/24/25 - 02/23/26, revealed an AIMS assessment was completed on 10/19/25. No other AIMS assessments were found. 3. Review of R97's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to, schizoaffective disorder, pseudobulbar affect, depressive episodes, generalized anxiety disorder, and vascular dementia. Review of R97's Annual MDS with an ARD of 11/22/25, revealed R97 had a BIMS score of 06 out of 15, indicating he had severe cognitive impairment. R97 showed no indicators of hallucinations or delusions and exhibited no behavioral symptoms towards himself or others. His medications included antipsychotic medication.Review of R97's Care Plan revealed, [R97] . is having mood and behavior needs. The goal revealed, [R97] will have a reduction in unwanted mood or behaviors, for an increased quality of life as evidenced by documentation in the medication record. Interventions directed staff to, Give medications as ordered. Monitor for side effects and effectiveness. Notify physician of changes or concerns. The Care Plan also revealed, [R97] is at risk for medication side effects r/t psychotropic drug use. The goal revealed, [R97] will not have any side effects from medication through next review. Interventions directed staff to, Monitor for side effects and report to MD.Review of R97's Orders revealed he was prescribed haloperidol 5 mg once every evening and haloperidol decanoate solution 100 mg/ml 1 ml injected into the muscle every 28 days. On 04/04/24, R97 had an order to have an AIMS assessment completed every three months on the 2nd day in January, April, June, and October. Review of R97's Observation History from 01/25/25 - 02/24/26, revealed an AIMS assessment was completed on 04/02/25, 07/02/25, 12/12/25, and 01/02/26. No AIMS assessment was found for June or October as ordered. During an interview with the Director of Nursing (DON) on 02/23/26 at 3:35 PM, she revealed while looking for the missing AIMS assessments for R92, We are looking for them. I only see the one you saw from October. I just completed the one that needed to be done in January. I'm giving you a copy of it with the October one.During a second interview with the DON on 02/24/26 at approximately 3:45 PM, she revealed, Our MDS nurse keeps the schedule of the AIMS assessments. She will notify me and the Unit Manager in our morning meetings which ones need to be completed. Either me, the Unit Manager, or the nurse taking care of the Resident will complete it. I was surprised our policy says, at least every six months. I am used to them being completed every three months. Since I am relatively new, I can only speak for what has happened since then. Since October, I have been trying to get the schedule for the AIMS assessments back on track. My expectation is they are completed as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) for 1 of 1 resident reviewed for Hospice care and services. Specifically, R92 began receiving Hospice care on 01/09/26, and a Significant Change MDS assessment was not completed as required. This failure had the potential for harm due to the Resident not being comprehensively assessed at the time of the significant change in her status. Findings include:Review of the facility policy titled Significant Change with a revision date of 05/05/23, revealed, Policy: 1. The nursing staff, as well as the interdisciplinary team, will evaluate the patient's/resident's change in status in accordance with the established guidelines from the Resident Assessment Instrument (RAI). Procedures: 4. All residents that are referred to Hospice need to have a Significant Change MDS completed.Review of the facility policy titled Minimum Data Set (MDS) with a revision date of 09/28/23, revealed, . 10. Each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified RAI process . A significant change is required when: A. A resident enrolls in a hospice program.Review of the facility policy title Hospice Care with a revision date of 05/05/23, revealed, . 5. The facility will complete an OBRA MDS SCSA and schedule an interdisciplinary care plan meeting for the facility team, hospice provider, and the resident and/or resident's family .Review of R92's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, chronic kidney disease, Type 2 diabetes mellitus, heart disease, congestive heart failure, chronic pain syndrome, chronic obstructive pulmonary disease, anxiety disorder, and schizoaffective disorder.Review of R92's Orders revealed R92 was admitted to Gentiva Hospice on 01/09/26.Review of R92's MDS Assessments revealed a Quarterly MDS was completed on 11/17/26, and an Annual MDS was completed on 02/17/26. No Significant Change MDS assessment was listed as having been completed in 01/2026 in response to R92's election for Hospice care and services. Review of R92's Comprehensive MDS with an Assessment Reference Date (ARD) of 02/17/26, revealed R92 was receiving Hospice care at the time of that assessment.During an interview on 02/24/26 at 10:15 AM, the Regional MDS Coordinator revealed, We usually learn about significant changes in the morning meeting. We will also pull orders in the morning to make sure we don't miss anything. A Significant Change MDS should have been done for [R92] when she was put into Hospice. There's no doubt about that. It should have been done. Usually, we have two Nurse Assessment Coordinators (NACs), but we were down to only one. Then, in early January, she just left. We just hired a new one two weeks ago.During an interview on 02/24/26 at 2:30 PM, the Social Services (SS) Director revealed, When a provider feels a Resident is appropriate for Hospice, I will call the family to discuss it with them and give them the names of the Hospice agencies we are contracted with for them to choose the Hospice provider. In [R92's] case, they chose Gentiva. I will then send the Resident's information to the Hospice provider. They will come and do an evaluation, and if the Resident is accepted, they will send me the Medicaid Election Form. I believe she was referred for Hospice because of her severe kidney disease for which she refused treatment.During an interview on 02/24/26 at approximately 3:45 PM, the Director of Nursing (DON) revealed, Our NAC nurse left in December, so we had a gap of having no NAC nurse. That is probably why the Significant Change MDS assessment wasn't done. I only started in this position officially in December.During an interview on 02/24/26 at approximately 4:15 PM, the Administrator revealed, Our NAC nurse was out the first few weeks of January. It is not normal for us to miss a Significant Change MDS. Our NAC nurse was out from 01/09/26 through 01/26/26, and she resigned on 01/27/26.

Based on review of facility policy, observation and interview, the facility failed to ensure unlabeled, outdated and expired medications were removed from 4 of 4 medication carts, and not stored with the current medications in use for residents.Findings include: Review of the facility policy titled, General Guidelines for Storage of Medication and Biologicals, states, 1. Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Procedures: . 5. Medications with manufacturer's expiration date expressed in month and year will expire on the last day of the month. (Unless a sooner expiration date has been placed on the package by the pharmacy). 10. Facility shall ensure that medications and biologicals are stored at the appropriate temperature, light, humidity according to manufacturer specifications and/or the United States Pharmacopeia, or WHO standards for safe storage and handling of medications, to preserve their integrity. 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. During an observation on 02/23/2026 at 2:45 PM, of Medication Cart A on the North Hall revealed the following: A house stock bottle of the medication, Zinc 50 milligrams, with Lot# 865X02, approximately 100 tabs, were expired on 01/2026 and still stored on the medication cart. One pen of Soliqua Insulin 100/33 with Lot# 5F701A in use with no open and no expiration date, the pen had a label that stated, If no open and expiration date, discard the insulin after 10 days. At this time the medications were confirmed by Registered Nurse (RN)1 and removed from the med cart. During an observation on 02/23/2026 at 2:50 PM, of Medication Cart C on the North Hall revealed, One Kwik Pen of Humulin 70/30 Insulin with Lot# 877490C in use with no open date and no expiration date, the pen had a label that stated, Discard after 10 days if no date is noted on the pen. The medication with no dates was confirmed by Licensed Practical Nurse (LPN)1 and removed from the cart. During an observation on 02/23/2026 at 3:15 PM, of Medication Cart D revealed, Two Kwik Pens of Novolog Insulin with Lot #RZF05L6 in use with no open date and no expiration date. The insulin pens with no open date and no expiration date were confirmed by LPN3 and removed from the medication cart. During an observation on 02/23/2026 at 3:35 PM, of the Medication Cart F revealed, One bottle of B Complex with Lot #205801,100 tablets, was expired on 01/2026. The bottle of expired B Complex tablets was confirmed by LPN4 and removed from the medication cart.

Based on review of facility policy and interviews, the facility failed to ensure resident's received their mail in a timely manner and unopened. This deficient practice had the potential to effect all residents in the facility that received mail. Findings include: Review of the undated facility policy titled Mail Distribution documented, To ensure that each patient's/resident's personal mail (incoming and outgoing) is handled in a private and confidential manner. It is the Facility's policy to: 1. Distribute all incoming mail to the addressed patient/resident unopened and within the same day on which it was delivered to the Activity Department. Procedures: 1. The Activity Staff or Designated Staff or Volunteer will: A. Deliver personal mail to the patient's/resident's room within 24 hours of receipt. B. Deliver all mail unopened, unless otherwise directed by the patient/resident or his/her qualified legal representative. The resident's care plan will include an approach related to staff assisting a resident to open mail if it occurs on a regular basis. C. Provide the patient/resident with privacy while opening/reviewing the mail, unless otherwise requested by the patient/resident or his/her qualified legal representative. D. Ask the patient/resident for his/her preference on where to place his/her mail. Review of the Resident Rights documented, The facility protects and promotes the rights of each resident in our care . 1. Basic Rights, each resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. The facility must provide equal access to quality care regardless of diagnosis, severity of condition or payment source . 14. Privacy in Communications. The resident has the right to privacy in written communications and other materials delivered to the facility for the resident through a means other than a postal service, including the right to send and promptly receive mail unopened and the right to have access to stationery, postage and writing implements at the resident's own expense. During the Resident Council meeting on 02/23/2026 at 1:40 PM, residents verbalized that their mail is opened and some times their mail is delivered late and not on the date it is delivered to the facility. During an interview with the Activity Assistant on 02/23/2026 at 2:05 PM, she stated that she was instructed by management to open all resident mail and inspect the contents before it is delivered to the residents. The Activity Assistance further stated this practice is in order keep residents safe, because sometimes residents order and receive things they should not have or have access to. The Activity Assistant stated that practice was to keep all residents safe. During an interview on 02/23/2026 at 2:15 PM, the Activity Director stated that she was instructed to open all mail belonging to residents, no matter how big or how small, prior to delivering it to the resident. She stated that letters are also opened before giving it to the residents.During an interview on 02/23/2026 at 3:18 PM, the Business Office Manager stated that she will open a resident's mail if she thinks it is something that she will need to fill out and send back for the resident, or an incoming check that is to pay for the resident's stay in the facility. She also stated that if she opens the mail and it is not pertaining to the resident payment, or a document she needs to fill out on behalf of the resident, she will ensure the resident receives it, even though it is addressed to the resident and has already been opened and reviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review and interview, the facility failed to report allegations of sexual abuse, to the State Agency (SA), involving Resident (R)1, R2 and R3, for 3 of 3 residents reviewed for allegations of sexual abuse.Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment states under, Component V. Reporting Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally, immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including the State Survey and Certification Agency. 2. An analysis is completed to determine what changes are needed, if appropriate, to prevent further occurrences. 3. Complete the Investigation Summary Log, maintained by the Administrator or his/her designee. 4. Employees always have the right to report allegations directly to the state agency for elder abuse prevention.Review of R1's Face Sheet revealed the facility admitted R1 with diagnoses including, but not limited to, cognitive communication deficit and dementia. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated severe cognitive deficits.Review of R2's Face Sheet revealed the facility admitted R2 with diagnoses including, but not limited to, alcohol dependence with alcohol-induced persisting dementia, post traumatic stress disorder, anxiety disorder, major depressive disorder and schizophrenia. Review of a Quarterly MDS dated [DATE] revealed a BIMS was not conducted due to R2 not able to understand and is not understood. Review of R3's Face Sheet revealed the facility admitted R3 with diagnoses including, but not limited to, dementia, transient ischemic attack (TIA) and cerebral infarction, convulsions, adult failure to thrive and cocaine use. Review of a Quarterly MDS with an ARD of 01/15/2026 revealed a BIMS of 6 out of 15 indicating severe cognitive deficits. Review of the progress notes for R1, R2 and R3 did not include any documentation of alleged abuse. The abuse allegations were mentioned in a morning meeting with staff on 02/06/2026, but according to staff some were informed on 02/04/2026 and some on 02/05/2026. The abuse allegations were not reported to the SA within the required 2 hour timeframe. R1 was observed by a Certified Nursing Assistant (CNA) to have her hands in the brief of R2. And it was also alleged that R2 and R3 had sexual intercourse, when R2 was found in the bed of R3. During interviews on 02/11/2026 with the Nutrition Director, the Staff Development Coordinator, Activity Director, the Admissions Director, the Assistant Director of Nursing, Licensed Practical Nurse (LPN)1 and LPN3, all knew of the allegations of abuse. The allegation of sexual abuse was reported to the nurse when it happened but the staff failed to report the allegation to the Abuse Coordinator and the Abuse Coordinator failed to report the allegation of sexual abuse to the SA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to implement Care Plan interventions related to fall prevention for Resident (R)4, for 1 of 2 residents reviewed for falls.Findings include:Review of the facility policy titled, Fall Management with a revision date of 05/05/23 indicated, The facility will identify each patient/resident who is at risk of falls and will plan care and implement interventions to manage falls . (1) The Fall Risk Evaluation assists in identifying the appropriate preventative interventions that will be recorded on the patient/resident's care plan . (5) The care plan reflects individualized interventions that are reassessed and revised as needed. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to dementia, history of falling, diabetes mellitus, hypokalemia, chronic kidney disease, and urinary tract infection.Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/25 revealed R4 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R4 was severely cognitively impaired. Further review of the MDS revealed R4 needed maximum assistance for bed mobility and was dependent on toilet transfers. The MDS also revealed R4 had no falls since admission or prior assessment.Review of R4's Care Plan dated 05/29/2024 with a target completion date of 02/28/2026 revealed the following, Impaired cognitive function related to dx (diagnosis) of dementia, at risk for falls related to my impaired, decreased mobility, History of falls, impaired vision, impaired cognition. Interventions directed staff to, I need a safe environment with: (SPECIFY: even floors free of clutter); Nursing to monitor resident when ambulating in the hall. Encourage the resident to wait for assistance before ambulating. Fall mat at bedside. Please remind me to call for assistance with the call bell prior to transfers and ambulating. Staff education.Review of R4's Fall Incident Report dated 10/19/2025 revealed R4 has a history of falling. The report stated, In October/November 2024, resident had no acute fracture or dislocation. Resident was noted as having femoral hardware. Also noted as osteopenia with moderate tricompartmental osteoarthritic changes and degenerative changes. [R4] is bed bound and requires a Hoyer-Lift and 2- person assist when transferring from bed to wheelchair. [R4's] last fall was October 24, 2024. During an observation on 02/11/2026 at 9:45 AM, R4 was in bed asleep. No fall mats in place per care plan. Residents bed was in the lowest position to the floor. During a 2nd observation on 02/11/2026 at 11:40 AM, R4 was in bed asleep, periodically pulling herself up in the bed using top bedrails. No fall mats in place per care plan. Residents bed was in the lowest position to the floor. During an interview with the Director of Nursing (DON) on 02/11/2026 at 2:32 PM, the DON stated, I just came into this position and all I know is that the care plan and the MDS wasn't updated. We only had one MDS nurse on staff at the time of the incident and she was behind when she started the position. We currently do not have an MDS nurse on staff. The Unit Managers are trying to get all MDS and care plans updated every day. The fall wasn't documented in the care plan. Interventions should have been put in place based on the submitted statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations and interviews, the facility failed to ensure medications and biological were not expired for 2 of 2 units reviewed.
Findings include:
Review of the facility policy titled Medication Storage last revised [DATE] revealed, Policy: Medications and biologicals are stored safely, securely and properly following manufacturers recommendations or those of the supplier. Once any medication or biological package is opened, the facility should follow manufacturers guidelines with respect to expiration date of opened medications.
An observation and interview on [DATE] at 9:25 AM of the medication room East Wing with Licensed Practical Nurse (LPN) 4 revealed the following: One unopened bottle of Pink Bismuth Regular Strength 8 fluid ounces with an expiration date of 12/24, one Laboratory Vacutainer blue top with an expiration date of [DATE], two insulin Novolog pens with an expiration date of [DATE] and Lot number MZF3X25 and two boxes of Blood Culture Collection Kits with an expiration date of [DATE] all confirmed by LPN 4.
An observation on [DATE] at 9:40 AM in the Central Supply Room, revealed the following: One box of 12 Tegaderm Dressings with an expiration date of [DATE] lot number (#) 33C893, confirmed by LPN 5 as expired.
During an interview on [DATE] at 9:43 AM, the Central Supply personnel stated, There should not be any expired items in here, I should be checking them, and I try to but don't have the time.
An observation and interview on [DATE] at 9:45 AM of the North Unit Treatment Cart revealed, one unopened Blood Culture Kit with an expiration date of [DATE], LPN 5 confirmed it was expired and said she was going to throw it away.
During an interview on [DATE] at 10:52 AM, the Director of Nursing (DON) stated, Insulin pens are stored in the fridge until open. The wound supplies should be current, not expired. There should not be expired meds in the med room or med room refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure that a medication was administered according to physician orders for 1 of 2 residents reviewed for tube feeding. Resident (R) 85 was admitted to the facility on [DATE] with diagnoses including, but not limited to severe intellectual disabilities, gastrostomy, schizophrenia and anxiety,
The facility policy on Physician Orders, revised May 5, 2023, states The qualified nurse will obtain and transcribe orders according to Facility Practice Guidelines, .PRN (as needed) medications: Transcribe or electronically enter all PRN Medication/Treatment Orders to properly identified area of MAR (medication administration record).
Findings:
On 3/24/25 at approximately 3:30 PM, a review of R 85's medical record revealed the following, dated 3/21/25, in the progress notes Res (resident) could be heard yelling out/screaming in the hallway and at the nursing station several times thus far in shift. Several interventions attempted; None effective. Res calms down when nurse consoles at bedside but soon as this nurse walks out room patient behaviors starts back. Res tells his roommate to shut up even though roommate doesn't say anything. Denies any pain or discomfort. NP 1 (Nurse Practitioner) Aware via telephone; Verbal order given for Benadryl 50 mg (milligram) by peg (percutaneous endoscopic gastrostomy tube) every 8 hours prn for 14 days. Med (medication) administered via peg without difficulty flowing. Will re-assess behavior LPN (Licensed Practical Nurse) 3
On 3/24/25 at approximately 4:19 PM, R 85 was yelling and the DON (Director of Nursing) stated that had R 85 had an order for Benadryl 50 mg for agitation.
On 3/24/25 at approximately 5:28 PM, during an interview RN (Registered Nurse) 1 confirmed that R 85 had been yelling, that she had tried to calm him down but had administered no medications for yelling. After reviewing the progress notes, RN 1 confirmed that on 3/21/25 Benadryl 50 mg PRN x 14 days by way of peg tube, a verbal physicians order, taken by LPN 3 did not appear in the EMR (electronic medical record) MAR and that none had been administered.
On 3/24/25 at approximately 5:07 PM, during an interview the DON confirmed her previous statement that there had been a verbal order on 3/21/25 for Benadryl 50 mg PRN. She reviewed the EMR physician orders and MAR and stated that the order had not been entered or administered, then called NP 1 on 03/24/25 at approximately 5:09 PM. NP 1 confirmed over the telephone that she had ordered Benadryl 50 mg PRN x 14 days on 3/21/25 and still wanted the order to be in place. The DON stated this physicians order should have been entered as a medication order in the EMR and administered as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow manufacturer's guidelines to ensure that blood glucose glucometers were sanitized/cleaned properly.
On 03/25/25 at 12:10 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.
On 03/25/25 at 12:15 PM, the Administrator was notified that the facility's failure to have systems in place to monitor for blood glucose glucometers constituted Immediate Jeopardy (IJ) at F880.
On 03/26/25 at 3:00 PM, the facility provided an acceptable IJ Removal Plan. On 03/26/25 at 4:10 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F880 at a lower scope and severity of D.
Findings include:
Record review of facility policy titled Staff Education/Orientation Policies and Procedures Blood Glucose Monitoring last revised 01/12/24 revealed reference facility specific Blood Glucose Monitoring Device manufacturer's recommendations. Clean Glucometers utilizing two-step process with an approved Environmental Protective Agency (EPA) disinfectant wipe which is labeled effective against Tuberculosis (TB), or Hepatitis B Virus (HBV), Hepatitis C (HCV), or Human Immunodeficiency Virus (HIV) to remove any visible contaminants, soil, or other debris. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.
Record review of facility policy Infection Prevention and Control Policies and Procedures Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (EBP), last revised 05/15/23 revealed EBP will be implemented for all residents with the following: infection or colonization with a Multidrug-resistant Organisms (MDRO) when contact precautions due not otherwise apply; wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.
Record review of the Manufacturer's recommendation for the Evencare G2 Meter revealed Cleaning and disinfecting the meter is very important in the prevention of infectious disease. The following products are validated for disinfecting the EVENCARE G2 Meter ., .Medline Micro-Kill Bleach Germicidal Bleach Wipes.
During a medication administration observation on 03/24/2025 at 5:20 PM with Registered Nurse (RN)1. She stated each resident has an individual glucometer. She pulled R86's pouch from the medication cart. The glucometer was not located in the pouch. She checked some of the other pouches and said R168's glucometer was not in his pouch either. She then looked in the drawers of the medication cart and found a glucometer and said this was R86's blood sugar check machine (finger stick blood sugar). She found an Even Care G2 glucometer. It did not have R86's name on it. RN1 said she checked her blood sugar this am. It was 153 at lunch. She wiped the machine with an alcohol prep pad and entered R86's room to perform the blood sugar checks check. She then returned to the medication cart afterward. She cleaned the glucometer with an alcohol prep pad. She returned the pouch back into the medication cart.
Observation on 3/24/25 at 5:50 PM, Licensed Practical Nurse (LPN) 1 was observed placing an Evencare G2 glucometer into a pouch. LPN1 stated she had just finished checking a resident's blood sugar and had cleaned it with an alcohol wipe since all residents have their own glucometer.
During an interview on 3/24/25 at 5:54 PM, LPN2 described how she cleans the Evencare G2 glucometers stating that she uses MicroKill Bleach Wipes even though each resident has their own glucometer.
On 03/24/2025 at 5:55 PM RN1 opened the medication cart. She opened each pouch and pulled the machine from the pouch to verify who had a glucometer. R168 and R67 did not have a glucometer in their pouches. When asked if she performed a blood sugar check on either of these residents, she stated, I had to do a blood sugar checks check earlier on R168, around noon. I used R86's blood sugar checks machine for him. I always clean with an alcohol pad, with each person. His blood sugar was 279.
Record review of R86's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus, binge eating disorder, and morbid obesity.
Record review of R86's quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 02/19/25 revealed a Brief Interview Mental Status (BIMS) score of 15, of 15, indicating she was cognitively intact.
Record review of R168's Face Sheet revealed he was admitted on [DATE] with diagnoses including but not limited to: orthopedic aftercare following surgical amputation.
Record review of R168's MDS admission MDS with an ARD date of 03/18/25 revealed a BIMS score of 15, of 15, indicating he was cognitively intact.
Record review of R168's MAR dated 03/24/25 at 12:30 PM indicated that a blood sugar check was performed, with a result of 279 mg/dL.
Record review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with the diagnoses including but not limited to: type 2 diabetes mellitus with hyperglycemia, hypertension, pain, and schizophrenia.
Record review of R67's quarterly MDS with an ARD of 03/14/25 revealed a BIMS score of 12 of 15 which indicates he is moderately impaired.
Record review of R67's Medication Administration Record (MAR) dated 03/24/25 at 12:00 PM, indicated that a blood sugar check was performed, with a result of 106 mg/dL.
During an interview 03/25/25 at 08:23 AM, the Director of Nursing (DON) said, for glucometer cleaning, wash hands, don gloves. Inspect the glucometer to see it is visibly soiled, wipe with an alcohol pad, then use Environment Protection Agency (EPA) approved germicidal wipes, wash hands, don gloves, place barrier down and place glucometer on it, wet it down, with blue top for 3 minutes. Each patient has their own glucometers, we have extras in the supply room. If they don't have one, we have replacements. She said it is not ok for a nurse to use another resident's glucometer; each resident has their own. In the room, they should transport the glucometer in a cup and or place a barrier down at bedside. Each resident has their own clear pouch. The Unit Manager audits the carts every Monday, making sure each resident has their own glucometer. I made sure we had at least 5 extras in the supply room.
During an interview on 03/25/25 at 10:48 AM RN2 stated, R188 has a wound vac and is not on EBP.
During an interview on 03/25/25 at 11:05 AM, LPN4 stated R86 should be on EBP and should have an order for it. She also confirmed R168 should have EBP signage on his door and an order for it as well.
The facility's removal plan dated 03/26/25 noted the following:
Residents who require blood glucose moitoring will be assessed for signs and symptoms of infection by the licensed nurses on 02/25/2025.
R#188 without negative effects. Resident #168 had EBP implemented on 03/25/2025.
EPA disinfectant wipes were placed in medication carts that store glucometers.
An audit of glucometers was completed by the DON/Designees on 03/25/2025 to validate each resident that requiring blood glucose monitoring has a glucometer available.
A review of current in house residents will be completed by the DON/Designee on 03/25/2025 to identify residents who require EBP which include;
Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions.
Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds.
Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters.
Residents identified as meeting the criteria for EBP will have a signage placed at the door, provider notified and order written, responsible party notified and care plan updated on 03/25/2025.
Licensed nurses will be reeducated with competency validation by the DON on 03/25/2025 on blood glucose monitoring including;
Validating the residents assigned glucometer is used.
Location and availability of additional glucometers.
Using a barrier to place the glucometer on if needed in residents room.
Using a 2 step process with an approved EPA disinfectant wipe to remove any visible contaminants, soil or other debris and using a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.
Validating EPA disinfectant is available on their medication cart at the beginning of their shift.
Licensed nurses will be reeducated by the DON on 03/25/2025 on EBP including criteria that required EBP:
Resident with an infection or colonization with a multi-drug resistant organism not on transmission based precautions.
Resident with wounds, including pressure, diabetic foot, unhealed surgical and venous wounds.
Residents with an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, and peripherally inserted central catheters.
Any licensed nurse not receiving this reeducation validation by 03/25/2025 will receive prior to their next scheduled shift. This will be presented in new hire orientation and in Agency orientation.
The DON will randomly observe 2 licensed nurses for 5 days performing blood glucose monitoring to validate proper procedure including infection control technique and correct glucometer is being utilized.
The DON/Designee will validate each morning for 5 days EPA disinfectant wipes and available on each med cart that stores glucometers.
The DON/Designee will review the facility activity report and 24-hour report in the clinical morning meeting Monday-Friday to identify any resident who require EBP and validate orders are written, provider and responsible party are notified, signage on residents door, PPE is available and care plan updated.
On 03/26/2025 at 4:00 PM the removal plan was accepted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, record review and interviews, the facility failed to ensure a room was clean and sanitary for 1 of 1 Residents (R) 80 reviewed for environment.
Findings include:
Review of the facility policy titled Patient/Resident Room Cleaning/Bathroom Cleaning dated 03/06, revealed, This routine procedure will clean and disinfect patient/resident rooms and bathrooms thereby providing a clean, safe decontaminated environment for our patients/residents. Expected results, patient/resident rooms and bathrooms that are clean, sanitary odor free and safe.
Record review of R80's facesheet revealed R80 was admitted to the facility on [DATE] with diagnosis that include but are not limited to: vascular dementia with anxiety, diabetes mellitus, hypertension and benign prostatic hyperplasia.
Record review of R80's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/25 revealed a Brief Interview of Mental Status (BIMS) of 00, indicating he was non interviewable.
Record review of R80's care plan revealed he has behavioral symptoms of rejection of care, defecating in the room, placing feces in his clothes and placing clothes into the drawers, smearing feces on the wall.
Record review of R80's psychiatry note dated 01/06/25 documented staff have difficulty getting him to shower. Staff denied physical or verbal aggression.
Observation on 03/23/25 at 11:55 AM, revealed a very offensive odor on the unit hall where R80's resides. Upon entering R80's room, observation revealed debris all over the room, along the base board and a strong foul odor. Deep yellow stains were noted on the floor that appear wet and some dry. There was wet toilet tissue throughout the room on the right side of the bed with feces. A yellow wet sign was observed by the door in the hallway.
Observation of R80's room on 03/23/24 at 12:30 PM, revealed, plastic food containers. The room had a very strong offensive odor. Urine all over the right side of the room and up in the corners as well. R80 was observed with gray jogging pants, not pulled up all the way, with holes and one shoe on his left foot. Wet toilet tissue with feces was noted to the right side of the head of the bed. There was debris all along the walls of the room. There was smeared feces on the walls in 2 areas. Gnats were observed flying near his bed and near where the feces were on the floor. The odor permeated out into and down the hallway.
Observation of R80's room on 03/23/24 at 2:00 PM, R80 is noted sitting on his bed with a soiled sheet on his bed with yellow stains. No change noted from previous observation at 12:30 PM.
Interview on 03/23/25 at 2:12 PM, Housekeeper (HK)1 stated, this room is not acceptable. I wouldn't have my family in a room like this. It's terrible. HK1 confirmed the feces and urine throughout the room on the floors. HK1 observed the walls and base boards with debris and said this could not be from 1 day. HK1 said he will clean it.
Interview on 03/23/24 at 2:14 PM, the Director of Housekeeping (DOH), said R80 did this on another hall in another private room. The tiles need to be replaced. He cannot have a roommate because he also had another room with a roommate and this was the problem. She confirmed R80 urinates in the trash and has bowel movements on the floor. He's been this way since he came in. She confirmed the room was very offensive with terrible odor and gnats throughout. She also confirmed he cannot have regular meal trays in his room, he uses disposables.
Interview on 03/23/25 at 2:14 PM, Certified Nursing Assistant (CNA)1 confirmed R80 was her resident and said she'd been in the room. She said she did not walk over to where the feces and urine were all over the right side of the room. She confirmed he always get disposable trays because he will not return the regular dishes and silverware. She said he will try to hit you if you try to help him with getting cleaned up. She confirmed his room had a terrible odor and the odor could be smelled from down the hall.
Interview on 03/24/25 at 10:30 AM the DOH stated, we will do a deep clean of everything in E-2 [R80's room] since he is in the hospital.
Interview on 03/25/25 at 10:07 AM, the Administrator stated, housekeeping should go in, wipe down bedside drawers and table, and we have a deep cleaning schedule. We try to hit all the rooms in that quarter. She tries to get 8-10 rooms some weeks. They sweep, mop, empty the trash, sweep/mop in the bathrooms. R80 goes through these cycles, where he is fixated that someone is going to pick him up to take him home. He will not let anyone near him. He will barricade himself in his room. They ask every day if they can clean his room, give him a shower, dress him. Residents have a right to refuse services. He won't let us clean, defecate and urinate on the floor. When he is escalated, they will serve him his meals in Styrofoam disposable. He is very territorial. He needs a Dementia Unit. We send email referrals out to try to find placement for him. He urinates in the fan. He won't use the bathroom when he's in that cycle. She agreed the room still needed to be cleaned every day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, observation and interviews, the facility failed to ensure residents right to be free from neglect by failing to provide Resident (R)107 Activities of Daily Living (ADL) care in a timely manner. 1 of 3 reviewed for abuse/neglect.
Findings include:
Review of the facility policy titled Leadership Policies and Procedures: Abuse, Neglect, Exploitation, Mistreatment last revised 10/23/19 revealed, The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors such as ignoring the patient/resident's needs requests etc.
Record review of R107's Face Sheet revealed was admitted to the facility on [DATE] with the diagnosis including but not limited to: sepsis, pressure ulcer of sacral region stage 4, muscle weakness, and unsteadiness on feet.
Record review of R107's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/25 revealed that R107 has a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicates that he is cognitively intact. Further review of the admission MDS revealed that R107 is dependent on staff for toileting hygiene, requires substantial/maximal assistance with showers/bathing and upper and lower body dressing.
Record review of R107 Care Plan last revised 01/13/25 revealed, R107 requires up to max/dependent assist with most ADLs at this time with interventions that included mechanical lift with two person staff assistance. Further review revealed, R107 experiences bladder incontinence related to right sided hemiplegia, post status stroke, decreased mobility, need for assistance. Interventions include report signs of Urinary Tract Infection (UTI), keep call light in reach, provide assistance for toileting, provide incontinence care after each incontinent episode.
An observation and interview on 03/24/25 at 12:47 PM with R107 and his Resident Representative (RR) revealed, R107 in bedtime wear and eating his lunch meal. R107 and their RR stated the resident often has to wait until the afternoon before someone assists them with getting dressed due to short staffing.
During an interview on 03/24/25 at 3:42 PM R107 revealed, staff often comes into his room and turns off his call light without providing assistance. R107 continued to state that at times he has waited thirty minutes to an hour for help at times because staff ignore his call light or don't provide him care when he first calls for assistance.
An observation and interview on 03/25/25 at 7:40 AM with R107 revealed him in bed and in need of ADL care. R107 stated I am wet and I waiting for someone to change me, I have been waiting for about 20 - 30 minutes, a staff member came into the room earlier and said that they would help me or get someone to help me and turned my call light off without helping me.
An observation and interview on 03/25/25 at 7:45 AM revealed Certified Nursing Assistant (CNA)5 entering R107's room turning off the resident's call light and exiting shortly after without providing R107 assistance. CNA5 stated they were not assigned to the resident and was going to find the resident's CNA.
An observation on 03/25/25 at 7:55 AM revealed Licensed Practical Nurse (LPN)1 along with CNA4 explaining to CNA5 that they should not turn off the resident's call light without providing assistance. During the observation that staff were having there were no observations of staff attempting to determine which resident needed care.
A follow up observation and interview on 03/25/25 at 8:15 AM with R107 revealed that two staff members had refused him care. R017 put his call light back on at this time and CNA4 entered the resident's room. R107 became frustrated with CNA4 and began yelling that's what the last lady said, and I still haven't been changed. CNA4 explained to R107 that they would be right back to provide him ADL care and turned off the resident's call light.
An observation on 03/25/25 at 8:17 AM CNA4 entered back into R107's room and provided him with ADL care, CNA4 exited the room on 03/25/25 at 8:22 AM.
A follow up interview on 03/25/25 at approximately 8:30 AM revealed that the resident's assigned CNA did not show up to work or called out. LPN1 further stated that all staff are responsible for responding to resident's call lights or requests.
An third observation on 03/25/25 at 12:00 PM revealed R107 in bed in nighttime wear, R107 stated, after they provided him ADL care earlier (8:22 AM), no one had come back to get him dressed in appropriate wear for the day. Resident continued to state that he turned on his call light but was ignored by staff.
Record review of R107 Point of Care History ADLs How did the resident maintain personal hygiene? section revealed the following documentation:
-03/23/25 at 1:49 AM - activity did not occur
-03/24/25 at 1:58 AM and 10:38 PM - total dependence
-03/25/25 at 10:24 PM - total dependence
-03/26/25 at 1:18 AM, 2:55 PM total dependence on 03/26/25 at 7:56 PM -extensive assistance
Record review of R107 Point of Care History ADLs Staff support provided for personal hygiene? section revealed the following documentation:
-03/23/25 - no documentation charted for this date
-03/24/25 at 1:58 AM and 10:30 PM - one-person physical assist
-03/25/25 at 10:24 PM - one-person physical assist
-03/26/25 at 1:18 AM, 2:55 PM, and 7:56 PM - one-person physical assist
Record review of R107's Point of Care History ADLs Type of Bath? section revealed the following documentation:
-03/23/25 - no documentation charted for this date
-03/24/25 - no documentation charted for this date
-03/25/25 - no documentation charted for this date
-03/26/25 at 2:55 PM -partial bed bath
Record review of R107 Point of Care History ADLs What is the resident's level of bladder function? section revealed the following documentation:
-03/23/25 at 1:51 AM - incontinent
-03/24/25 at 1:52 AM and 10:30 PM - incontinent
-03/25/25 at 10:25 PM -incontinent
-03/26/25 at 1:18 AM, 2:55 PM - incontinent; at 7:57 PM - continent
Record review of R107 Point of Care History ADLs What is the resident's level of control with bowel function? revealed the following documentation:
-03/23/25 at 1:51 AM - incontinent
-03/24/25 at 1:52 AM and 10:30 PM - incontinent
-03/25/25 10:25 PM - incontinent
-03/26/25 at 1:18 AM, 2:55 PM, and 7:57 PM - incontinent
An interview on 03/25/25 at 1:25 PM with the Administrator and Director of Nursing (DON) revealed, their expectation is that when a staff member see's a resident call light is on is to answer the call light and complete the resident's request prior to turning off the call light. The Administrator further stated that if the staff member that first see the resident call light is not able to answer the resident's request (CNA answer's call light but the resident requested medication) then the call light should remain on until the appropriate staff person can assist the resident.
An interview on 03/26/25 at 2:16 PM with LPN5 revealed, they were informed of the situation that occurred on 03/25/25 with R107. LPN5 further revealed that staff ignoring the resident's request to be provided with ADL care in a timely manner is considered neglect. LPN5 finally stated, CNA4 was the resident's assigned CNA for 03/25/25 and is now placed on the Do Not Return list for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, observation and interview, the facility failed to revise/implement Care Plan interventions for Resident (R)41 to reflect his need for assistance with dining/feeding after an injury to the residents' dominant hand for 1 of 3 residents reviewed for nutritional care plans.
Findings include:
Review of facility policy titled Social Services Policies and Procedures Person-Centered Care Plan last revised 06/09/23 revealed, The resident has the right to be informed of and participate in the development of a baseline and or comprehensive care plan for each patient/resident. Care plans include baseline care plan developed and initiated within 48 hours of admission; comprehensive care plan developed after completion of the discipline-specific assessment and within (1) week after completion of the Minimum Data Set (MDS); will be reviewed and updated as needs are identified and after each MDS assessment (excluding discharge). The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care, and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care.
Record review of R41's Face Sheet revealed he was admitted to the facility on [DATE] with the diagnosis including but not limited to nontraumatic ischemic infarction of muscle left hand, legal blindness, end stage renal disease, and mild cognitive impairment of uncertain or unknown etiology.
Record review of R41's Annual MDS with and an Assessment Reference Date (ARD) of 02/16/25 revealed that R41 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates that he is cognitively intact. Further review of the Annual MDS revealed that during this period R41 required set up or clean up assistance with meals.
Record review of a Nurses Note dated 01/03/25 at 9:26 AM revealed Noted swelling to left and band-aid on left middle finger. R107 states had a hangnail that he bit off, and it's been hurting ever since. Band-aid removed, noted swelling to left middle finger, nailbed pale bluish white with small amount of dried blood present. Complaints of discomfort while making a fist, Medical Director present and check R41 hand, new order received for Bactrim two times a day after meals for seven days. Resident Representative contacted and informed of findings and new order, voice understanding.
Record review of a Nurses Note dated 01/06/25 at 6:26 AM revealed Unit manager noted resident in continuous pain despite pain medication, antibiotics, and application of topical antibiotic ointment. Called Nurse Practitioner and notified him of warmth, swelling, tender to touch of left upper digits. Per patient he would like to be sent out, per provider, sent patient to emergency department for further evaluation and treatment.
Record review of a Nurses Note dated 01/10/25 at 6:21 AM revealed Resident returned to facility via stretcher transport from local hospital transferred to his wheelchair per request. Alert and responds appropriately, continue to have swelling to left hand. Left middle finger dark with pale, bluish nailbed, complaints of tenderness to finger. Lateral distal aspect of middle finger slightly red with small blister noted, requests dinner at this time.
Record review of R41's Care Plan with a last Care Plan Conference date of 02/25/25 revealed no Care Plan interventions related to the resident's injured hand or his need for assistance with meals.
An observation and interview on 03/23/25 at 10:53 AM with R41 revealed him in his room sitting in his wheelchair with gauze and medical tape on the resident's left hand, index finger and middle finger. R41's right hand was noted with long and dirty fingernails. R41 revealed he injured his hand by biting off a hangnail, but it later got infected. R41 further stated that he is legally blind, and his left hand is his dominant hand and that he has had a difficult time feeding himself since he injured his hand. R41 finally stated that some days staff assist him with meals, but it is not consistent so most days he has to feed himself.
An observation and interview on 03/24/25 at 6:28 PM revealed the Administrator setting up and providing a clothing protector to R41 for his dinner meal. Licensed Practical Nurse (LPN)5 then assisted the resident with his dinner meal. LPN5 stated, residents who need assistance with meals have a red napkin for staff to identify those specific residents. R41 did not have red napkin on his tray.
An observation and interview on 03/25/25 at 7:35 AM revealed R41 eating his breakfast meal without staff assistance. During observation resident had a difficult time determining how much grits and eggs were on his tray. Grits were observed on the side of the resident's face and on his clothing protector and his tray. R41 stated that he asked staff for assistance, but staff became argumentative with him and told him that he could feed himself.
An observation and interview on 03/25/25 at 7:37 AM with Certified Nursing Assistant (CNA)4 and LPN1 revealed them at the nursing station and having a personal conversation. During interview with CNA4 and LPN1 both stated that the R41 could feed himself. CNA4 stated they were not the resident's assigned CNA for the day but volunteered to assist the resident. Further interview with LPN1 revealed that the resident can feed himself but does require staff assistance. LPN1 finally stated that R41 does not have care plan interventions related to his hand injury or assistance with meals due to his injury.
An observation on 03/26/25 at 9:04 AM revealed R41 feeding himself his breakfast meal tray with difficulty.
An interview on 03/26/25 at 12:47 PM with the Dietary Manager (DM) and Registered Dietitian (RD) revealed R41 should be assisted with meals. Therapy attempted to work with the resident after R41 injured his hand but was unsuccessful. Further interview revealed R41's care plan had not been revised to reflect a change of condition with the resident's ability to feed himself.
An interview on 03/26/25 at 1:05 PM with the Director of Rehabilitation (DOR) revealed R41 received Occupational Therapy (OT) shortly after he injured his dominant hand. During OT there were attempts to have the resident use his right hand for meals, but it was unsuccessful. The DOR finally stated that the resident does require assistance with meals and was unable to locate care plan interventions related to this change of condition.
An interview on 03/26/25 at 4:01 PM with the Director of Nursing (DON) revealed they would have expected the resident's care plan to have been revised to reflect his change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to provide appropriate supervision to prevent Resident (R)1's elopement from the facility.
On 06/14/24 at 1:28 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in a successful elopement from the facility, constituted Immediate Jeopardy (IJ) at F689.
On 06/14/24 at 1:28 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 06/11/24. The IJ was related to 42 CFR 483.25 - Quality of Care.
On 06/14/24 at approximately 2:18 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The survey team considers the IJ at Past Non-Compliance as of 06/12/24.
An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.
Findings include:
Review of the facility's policy titled Elopement last revised 11/01/17, stated, To safely and timely redirect patients/residents to a safe environment.
Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: vascular dementia, abnormalities of gait and mobility, lack of coordination, difficulty in walking, unsteadiness on feet, reduced mobility, altered mental status, fall from bed, neurocognitive disorder with Lewy bodies, and depression.
Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/08/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R1 was severely cognitively impaired. Further review of the MDS revealed that wandering behaviors occurred 1 to 3 days.
Review of R1's Elopement Risk Tool dated 05/02/24, revealed R1 is not alert and oriented. R1 is confused and does not have safe decision-making capabilities. R1 has a history of wandering and has previously attempted to leave the health care center. Further review revealed, R1 has diagnoses that requires supervision.
Review of R1's Physician Orders dated 08/01/23, revealed the following order, Wander guard to right ankle; check placement and function Q shift.
Review of R1's Progress Note dated 06/11/24 at 7:21 PM, revealed, At 6:30 resident attempt to go out of building doors was opened, but I the nurse and staff re-direct her back into the building.
Review of R1's Progress Note dated 06/11/24 at 9:32 PM revealed, At 7.18pm this nurse was in the med room. when i got out of the med room I saw other nurses running towards the back door. This nurse left the stuff she was carrying in the cart and rushed to where the other nurses where running to. Upon going out, this nurse saw that it was her resident who was on the ground. Assessment done on resident she reported she hit her head .
During an interview on 06/14/24 at 11:59 AM, Licensed Practical Nurse (LPN)1 stated that on the night of 06/11/24 at approximately 7:15 PM, the door alarm/wander guard system alarm went off, LPN1 then went to check the panel to see which door it was, it was 2B, LPN1 then went down the hall, however it was the wrong hall. LPN1 then went down E hall and out the door and found R1 lying on the ground in the parking lot next to a light pole. LPN1 states that R1 reported to her that she fell and hit her head. 911 was then called for R1.
During an interview on 06/14/24 at 12:09 PM, R1 stated that she wanted to go to the white house across the street, so just got up and walked out the door. R1 further stated that she fell in the parking lot on a curb and hit her head and was sent to the emergency room.
During an interview on 06/14/24 at 12:45 PM, LPN2 stated that R1 was wearing a white top, pink pants and non-slip socks, when she was found in the parking lot.
According to the Weather Channel, on 06/11/24, the high was 89 degrees Fahrenheit with a low of 63 degrees Fahrenheit.
On 06/14/24 at approximately 2:18 PM, the facility provided a removal plan, which included the following:
Resident R1 had fall, possibly hitting head. Sent to ED for evaluation as precaution. Elopement risk evaluation repeated. Resident had Wandergard in place and properly functioning at time of incident. MD/RP notified. Administrator and CSD notified of incident. Residents at risk of elopement have the potential to be affected. Elopement risk evaluations done in the past 90 days on current residents in facility reviewed by nursing managers for accuracy. Residents identified at risk will be reviewed for appropriate interventions. All doors check for auditory alarm; found to be in working order. Educate facility staff the expectation that if a door is noticed to be alarming, immediately report to door to verify no resident has eloped then do a facility wide head count of residents. If door is found to be malfunctioning, administrator to be notified immediately and an employee posted at the door until otherwise indicated and redirected by a member of management. Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. Staff will be reeducated on appropriate response to alarms. This re-education will be initiated on 06/11/2024 and completed by 06/12/2024. Any member of target audience not receiving this by this date will receive prior to next scheduled shift. New admissions will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process. Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the MDS/Care planning process. The Director of Nursing or designee will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy. The maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months. The Administrator or designee will make rounds weekly for 4 weeks then monthly for 2 additional months to validate that doors are functioning properly. The maintenance director or designee will activate a door alarm once a month on each shift to validate appropriate response for 3 months or until compliance. Ad hoc QAPI held on 06/12/2024. Medical Director was notified of the incident and plan for improvement on 06/12/2024. This process will be reviewed in QAPI for a minimum of 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled, Catheter- Urinary Catheter, Cleaning and Maintenance, observations, and interviews, the facility failed to follow a procedure during catheter care for Resident (R)1 to prevent the likelihood of infection for 1 of 1 residents observed for Foley catheter care.
Findings include:
Review of the facility policy titled, Catheter- Urinary Catheter, Cleaning and Maintenance last revised May 2023 states under Catheter care: Gather and prepare the necessary equipment and supplies, perform hand hygiene, confirm the patient's identity using at least two patient identifiers, provide privacy, raise the patient's bed to waist level before performing patient care, perform hand hygiene, put on gloves and other personal protective equipment, as needed, to comply with standard precautions, provide routine hygiene for meatal care. Further review stated, Keep the catheter and drainage tubing free from kinks and avoid dependent loops to allow the free flow of urine.
R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to cystitis with hematuria, sepsis, urinary tract infection, diffuse traumatic brain injury and a need for assistance with personal care.
Observation on 02/22/24 at 10:35 AM of catheter care for R1 went as follows: Certified Nursing Assistant (CNA)1 along with CNA2, explained the procedure and provided privacy. CNA1 proceeded to wash her hands and donned (put on) gloves. She then touched the over-bed table to move it closer to the bed, touched the curtain to pull it open and then close, then set up the supplies on the over-bed table, which consisted of wipes that she had placed on the over-bed table. CNA1 then took the bed control in hand and raised the bed. She then removed the bed cover and pulled R1's gown up, folding it above her waist. She then unfastened her brief.
Observation revealed CNA1 did not remove her gloves, cleanse her hands or apply clean gloves, prior to taking a wipe in hand and wiping down the left- side of R1's groin. She then discarded the wipe and wiped down the right side of the groin area, and then wiped down the tubing, fastened the brief, pulled the gown down, and lowered the bed. She then removed her gloves and washed her hands.
During an interview on 02/22/24 at 10:41 AM with CNA1 and CNA2, CNA2 confirmed the observation. CNA1 then stated that she typically provided catheter care for R1 daily and as needed when working and that the CNAs are responsible for catheter care, but Nurses provide the care as well. CNA1 acknowledged that R1 did not have a securement device in place and did not place one during the observation nor did she adjust R1's foley to unkink the line.
During an interview on 02/22/24 at 11:05 AM with the Director of Nursing (DON), the DON stated that it is her expectations that the CNAs follow policy when providing catheter care and that it should be daily and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to provide and document sufficient preparation and orientation to a resident to ensure safe and orderly discharge from the facility for 1 of 1 residents reviewed for discharge. Specifically, Resident (R)1, nor his representative was adequately prepared or informed of R1's discharge from the facility.
On 09/01/23 at 5:30 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.
On 09/01/23 at 5:30 PM, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to ensure a proper and safe discharge for R1 constituted IJ at F624 with a start date of 08/29/23.
The facility presented an acceptable removal plan for F624 on 09/01/23 via email. The survey team returned to the facility on [DATE] to verify the removal of the IJ. Following a review of the facility's implementation plan, along with a review of audits, education, and interviews, the IJ was verified as removed as of 09/01/23 and the facility remained out of compliance at a lower scope and severity level of D.
Finding Include:
Review of the facility policy titled Discharge Notification, with a complete revision date of 10/01/20, documented, All patients/residents will be discharged /transferred from the Facility by order of his/her attending physician, in a safe, secure and correct manner.
Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia with other behavioral disturbances, morbid obesity, diabetes mellitus, and cognitive communication deficit.
Review of R1's Physician Orders revealed R1 received, Levemir FlexTouch U-100 Insulin (insulin determir u-100) 100 unit/mL (3 m/L) insulin pen twice a day 45 units, subcutaneous, twice a day, Depokote (divalproex) 250 mg tablet, delayed release (DR/EC), Enema (sodium phosphates) 19-7 gram/118 mL enema once a day - PRN (as needed), 19-7 gram/118ml, rectal, once a day - PRN, may have enema if no bowel movement x7 days, and nitroglycerin 0.4 mg tablet, sublingual, 1 tablet, sublingual, every shift - PRN, place 1 tablet under the tongue every 5 minutes as needed for chest pain.
Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/23 revealed R1's Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating R1 was severely cognitively impaired. Review of R1's functional status revealed R1 required limited assistance with one person physical assist with Activities of Daily Living (ADL). Further review of the MDS revealed R1 utilizes an indwelling catheter and is occasionally incontinent of bowel. Documented under Medications revealed R1 received insulin injections during the last 7 days. The MDS also indicated that R1 has no guardian or legally authorized representative.
Review of R1's discharge MDS with an ARD of 08/29/23 revealed R1 was discharged on 08/29/23 and indicated the type of discharge was Planned. The MDS indicated R1 was discharged to the community. Further review of the MDS revealed R1 required physical help in part of bathing activity. R1 was not rated for urinary continence due to R1 having a catheter, urinary ostomy, or no urine output. The MDS documented that R1 was occasionally incontinent of bowel.
Review of R1's Care Plan dated problem start date 07/31/23, revealed the following, [R1] has not had a fall but he is at risk due to psychoactive medication use and unsteadiness in transitions. He has dx [diagnosis] of dementia. ADL/Dental/Vision; [R1] has teeth with some in poor appearance. He has not c/o [complaints of] mouth or teeth pain. He has impaired hearing and vision. [R1] scored 7 on his BIMS, has impaired cognitive skills with impaired memory recall and he requires supervision. He has unclear speech but is able to make concrete requests and he responds adequately to simple direct communication and he has dx of Dementia AND bilateral conductive hearing loss. [R1] is at risk for infection r/t [related to] use of foley catheter. He has dx of urinary retention/obstructive uropathy. [R1] is at risk for medication side effects r/t psychotropic drug use. he has dx of dementia and depression. [R1] has potential for fluctuating of blood pressure, headaches, lightheadedness/dizziness r/t dx of hypertension/hypotention.
Review of R1's Social Service Review dated 07/27/23 revealed R1 has severe impairment with behaviors of wandering and removing catheter from privacy bag. The Social Service Review also indicated under Discharge Planning, Remain in facility.
Review of R1's Discharge summary dated [DATE] revealed R1 is Discharge per facility. He is being discharged per facility order due to behavioral issues, he is to be picked up by his son today. The Discharge Summary further documented, Follow up with PCP in 30 day. and Needs to follow up with urology regarding long term foley catheter or alternatives for treatment of urinary retention.
Review of R1's Progress Note dated 08/29/23 at 11:21 AM documented, Resident discharged and left facility via transport to brothers house. Transport driver called and notified facility that resident was dropped off at brothers home.
In an interview on 09/01/23 at 12:11 PM, R1's representative (RR1) revealed the facility called him the day of and stated that the resident went into another resident's room and touched her inappropriately. RR1 stated that the resident likes to talk with his hands. The facility told him They needed to pick the resident up right now or they are kicking him out. RR1 stated he couldn't pick him up, which he was not in agreement with because the resident was supposed to stay long-term. RR1 stated, The only thing the facility was concerned about was where to send him because they were kicking him out. RR1 further stated that he is active in his brother's care and participated in his care plan meeting and a discharge was not discussed.
An attempted interview with the Social Services Director was unsuccessful.
An attempted interview with R1's Physician was unsuccessful.
In a follow up interview on 09/01/23 at 4:08 PM, RR1 stated, That night they called me and told me I needed to come get him right now. I told them I have no means to take care of him or pick him up. They said they could put him in an Uber the next day. I called them back the next morning and they said they sent him about 15 mins ago. He arrived in a transport van, he had a Walmart bag full of medicine. He can't take his own medication. They (the facility) didn't provide me with any education or anything. He arrived in a broken wheelchair, and I called 911 to pick him up. Because I couldn't take care of him. He is currently in room L502 at the local hospital. I had a couple phone meetings with the facility about updates, we never discussed any discharge plans for him. They literally kicked him out and I didn't know he left until I called and they said he was 15 minutes out.
In an interview on 09/01/23 at 5:00 PM, R1's Nurse Practitioner (NP) stated, I was told by the facility that they were getting him out of the facility. I was told that he was going home with his son. I was not informed that the resident was not able to be cared for upon discharge. This is the first time I have dealt with a situation like this. Normally people are set up with home health and physical therapy and have a plan for discharge. I was not aware of the full situation, I was told that they were going home and it was a quick discharge given the situation. I was under the impression that family was going to be caring for him.
On 09/01/23 the facility provided a removal plan which included the following:
Notification to resident responsible party on 08/28/2023 RP agreed to accept custody of resident and requested facility arrange transportation.
Primary Care Physician notified of event on 08/28/2023 and order received to discharge resident to RP brothers care
On 8/28/23 via phone with RP DON offered to set up home health care and RP declined, stated he would use family PCP.
Transportation arranged on 8/29/23
[R1] discharged on 08-29-2023 to care of POA with additional catheter kit, medications, personal belongs.
Social services attempted to set up additional home health services with RP on 8/31/23 via phone, no answer- message left.
Residents who have been discharged in past 48 hours have been reviewed to validate safe, orderly transfer/discharge. 1 resident identified and has transferred back to facility no concerns.
Re-education facility staff responsible for discharge planning (Administrator, Social Services, DON, Therapy Director, Medical Supply) will be completed by 9/1/23. Any staff member not receiving this education by this date will receive prior to next scheduled shift.
DON, Social Services and Administrator will review anticipated discharges in morning meeting Monday-Friday times 3 months to identify preparation for safe, orderly transfer/discharge.
The Administrator will review monitored information with identified changes of for 4 weeks then monthly for 2 months.
Ad-hoc QAPI held on 09/01/23.
Medical Director was notified of the incident and plan for improvement on 9/1/23 (via phone call).
Results of the monitoring will be presented to the Quality Assurance Performance Improvement committee for review and recommendations for a period of 3 months. Concerns identified will be addressed at time of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to notify Resident (R)5's Resident Representative of a hospitalization in a timely manner as required by federal regulation, for 1 of 2 residents reviewed for transfer/discharge.
Findings include:
Review of the facility policy titled Discharge Notification last revised 10/01/20 revealed, In compliance with federal and state regulation, all facility- initiated transfers and discharge require proper notification to the patient/resident and, if known, a family member or legal representative.
Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE] with the diagnoses including but not limited to osteoarthritis, dysphagia, insomnia, muscle weakness, type 2 diabetes, and hypertension.
Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/17/23 revealed R5 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates R5 was cognitively intact.
In a phone interview on 09/01/23 at 3:51 PM, R5's Resident Representative (RR) revealed, The resident was sent to the hospital by the facility on 08/25/23 but they were not informed until 08/27/23 by hospital staff. The resident was transferred to the local hospital then transferred again to another hospital about 2 hours away and is still there. The RR further stated that they do not have voicemail set up on their phone but called the facility back without a response.
Review of R5's Bed-Hold for temporary leave dated 08/28/23 revealed, Notice provided to R5's RR on 08/28/23 on behalf of R5, currently residing in the facility. Bed-Hold days remaining (10) as of 08/25/23.
Review of R5's Nurses Note dated 08/25/23 at 10:13 AM revealed, walked into the patient room and noticed patient right side of face swollen, red, and warm to touch, alerted Medical Director (MD). MD gave verbal orders to send the patient to the Emergency Department. RR was called and could not leave a message, will try RR again to follow up.
An attempted phone interview with Social Services on 09/01/23 at 4:01 PM was unsuccessful, a voicemail was left with contact information.
In an interview with the Director of Nursing (DON) on 09/01/23 at 4:39 PM, revealed nursing staff or the Social Services Director are required to inform resident representatives that residents have been transferred to the hospital. Staff are required to make two attempts on the phone and should be sent the bed-hold within 24 hours on business days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility policy, record reviews, and interviews, the facility failed to protect 1 of 1 residents from sexual abuse. Resident (R)1 inappropriately touched R2 on 08/28/2023 at approximately 5:20 p.m. This was observed by staff members.
On 09/01/2023 at 05:30 pm, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.
On 09/01/2023 at 05:30 pm, the survey team presented the Administrator with the Immediate Jeopardy (IJ) template, notifying her that the failure to protect R2 from sexual abuse by R1 constituted IJ at F600 with the start date of 08/28/2023.
The facility presented an acceptable removal plan for F600 on 09/01/2023 via email. The SA returned to the facility on [DATE] to verify the removal of the IJ. Following a review of the facility's implementation plan, along with a review of audits, education, and interviews, the IJ was verified as removed as of 09/01/2023 and the facility remained out of compliance at a scope and severity level at D.
An extended survey was conducted in conjunction with the complaint survey constituting substandard quality of care.
Findings include:
A review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revised 10/01/2020, states Sexual abuse is non-consensual sexual contact of any type with a resident. C- Rape, Molestation, or other inappropriate sexual behavior against a resident such as Sexual harassment, Sexual assault, Sexual Coercion, or Inappropriate sexual behaviors displayed by and/or toward incapable resident.
R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia with other behavioral disturbances and cognitive communication deficit. R1 scored a Brief Interview of Mental Status (BIMS) of 07 out of 15, indicating severe cognitive impairment, as of 07/26/2023 on quarterly Minimum Data Set (MDS).
Review of R1's Physician orders revealed R1 had an order for 1:1 supervision with a start date of 07/13/2023. A policy was requested for 1:1 supervision, however, the facility Administrator stated there was no policy related to 1:1 supervision.
R1 had been care-planned since 07/31/2023 for Unwanted touching of female and entering other resident's rooms without permission. Interventions included redirection, visits with psychiatric services, and Gradual Dose Reduction (GDR) attempts.
R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, cognitive communication deficit and major depressive disorder. R2 scored a BIMS of 11 out of 15 indicating she was moderately, cognitively impaired as of 08/02/2023 on a quarterly MDS.
An interview with the Facility Administrator and DON (Director of Nursing) on 09/01/2023 at 12:40 PM revealed that they were informed by the agency nurse who worked the floor that she had witnessed R1 in R2's room with his hand on her breast, outside of clothing, while R2 was resting, and was not aroused. There was no evidence of the resident making inappropriate comments. The DON stated that R1 did not attempt to remove any of her clothing and that R1 has a history of using physical touch to communicate. The DON stated that two (2) staff members were suspended for failure to provide R1 with 1:1 supervision. The scheduler pulled the 2nd shift sitter to work a group setting because R1 was going to have a decrease on 1:1 due to behaviors improving. The 7-3 sitter clocked out early due to her relief showing up. The DON also stated that a review of the Resident's Psych notes confirms that the resident is being seen for impulse control. The DON also stated that clarification of staff interviews related to inappropriate touching reveals resident will use terms such as dear, baby, honey when addressing staff and places his hand on the female hip and/or lower back. The DON stated that R1 has a tendency to become irate and agitated when questioned because he believes that his behaviors are appropriate, and gestures are his normal way of communicating. The DON stated that psych services continue to reinforce accountability and work on impulsive behaviors. The DON stated that R2, who was the victim has a BIMS of 9 and was startled upon the male resident being in the room. R2 was easily calmed down by staff when staff saw and immediately removed R1 from the room. DON stated that Social Services Director did refer R2 to psych services due to initial trauma from waking up and being startled. DON stated that R1 was discharged home the next day, 08/29/2023 into the custody of his brother and R2 remains at baseline and followed by psych services as a preventative measure.
In an interview with R2 on 09/01/2023 at 1:55 PM she revealed, I was sleeping, and he was kissing me in my mouth, he touched me (pointing at both breasts), I woke up scared and said, You got to go, and he did not leave. R2 stated that two staff members saw R1 and pulled R1 out of the room and started checking me. R2 stated that she fears for her life, she can't sleep, and every time she closes her eyes, she sees him. R2 stated that staff comes in to visit and try to cheer her up, however, she just wants to go home.
The Social Services Director was unavailable for interview.
A phone interview with Licensed Practical Nurse (LPN)1 on 09/01/2023 at 02:38 PM revealed that R1 was on 1:1 supervision when the incident occurred. LPN1 stated that she was walking with R1 at the nurse's station and turned around to talk to another staff member for less than 30 seconds and when she (LPN1) turned around to check on R1, he was gone. LPN1 stated that she started searching for him due to wandering behaviors and she (LPN1) located R1 in R2's room in his wheelchair, on the right side of R2's bed, with his hand on R2's right breast, over her clothing. LPN1 stated that R2 stated Get off of me, and immediately removed R1 from the room and notified another nurse to report it to the DON.
The facility's removal plan included:
Staff and resident interviews did not reveal any other concerns, completed on 08/28/2023.
Re-Education on Abuse, Neglect, and Misappropriation and Abuse policy to staff. This re-education will be completed by 09/01/2023. Any staff member not receiving this education by this date will receive it prior to the next scheduled shift. DON or Social Services will review the resident's reported inappropriate behaviors in the clinical morning meeting Monday-Friday to validate that safety interventions are appropriate and in place to maintain a safe environment. The administrator will review monitored information and the clinical morning meeting agenda with identified changes of condition/signs and symptoms of trauma, including grief weekly for 4 weeks then monthly for two months.
Ad-hoc QAPI held on 08/29/2023. The Medical Director was notified of the incident and plan for improvement on 08/29/2023 (via phone call). The results of the monitoring will be presented to the Quality Assurance Performance Improvement Committee for review and recommendations for a period of 3 months. Concerns identified will be addressed at the time of discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and interviews, the facility failed to follow a procedure during wound care for Resident (R)28 to promote healing and to prevent or decrease the likelihood of infection for 1 of 5 residents reviewed with pressure ulcers.
Findings include:
Review of the facility policy titled, Performing A Dressing Change, with a revised date of 06/01/15, under Procedures states: 1. DON gloves 2. Remove old dressing (if present). (Change gloves) 3. Cleanse the wound of drainage, debris or dressing/filler residue. (Change gloves) 4. Assess the wound (measuring done here). (Change gloves) 6. Apply a cover dressing - date and initial cover dressing, place time reference on it. (remove gloves, discard waste).
Review of R28's Face Sheet revealed R28 was admitted to the facility on [DATE] with diagnoses including but not limited to, metabolic encephalopathy and vascular dementia.
Review of R28's Care Plan dated 07/10/23, revealed a care plan for a pressure ulcer infection on R28's left foot.
Review of R28's Physician Order dated 07/14/23, revealed an open ended physician order to Cleanse medial foot next to great toe with WC (wound cleanser), pat, dry, apply Betadine moist gauze then cover with dry dressing. Strict offloading in boot. Change dressing Q (every) day or PRN (as needed) with soilage.
During an observation on 08/09/23 at approximately 1:50 PM of wound care, Licensed Practical Nurse (LPN)2 washed her hands, used hand sanitizer, donned gloves and removed a spray bottle of Skintegrity Wound Cleanser, a gauze roll, tape, Betadine Solution and foldable gauze from the Treatment Cart. LPN2 placed foldable gauze in a clear plastic cup and saturated the gauze with Betadine Solution. LPN2 knocked on the door, entered the room of R28 and proceeded to used her gloved hands to raise the bed with the electric controller, pulled the covers off the resident's left leg and foot while reassuring R28. LPN2 removed the tape and gauze from the previous treatment, cleansed the wound on the left foot with Skintegrity Wound Cleanser using clean gauze, setting the just removed and used gauze aside. LPN2 then applied Betadine soaked gauze to the wound, wrapped the wound with the rolled gauze, removed scissors from the right pocket of her uniform and used the scissors to cut the tape and placed atop the fresh gauze. LPN2 then replaced scissors to the right pocket of her uniform and removed a Sharpie and used it to write the date and time on the tape, then placed the Sharpie to the right pocket of her uniform. LPN2 then covered R28, lowered the bed and removed the old dressing and supplies from the room. LPN2 placed the Skintegrity, Betadine and tape back in the treatment cart, then removed and discarded the same gloves which had been donned at 1:50 PM.
During an interview on 08/09/23 at 2:05 PM, LPN2 acknowledged that she had never changed her gloves, washed her hands or used hand sanitizer at any point while providing wound care to R28.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy, observations, and interviews, the facility failed to ensure that a Schedule III controlled substance was double locked and a lock box for controlled substances in the refrigerator was secured inside the refrigerator for 1 of 2 medication rooms. (Refer to F761)
Findings include:
Review of the facility policy titled, General Guidelines for Storage of Medication and Biologicals, with a revised date of [DATE] under Procedures state, 9. All Scheduled medications and other drugs subject to abuse are stored in a separate, permanently affixed area and are under double lock. 12. Outdated, contaminated or deteriorated medications and those in containers cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the Pharmacy, if replacements are needed. 14. Facility should ensure that medications and biologicals for expired and/or discharged residents are stored separately, away from use, until destroyed or returned to the provider.
During an observation on [DATE] at approximately 12:42 PM, of the Medication Room for Halls D, E, and F, revealed one opened bottle of dronabinol (Marinol) 2.5 mg (milligram) capsules, a Schedule III controlled substance was located inside an unlocked refrigerator with no lock on the refrigerator door and a controlled substance box, with a lock, was not attached to the inside of unlocked refrigerator.
During an interview on [DATE] at approximately 12:58, Licensed Practical Nurse (LPN)5 stated that the bottle of dronabinol 2.5 mg should be locked inside the controlled substance box inside the refrigerator. LPN5 unlocked the narcotic box, found it empty and tried unsuccessfully to fit the bottle of dronabinol 2.5 mg inside the narcotic box, as the lid would not close. LPN5 verified that the controlled substance box was not permanently attached to the inside of the refrigerator.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the walk-in refrigerator and freezer, dry storage, emergency storage and resident dietary rooms were properly labeled and discarded by the manufacturer's expiration date.
Findings Include:
Review of the facility policy titled, Food Safety in Receiving and Storage, with a complete revision date of 06/20/23, revealed, Food will be received and stored by methods to minimize contamination and bacterial growth. Receiving Guidelines: 5. Inspect food when it is delivered to the facility and prior to storage for signs of contamination. Food packages shall be in good condition to protect the integrity of the contents to that the food is not exposed to adulteration or potential contaminants. A. Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks. 6. Check expiration dates and use-by dates to assure the dates are within acceptable parameters. 7 Dented cans are stored in a designated location (labeled dented cans) until they can be returned to the vendor. 9. When adding newly delivered food into current inventory, use the FIFO (First In, First Out) method so old stock is rotated to the front and utilized first. General Food Storage Guidelines: 3. Place food that is repackaged in a leak-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date.
During an observation on 08/08/23 at 10:55 AM, of the walk-in refrigerator revealed:
Large square white bucket of approximately 18-20 boiled eggs in a water substance- not labeled/dated,
Ziploc bag of parmesan cheese with an expiration date date of 02/19/23,
Six pieces of cooked bacon wrapped in aluminum foil-not labeled/dated,
Large bag of shredded lettuce - not labeled/dated,
Small bag of shredded carrots- not labeled/dated,
One block of yellow cheese - not labeled/dated.
During an observation on 08/08/23 at approximately 11:05 AM, of the walk-in freezer revealed:
Open Bag of Frozen cookies with an expiration date of 12/20/22,
Open half bag of green peas - not labeled/dated,
Open half bag of dinner rolls - not labeled/dated,
Open box of Cobbler Crust dough sheet - not labeled/dated,
Open half bag of tator tots - not labeled/dated,
Open half bag of chicken tenders - not labeled/dated,
Three sausage patties exposed in box not covered, labeled/dated,
Open bag of Lion Center pork chop - not labeled/dated,
During an observation on 08/08/23 at approximately 11:15 AM, of the Emergency Food storage revealed:
Two 12 can boxes of green bean puree, 15oz cans- Dated 08/28/19 and 04/24/19
Two 12 can boxes of carrot and pea puree 15oz cans- dated 03/06/19
Two 12 can boxes of seasoned green bean puree- dated 03/06/19
One 12 can box of sweet corn puree- dated 03/18/20
Two 12 can boxes of beef puree- dated 02/20/19
Five 49oz cans of pulled chicken- dated 03/18/20
Six 68oz cans of fruit blend- dated 03/18/20
All items were confirmed and removed by the Assistant Dietary Manager.
During an observation on 08/08/23 at 1:49 PM, of the East Hall dietary room, revealed a Glucerna 33.8 fl oz bottle with an expiration date of 07/01/23.
During an interview on 08/08/23 at 1:50 PM, Licensed Practical Nurse (LPN)8 confirmed this finding and removed the expired item.
During an interview on 08/08/23 at 12:20 PM, the Certified Dietary Manager (CDM) revealed that food is rotated daily, and we use a first in, first out method. Staff is expected to check and make sure foods are not expired and they are properly labeled. Labeling training is provided once a year and when staff is first hired. The Administrator does a sanitation inspection weekly and I pop in once a week to look for food that maybe expired. The CDM stated the issue of not labeling properly needs to be corrected immediately, if items are not able to be identified when they came in or when they were opened, we then throw them out and educate the staff. Every six months we do a deep cleaning.
During an interview on 08/09/23 at 12:12 PM, with the Assistant Dietary Manager (ADM) revealed that she does the cleaning schedule, and everyone is assigned a cleaning task every week. The cooks are responsible for the machines that they work with, such as the grill, fryer, or steam table and the aides have the tea urns, coffee machines, and trash cans. They all tackle the walls, sweeping, mopping. She completes a walk through every morning which consists of rotating stock and replacing items the day before they receive a delivery. The ADM states everything should be labeled when something is taken out of the box, anything that is opened, and all cooked foods should be labeled with a three-day life span. She explains labeling should include a use by date and should be done in rotation. Everyone is responsible for labeling and if that practice is not followed, kitchen management follows up with in-services for labeling and rotation. It is a daily process, for everyone, and it is a daily responsibility of hers, when she is not covering a shift.
During an interview on 08/09/23 at 1:45 PM, a Dietary Aide revealed that anything that is opened must be labeled or dated, anything cold goes in the walk-in refrigerator, and hot items have to stay at certain temperatures. The Dietary Aide explains that expired foods need to be thrown away, and checked every week, the kitchen staff is required to check the date on the label and the date that is written on all items. She also includes that she is assigned to all areas of the kitchen.
During an interview on 08/09/23 at 2:46 PM, the Administrator revealed that she completes weekly kitchen and sanitation reports on Wednesdays, which includes checking for cleanliness, dating/labeling, the temperature of cooler/freezer, sinks water, and making sure items are wrapped appropriately. If she is not here to do it, then the dietary manager completes it. The Administrator states that she is aware of the outdated items in the emergency storage but did not want to discard them because they are unable to find/order canned puree items from their current vendor, but they have now been tossed. She stated that those items did not have expiration dates, the surveyor asked how do you know when to discard the items, the Administrator responded, I'm not going to argue with you. She continued that she does not check every area on the check list from her weekly inspection, it is only spot checks during her weekly report. The Administrator states that her expectations are for all items to be labeled and expired foods to be discarded on the dates provided.

Based on review of facility policy, observations, record reviews, interviews, and manufacturer labeling/package inserts, the facility failed to ensure that expired medications were removed from active storage, that opened and in-use medications were properly dated, that unattended medication carts were locked, that unsecured and unattended medications were not left atop medication cart and that sterile/single-use products were removed from active storage in 6 of 6 medication carts. (Refer to F755)
Findings include:
Review of the facility policy titled, General Guidelines for Storage of Medication and Biologicals, with a revised date of 04/01/22, under Procedures state, 2. The medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members. 6. Once any medication or biological package is opened, the facility should follow: manufacturer/supplier guidelines with respect to expiration dates of opened medications. 7. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products (e.g. inhalers, insulin ophthalmics, otics and the like) with the date opened and follow manufacturer/supplier guidelines with respect to expirations dates. 12. Outdated, contaminated or deteriorated medications and those in containers cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the Pharmacy, if replacements are needed. 13. Medication storage areas are kept clean, secure, well lit, and free of clutter. 14. Facility should ensure that medications and biologicals for expired and/or discharged residents are stored separately, away from use, until destroyed or returned to the provider.
During an observation on 08/08/23 at approximately 11:03 AM, of the front medication cart for Hall A, B, and C, revealed one opened and undated container of Spiriva Respimat 2.5 mcg (microgram)/inhalation. The inhaler had been labeled by the Boehringer Ingelheim (manufacturer) Discard 3 months after insertion into inhaler.
During an interview on 08/08/23 at approximately 11:15 AM, Licensed Practical Nurse (LPN)1 verified that the inhaler was in-use and had not been dated.
During an observation on 08/08/23 at approximately 11:18 AM, of an unlocked and unattended Treatment Cart on F Hall, revealed the following: visitors and wandering residents passing by the Treatment Cart, one opened container of Curad 6 x 36 (inch) labeled Sterile until opened, one opened container of Maxiorb II wound dressing 1 x 12 by Medline labeled Sterile Single Use, one bottle of Povidone Iodine Solution with an expiration date of 6/23.
During an interview on 08/08/23 at approximately 11:21 AM, LPN2 verified that these products were in-use and/or expired and not properly stored.
During an observation on 08/08/23 at approximately 11:24 AM the medication cart parked outside Room F-9 was found to be unattended for approximately eight minutes, with residents and visitors passing by, the computer screen was open showing resident information, and the following medications sitting atop the cart; Levetiracetam solution 100 mg/ml (milliliter), Cetirizine HCl USP (United States Pharmacopoeia) 10 mg, and ClearLax PEG (polyethylene glycol) 3350.
During an interview on 08/08/23 at approximately 11:32 AM, LPN3 confirmed these findings and stated yeah, uh-huh that's my cart.
During an observation on 08/08/23 at approximately 11:38 AM, of the back medication cart for Hall A, B, and C, revealed one opened and undated Levemir Flexpen labeled expires 42 days after opening.
During an interview on 08/08/23 at approximately 11:44 AM, LPN4 confirmed that the Levemir was in-use and had not been dated when opened.
During an observation on 08/08/23 at approximately 12:42 PM, of the D,E, and F Hall medication room refrigerator revealed an IV (intravenous) Daptomycin 250 mg/100 ml NS (Normal Saline) with a use by date of 07/18/23.
During an interview on 08/08/23 at approximately 12:58 PM, LPN 5 verified the Daptomycin as being out of date and stated the resident had been discharged .
During an observation on 08/08/23 at approximately 3:45 PM, of the front medication cart for Hall D,E, and F revealed a sticky substance and medication bottles in the bottom drawer, one Lispro Flexpen opened and in-use but not dated (illegible), two Lantus Flexpen opened an in-use but not dated, one Lispro open and in-use but not dated, two Humalog Mix 75/25 Flexpens for with one open and in-use but not dated (illegible) and labeled discard after 10 days, and the second open and in-use but not dated.
During an interview on 08/08/23 at approximately 3:52 PM, LPN3 verified these findings.
During an observation on 08/08/23 at approximately 4:09 PM, of the back medication cart for Hall D, E, and F revealed one Novolog Flexpen open and in-use but not dated, one Novolog Flexpen open and in-use but labeled with two different open dates of 07/03 and 07/28, one Humalog Kwikpen open and in-use dated 07/03/23, Symbicort 160/4.5 mcg Inhaler open and dated 04/19/23, in-use and labeled expires 3 months after removing from foil pack.
During an interview on 08/08/23 at approximately 4:22 PM, LPN3 confirmed these findings
During an observation on 08/09/23 at approximately 1:30 PM a Treatment Cart was found unlocked and unattended outside Room B-4, with wandering residents passing by.
During an interview on 08/09/23 at approximately 1:42 PM, LPN5 confirmed this finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a privacy bag was provided to Resident (R)354's catheter bag for 1 of 1 resident reviewed.
Findings Include:
Review of the facility's policy titled, Patient/Resident Rights, with a complete revision date of 10/01/20, revealed, The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities . The Facility treats each resident with respect and dignity . The facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life, recognizing each resident's individuality.
Review of R354's Face Sheet revealed R354 was admitted to the facility on [DATE] with diagnoses including but not limited to, diffuse traumatic brain injury, acute respiratory failure, tracheostomy and gastrostomy status, and need for assistance with personal care.
Review of R354's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/23 revealed a Brief Interview for Mental Status (BIMS) should not be conducted as the resident is rarely/never understood.
Review of R354's physician's order dated 08/10/23 indicated an Indwelling foley catheter 16fr, continuous and a privacy bag in place, every shift.
Review of R354's progress note dated 08/04/23 at 6:39 PM revealed, foley in place #16 french below bladder with yellow cloudy urine.
Review of R354's progress note dated 08/08/23 at 2:49 PM revealed, resident has a foley catheter place that is draining blood, tinged, orange color urine.
During an observation of R354 on 08/10/23 at 1:43 PM, revealed the resident lying in bed in her room with the door open to visual inspection from the hall, privacy curtain not drawn, and catheter bag hung on the door side of her bed. There was no privacy bag covering the catheter bag.
During an observation of R354 on 08/11/23 at 8:47 AM, revealed the resident lying in bed in her room with the door open to visual inspection from the hall, there was no privacy bag covering the catheter bag.
During an interview on 08/11/23 at 10:44 AM, the Director of Nursing (DON) revealed that privacy bags are put in place when the resident is in the hallways, but when the resident is in their room, that is optional, the choice is up to the resident or resident representative. Nursing asks residents or representatives if they want a privacy bag, but it is not documented/care planned anywhere in their medical records. The DON stated she was aware that the representative was questioning the contents of R354's catheter bag and the physician and I addressed her about that on yesterday. The DON includes that being able to view the contents from the hall would be a dignity issue and it would be addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to ensure the administration of medication for 2 of 25 residents reviewed for medication administration. Specifically, Resident (R)46 and R94 did not receive their medication as ordered by the physician.
Findings Include:
Review of the facility's policy titled Medication Management program, dated 05/05/23, revealed The facility will ensure the schedules for administrating medications : 1) maximize the effectiveness of the medications .Authorized staff must understand: effectiveness for achieving the therapeutic goal .The authorized staff member administers medications according to accepted standards of practice and incompliance with regulatory requirements .If a medication is unavailable, contact the pharmacy and document accordingly. Notify the physician for possible alternatives in e-kits at time of discovery.
1. Review of R46's undated Face Sheet, located in R46's electronic medical record (EMR) under the Face Sheet tab, indicated R46 was admitted to the facility on [DATE], with a readmission on [DATE], and diagnoses including but not limited to, end stage renal disease, hypertension, and atrial fibrillation.
Review of R46's Medication Administration Record (EMAR), for 07/12/23 through 08/11/23, located in R46's EMR under the EMAR tab, revealed an order, dated 09/24/21, for Lido-Prilo [NAME] Pack (lidocaine-prilocaine) kit, with instructions to apply small amount to access site (R) right, upper arm one hour prior to dialysis. Further review of the EMAR of the lidocaine revealed the medication was not applied on 07/31/23, 08/02/23, and 08/09/23, due to unavailability of medication.
During an interview with R46 on 08/08/23 at 4:04 PM, R46 stated she had not received her lidocaine medication to her dialysis site for two weeks. R46 added she had spoken with the nurses, and they were waiting for the pharmacy to refill the lidocaine.
During an interview with Licensed Practical Nurse (LPN)7 on 08/11/23 at 12:00 PM, LPN7 stated she had documented incorrectly that she had administered the lidocaine to R46 on 08/07/23 and 08/11/23. The medication was not available.
During an interview on 08/11/23 at 12:29 PM the Director of Nursing (DON) and the Corporate Clinical Coordinator (CSS), both stated the expectation was for the nurse to contact the pharmacy, if medication was not available, and to contact the physician for alternative medications. Additionally, they would have expected nurses to use critical thinking during the medication pass.
2. Review of R94's undated Face Sheet, located in R94's EMR under the Face Sheet tab, revealed R94 was admitted to the facility on [DATE] with diagnosis including but not limited to, insomnia.
Review of R94's admission MDS with an ARD of 06/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R94 was cognitively intact.
Review of R94's Physician Orders revealed an order with a start date of 07/17/23 for, Unisome (doxylamine) dosylamine succinate OTC 25MG amt 0.5 tab oral at bedtime.
Review of R94's EMAR for the following dates 07/21/23 thru 8/10/23, revealed the physician order for Unisome (doxylamine) dosylamine succinate OTC 25MG amt 0.5 tab oral at bedtime was not administered.
Review of R94's Physician Progress Note dated 07/28/23 revealed, patient states chronic, has been ongoing prior to hospitalization. PT states has tried melatonin in past but did not keep pt asleep. PT states full dose of unisom improved sleep but cause vivid dreams. will order 1/2 tab (12.5mg) for trial and will assess reason pt has not received.
Review of R94's Physician Progress Note dated 07/31/23 revealed, pt states chronic, has been ongoing prior to hospitalization PT states has tried melatonin in past but did not keep pt asleep Pt states full does of unisom improved sleep but cause vivid dreams, will order 1/2 tab (12.5mg) for trial and will assess reason pt has not received-checking with facility regarding obtaining OTC med to provide for pt.
During the Resident Council Meeting on 08/09/23 at 1:30 PM, R94 stated that she had not received her Unisome medication in weeks. R94 further stated she asked the nurse and the Nurse Practitioner (NP) about her medication, but she still has not received her medication.
During an interview with on 8/10/23 at 11:13 AM, the NP revealed that she has listed on the progress notes that R94 has not received her medication, and was checking into this, because medication was prescribed in July 2023.
During an interview on 08/10/23 at 4:25 PM, the DON revealed she was not aware the resident did not have her medication, but was informed on today. The DON stated that the pharmacy has not sent it and she has spoke with the NP to change the medication. The DON concluded the normal process to receive medication from the pharmacy is one to two days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to provide 2 of 2 residents with Activities of Daily Living (ADL) care. Specifically, Resident (R)16 and R354 did not receive routine bathing, incontinent care, and linen changes. Resulting in the potential for skin irritation, infection, and complications with pressure ulcers.
Findings Include:
Review of the facility policy titled, Activities of Daily Living, Optimal Function, with a complete revision date of May 5, 2023, documented, The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Procedures: 1. Facility staff recognize and assess an inability to perform ADL's, or a risk for decline in any ability to perform ADL's by reviewing the most current comprehensive or most recent quarterly assessment.
1. Review of R354's face sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to, diffuse traumatic brain injury, acute respiratory Failure, tracheostomy and gastrostomy status, and need for assistance with personal care.
Review of R354's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/23 revealed a Brief Interview for Mental Status (BIMS) should not be conducted as the resident is rarely/never understood.
Review of R354's Shower Schedule indicates that R354 should be showered on Monday, Wednesdays, and Fridays during the hours of 7AM-3PM.
During an observation on 08/08/23 at approximately 1:30 PM, revealed a black stain in the shape of a circle on R354's linen.
During an observation on 08/10/23 at 1:43 PM, revealed the same black stained circle on her linen which was observed on 08/08/23.
During an observation on 08/11/23 at 8:47 AM, revealed the same black stained circle on R354's linen which was observed the previous two times.
During an interview on 08/11/23 at 10:44 AM, the Director of Nursing (DON) revealed Linens are changed on shower days and anytime they are soiled. If the resident refused, they are offered a bed bath, then they change the linen, some residents don't want to roll because it's painful. Third shift is really good about changing linen so they can start the day off with clean linens. There has only been a sheet shortage twice since she's been there. We'll find out why they didn't change her linen.
2. Review of R16's face sheet revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to, chronic obstructive pulmonary disease, pain, muscle weakness, abnormal weight loss, cognitive communication deficit, chronic osteomyelitis, right femur flexion deformity, retention of urine, type 2 diabetes mellitus, vascular dementia with behavioral disturbance, anxiety disorder, sepsis, chronic kidney disease, and dysphagia.
Review of R16's Annual MDS with an ARD of 07/06/23 revealed a BIMS was not able to be conducted as the resident has severely impaired daily decision making. R16's functional status revealed she is totally dependent with bed mobility, personal hygiene, toilet use, and bathing as she has an impairment on both sides of her upper and lower extremities. The MDS further revealed R16 is always incontinent of bowel and bladder.
Review of R16's Care Plan revealed R16 is incontinent with bowel and bladder with the potential of further skin breakdown r/t [related to] incontinence and impaired bed mobility. An approach of incontinent checks every 1-2 hours and PRN (as needed) was established on 08/05/20.
Review of R16's Care Plan revealed R16 requires assistance with ADL's r/t dx [diagnosis] of dementia, muscle weakness, pain, age-related physical debility, right knee contracture. An approach of incontinent checks every two hours, staff to assist with bathing, pressure ulcer risk assessment done quarterly, and weekly body audit established on 08/05/20.
Review of R16's Progress Note dated 06/14/23 at 2:49 PM, revealed an IDT [interdisciplinary team] meeting to discuss resident pain control. Resident requested PRN pain control 3/7 days last week. New order to reposition resident as tolerated to help with off-loading pressure.
Review of R16's Progress Note dated 06/28/23 at 2:39 PM, revealed that the resident had Bactrim ds ordered 06/17-06/24 r/t R hip wound infection. Lab work confirmed presence of staph aureus. No adverse reactions noted.
Review of R16's Progress Note dated 08/02/23 at 1:32 PM, revealed wound care completed today with wound care NP [Nurse Practitioner]. Right hip does have purulent drainage, cleansed with dakins, applied silver alginate and dry dressing.
Review of R16's Progress Note dated 08/08/23 at 12:50 PM, revealed wound care completed today on hip and foot, noted small amount of drainage to hip and foot. Cleansed and dressed as ordered.
Review of R16's Shower Schedule indicates that R16 should be showered on Tuesdays, Thursdays, and Saturdays during the hours of 7AM-3PM.
Review of the Point of Care (POC) history for the last 30 days from 07/10/23 - 08/10/23, revealed R16 was totally dependent for moving in the bed and was assisted only one time per day for 12 days, two times a day for 11 days, and two days of the month there was no documentation of R16 being assisted with repositioning/mobility in bed.
Review of the POC history for the last 30 days from 07/10/23 - 08/10/23, revealed R16 was total dependent for toilet use and was assisted only one time per day for 13 days, two times a day for nine days and three days of the month there was no documentation for R16 being assisted with toileting.
Review of the POC history for the last 30 days from 07/10/23- 08/10/23, revealed R16 was only assisted with complete or partial bed baths.
During an observation and interview on 08/10/23 at 10:42 AM, R16's floor under bed revealed a dark spot that was confirmed by housekeeping was a urine stain. The linen was removed from R16's bed, revealing the mattress which had an indented, stained area of approximately two feet long and eighteen inches wide, was directly over the stain on the floor. The mattress cover was opened by the Maintenance Director (MD), and he stated that the cover was deteriorating. The Housekeeping manager also confirmed that urine had seeped through the mattress and was on the rails of the bed as well as the floor.
During an interview on 08/10/23 at 9:34 AM, R16's Resident Representative (RP) stated she was very concerned about the care that her loved one was receiving. She further stated that they make several complaints, the staff is always new, and no one ever knows anything. R16 is not changed frequently, and her room and mattress always has a strong urine scent. They have requested the mattress to be changed numerous times. She also states that she visits at least every two weeks, and they always have to find someone to come and provide care because she is always in the bed, without being bathed or groomed for the day.
During an interview on 08/10/23 at 10:42 AM, the MD revealed that the mattress is deteriorating. The MD unzipped the mattress cover and the insides of the mattress contents were stained and disintegrating. There was a permanent stain in one area of the mattress. The MD informed us that they were replacing the mattress and housekeeping was going to deep clean the room.
During an interview on 08/11/23 at 10:44 AM, the Director of Nursing (DON) revealed the resident should be repositioned every couple of hours, usually if she hollers, she needs something. They have implemented an air loss mattress, repositioning, minimal positioning as sometimes it is painful for her to be in other positions, as well as trying all non pharmalogical approaches. The DON stated that the mattress is indicative of a soiled mattress for a heavy wetter. She also confirms that if the mattress was soaked that would cause the floor stain, but she doesn't have an answer as to how that would have gotten overlooked. The DON futher stated that she would propose that the resident be checked more often, try to have the same staff each day because they know their residents inside and out. If they are a heavy wetter, it is not documented in the chart but it would be care planned, but it is discussed in twenty four hour care plan each night, then the nurse provides the information to the staff so they will know to check that resident more frequently. The DON later confirms that R16 is not care planned for being a heavy wetter because she is not a heavy wetter and they are currently following the South Carolina board of nursing standards.
During an interview on 08/11/23 at 11:56 AM, Certified Nursing Assistant (CNA)3 revealed that R16 is a heavy wetter, and she drinks a lot of fluids. CNA3 states R16's daughter informed them to put a pad down on the bed, so the urine won't roll over on the floor. CNA3 knows to check R16 more frequently, every 45min to an hour, just because she provides care for this resident regularly.
During an interview on 08/11/23 at 12:42 AM, the Housekeeping Manager revealed that they deep clean rooms once every month, but they don't change out the mattress. If the resident is out of the bed, they will lift the mattress up and clean the frame of the bed. The Housekeeping Manager stated she typically sees urine staining around trashcans but that looks more so of a liquid diarrhea stain. She also states that they were able to get down to fifteen percent of the stain removed from the floor by stripping and waxing it, but in order to remove the stain from the floor 100 percent, maintenance will have to replace the tile.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, interviews, and record review, the facility failed to properly label and date the oxygen tubing for 1 of 2 residents reviewed for respiratory care, Resident (R)49.
Findings include:
Review of the facility's policy titled, Oxygen Therapy General Policy dated (complete manual revision) 04/01/22 revealed, (15) Label tubing and humidifier with date, time, and RC practitioner initials.
Review of R49's Face Sheet revealed R49 was admitted to the facility on [DATE] with diagnoses including but not limited to; pneumonia, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia.
Review of R49's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 05/30/2023 revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R49 has severe cognitive impairment.
Review of R49's Care Plan with a start date of 02/28/23 documented, potential for dyspnea, wheezing, shortness of breath and impaired gas exchange from COPD/HX of chronic respiratory failure with Hypoxia. Further review of the Care Plan revealed the following approach, 02 as ordered, clean 02 filters. Change Humidifier and Tubing as ordered.
Review of R49's Physician Order with a start date of 02/22/22 documented, 02 at 2 liters per minute via nasal cannula and Change O2 tubing/nasal cannula/mask/humidification system weekly.
During an observation of R49's room on 08/08/23 at 12:11 PM, revealed no label or date on the oxygen tubing, oxygen tank was dirty, with a dried dark substance.
During an observation of R49's room on 08/09/23 at 12:00 PM, revealed there was still no label or date on oxygen tubing, oxygen tank was still dirty and covered with the dried dark substance. Further observation revealed R49's nasal cannula was not properly in place in R49's nostrils.
During an interview and observation on 08/09/23 at 12:03 PM, the Director of Nursing (DON) revealed R49 just tested positive for COVID. The DON entered R49's room and checked her tubing and acknowledged that it was not labeled or dated. The DON stated the tubing should be changed every Sunday. The DON concluded if the tubing is not labeled it is replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and the review of the facility's policy titled Abuse, Neglect, Exploitation and Mistreatment, the facility failed to prevent a successful elopement for 1 of 3 residents reviewed for Neglect. Resident (R)1 had a successful elopement from the facility on 05/09/23 at an unspecified time and was without supervision for an extended period of time. R1 was found by the police at the baseball field, across the street from the facility on 05/09/23 around 08:50 PM and at 9:00 PM Licensed Practical Nurse (LPN)2 went to the baseball field and returned R1 back to the facility.
On 5/16/23 at approximately 10:00 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 5/16/23 at 10:50 AM, the Administrator was notified that the allegation of elopement for R1 constituted Immediate Jeopardy (IJ) at F600 and the IJ template was presented.
On 5/16/23 at 3:31 PM, the facility provided an acceptable plan of removal for the IJ. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm, that is not immediate jeopardy.
An extended survey was conducted on 5/16/23 due to the failure constituting substandard quality of care.
The facility's implemented removal plan included required facility wide training, along with in-services to be conducted, beginning 5/16/23 related to elopement/neglect.
Findings include:
Review of the facility's policy Abuse, Neglect,, Exploitation, or Mistreatment, with a revision date of 11/1/17 revealed The facility's leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately.
R1 was admitted to the facility on [DATE] from an acute care hospital. Review of R1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. R1 has diagnoses including but not limited to; age-related physical debility, acquired absence of left leg, and muscle weakness. R1 requires assistance with activities of daily living (ADL)s.
Review of R1's care plan revealed no evidence related to R1's ability to sign himself out of the facility, unsupervised.
Review of R1's Physician Orders did not indicate an order allowing R1 to sign himself out.
An observation of R1 on 5/15/23 at 06:42 PM revealed R1 was appropriately dressed without odors noted.
Review of R1's elopement assessment dated [DATE] revealed R1 was not at risk for elopement/wandering at this time. There was no other elopement assessment made available at the time of the survey.
During an interview on 5/15/23 at 6:15 PM, LPN1 reported that R1 did not elope from the facility. She stated he is alert and oriented and is capable of signing himself in and out of the facility. On this day, he signed himself out and went to the ball game. LPN1 reported that R1 is not an elopement risk.
During an interview on 5/15/23 at 6:42 PM, R1 revealed he left the facility and failed to sign himself out when he left. He stated he wanted to watch the baseball game and the police was called and this was the first time something like this has occurred. R1 reported he was fussed at by staff for not signing himself out to attend the ball game.
During an interview on 5/15/23 at 6:50 PM, the Administrator stated that R1 did not elope from the facility. She stated, R1 signed himself out of the facility and has a BIMS of 13 or 15. She reported that she received a phone call from the on-call nurse reporting that R1 was across the street at the ball game and saw a former nurse of the facility, who called the police and R1 did not understand why this occurred since he had previously watched the games.
During an interview on 5/15/23 at 8:43 PM, LPN2 reported to be R1's nurse on the night of the elopement and she was not aware that R1 was not in the facility. She reported passing medications on D hall and was going to pass some of the meds on C hall, as she and another nurse split that hall and she reported hearing staff say R1 was at the baseball game on 5/9/23. She reported working the 7:00 PM -7:00 AM shift and learned at 8:50 PM that R1 was not in the facility and walked over to the ball game get him at 9:00 PM. She reported she pushed him back in his wheelchair.
During an interview on 5/16/23 at 09:45 AM the DON reported R1 had 2 elopement assessments in the system. The DON reported getting a call at 9:30 PM on 5/9/23 from the Administrator informing her that a resident had left the facility. She was unsure at this time what resident had left the facility. The DON reported she called the facility and asked who was out of the building and a nurse reported that R1 was not in facility and had signed himself out and at this time this was all over Facebook. The DON stated, The receptionist at the front desk put the code in to allow R1 to leave and this would have occurred before 8:00 PM. The DON reported that when residents leave the facility, they ring the doorbell to come back into the facility. The DON said the facility interprets R1's leaving the facility as a leave of absences and not an elopement.
During an interview on 5/16/23 at 11:15 AM, the Receptionist revealed that R1 went to the front door and told her he had signed himself out of the facility at the nurse' station. The Receptionist could not confirm the time R1 left and estimated it to be between 6:00 and 6:30 PM on 5/9/23. The Receptionist was asked what time R1 returned to the facility, and she reported prior to her leaving for the day, which is between 8:00 PM and 8:05 PM. The Receptionist confirmed she does not verify with the nurses' station if a resident signs out, she takes their word. She also confirmed she did not notify anyone of R1 being out of the building.
Review of the Leave of Absence (LOA) sign in/out log revealed a signature, however, it indicated a time of 8:02, with no indication of AM/PM. The Receptionist confirmed R1 was supposed to be back in the facility prior to her leaving, so she was unsure how he got back out of the facility.
During an interview on 5/16/23 at 1:06 PM, the Social Worker (SW) reported being advised about R1 leaving the facility on 5/10/23 when she reported to work. She said R1 went to a baseball game. She said I do not get any information about him signing himself out, just that he was found at the baseball field and no time given. The SW reported not being aware of R1 going to the games.
The facility's removal plan included:
1. R1 has a BIMS level 15 reviewed on 05/09/23 and was reviewed by Nurse Practitioner on 05/16/23, no concerns with LOA privileges.
2. Review of Sign in/Sign out LOA log revealed R1 signed out 8:02 on 05/09/23.
3. Facility staff completed an audit of all the remaining residents. All residents were accounted for on 05/09/23.
4. Phone interview completed with evening receptionist. Statement obtained. Resident did not elope independently, signed LOA. Receptionist allowed him to leave.
5. Exit doors locked and secure. Audit revealed exits secure, environment safe.
6. Residents at risk for elopement accounted for with wanderguard in place.
7. R1 re-educated on LOA process, verbalized understanding.
8. Staff re-educated on LOA process with focus on checking sign in/out binder to validate in house census.
9. Re-education on F600/F689. Staff not present will received prior to next scheduled shift after 05/16/23.
-Residents at risk for elopement have the potential to be affected. Residents at risk for elopement accounted for with wanderguard in place.
-Capable residents with a BIMS of 15 or higher with privileges will be re-educated on LOA process.
-The DON will randomly interview a minimum of 2 staff and 2 capable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with LOA sign in/out process.
-The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months.
-The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with Maintenance Director to validate that doors are functioning properly.
-Adhoc QAPI held on 05/16/23. This process will be reviewed in QAPI for a minimum of 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and the review of the facility's policy, the facility failed to provide adequate supervision to prevent a successful elopement for 1 of 3 residents reviewed for accidents. Resident (R)1 had a successful elopement from the facility on 05/09/23 at an unspecified time and was without supervision for an extended period of time. R1 was found by the police at the baseball field, across the street from the facility on 05/09/23 around 08:50 PM and at 9:00 PM Licensed Practical Nurse (LPN)2 went to the baseball field and returned R1 back to the facility.
On 5/16/23 at approximately 10:00 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 5/16/23 at 10:50 AM, the Administrator was notified that the allegation of elopement for R1 constituted Immediate Jeopardy (IJ) at F689 and the IJ template was presented.
On 5/16/23 at 3:31 PM, the facility provided an acceptable plan of removal for the IJ. The IJ was lowered to a scope and severity of D for no actual harm with potential for more than minimal harm, that is not immediate jeopardy.
An extended survey was conducted on 5/16/23 due to the failure constituting substandard quality of care.
Findings include:
Review of the facility's policy titled, Leadership Policies and Procedure subject Elopement, last revised November 1, 2017, revealed, To safely and timely redirect patients/residents to a safe enviroment.
R1 was admitted to the facility on [DATE] from an acute care hospital. Review of R1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. R1 has diagnoses including but not limited to; age-related physical debility, acquired absence of left leg, and muscle weakness. R1 requires assistance with activities of daily living (ADL)s.
Review of R1's care plan revealed no evidence related to R1's ability to sign himself out of the facility, unsupervised.
Review of R1's Physician Orders did not indicate an order allowing R1 to sign himself out.
An observation of R1 on 5/15/23 at 06:42 PM revealed R1 was appropriately dressed without odors noted.
During an interview on 5/15/23 at 6:15 PM, LPN1 reported that R1 did not elope from the facility. She stated he is alert and oriented and is capable of signing himself in and out of the facility. On this day, he signed himself out and went to the ball game. LPN1 reported that R1 is not an elopement risk.
During an interview on 5/15/23 at 6:42 PM, R1 revealed he left the facility and failed to sign himself out when he left. He stated he wanted to watch the baseball game and the police was called and this was the first time something like this has occurred. R1 reported he was fussed at by staff for not signing himself out to attend the ball game.
During an interview on 5/15/23 at 6:50 PM, the Administrator stated that R1 did not elope from the facility. She stated, R1 signed himself out of the facility and has a BIMS of 13 or 15. She reported that she received a phone call from the on-call nurse reporting that R1 was across the street at the ball game and saw a former nurse of the facility, who called the police and R1 did not understand why this occurred since he had previously watched the games.
During an interview on 5/15/23 at 8:43 PM, LPN2 reported to be R1's nurse on the night of the elopement and she was not aware that R1 was not in the facility. She reported passing medications on D hall and was going to pass some of the meds on C hall, as she and another nurse split that hall and she reported hearing staff say R1 was at the baseball game on 5/9/23. She reported working the 7:00 PM -7:00 AM shift and learned at 8:50 PM that R1 was not in the facility and walked over to the ball game get him at 9:00 PM. She reported she pushed him back in his wheelchair.
During an interview on 5/16/23 at 09:45 AM the DON reported R1 had 2 elopement assessments in the system. The DON reported getting a call at 9:30 PM on 5/9/23 from the Administrator informing her that a resident had left the facility. She was unsure at this time what resident had left the facility. The DON reported she called the facility and asked who was out of the building and a nurse reported that R1 was not in facility and had signed himself out and at this time this was all over Facebook. The DON stated, The receptionist at the front desk put the code in to allow R1 to leave and this would have occurred before 8:00 PM. The DON reported that when residents leave the facility, they ring the doorbell to come back into the facility. The DON said the facility interprets R1's leaving the facility as a leave of absences and not an elopement.
During an interview on 5/16/23 at 11:15 AM, the Receptionist revealed that R1 went to the front door and told her he had signed himself out of the facility at the nurse' station. The Receptionist could not confirm the time R1 left and estimated it to be between 6:00 and 6:30 PM on 5/9/23. The Receptionist was asked what time R1 returned to the facility, and she reported prior to her leaving for the day, which is between 8:00 PM and 8:05 PM. The Receptionist confirmed she does not verify with the nurses' station if a resident signs out, she takes their word. She also confirmed she did not notify anyone of R1 being out of the building.
Review of the Leave of Absence (LOA) sign in/out log revealed a signature, however, it indicated a time of 8:02, with no indication of AM/PM. The Receptionist confirmed R1 was supposed to be back in the facility prior to her leaving, so she was unsure how he got back out of the facility.
During an interview on 5/16/23 at 1:06 PM, the Social Worker (SW) reported being advised about R1 leaving the facility on 5/10/23 when she reported to work. She said R1 went to a baseball game. She said I do not get any information about him signing himself out, just that he was found at the baseball field and no time given. The SW reported not being aware of R1 going to the games.
The facility's removal plan included:
1. R1 has a BIMS level 15 reviewed on 05/09/23 and was reviewed by Nurse Practitioner on 05/16/23, no concerns with LOA privileges.
2. Review of Sign in/Sign out LOA log revealed R1 signed out 8:02 on 05/09/23.
3. Facility staff completed an audit of all the remaining residents. All residents were accounted for on 05/09/23.
4. Phone interview completed with evening receptionist. Statement obtained. Resident did not elope independently, signed LOA. Receptionist allowed him to leave.
5. Exit doors locked and secure. Audit revealed exits secure, environment safe.
6. Residents at risk for elopement accounted for with wanderguard in place.
7. R1 re-educated on LOA process, verbalized understanding.
8. Staff re-educated on LOA process with focus on checking sign in/out binder to validate in house census.
9. Re-education on F600/F689. Staff not present will received prior to next scheduled shift after 05/16/23.
-Residents at risk for elopement have the potential to be affected. Residents at risk for elopement accounted for with wanderguard in place.
-Capable residents with a BIMS of 15 or higher with privileges will be re-educated on LOA process.
-The DON will randomly interview a minimum of 2 staff and 2 capable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with LOA sign in/out process.
-The Maintenance Director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months.
-The Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with Maintenance Director to validate that doors are functioning properly.
-Adhoc QAPI held on 05/16/23. This process will be reviewed in QAPI for a minimum of 3 months.

Based on interviews, documentation review, and review of the facility policy, the facility failed to ensure sufficient and competent nursing staffing. For 35 Certified Nursing Assistants (CNA)s annual training reviewed, 7 did not have a minimum of 12 hours of annual training. The facility failed to provide nurse aide in-services, to include at least 12 hours annual training for CNAs #1-7.
Findings include:
Review of the facility's policy titled: In-Service Training and Education HR Policy 7.2, last revised 1/2007, revealed Employees will receive necessary training to perform job responsibilities. Training and education will be provided to meet the entity's procedures and will comply with any applicable licensing or accrediting body regulation or state and federal mandates.
Review of the facility's expectations revealed, In addition to the in-service required for all employees, departments develop and provide periodic in-services to meet the specific education and training needs of their employees and requirements of licensing and regulatory agencies or state and federal laws.
Review of the provided in-service training hours provided by the Director of Nursing (DON) revealed the following:
CNA1 with a hire date of 11/06/18 obtained 7.5 hours of annual training.
CNA2 with a hire date of 12/09/20 obtained 6.75 hours of annual training.
CNA3 with a hire date of 07/30/19 obtained 10.25 hours of annual training.
CNA4 with a hire date of 04/26/06 obtained 10.25 hours of annual training.
CNA5 with a hire date of 11/11/21 obtained 11.50 hours of annual training.
CNA6 with a hire date of 03/24/20 obtained 10.25 hours of annual training.
CNA7 with a hire date of 05/22/18 obtained 1.75 hours of annual training.
During an interview on 5/16/23 at 3:45 PM the Administrator revealed she was not aware the 7 CNAs in question did not have the minimum 12 hours of training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record reviews, and interviews, the facility failed to notify the Department of an elopement. On 05/09/23 at an unidentified time, Resident (R)1 was found to not be in the facility. R1 was located across the street from the facility at the ball field.
Findings include:
Review of the facility's policy Abuse, Neglect,, Exploitation, or Mistreatment, with a revision date of 11/1/17 revealed The facility shall report immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation due to not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protection services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
R1 was admitted to the facility on [DATE] from an acute care hospital. Review of R1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. R1 has diagnoses including but not limited to; age-related physical debility, acquired absence of left leg, and muscle weakness. R1 requires assistance with activities of daily living (ADL)s.
Review of R1's care plan revealed no evidence related to R1's ability to sign himself out of the facility, unsupervised.
Review of R1's Physician Orders did not indicate an order allowing R1 to sign himself out.
During an interview on 5/15/23 at 6:42 PM, R1 revealed he left the facility and failed to sign himself out when he left. He stated he wanted to watch the baseball game and the police was called and this was the first time something like this has occurred. R1 reported he was fussed at by staff for not signing himself out to attend the ball game.
During an interview on 5/15/23 at 6:50 PM, the Administrator stated that R1 did not elope from the facility. She stated, R1 signed himself out of the facility and has a BIMS of 13 or 15. She reported that she received a phone call from the on-call nurse reporting that R1 was across the street at the ball game and saw a former nurse of the facility, who called the police and R1 did not understand why this occurred since he had previously watched the games. The Administrator confirmed this was not reported due to her feeling it was not an elopement.