Oakmont Guest Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or at the option of the physician, after the initial visit, alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for four of 10 residents (Residents #1, #5, #9 and #10) reviewed for physician services.<BR/>1. The facility failed to ensure Residents #1 was seen one every 30 days for the first 90 days after admission. <BR/>2. The facility failed to ensure Residents #5, #9 and #10 were seen by the facility's attending physician and/or the physician's extender at least once every 60 days. The physicians were, however, consulted about critical lab values and changes in condition.<BR/>These failures could place residents at risk of not receiving appropriate and adequate medical care and a lack of oversight by the physician, which could place the residents at risk of harm and health decline. <BR/>Findings include:<BR/>1. Record review of Resident #1's quarterly MDS assessment, dated 06/21/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her active diagnoses included non-Alzheimer's dementia (the loss of cognitive functioning-thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech), cerebrovascular accident (an interruption in the flow of blood to cells in the brain), multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), anxiety [a feeling of fear, dread, and uneasiness], depression [Feelings of sadness, tearfulness, emptiness or hopelessness] and hypertension (is when the pressure in your blood vessels is too high). Resident #1 had unclear speech, was usually understood by others and she sometimes understood others (responds to simple, direct communication only) and had a BIMS score of 07, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium (inattention, disorganized thinking or altered level of consciousness), no mood issues, and no behaviors which included psychosis (hallucinations and delusions), no physical and verbal behaviors, no rejection or care or wandering. Resident #1 required limited assistance with her ADLs of one person and used a walker and wheelchair for ambulation. Resident #1 received antidepressant medication as the only psychoactive medication at the time of the MDS assessment and she was not on hospice care.<BR/>Record review of Resident #1's care plan, initiated on 03/23/23 and last revised 05/17/23, reflected only four care planned areas: 1) Risk for Harm: Self Directed or Other- Directed r/t Mood Disorders Secondary to clinical diagnosis of depression; 2) Acute pain/Chronic Pain; 3) Limited physical mobility related to multiple sclerosis [an autoimmune disease that affects the brain and spinal cord (central nervous system)]; and 4) a fall on 03/11/23. <BR/>Record review of Resident #1's face sheet, dated 08/15/23, reflected her current physician was MD D as of 07/31/23. Prior to that date, her previous attending physician was noted in her chart as PHY DD. <BR/>Record review of Resident #1's clinical chart reflected no evidence of any physician or physician extender visits since her admission to the facility on [DATE]. <BR/>Record review of Resident #1's August 2023 physician orders reflected she was prescribed the current medications while under PHY DD's medical care: Acetaminophen Rectal Suppository 650 MG one capsule rectally every six hours as needed for pain, B-Complex Oral Tablet one tablet by mouth one time a day for vitamin, Bisacodyl Rectal Suppository 10 MG one capsule rectally every 6 hours as needed for constipation, Donepezil HCl Oral Tablet 10 MG one tablet by mouth at bedtime for psychotherapeutic agent, Duloxetine HCl Oral Capsule Delayed Release Particles 30 MG three capsules by one time a day for depression, Ezetimibe Oral Tablet 10 MG one tablet a day for hyperlipidemia[an elevated level of lipids- like cholesterol and triglycerides in the blood], Levothyroxine Sodium Oral Tablet 75 MCG one tablet by mouth in the morning for hypothyroidism [A condition where the thyroid does not create and release enough thyroid hormone into your bloodstream which could make the metabolism slow down], [NAME]/SL Sublingual Tablet Sublingual 0.125 MG (Hyoscyamine Sulfate) Give one tablet sublingually every four hours as needed for oral secretions, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give one tablet by mouth three times a day for decreased blood pressure, Morphine Sulfate Oral Solution 20 MG/5ML 0.25 ml by mouth every three hours as needed for pain, Rosuvastatin Calcium Oral Tablet 20 MG one tablet by mouth at bedtime for treating high cholesterol, Seroquel Oral Tablet 25 MG 0.5 tablet by mouth at bedtime for agitation related to unspecified psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality] , Tylenol Oral Tablet 325 MG give two tablets by mouth every six hours as needed for Pain, Vitamin D-3 Oral Tablet 125 MCG (5000 UT), Cholecalciferol one tablet by mouth one time a day for vitamin, and Zofran Oral Tablet 4 MG one tablet by mouth every six hours as needed for Nausea/Vomiting.<BR/>Record review of Resident #1's nursing progress notes reflected the following medical/health issues:<BR/>-03/18/23-Resident #1 had a critical lab for Potassium with a value of 6.6 (reference range is 3.5-5.1) and a Glucose value of 699 (reference range is 74-109). (Note: High potassium levels may be a sign of kidney disease; too much potassium may mean the kidneys are not working well; Blood sugar more than 600 can cause a coma. Dangerously high blood sugar levels cause ketoacidosis which is a serious diabetic complication where the body produces excess blood acids-ketones)<BR/>-06/11/23-Resident #1 had a fall which resulted her being sent to the ER. Resident #1 had a hematoma in the center of forehead her measuring 5x5 cm and under her right eye with a laceration measuring 3cm x 1 cm that was glued in the ER. <BR/>-06/11/23-Resident #1's blood sugar was noted to be 600, and her attending physician was notified (PHY DD) and stated to administer one time order of 3 units of insulin. <BR/>-07/14/23- [LVN A] was notified of Resident #1 attempting to leave facility (front entrance). Resident stated, I want to leave why am I here Nurse contacted hospice for PRN medication. <BR/>-07/27/23- Hospice RN ordered Seroquel for Resident #1 at bedtime due to agitation.<BR/>-07/31/23- A new order was received to change Resident #1's primary physician to MD D.<BR/>-08/07/23- Resident #1 was showing signs of hypoglycemia [a condition in which the blood sugar (glucose) level is lower than the standard range], was sweaty and slumped over in her walker. A finger stick blood sugar reflected her blood glucose was 40.The nurse administered Glucagon 1mg IM . Resident #1 was able to get back to baseline and her fsbs was 87. <BR/>-08/17/23- Resident experienced change of condition (dizziness, slowly eating and speaking). MD order implemented for rehydration and insulin monitoring ongoing. Stat Cath UA, CBC, and CMP, Doxycycline 100 mg BID for seven days for Sepsis; IV NS at 70 ML/Hr. x 3 liters. <BR/>2. Record review of Resident #5's annual MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's active diagnoses included aphasia (loss of ability to understand or express speech), dysphagia (swallowing difficulties), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and arm contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Resident #5 had unclear speech, was rarely understood and had short/long term memory deficits. Resident #5 required one person physical assistance for all ADLs and had range of motion impairment on one side of her upper extremity. She used a wheelchair for mobility. <BR/>Record review of Resident #5's care plan, initiated 05/15/23 and last revised on 08/14/23, had three focus areas: 1) Resident #5 was resistive to care and would refuse care such as medications, ADL care, lab draws; 2) Resident #5 had an actual fall related to poor safety awareness and unsteady gait; and 3) Resident #5 used an anti-depressant.<BR/>Record review of Resident #5's face sheet, dated 08/15/23, reflected her current physician was PHY BB as of 07/31/23. Prior to that date, her previous attending physician was noted in her chart to be PHY DD.<BR/>Record review of Resident #5's clinical chart reflected no evidence of any physician or physician extender visits from PHY DD from 03/21/23 to 08/01/23, when she was seen by her new doctor, PHY BB.<BR/>Record review of Resident #5's August 2023 physician orders reflected she was prescribed the following, current, medications while under PHY DD's medical care: Acetaminophen Tablet 325 MG give two tablets by mouth every four hours as needed for pain, aspirin 81 mg chewable once a day for heart disease, Atorvastatin 40 mg once a day for heart disease, Calcium-Cholecalciferol Oral Tablet 500-5 MG-MCG -one tablet one time a day for supplement, Clopidogrel 75MG one tablet once a day for Cerebrovascular disease, Magnesium oxide 400mg once a day for muscle wasting and atrophy, Melatonin Oral Tablet 5 MG (Melatonin) once at bedtime for insomnia, Nifedipine 60 mg ER on ce a day for hypertension, Pantoprazole Sodium 40 mg once in the morning for bacterial infection unspecified and Sodium Bicarbonate 650 mg twice a day for acid reduction. <BR/>Record review of Resident #5's nursing progress notes reflected the following medical/health issue prior to PHY DD seeing her on 08/01/23:<BR/>-03/23/23-Resident #5 had a change of condition- She was noted to have numerous cavities to top and bottom teeth and was in pain. Resident #5 ended up having a dental infection and required antibiotics for ten days.<BR/>-04/20/23-Resident #5 noted to have decline in weight possibly indicating malnutrition. PHY DD notified received order for labs: CMP and Albumin.<BR/>-05/02/23- BMP results for Resident #5 provided to PHY DD who stated, Not bad but poor kidney function-no new orders.<BR/>-0709/23-Resident #5 fell in her room, no injuries. <BR/>-07/31/23-Resident #5's primary attending physician changed from PHY DD to PHY BB. <BR/>-08/05/23- Resident #5's new attending physician (PHY BB) ordered STAT - CBC and CMP<BR/>-08/06/23-Resident #5 had a critical calcium value of 5.9 and was sent to the ER for further evaluation and was diagnosed with a UTI.<BR/>Record review of Resident #5's clinical chart reflected PHY DD did not write any progress notes over the course him being her attending physician from March 2023 through July 2023 to show he was monitoring her health conditions and medications.<BR/>3. Record review of Resident #9's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #9's active diagnoses included Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), essential tremors (a type of involuntary shaking movement), hyperlipidemia (An excess of fats or lipids in the blood), peripheral vascular disease (a slow and progressive circulation disorder) and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). Resident #9 had short/long term memory deficits and moderately impaired cognitive skills for daily decision making. Resident #9 had signs and symptoms of delirium as evidenced by continuously present inattention, as well as mood issues that involved trouble with concentration. Resident #9 required one person physical assistance for all ADLs, was always incontinent of bowel and bladder and used a wheelchair for mobility. <BR/>Record review of Resident #9's care plan, dated 02/01/23 and last revised on 03/29/23, reflected the following care areas: 1) High risk for falls, 2) Requires staff assist for ADLs, 3) Behavior of sleeping on the floor, 4) Impaired cognitive function and thought processes due to dementia, 5) Diagnosis of hypertension related to lifestyle choices, 6) Use of anti-depressant medication due to sleep disturbances, 7) Resident is on anti-Parkinson medication therapy, 8) Risk of skin integrity impairment due to incontinence, and 9) Impaired visual function related to cataracts.<BR/>Record review of Resident #9's face sheet, dated 08/15/23, reflected his current physician was PHY BB as of 07/31/23. Prior to that date, his previous attending physician was noted in his chart to be PHY DD.<BR/>Record review of Resident #9's clinical chart reflected no evidence of any physician or physician extender visits PHY DD from 03/01/23 to 08/01/23, until when he was seen by his new doctor, PHY BB.<BR/>Record review of Resident #9's August 2023 physician orders reflected he was prescribed the following current medications while under PHY DD's medical care: Folic acid 1 MG once a day, Magnesium Oxide 400MG once a day for anemia, Pravastatin Sodium 40GM once a bedtime, Ropinirole HCL 1 MG once at bedtime, Tamsulosin 0.4MG once a day for benign prostate, Trazadone HCl Oral Tablet 50 MG give 1.5 tablet by mouth at bedtime for insomnia, Vitamin D3 Oral Tablet 125 MCG once a day for anemia, and Carbidopa-Levo 25MG-100MG four times a day.<BR/>4. Record review of Resident #10's quarterly MDS assessment, dated 06/30/23, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with active diagnoses which included macular degeneration [an eye disease that can blur your central vision], polyneuropathy [the simultaneous malfunction of many peripheral nerves throughout the body], peripheral vascular disease [the reduced circulation of blood to a body part other than the brain or heart], hypertension [when the pressure in your blood vessels is too high (140/90 mmHg or higher)] and hyperlipidemia [an elevated level of lipids like cholesterol and triglycerides in the blood] . Resident #10 had a BIMS score of 10, which indicted no cognitive impairment. Resident #10 required one person physical assistance for all ADLs except eating, which she required supervision only. Resident #1 used a walker for mobility, had frequent pain present that was mild and was on a scheduled pain regimen. Resident #10 received a diuretic medication. <BR/>Record review of Resident #10's care plan, initiated and dated 08/11/23, reflected the following care areas: 1) Resident #10 had a diagnosis of hypertension, 2) Resident #10 had a diagnosis of hyperlipidemia , 3) At risk for falls related to vision/hearing problems and unsteady gait, 4) On diuretic therapy related to edema, 5) Potential for nutritional problem related to obesity, 6) Had chronic pain, 7) At risk for breakdown in skin integrity, and 8) Impaired visual function due to macular degeneration.<BR/>Record review of Resident #10's face sheet, dated 08/15/23, reflected her current physician was PHY BB as of 07/31/23. Prior to that date, her previous attending physician was noted in his chart to be PHY DD.<BR/>Record review of Resident #10's clinical chart reflected no evidence of any physician or physician extender visits from PHY DD from 03/01/23 to 08/01/23.<BR/>Record review of Resident #10's August 2023 physician orders reflected she was prescribed the following current medications while under PHY DD's medical care: Preservision 1.25MG twice a day for dry eye, Senexon-S 8.6MG-50MG once a day, Tramadol 50 MG once every eight hours as needed for pain, Tylenol Oral Tablet 325 MG two tablets every four hours as needed for pain, Vitamin D3 Oral Capsule 50 MCG twice a day for vitamin deficiency, Acetaminophen PM Extra Strength Oral Tablet 500-25 MG two tablets at bedtime for pain, Amlodipine Besylate-Benazepril 5 MG-20 MG twice a day for hypertension, Biotin 5000MCG CAPSULE once a day for vitamin deficiency, HCTZ [Hydrochlorothiazide] 25MG once a day for edema, Lovastatin 40 MG once at bedtime for hyperlipidemia, and Neurontin Oral Capsule 100 MG (Gabapentin) two capsule by mouth three times a day for nerve pain.<BR/>An interview with ADON C on 08/11/23 at 2:26 PM revealed she had been employed at the facility for a few weeks and she did not know how often the attending physicians were supposed to see their residents. She stated usually MDS and medical records staff would remind the doctors when their visits were due. ADON C stated the importance of physician visits were to make sure the residents were being followed up on and medications were verified during those visits. She said the physicians were supposed review medication during their face-to face visits, make sure everything was good and nothing was being missed and it also gave the resident a chance to talk to them directly. ADON C stated, It is critical.<BR/>An interview with LVN F on 08/11/23 at 3:46 PM revealed she was the MDS coordinator and typically medical records oversaw the physician visits because that department received the physician notes directly, they had a link or an email and they could also e-fax them. LVN F stated the physicians were supposed to send in their notes and if a physician was late on a visit, medical records was supposed to contact them to get any progress notes or see if they visited their resident(s). She said if the physician was not visiting, the ADM should be notified. LVN F stated the risk of the physicians not completing their visits per the required timeframes could be an issue if medications were not being reviewed as needed. LVN F stated, Face to face visits are important because they need to lay eyes on their patients, for one to ensure, that is your patient and they are physically still here, but also to sit and visit to get their residents' input on their care. LVN F stated the facility had some issues with three physicians recently and they were let go.<BR/>An interview with MR on 08/11/23 at 4:22 PM revealed he had some issues with PHY DD and a couple other physicians getting his notes to the facility. MR stated he was supposed to reach out to PHY DD and he was having some problems with him providing those progress notes from his visits. He said, So I guess when the new ADM started, I guess he got rid of them . MR stated he tried to keep track of the when each physician was due to visit and if he saw the physicians in the facility, he would get progress notes from some of them . <BR/>An interview with the ADM on 08/11/23 at 4:38 PM revealed when he started working at the facility (which he claimed was a month prior), he heard through the DON there were some doctors not turning in their notes or doing visits, so the facility terminated three of their contracts. He said he knew it was an issues and even though he was a newer Administrator, he was on it and the facility was trying to get new processes in place. The ADM stated he had not had a QAPI on that issue yet or completed a PIP, but he was working on it and knew it was already an issue. <BR/>Interview with NP K on 08/15/23 at 12:55 PM revealed she was the nurse practitioner for the medical director (MD D) and they had recently picked up about 25 residents on their caseload at the end of July 2023 due to some issues with the other attending physicians. She said she was still in the process of making sure everyone had been seen and reviewing orders and labs. NP K said she did not know what was going on with the other physicians and did not know about any concerns, only that they were gone and she and MD D had new residents as a result. <BR/>An interview with LVN H on 8/15/23 at 1:47 PM revealed he was told some of the attending physicians did not have residents on their caseload anymore, and he did not know why. He said he did see them come out to visit their residents, including PHY DD . <BR/>An interview with the ADM and DON on 08/15/23 at 2:19 PM revealed medical records staff was supposed to oversee the physician visits and ensure they were turning in their progress notes and completing their visits. She said as far as care issues and concerns, the DON would contact the doctor. The DON was not sure when the physicians were supposed to complete a face-to-face visit with their resident but stated the three physicians who were transitioned away from working at the facility (which included PHY DD) had chronic issues and warnings from previous administrators and she and the current administrator inherited the issue. The DON said they had now switched over and between MD D and his NP K, who were in the facility once a week, they were getting everyone caught up on their visits and progress notes. The ADM stated the physicians (to include PHY DD) did come to the facility, text and call the nurses, but the follow up was slower with the nurses and receiving orders. The DON then stated the risk of the physicians not visiting the residents face to face and providing progress notes at those visits was, Just poor outcome, not reviewing medications for necessary changes, not having progress notes for review, it could affect how the interdisciplinary team is approaching care. We need communication.<BR/>An interview with MD D on 08/23/23 at 1:00 PM revealed he was the medical director for about a year and he was aware the attending physicians were not keeping up, answering phone calls and the facility finally made the decision to dismiss three of them in July 2023 (to included PHY DD). MD D stated he would see the physicians in the facility, such as PHY DD and word of mouth is that they were seeing the residents, just not doing documentation, I don't know how they got paid. I was actually seeing them and saying hi to them and I wasn't aware of their lack of documentation. I heard through the grapevine one of the doctors has everything hand-written at home .<BR/>Record review of the facility's policy titled, Physician Services, revised February 2021, reflected, .7. Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 resident (Residents #1) of 7 residents reviewed for respiratory care. -The facility failed to ensure that Residents #1, who required continuous oxygen therapy, received adequate oxygen when his portable oxygen tank ran out of oxygen while the resident was in the community at an appointment on 10/29/2025. Resident #1 was transported to the local hospital and diagnosed with acute hypoxia (low levels of oxygen) The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 10/29/25 and ended on 10/30/25. The facility had corrected the non-compliance before the state's investigation began. This failure could place residents who receive oxygen therapy at risk of receiving inadequate oxygen support, which could result in serious harm or death.Findings included:Record review of Resident #1's face sheet, dated 10/31/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (lung disease) and acute and chronic respiratory failure. Record review of Resident 1's Nursing Home PPS MDS assessment, dated 09/12/25, reflected his BIMS score was 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required supervision to moderate assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1 had a primary medical condition of cardiorespiratory with other comorbidities that included chronic lung disease, asthma, and respiratory failure. Further review of this document, under Section O-Special Treatments, Procedures, and Programs, reflected Resident #1 received continuous oxygen therapy. Record review of Resident 1's care plan, revised 09/08/25, reflected the resident had altered respiratory status/difficulty and was on continuous oxygen therapy r/t acute and chronic respiratory failure with hypoxia. Interventions included: administering medication as orders, monitoring for effectiveness and s/sx of respiratory distress and reporting to the MD. Record review of Resident #1's consolidated physician orders, dated 10/31/25, reflected in part the following: -Oxygen at 2-4 lpm via nasal cannula continuous for COPD -start date: 10/31/25-Continuous BIPAP at night at bedtime-start date: 09/09/25 Record review of Resident #1's progress notes, dated 10/29/25 at 1:45 PM by ADON A, reflected the following: [Resident #1] on the way from dental appointment. [CNA D] report [Resident #1] is having SOB in transport although resident is on oxygen tank via nasal canula. [MD] informed HGB was 6.4 and [Resident #1] is now having SOB. Order given to send to [local hospital]. Transport pulled over van and 911 called. Record review of Resident #1's hospital records, dated 10/29/25, reflected in part the following: Chief Complaint: hypoxic- pt on 02 at baseline, was being transported to doctor's appointment by [transportation service] and ran out of 02, leading to hypoxia w/ Spo2 50% on EMS arrival. EMS implemented CPAP PTA and sats came up 100%. History of present illness:[Resident #1] is a 74 y.o. male with past medical history of chronic respiratory failure secondary to COPD and chronic diastolic CHF was transported from his long-term facility to a dental appointment where apparently he had longer than usual stay and his tank ran out of oxygen. EMS called and patient was noted to be hypoxic. The patient was then brought to the hospital for further evaluation. Upon arrival, the patient noted to be in acute on chronic respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide). In the ED, chest x-ray showed peripheral infiltrate (fluid/substance in lungs) over the right lower lobe. The patient was having difficulty breathing but was on BiPAP when interviewed. The patient denied any chest pain. Does complain of some shortness of breath. Denies any nausea vomiting or abdominal pain. No headache or blurry vision. In an interview on 10/31/25 at 10:43 AM, ADON A stated she worked at the facility for about 1 and 1/2 years. She stated Resident #1 had a dental appointment at the VA and he left the facility around 8:00 AM with a full portable oxygen tank. ADON A stated Resident #1 was escorted to his appointment by CNA D, and the appointment was expected to last about 30 mins because Resident #1 was only picking up new dentures. However, ADON A stated the appointment lasted longer than expected. She stated a full portable oxygen tank could last 3-4 hours, but Resident #1 was away from the facility for approximately 5 hours. ADON A stated around 1:00 AM, CNA D notified her that Resident #1 was complaining of shortness of breath. ADON A stated she advised them to pull the van over and call 911, and Resident #1 was transported to the local hospital. ADON A stated she had never experienced a resident running out of oxygen while away from the facility because the nurses always ensured they had full portable oxygen tanks before leaving, and the residents returned when expected. She stated the facility immediately held an IDT meeting and implemented interventions to prevent this from happening again. ADON A stated they updated the procedures for oxygen care to include sending an extra portable oxygen tank to appointments with residents who were on continuous oxygen therapy and training all staff on oxygen care. ADON A stated she had designated aides who escorted residents to all appointments with other aides who could assist if needed, and she ensured those staff were trained on how to check the oxygen tanks for oxygen levels and settings. She also stated that nurses were responsible for ensuring that the oxygen tanks were full and functioning while preparing the residents for their appointments, and aides were expected to assist with checking the oxygen tanks and reporting any issues to the nurses. In an interview on 10/31/25 at 12:35 PM, with the Assistant Administrator and DON, the DON stated the expectation was for the nurses to check all oxygen tanks before a resident left the facility to ensure the portable oxygen tanks were full and working properly. The DON stated the incident of Resident #1 running out of oxygen at his appointment was a huge learning lesson for the facility because it had never happened. The DON stated they updated the procedures to ensure that it did not happen again. The Assistant Administrator stated they prioritized in-servicing all dayshift staff since that was when resident appointments took place; however, the training was ongoing to include all staff before the start of their shifts. The DON stated not ensuring residents received adequate oxygen at all times could place them at risk of inadequate oxygen and death. In an interview on 10/31/25 at 12:51 PM, CNA D stated she worked at the facility since August 2025. She stated she escorted Resident #1 to his dental appointment on 10/29/25. CNA D stated she and the nurse checked Resident #1's portable oxygen tank before leaving the facility and it was full. She stated they left the facility at about 8:00 AM, and Resident #1 was fine during the ride to his appointment. She stated his appointment time was 9:00 AM; however, they waited a long time for the resident to be called back. CNA D stated after waiting at the clinic and waiting for transportation to pick them back up, it was 1:00 PM. CNA D stated they were on the van returning to the nursing facility when Resident #1 stated he could not feel any oxygen coming out of his cannula. CNA D stated she checked, and the oxygen was very low, so she called ADON A, and they were told to pull over and call 911. She stated Resident #1 was still able to talk but she could tell that he was having a hard time breathing. CNA D stated Resident #1 remained conscious until the EMTs arrived and transported him to the local hospital. She stated she escorted a lot of residents on appointments and that was the first time a resident ran out of oxygen. CNA D stated the following day she was in-serviced on oxygen care, which included a new procedure to take an extra portable oxygen tank on appointments with residents who were on continuous oxygen. CNA D stated the aides knew to check oxygen tanks to make sure they were full and to report any issues to the nurse. She stated the aides were not allowed to change or adjust the oxygen equipment. In an observation and interview on 10/31/25 at 3:08 PM, Resident #1 stated he had just returned to the facility from the hospital and felt better. Resident #1 stated he was admitted to the hospital for 2 days because they found that he also had pneumonia. Resident #1 stated he did not feel any symptoms of pneumonia while at the facility. He stated he resided at the facility for about 5 months and had never run out of oxygen at any time. Resident #1 stated he was at his dental appointment for a long time because the VA was slow. He stated he was fine while waiting at the appointment; however, on the way back to the facility, he remembered feeling like he could not breathe, and he let the aide know. Resident #1 stated he tried to remain calm, but it was scary not being able to breathe. He stated he felt himself blacking out before hearing 911 arrive, and that was all he could recall. Observation of Resident #1 revealed he was wearing a nasal cannula that was connected to an oxygen concentrator set on 3 lpm, and the resident showed no signs of respiratory distress. Review of the facility's policy titled Oxygen Administration, undated, revealed in part the following: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify that there is a physician's order for this procedure2. Assemble the equipment and supplies as needed.Further review of this document reflected it did not address transporting residents on continuous oxygen therapy. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 10/29/25 and ended on 10/30/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of a document provided by the Assistant Administrator titled AD HOC QA, dated 10/30/25, reflected an IDT meeting was held to discuss the failure and implement interventions. Record review of an in-service titled Transporting Residents on Oxygen, dated 10/30/25, reflected all staff, who were responsible for preparing residents and escorting them on appointments/outings, had been educated by ADON A on ensuring that residents receiving continuous oxygen therapy were transported with an extra portable oxygen tank. The education was ongoing to include all staff. Record review of an in-service titled Oxygen Tanks, dated 10/30/25, reflected all staff, who were responsible for preparing residents and escorting them on appointments/outings, had been educated by ADON A on ensuring that residents receiving oxygen therapy had oxygen tanks that were full and working properly. The education was ongoing to include all staff. Record review of an in-service titled Appointment Scheduling and Dashboard, dated 10/30/25, reflected central supply staff, ADON A, ADON B, and ADON C were all educated on monitoring appointments to ensure that residents who were on continuous oxygen therapy left the facility with a second regulator. In an interview on 10/31/25 at 10:43 AM, ADON A stated a chart audit was completed on all residents receiving oxygen therapy to ensure they had orders and care plans with appropriate intervention in place. Record review of a document provided by the Assistant Administrator titled Order Listing Report (O2), dated 10/30/25, reflected the facility had 20 residents receiving oxygen therapy, with 3 being on continuous oxygen therapy. Observation on 10/31/25 at 3:00 PM of the facility's oxygen closet revealed there were 36 extra portable oxygen tanks available and functioning. Interviews on 10/31/25 at various times from 9:30 AM-3:00 PM, conducted with the Assistant Administrator, DON, ADON A, ADON B, ADON C, nurses, MAs, and CNAs: CNA D (1st shift), LVN E (1st shift), CNA F (1st shift), CNA G (1st shift), MA H (1st shift), CNA I (1st/2nd double weekends), LVN J (2nd shift), CNA K (1st shift), LVN L (1st shift), CNA M (1st shift), CNA N (1st/2nd double weekends), LVN O (1st/2nd double weekends), CNA P (3rd shift), CNA Q (3rd shift), CNA R (2nd shift), LVN S (2nd shift), and CNA T (3rd shift) indicated they all participated in in-service trainings on 10/30/25. The nurses were able to state they were responsible for ensuring that residents who required oxygen therapy received treatment according to orders, always had adequate oxygen available, and residents who required continuous oxygen therapy had 2 full portable tanks when leaving the facility. The CNAs were able to state that while providing care to residents with portable oxygen tanks, they were responsible for checking the tanks to ensure there was adequate oxygen and to immediately notify the nurse of any issues. The Assistant Administrator, DON, and ADONs stated it was their responsibility to ensure the effectiveness of interventions. Interviews on 10/31/25 at various times from 10:00 AM-3:00 PM with Residents #1, #2, #3, #4, #5, #6, and #7, who all received oxygen therapy, revealed no concerns for respiratory care. All sampled residents denied ever running out of oxygen at the facility or while out in the community. Resident #1 stated the incident on 10/29/25 was the first time he had ever run out of oxygen since being admitted to the facility. Observations on 10/31/25 at various times from 10:00 AM-3:00 PM of Residents #1, #2, #3, #4, #5, #6, and #7, who all received oxygen therapy, revealed no s/sx of respiratory distress and they all had clean and working oxygen concentrators and portable oxygen tanks available Record reviews of EHRs for Residents #1, #2, #3, #4, #5, #6, and #7 revealed they all had orders and care plans that included appropriate interventions to address respiratory needs.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Residents #41, #28, #59, #83 and #105) of 20 residents observed for infection control.<BR/>1. LVN C failed to perform proper disposal of dressing materials after performing wound care for Resident #41.<BR/>2. LVN B failed to perform proper sanitization of equipment during blood sugar check for Resident #41 and Resident #28.<BR/>3. The facility failed to ensure Resident #105, who shared a room with Resident #83, was immediately isolated when the resident tested positive for COVID-19. <BR/>4. The facility failed to properly disinfect and handle the dietary cart and dishes used on the isolation hall and failed to ensure the dietary cart was properly disinfected after it was touched by Resident #59. <BR/>These failures placed all residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Observation on 02/07/23 at 12:31 PM during facility initial tour, revealed a soiled wound dressing discarded in the trash can that was left exposed with some of the dressing stuck on the edge of the trash can, in Resident #41's room.<BR/>Interview on 02/07/23 at 12:35 PM with LVN C, who was the charge nurse, revealed he had provided wound care to Resident #41 at around 11:00 AM. He stated he was aware he was supposed to use a biohazard bag while performing wound care or use a plastic bag and after procedure dispose soiled materials on the biohazard box in the biohazard room. He stated he did not have the biohazard bag on the nurse's cart, and he was in a hurry. He stated he forgot to dispose of the dressing materials properly by removing them from the room. He stated failure to dispose soiled dressing materials properly could lead to cross contamination then spread of infection. He stated he is aware of the right procedure, but he forgot. He stated he is from agency, and he had not received training in this facility on wound dressing and care of soiled dressings materials. <BR/>Interview with DON on 02/07/23 at 4:14 PM revealed his expectation was for nurses to discard the soiled dressing materials on biohazard bag or plastic bags. He stated he expected the nurse to use the plastic bags and after the procedure they should remove the bag from the resident room and discard in the biohazard box. He stated failure to discard the soiled materials properly could cause contamination and spread of infection. He stated he had done training on infection control with the facility staff but not with agency nurses, because he expected them to have basic knowledge from their companies. He stated he only orient the agency nurses on the unit on their first day.<BR/>Observation on 02/08/23 at 11:35 AM revealed LVN B perform hand hygiene and don gloves and prepared to check blood glucose level on Resident #41. She was observed cleansing the finger with alcohol pad and she pricked the resident finger and got the sample. She discarded the sharps on the sharp container and the soiled alcohol pad. She removed the gloves sanitized and recorded the readings. She did not disinfect the glucometer, and she wheeled her cart to another hall to check blood sugar levels for Resident #28.<BR/>Observation on 02/08/23 at 11:43 AM revealed LVN B perform hand hygiene and removed gloves and prepared to check blood glucose level on Resident #28. She took the glucometer machine from the top of her cart without disinfecting it. She was observed cleansing the finger with alcohol pad, she pricked the resident finger, and got the sample. She was observed using the same glucometer without disinfecting on Resident #28. She discarded the needle on the sharp container and the soiled alcohol pad. She removed the gloves sanitized and recorded the readings.<BR/>Interview with LVN B on 02/08/23 at 11:47 AM revealed she knew she was supposed to disinfect the glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in blood) between each resident and with every use to prevent contamination and spread of infection. She stated she was supposed to use the disinfectant wipes but she did not have some on her cart. She stated she did not have enough reason why she did not disinfect the glucometer machine because she had alcohol pads that she could have used. She stated she is an agency nurse and had not received training on infection control in this facility but she had been trained in another facility. She stated failure to disinfect the glucometer machine could lead to spread of infection from one resident to another.<BR/>Interview with DON on 02/08/23 at 1:30 PM revealed his expectation was the nurse to disinfect the glucometer after each use and between the residents. He stated if the nurses were not disinfecting the glucometer machine it could lead to cross contamination and spread of infection from one resident to another. He stated he had not trained the agency nurse because he expected them to have the basic knowledge on infection control.<BR/>3. An observation on 02/07/23 at 11:18 AM revealed Resident #105 was symptomatic with a cough and tested positive for COVID while sharing room with Resident #83.<BR/>An observation on 02/07/23 at 11:52 AM revealed Resident #83 was observed in the hall with no mask. Resident #83 put other residents at risk for COVID transmission.<BR/>An observation on 02/07/23 at 1:01 PM revealed Resident #83 was congregating with other residents in the hallway without a mask. Resident #83 confirmed that she was coming from a smoke break and had not been informed Resident #105 had tested positive for COVID. <BR/>An interview with the DON on 02/07/23 at 3:52 PM revealed Resident #83 was to have smoke breaks alone and not congregate with other residents. He stated COVID negative resident (Resident #83) had been sharing a room with COVID positive resident (Resident #105) since that morning. The DON stated COVID positive and COVID negative roommates are to be separated immediately. He stated if residents were not separated immediately, it could lead to cross contamination and spread of infection from one resident to another. <BR/>4. An observation and interview with the DON on 02/08/23 at 8:56 AM revealed, 100 hallway was the hall dedicated for COVID positive residents. Observation revealed a dietary cart on 100 hall with reusable dishes loaded on the dietary cart. The DON stated residents with COVID are to use only Styrofoam plates, cups, and eating utensils when eating to prevent the risk of cross contamination. He stated clean items enter at the front entrance on 100 hall and dirty items exit through the back door on 100 hall. <BR/>An observation and interview at 02/08/23 at 9:59 AM revealed the dietary cart had been placed outside the front entrance of 100 hall. Observation also revealed Resident #59 touching the dietary cart in an attempt to enter the 100 halls. Social Worker assisted Resident #59 away from 100 hall and to her room. Interview with RN E revealed that dietary cart would be picked up by dietary staff. When asked if it was to be picked up from that location, RN E replied, yes.<BR/>An observation on 02/08/23 at 10:09 AM revealed the dietary cart from 100 hall was sprayed with Comet Cleaner with Bleach and the dietary cart was not labeled with a dedicated hall. Dietary Aide F had allowed three minutes for contact time before she had rinsed dietary cart. <BR/>An interview with Dietary Aide F on 02/08/23 at 10:13 AM revealed the Comet disinfectant contact time was five min before rinsing. She stated if the correct contact time was not done then the dietary cart would still be contaminated and could make residents sick. <BR/>Record review revealed the correct contact time for Comet Cleaner with Bleach was 10 minutes before rinsing. <BR/>Review of the facility's Dressing, soiled/contaminated policy, dated August 2009, reflected: .1. Disposable items such as bandages, applicators, gauze pads etc., that are soiled or contaminated with ineffective material, blood, or body fluids must be placed in a plastic bag and removed from the resident's room upon completion of any procedure.<BR/>Review of the facility's Blood sampling -Capillary (finger sticks) policy, dated September 2014, reflected: .Following manufacturer's instructions, clean and disinfect reusable equipment, parts and /or devices after each use. <BR/>Review of the facility's policy titled COVID-19 Response for Nursing Facilities, dated 06/27/22, reflected: Once a case of COVID-19 is identified in the NF, immediate action must be taken to isolate the resident who is positive for COVID-19 away from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #10 and Resident #66) reviewed for ADLs.<BR/>The facility failed to ensure Resident #10, and Resident #66 had feeding assistance for more than 30 minutes after lunch trays were delivered to their rooms. <BR/>This failure could place residents at risk for not receiving appropriate care, assistance when needed, and decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #10's face sheet reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had diagnoses which included Huntington's Disease (progressive breakdown of nerve cells in the brain), Dementia, muscle weakness, lack of coordination, speech and language deficit, contracture of muscle in both left and right hands. <BR/>Record review of Resident #10's MDS, dated [DATE], reflected a BIMS score of 03, which indicated she had severe cognitive impairment. Her Functional Status indicated she required substantial/maximum assistance with eating and oral hygiene, and she was dependent on staff for personal hygiene. Section K - weight 103 pounds, no loss of 5% or more in the last month or loss of 10% or more in the last 6 months, Mechanically altered diet - while a resident.<BR/>Record review of Resident #10's care plan reviewed on 03/18/24 revealed Resident #10 has a daily living self-care performance deficit related to disease process (Huntington's Disease) and is dependent on staff for all daily living tasks. Goal: The resident's needs will be met. Interventions: Eating: resident is totally dependent on one staff for eating. Resident has potential nutritional problems related to being dependent on staff with feeding and being underweight. Goal: The resident's nutritional needs will be met as evidence by maintaining a steady weight and or gaining weight as prescribed by physician. Intervention: Monitor/record/report to physician signs and symptoms of malnutrition: Emaciation (thinness), muscle wasting and significant weight loss. Registered Dietician to evaluate and make diet change recommendations. <BR/>Resident has a swallowing problem related to history of stroke (Huntington Disease) Goal: Resident will not have injury related to aspiration. Intervention: The resident is a feeder and requires one staff member to assist with eating. <BR/>Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function was disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), chronic obstructive pulmonary disease (lung disease), Hypothyroidism (lack of hormones), <BR/>Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with eating. Section K - weight 102 pounds, no loss of 5% or more in the last month or loss of 10% or more in the last 6 months, Mechanically altered diet - while a resident. <BR/>Record review of Resident #66's care plan reviewed on 03/18/24 revealed focus areas: Diagnosis of Hypothyroidism (lack of hormones), Use of antidepressant medication, Chronic Pain related to primary Osteoarthritis (joint disease), Fibromyalgia (condition that causes widespread pain) all with interventions to monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. Care plan did not address Resident #66's concerns with weight loss; to have a health shake with lunch and dinner; or required assistance with feedings. <BR/>Record review of Resident #66's orders revealed: Health Shake two time a day provide Chocolate Health Shake twice daily. Start 02/29/24<BR/>Observation and interview on 03/18/24 at 12:20 PM, revealed Resident #66 in her room, in low bed, resting while Family Member was sitting at bedside. Observation prior to exiting Resident #66's room staff entered the room with pureed lunch tray; delivered it to bedside table not located near resident. According to Family Member Resident #66 was supposed to have assistance with her feeding, but since she was present staff may have expected her to do the feeding. <BR/>Observation on 03/19/24 between 12:55 PM-1:30 PM revealed staff was exiting Resident #10's room. When asked if she was facility staff and was going to assist Resident #10 with eating, she responded that she was hospice and she was headed to look for staff for assisting resident with eating. Resident #10 responded Yes that she was ready to eat. Resident #66 received her lunch tray; tray was sitting on bedside table not within reach. Resident #66's tray did not include a health shake. Resident #66 stated she was ready to eat and there had not been anyone to return to assist her with eating. Surveyor observed the hall for at least 30 minutes for noticing staff walked up to the nursing station. Surveyor asked staff to observe both Resident #10's tray sitting in front of her and Resident #66's food sitting on bedside table not within reach; and no one to assist either resident with eating their lunch. <BR/>Interview on 03/19/24 at 1:35 PM CNA K stated she would assist Resident #10 with eating and would contact someone else to assist Resident #66 with eating her lunch. According to CNA K, when staff are oriented to their halls that they are working, it was then expected for staff to know which residents required assistance with eating. CNA K stated the person doing the training and orientation will alert staff which residents required assistance with eating. CNA K stated it was the responsibility of the facility staff to ensure residents are being fed, however if a family member is present and want to do the feeding, it could be ok.<BR/>Observation on 03/19/24 at 1:45 PM revealed Family Member entered Resident #66's room to find Resident #66 was alone and lunch tray had not been touched. Family Member began assisting Resident #66 with her feeding. <BR/>Interview on 03/20/24 11:32 AM with LVN C revealed she was responsible for Resident #10 and Resident #66's hall on 03/19/24 and 03/20/24. LVN C stated she had dining room duty during lunch each day which left nurse aides on the floor to ensure each resident received their lunch trays and was assisted with eating. LVN C stated she was aware Resident #10 and Resident #66 required assistance with all meals. According to LVN C, CNA J was the CNA working on the hall and was responsible for ensuring residents were assisted with lunch on 03/19/24 and 03/20/24. According to LVN C she was not aware Residents #10 and #66 were delivered their lunch tray without assistance with eating. LVN C stated she expected aides on the hall to pass trays to all residents on the hall and assist those that required assistance with eating. LVN C stated she also could help with feeding assistance, however she was scheduled to work in the dinning hall, therefore aides are expected to find someone to come assist if they needed help with more than one resident. LVN C stated not assisting residents that require help with eating placed them at risk of malnutrition, vitamin deviancies', and starvation.<BR/>Interview on 03/20/24 at 1:57 PM with CNA I revealed she did not work on the hall with Residents #10 and #66, however she used to work with Resident #10 and knew she required assistance with eating so she would often come by to check on her. CNA I stated on 03/19/24 she did come by to check on Resident #10 but when she came by Resident #10 had already eaten her lunch. CNA I stated when working your hall, nurses and aides are alerted to which residents require assistance with eating. CNA I stated aides are responsible for ensuring that every resident on the hall had eaten. CNA I stated not doing so placed residents at risk of being weak and die, if you don't eat you are not strong. CNA I stated if there was a resident on the hall that had not eaten aides should report that information to the nurse. <BR/>Interview on 03/20/24 at 2:26 PM with CNA J revealed she is currently the CNA working on Resident #10 and #66's hall. CNA J stated she also was scheduled dining room duty and was also working a different hall. CNA J stated when the carts enter the hall everyone assist with passing out food trays. CNA J stated she was not able to identify who passed the lunch trays on 03/19/24, but it was the responsibility of the aide that passed the tray to stay with residents that require feeding assistance to ensure they eat. CNA J stated when she completed her dining room duty and walked the halls to begin her feeding duties, Resident #10 was being assisted by CNA K and Resident #66 was being assisted by a Family Member, so she went on to the next hall to check on other residents that required assistance with eating. CNA J stated she was responsible on 03/19/24 to ensure Resident #10 and #66 received assistance with eating, not doing so placed them at risk of not eating to meet their nutritional needs and could present a physiological effect. <BR/>Interview on 03/20/24 at 2:46 PM with CNA K revealed she was also the staffing scheduler. CNA K stated on 03/19/24 they had an aide that called off which left aides to fill in on the hall with Resident #10 and #66's. According to CNA K the goal was to divide up the hall, at lunch time the procedure included everyone available to help pass lunch trays. CNA K stated if you pass the tray, you should stay in the room to assist residents that required assistance with eating. CNA K stated Residents #10 and #66 should have had their trays passed last so staff are able to stay in the room and not leave the tray, allowing residents to see the food sitting in front of them and having to wait until someone else returned to assist them with feedings. According to CNA K the risk included neglect, leaving resident hungry, and ready to eat, looking at it and cause a negative reaction. <BR/>Interview on 03/20/24 at 05:09 PM the DON stated she was not aware who passed Resident #10's and #66's lunch tray because all available aides were responsible for passing trays on the hall. The DON stated her expectation was for nurses to assist aides with duties on the floor, feeding residents that require assistance was priority, it was not being monitored, it was expected. The DON stated ultimately the aide that worked Resident #10 and #66's hall was responsible for ensuring they delivered trays to residents that could feed themselves first and then deliver trays to residents that require assistance with eating and staying in the room to complete the feeding. The DON stated if the aide was not able to stay and complete the feeding, they should notify another aide to assist, contact their nurse or ADON or DON, someone to come and complete the task. The DON stated the risk included residents not receiving nutrition, becoming mentally disturbed, weight loss and all sorts of things are at risk for residents that required feeding assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 2 of 5 residents (Resident #14 and #98) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. <BR/>The facility's Pharmacist Consultant recommended Residents #14 and #98 antipsychotic medication Quetiapine required an additional consent on the Form 3713 to be completed and uploaded to the resident's chart.<BR/>These failures could place residents on psychotropic medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #14's face sheet dated 03/21/24 revealed the resident was a [AGE] year-old male who originally admitted to the facility 04/05/2023.The diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), delusional disorders and adjustment disorder with mixed disturbance of emotions.<BR/>Record review of Resident #14's quarterly MDS dated [DATE] revealed a BIMS score of 09 indicating he was moderately cognitive impaired. <BR/>Review of Resident #14's physician's orders reflected an order for: Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors, with a start date of 02/13/24.<BR/>Review of Resident #14's January 2024 MAR reflected the following: <BR/>Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors and indicated Resident #14 received the medication the entire month of January 2024.<BR/>Review of Resident #14's February 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors and indicated Resident #14 received the medication the entire month of February 2024.<BR/>Review of Resident #14's March 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 50MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors and indicated Resident #14 received the medication the entire month of March 2024.<BR/>Review of Resident #14's care plan, revised on 08/29/23, reflected: The resident uses psychotropic medications (Seroquel .) rule out behavior management.<BR/>Review of Resident #14's Medication Regimen Review, dated 01/30/24, reflected the following: Resident has an order for the antipsychotic medication, Quetiapine. Effective January 2022 consent is required to on Form 3713 provided by Texas Health and Human Services. Please ensure form is completed and uploaded to resident's chart.<BR/>2. Review of Resident #98's face sheet, dated 03/21/24, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included persistent mood disorders (a continuous, long-term form of depression), unspecified dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), and generalized anxiety disorder (a common mental disorder that makes you worry excessively about everyday thing).<BR/>Review of Resident #98's quarterly MDS Assessment, dated 02/15/24, reflected she had a BIMS of 14 indicating no cognitive impairment. <BR/>Review of Resident #98's physician's orders reflected an order for: Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders with a start date of 02/13/24.<BR/>Review of Resident #98's January 2024 MAR reflected the following: <BR/>Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders and indicated Resident #98 received the medication the entire month of January 2024.<BR/>Review of Resident #98's February 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders and indicated Resident #98 received the medication the entire month of February 2024.<BR/>Review of Resident #98's March 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders and indicated Resident #98 received the medication the entire month of March 2024.<BR/>Review of Resident #98's care plan, revised on 03/05/24, reflected: The resident uses psychotropic medications (Seroquel .) r/t behavior management.<BR/>Review of Resident #98's Medication Regimen Review, dated 01/29/24, reflected the following: Resident has an order for the antipsychotic medication, Quetiapine. Effective January 2022 consent is required on Form 3713 provided by Texas Health and Human Services. Please ensure form is completed and uploaded to resident's chart.<BR/>Interview on 03/21/24 at 4:08 PM with the DON revealed she was not aware Form 3713 was a requirement for psychotropic medications. The DON said regarding the pharmacy consultant recommendations that she was primarily responsible for following up on them but the ADON's also assisted. The DON said the Pharmacy Consultant was at the facility yesterday (03/20/24) and asked them about the Form 3713 and said it was for consents which the facility already had so the DON thought the facility had everything already . The DON said she had a chance to glance at the form and the purpose of it was for the doctor to evaluate the resident, give a diagnosis, and that the family has confirmed they had been notified and were aware of the medication being given. The DON said it was a separate version of the consent form already signed off for the medications the resident was receiving. The DON said it appeared to be a form the doctor would complete.<BR/>Record review of the antipsychotic medication use policy revised December 2016 did not address Form 3713.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #40) reviewed for unnecessary medications. <BR/>The facility failed to ensure Resident #40 had an appropriate diagnosis for her prescribed Seroquel (used to treat depression).<BR/>This failure could place residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.<BR/>Findings included:<BR/>Record review of Resident #40's admission Record, dated 04/10/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE].<BR/>Record review of Resident #40's Quarterly MDS Assessment, dated 03/24/25, reflected she had a BIMS score of 12 indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident/transient ischemic attack/stroke, non-alzheimer's dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), anxiety disorder (refers to a group of specific psychiatric disorders characterized by extreme fear or worry), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). For the medication review, it was noted Resident #40 received antipsychotics on a routine basis. <BR/>Record review of Resident #40's care plan, revised 01/24/25, reflected the following: Focus: [Resident #40] uses psychotropic medications -Resident takes Seroquel .Goal: [Resident #40] will reduce the use of psychotropic medication through the review date .Interventions: Administer PSYCHOTROPIC [sic] medications as ordered by physician.<BR/>Record review of Resident #40's Order Summary Report, dated 04/10/25, reflected the following :<BR/>- Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for ANTIPSYCHOTICS/ANTIMANIC AGENTS [sic], Take one tablet by mouth in the morning<BR/>Record review of Resident #40's April 2025 MAR reflected she received Seroquel every day as ordered.<BR/>Record review of Resident #40's Consultant Pharmacist/Physician Communication Report, dated 10/13/24, reflected: Dear [Physician A], This resident was admitted on an antipsychotic, Quetiapine. Please ensure approved psych diagnosis has been documented to support continued use .Physician/Prescriber Response 'acute on [illegible] psychosis'. The report was signed by Physician A on 10/17/24.<BR/>Record review of Resident #40's Medication Regimen Record review Report, dated 11/13/24, reflected: Resident has an order for the following medication. I recommend including a diagnosis to the medication order to support therapy. Quetipaine.<BR/>Observation and interview on 04/08/25 at 12:00 PM with Resident #40 revealed she was in her room with a family member. Resident #40 said she was doing okay today. <BR/>Interview on 04/10/25 at 3:27 PM with LVN B revealed she was caring for Resident #40. LVN B said she reviewed Resident #40's Seroquel order and saw that a diagnosis was missing. LVN B said there should be a diagnosis listed with the medication which would come from the doctor. <BR/>Interview on 04/10/25 at 3:50 PM with the Interim DON revealed normally the Charge Nurse would put an order for an antipsychotic medication into a resident's chart with the indications for use and a nurse manager, such as herself, would add the diagnosis. The Interim DON said Resident #40 should have had a diagnosis associated with her antipsychotic medication and staff should have caught that. The Interim DON said she just stepped into her role last week and the previous DON would have been responsible for ensuring the Pharmacist's recommendations were followed up on. The Interim DON said she was now responsible for them going forward, however. The Interim DON said the purpose was to complete or respond to the recommendations based on the regulations and to allow for communication between the pharmacist and the doctor to occur. The Interim DON said the previous DON was the only one following up on the recommendations and there was not anyone going behind her to ensure they were completed. The Interim DON said the previous DON was expected to complete the recommendations herself.<BR/>Interview on 04/10/25 at 4:15 PM with the Interim DON revealed the facility did not have a policy regarding pharmacy recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #66) of 6 residents reviewed for care plans.<BR/>1. The facility failed to develop a care plan for Resident #66 that addressed her use of dentures.<BR/>2. The facility failed to update Resident #66's care plan to address changes in diet texture, weight loss, or health shakes at lunch and dinner.<BR/>3. The facility failed to develop a care plan that addressed Resident #66's need to have assistance for eating. <BR/>4. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #66, hospice services.<BR/>These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs.<BR/>Findings included:<BR/>Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function is disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), Anemia (blood disorder), <BR/>Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with eating, substantial/maximum assistance with dental hygiene, and supervision/touching assistance with personal hygiene. Section L - Oral/Dental status revealed none of the above were present which included: Broken or loosely fitting full or partial denture. <BR/>Record review of Resident #66's care plan reviewed on 03/18/24 did not indicate she had or required the use of dentures. Resident #66's care plan did not address her change of diet to pureed texture, weight loss or need to have health shakes at lunch and dinner. Resident #66's care plan did not address her need to have assistance with eating. Resident's #66's care plan was not updated with measurable timeframes to address Resident #66 hospice services when she admitted on [DATE].<BR/>Record review of Resident #66's Order Summary Report dated 03/21/24, reflected: <BR/>Regular diet Pureed texture, Thin liquids consistency, health shakes with lunch and dinner (prefers chocolate flavor) for difficulties chewing. Start date 03/05/24.<BR/>Activity level: bedbound. Diet: comfort feeds as tolerated. Start date 03/07/24.<BR/>May see dentist, Start date 04/03/23.<BR/>Admit to Community Healthcare of Texas for Terminal Sepsis, Report change in condition or death. Start date 03/07/24.<BR/>Record review of Resident #66 progress note, dated 02/27/24 at 9:53 PM, written by the LVN reflected Resident #66 went to dental appointment with her Family Member, she came back with no new order, she has been sleeping since she came back, respiration 18, even and unlabored, no s/s of discomfort was notes, oncoming nurse to monitor. <BR/>Record review of Resident #66's progress note dated 02/28/24 revealed Resident #66 was seen by the dietician today with recommendations to add a chocolate health shake related to weight loss. Resident and Representative made aware. <BR/>Record review of Resident #66's physician order dated 03/05/24 revealed Regular diet, Pureed Texture, Thin Liquids consistency. Health Shakes with lunch and dinner (Prefers Chocolate flavor) for difficulties chewing. <BR/>Record review of Resident #66's Dietary Profile upon readmission on [DATE] revealed current diet order: Puree as tolerated, Current Texture of food: Regular, small portions, poor appetite, Eating/Chewing: Denture Both, Eating Assistance: Total Assistance<BR/>Observation and interview on 03/18/24 at 12:20 PM, revealed Resident #66 in her room, in low bed, resting while Family Member was sitting at bedside. When Resident #66 heard voices in the room she awoke and greeted the surveyor, revealing she did not have any teeth. According to the Family Member Resident #66 entered the facility almost a year ago, recently had a decline in weight. The Family Member stated she felt Resident #66's decline started when she lost her dentures about 4 months ago. The Family Member stated she spoke with facility about Resident #66's missing dentures, however they had never received any feedback. The Family Member stated she then decided to go outside the facility to replace the missing dentures since she never got any assistance from the facility. The Family Member stated it took a while before the facility provided Resident #66 with alternate accommodations for her to eat well. The Family Member stated the facility did not provide Resident #66 with health shakes. The Family Member stated she began to bring supplemental beverages for Resident #66 to ensure she was getting proper nutrition. Observation prior to exiting Resident #66's room revealed pureed lunch tray delivered to bedside table not near resident. Observation of Resident #66's meal ticket revealed she should have a shake at meals, however there was not a shake on the tray. According to the Family Member Resident #66 is supposed to have assistance with her feeding, but since she was present staff expected her to do the feeding. <BR/>Interview and record review on 03/20/24 at 3:33 PM with MDS Coordinator #1 and MDS Coordinator #2 about Resident #66's care plan missing documentation about her being admitting to hospice upon readmission to the facility. MDS Coordinator #2 stated when Resident #66 returned from the hospital she entered a focus area for hospice on her care plan dated 03/07/24. Surveyor pointed out there was not an entry indicated on the care plan prior to 03/20/24 and now the care plan was updated with hospice as of 03/18/24 made by MDS Coordinator #2. MDS Coordinator #1 stated the care plan for hospice was started and the care plan was left open so that facility staff, nursing staff could go into the care plan to edit up until the next care plan review. MDS Coordinator #1 denied updating hospice information on 03/18/24. According to both MDS Coordinators #1 and #2 it was important to have resident's care plan updated so that staff would be knowledgeable about each resident's care. MDS Coordinator #2 stated it was the responsibility of the nursing staff to keep resident's care plan updated at all times. MDS Coordinator #2 stated not updating the care plan with new order, activities of daily living and resident care needs placed residents at risk for not receiving proper care while in the facility. MDS Coordinator #2 stated upon admission they try to capture how to care for residents in every area. <BR/>Interview on 03/20/24 at 3:43 PM with ADON revealed the facility was missing the required focus areas on the care plan when came to hospice, nutrition, and eating. According to the ADON, MDS Coordinators could do the initial hospice, nutrition and any focus areas to the care plans. The ADON stated the nursing staff was also responsible to enter updated care plan information in any areas so that the nursing staff would be able to know how to care for residents. The ADON stated the care plans are required for all residents and not having care plans updated would place residents at risk of neglect. <BR/>Interview on 03/21/24 at 12:51 PM with ADON L revealed if residents had any changes in their care, she was responsible to ensure resident's care plan was updated. ADON L stated she was asked if Resident #66's care plan addressed eating requirements and when she looked, she noticed it had not been updated. ADON L stated she knew Resident #66 had dentures before January however she was not in the ADON's role at this time to ensure the care plan was updated with her use of dentures. ADON L stated while working on the floor she could recall the Family Member handling the issue with getting the dentures fitted properly for Resident #66. ADON L stated Family Member did bring up the concern for the dentures missing and tried looking for them. ADON L stated she did not bring it to anyone's attention to complete a grievance and she did not notify the Social Worker which was in charge of dental appointments. ADON L stated she did observe Family Member bringing in softer foods and after Resident #66's hospital visit when she started pureed foods. ADON L stated upon Resident #66's return from the hospital in February, she required assistance with eating. ADON L stated when staff passed the trays whomever passed Resident #66's trays were responsible for staying in their room to assist with feedings. According to ADON L staff are trained during orientation to the floor which residents required feeding assistance. ADON L stated not doing so would place residents at risk of not knowing her needs with weight loss, proper diet requirements and her need to have assistance with eating, that she needed someone to feed her. <BR/>Interview on 03/21/24 03:09 PM with the DON revealed when a resident entered the facility the MDS Coordinators would enter information for the MDS, and that information would transmit to the care plan. The DON stated it was the responsibility of the nursing staff and ADONs to ensure the care plan was updated with focus areas, goals, and interventions for resident's care. The DON stated she was not aware Resident #66's care plan did not address her dentures, weight loss, health shakes, need for assistance for eating or her admission to hospice. DON stated she was responsible to overlook the care plans to ensure they are up to date and completed accurately. The DON stated not having an updated care plan placed the resident at risk for missed opportunities of care. <BR/>Record review of facility policy revised March 2022, titled Care Planning - Interdisciplinary Team revealed the interdisciplinary team is responsible for the development of resident care plans. <BR/>1. <BR/>Resident care plans are developed according to the time frames and criteria established by $483.21.<BR/>2. <BR/>Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). <BR/>3. <BR/>The IDT includes but is not limited to.<BR/>a. <BR/>The resident's attending physician. <BR/>b. <BR/>A registered nurse with responsibility for the resident; <BR/>c. <BR/>A nursing assistant with responsibility for the resident; <BR/>d. <BR/>A member of the food and nutrition services staff; <BR/>e. <BR/>To the extent practicable, the resident and/or the resident's representative; and <BR/>f. <BR/>Other staff as appropriate or necessary to meet the needs of the resident or as requested by the resident. <BR/>4. <BR/>The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. <BR/>5. <BR/>Care plan meetings are scheduled at the best time of the day for the resident and family when possible. <BR/>6. <BR/>If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 5 residents (Resident #1) reviewed for foot care. <BR/>The facility failed ensure foot care, specifically trimming of toenails, was provided for Residents #1.<BR/>This failure could result in residents developing fungal infections or other podiatric problems. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 11/21/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 10/30/24, reflected her diagnoses included cirrhosis (severe scarring) of liver, hypertension, pain, muscle weakness, and need for assistance with personal care. Resident #1 had a BIMS score of 07, which indicated severe cognitive impairment. The MDS further revealed Section GG - Functional Abilities indicated resident was totally dependent on staff to assist with getting personal hygiene and getting dressed. <BR/>Record review of Resident #1's care plan, revised 11/18/24, reflected: Focus: [Resident #1] has a terminal prognosis r/t alcoholic cirrhosis of the liver. She has chosen [Hospice Name] hospice for her end-of-life care provider. Goal: [Resident #1] comfort will be maintained through the review date. Interventions/Tasks: Adjust provision of ADLs to compensate for resident's changing abilities. The care plan did not address Resident #1's ADL care or nail care. <BR/>Record review of the facility's podiatry visits for 10/09/24 and 11/05/24 reflected Resident #1 had not been seen by the Podiatrist. Resident #1 was also not scheduled to see the Podiatrist on 12/09/24.<BR/>Interview on 11/21/24 at 9:39 AM with Resident #1 revealed she had some concerns regarding her toenails. Resident #1 stated her toenails were long and they were bothering her. She stated the second and third toe from her right foot bother her the most. She stated since being admitted she had never seen a Podiatrist, and her toenails had not been cut but staff. She stated she had attempted to cut her own toenails a few weeks ago, but she was not able to cut them. She stated she had asked several staff to cut her toenails, but staff would not do it. She stated she was told by staff the Podiatrist would need to cut her toenails. She stated the Social Worker informed her the Podiatrist would see her on 10/09/24, but she was never seen by the Podiatrist. <BR/>Observation and interview on 11/21/24 at 11:34 AM with RN A revealed the second and third toenails on Resident #1's right foot were long and curving in. RN A stated Resident #1's toenails were overgrown and needed to be cut. Resident #1 stated her toenails bothered her. RN A stated he would notify the Social Worker and request that she put in a Podiatry referral for Resident #1. RN A stated he was able to cut Resident #1 toenails, but the second toenail might need to be cut by the Podiatrist. RN A stated if residents were not diabetic, the nurses or CNAs would be able to cut them; otherwise, the Podiatrist would have to cut their toenails. RN A stated he could not recall if the resident had been seen by the Podiatrist or when her toenails were last cut. He stated he was not aware Resident #1 toenails needed to be cut. He stated the resident was able to make her needs known, and she never mentioned it to him. RN A stated neither facility staff nor the hospice aide had mentioned anything about cutting Resident #1's toenails. He stated the potential risk of not cutting the resident's toenails was that it could lead to ingrown toenail or the toenail cutting into the skin. <BR/>Interview on 11/21/24 at 11:43 AM with CNA B revealed she was the CNA assigned to Resident #1. She stated Resident #1 was a hospice patient, and the hospice aide would come daily to give the resident a shower and get the resident ready for the day. She stated at times she would assist the resident with putting her socks on. She stated she had seen Resident #1's toenails and they were long; however, Resident #1 had not mentioned anything to her about wanting them cut. She stated she had not asked if she wanted her toenails cut. CNA B stated the nurses or the Podiatrist were responsible for cutting residents' toenails. She stated the risk of not trimming residents' toenails was that it could lead to discomfort or the toenails cutting into the skin. <BR/>Interview on 11/21/24 at 12:16 PM with the Social Worker revealed she was responsible for completing referrals, and today (11/21/24) she sent a referral for podiatry for Resident #1. She stated prior to today Resident #1 had not been referred to the Podiatrist nor had she been seen by Podiatrist. She stated no one had mentioned to her that Resident #1 needed to be seen by the Podiatrist. She stated Resident #1 had not mentioned anything to her about wanting to see a Podiatrist. She stated the Podiatrist last visited the facility on 10/09/24 and 11/05/24, and the next visit would be 12/09/24. <BR/>Interview on 11/21/24 at 1:20 PM with the ADON revealed podiatry was responsible for cutting residents' toenails. She stated if a resident needs a podiatry referral, the staff would notify the Social Worker, who would then send a referral. She stated she was unsure if Resident #1 had ever been seen by the Podiatrist. She stated Resident #1 had not mentioned anything regarding her toenails and had not asked to be seen by the Podiatrist. <BR/>Interview on 11/21/24 at 2:19 PM with the DON revealed all the residents' toenails were cut by the Podiatrist. She stated during morning meetings they verbally talked about referrals that were needed. She stated no one had mentioned to her that Resident #1 needed to be seen by the Podiatrist. She stated Resident #1 was able to make needs known, and she had not mentioned anything regarding her toenails. She stated the potential risk of not keeping toenails trimmed was that it could lead to pain or skin issues. <BR/>Interview on 11/21/24 at 2:33 PM with the Administrator revealed not all residents were seen by the Podiatrist. He stated if podiatry was needed, the Social Worker would send a referral. He stated residents' needs were communicated during clinical meetings and by report. He stated Resident #1 had not mentioned her toenails to anyone nor had she requested needing podiatry. He stated Resident #1 was capable of making her needs known and had a daily opportunity to report to staff that she needed podiatry care. <BR/>Record review of the facility's Foot Care policy, revised October 2022, reflected the following: <BR/>Residents receive appropriate care and treatment in order to maintain mobility and foot health. <BR/>-Residents are provided with foot care and treatment in accordance with professional standards of practice. <BR/>-Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for resident without complicating disease processes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 5 (Administrator, [NAME] Z, Dietary Aide X, Dietary Aide W, and Dietary Aide V) of 5 staff and 1 of 1 kitchen reviewed for kitchen sanitation, in that:<BR/>1. [NAME] Z placed food containers of the lunch meal in the steamtable that contained contaminated water.<BR/>2. The Administrator, Dietary Aide X, Dietary Aide W, and Dietary Aide V failed to wear a hair restraint while in the kitchen. <BR/>These failures could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>1. In a continuous observation on 03/19/24 from 11:08 AM to 11:11 AM of the kitchen's steamtable revealed of the five compartments, the second compartment from the left side had a few inches of brown tinted water in it as well as food particles. [NAME] Z placed a tray of cooked mashed potatoes in the dirty steamtable compartment. [NAME] Z a tray of cooked carrots in the third compartment from the left side that had a few inches of brown tinted water in it as well as food particles. [NAME] Z placed a container of mechanical soft chicken nuggets, a container of pureed carrots, and a container of pureed chicken nuggets into the fourth compartment form the left side that had a few inches of brown tinted water in it as well as food particles. <BR/>Observation on 03/19/24 at 11:30 AM revealed [NAME] Z placed a container of creamed gravy into the fourth compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Observation on 03/19/24 at 11:32 AM revealed [NAME] Z placed a container of chicken fried steaks in the first compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Observation on 03/19/24 at 11:38 AM revealed [NAME] Z placed a container of French fries in the fifth compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Observation on 03/19/24 at 11:58 AM revealed [NAME] Z placed a container of mechanical soft burger patties and a container of burger patties into the fifth compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Interview on 03/19/24 at 1:09 PM with the Dietary Manager revealed the steamtables appeared to have brown water because of the rust inside of the compartments. The Dietary Manager said the steamtables also had food particles from breakfast in each of them. The Dietary Manager said the night shift staff were responsible for emptying and refilling the water in each of the steamtable compartments. The Dietary Manager said if the dietary staff noticed the steamtables were dirty between meals they could stop and clean it but it was usually done at night. The Dietary Manager said the purpose of having clean compartments was related to bacteria and germs. The Dietary Manager said [NAME] Z was responsible for ensuring the compartments were cleaned before placing cooked food on the line. The Dietary Manager said [NAME] Z had already gone home for the day. <BR/>Review of the Federal Food Code 2022 reflected: 4-602.11 Equipment Food-Contact Surfaces and Utensils .3) Containers in serving situations such as salad bars, [NAME], and cafeteria lines hold READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is maintained at the temperatures specified under Chapter 3, are intermittently combined with additional supplies of the same FOOD that is at the required temperature, and the containers are cleaned at least every 24 hours.<BR/>Interview on 03/21/24 at 5:30 PM revealed the facility did not have a policy addressing kitchen equipment.<BR/>2. Observation on 03/19/24 at 10:26 AM revealed Dietary Aide X was sitting at a prep table in the kitchen rolling silverware and not wearing a hair restraint. <BR/>Interview on 03/19/24 at 10:27 AM with Dietary Aide X revealed she knew she was supposed to have a hair restraint on while in the kitchen. Dietary Aide X said she left the kitchen earlier and forgot to put one back on. Dietary Aide X said the reason to wear a hair restraint was to keep the food safe. <BR/>Observation on 03/19/24 at 10:50 AM revealed the Administrator walked into the kitchen without a hair restraint on. <BR/>Observation on 03/19/24 at 11:15 AM revealed Dietary Aide W walked through the kitchen from the back area without a hair restraint on.<BR/>Interview on 03/19/24 at 11:16 AM with Dietary Aide W revealed she came from outside of the kitchen in the back area and walked through the kitchen area without a hair restraint on. Dietary Aide W said she had to walk through the kitchen because there were not any hair restraints available at the back door. <BR/>Observation on 03/19/24 at 12:13 PM with Dietary Aide V revealed he walked into the kitchen without a hair restraint on or beard restraint to cover his facial hair on his chin. <BR/>Interview on 03/19/24 at 1:09 PM with the Dietary Manager revealed she saw that multiple staff had not been wearing hair restraints while in the kitchen. The Dietary Manager said the purpose of wearing hair and beard restraints was to avoid hair falling in the food. The Dietary Manager said it was the responsibility of each staff and her as well to make sure they were wearing hair and beard restraints. The Dietary Manager said she needed to stock some more at each of the entrance doors to the kitchen so staff did not have to walk through the kitchen to get hair restraints. <BR/>Record review of the Federal Food Code 2022 reflected: <BR/>2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.(8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions <BR/>Review of the facility's policy, revised October 2017, and titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices reflected: 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for one (Resident #1) of three residents reviewed for discharge notices.<BR/>The facility failed to notify Resident #1 or her representative in writing of her transfer/discharge to the hospital for behavioral reasons, the reason for the transfer, and the right to appeal and they failed to send a copy of the notice to the ombudsman as soon as practicable of the transfer/discharge. <BR/>This failure could place residents at risk of being transferred or discharged , and not having access to available advocacy services, discharge/transfer options, and appeal processes.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 09/04/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged [DATE] to an acute care hospital. <BR/>Record review of Resident #1's 5-day scheduled MDS assessment, dated 03/26/24, reflected a BIMS score of 12, which indicated moderate cognition impairment. Her diagnosis included encephalopathy (brain dysfunction), legal blindness, acute respiratory failure, and schizophrenia. <BR/>Record review of Resident #1's Nurses Notes, dated 03/28/24, reflected the following: <BR/>[Resident #1] was discharged today to the VA Hospital due to her increasing and escalating mental health concerns that were preventing her from fully participating in her rehab here at this facility. VA LCSW confirmed she spoke with the VA physician as well as the VA ER LSW and sent notes stating [Resident #1] had been discharged from the VA CCN Contract program effective today due to her needs not being able to be safely met at this facility. Facility Administrator phoned and notified [Resident #1] guardian, [Guardian Name]. [Guardian Name] stated she and the family would be at this facility at some point this weekend to pick up [Resident #1] personal belongings.<BR/>Review of Resident #1's clinical record reflected there was no documentation of the resident, the resident's responsible party, or the Ombudsman being notified in writing of the resident's discharge or the reason for the resident's discharge. <BR/>Interview on 09/04/24 at 10:01 AM with Resident #1's POA revealed she had received a phone call on 03/28/24 at around 11 AM stating Resident #1 was going to be transferred to the VA ER to get a mental health evaluation and medication adjustment. Resident #1's POA stated the same day 03/28/24 at around 3 PM she received a call from the Administrator, and he stated the resident was going to be discharged from the facility. Resident #1's POA stated she did not receive any paperwork or discharge information. <BR/>Interview on 09/04/24 at 4:11 PM with the Ombudsman revealed she was not notified of Resident #1's discharge. <BR/>Interview on 09/04/24 at 4:32 PM with the Administrator revealed Resident #1 was transferred to the hospital for a mental health assessment and stabilization. He stated Resident #1 was being combative, verbally aggressive, and refusing care. He stated by Resident #1 agreeing to go to the hospital Resident #1 initiated the transfer. The Administrator stated the VA ended Resident #1's contract on 03/28/24 and the resident was discharged . He stated the family was made aware verbally. He stated nothing in writing had been sent with the resident or family explaining the reason for her discharge. The Administrator stated he was not aware the Ombudsman had to be contacted for any discharges other when a resident was issued a 30-day discharge notice.<BR/>Review of the facility's current Transfer and Discharge, facility - Initiated policy, revised October 2022, reflected the following:<BR/>Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. <BR/>Notice of Transfer or Discharge (Emergent or Therapeutic Leave) <BR/>1. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfer, NOT discharges, because the resident's return is generally expected. <BR/>2. Residents who are sent emergently to an acute care setting, such as hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility .<BR/>3. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable. <BR/>4. Notice of facility bed-hold and return policies are provided to the resident and representative within 24 hours of emergency transfer. <BR/>5. Notices are provided in a form and manner that the resident can understand, taking into account the resident educational level, language, communication barriers, and physical or mental impairments.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Residents #41, #28, #59, #83 and #105) of 20 residents observed for infection control.<BR/>1. LVN C failed to perform proper disposal of dressing materials after performing wound care for Resident #41.<BR/>2. LVN B failed to perform proper sanitization of equipment during blood sugar check for Resident #41 and Resident #28.<BR/>3. The facility failed to ensure Resident #105, who shared a room with Resident #83, was immediately isolated when the resident tested positive for COVID-19. <BR/>4. The facility failed to properly disinfect and handle the dietary cart and dishes used on the isolation hall and failed to ensure the dietary cart was properly disinfected after it was touched by Resident #59. <BR/>These failures placed all residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Observation on 02/07/23 at 12:31 PM during facility initial tour, revealed a soiled wound dressing discarded in the trash can that was left exposed with some of the dressing stuck on the edge of the trash can, in Resident #41's room.<BR/>Interview on 02/07/23 at 12:35 PM with LVN C, who was the charge nurse, revealed he had provided wound care to Resident #41 at around 11:00 AM. He stated he was aware he was supposed to use a biohazard bag while performing wound care or use a plastic bag and after procedure dispose soiled materials on the biohazard box in the biohazard room. He stated he did not have the biohazard bag on the nurse's cart, and he was in a hurry. He stated he forgot to dispose of the dressing materials properly by removing them from the room. He stated failure to dispose soiled dressing materials properly could lead to cross contamination then spread of infection. He stated he is aware of the right procedure, but he forgot. He stated he is from agency, and he had not received training in this facility on wound dressing and care of soiled dressings materials. <BR/>Interview with DON on 02/07/23 at 4:14 PM revealed his expectation was for nurses to discard the soiled dressing materials on biohazard bag or plastic bags. He stated he expected the nurse to use the plastic bags and after the procedure they should remove the bag from the resident room and discard in the biohazard box. He stated failure to discard the soiled materials properly could cause contamination and spread of infection. He stated he had done training on infection control with the facility staff but not with agency nurses, because he expected them to have basic knowledge from their companies. He stated he only orient the agency nurses on the unit on their first day.<BR/>Observation on 02/08/23 at 11:35 AM revealed LVN B perform hand hygiene and don gloves and prepared to check blood glucose level on Resident #41. She was observed cleansing the finger with alcohol pad and she pricked the resident finger and got the sample. She discarded the sharps on the sharp container and the soiled alcohol pad. She removed the gloves sanitized and recorded the readings. She did not disinfect the glucometer, and she wheeled her cart to another hall to check blood sugar levels for Resident #28.<BR/>Observation on 02/08/23 at 11:43 AM revealed LVN B perform hand hygiene and removed gloves and prepared to check blood glucose level on Resident #28. She took the glucometer machine from the top of her cart without disinfecting it. She was observed cleansing the finger with alcohol pad, she pricked the resident finger, and got the sample. She was observed using the same glucometer without disinfecting on Resident #28. She discarded the needle on the sharp container and the soiled alcohol pad. She removed the gloves sanitized and recorded the readings.<BR/>Interview with LVN B on 02/08/23 at 11:47 AM revealed she knew she was supposed to disinfect the glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in blood) between each resident and with every use to prevent contamination and spread of infection. She stated she was supposed to use the disinfectant wipes but she did not have some on her cart. She stated she did not have enough reason why she did not disinfect the glucometer machine because she had alcohol pads that she could have used. She stated she is an agency nurse and had not received training on infection control in this facility but she had been trained in another facility. She stated failure to disinfect the glucometer machine could lead to spread of infection from one resident to another.<BR/>Interview with DON on 02/08/23 at 1:30 PM revealed his expectation was the nurse to disinfect the glucometer after each use and between the residents. He stated if the nurses were not disinfecting the glucometer machine it could lead to cross contamination and spread of infection from one resident to another. He stated he had not trained the agency nurse because he expected them to have the basic knowledge on infection control.<BR/>3. An observation on 02/07/23 at 11:18 AM revealed Resident #105 was symptomatic with a cough and tested positive for COVID while sharing room with Resident #83.<BR/>An observation on 02/07/23 at 11:52 AM revealed Resident #83 was observed in the hall with no mask. Resident #83 put other residents at risk for COVID transmission.<BR/>An observation on 02/07/23 at 1:01 PM revealed Resident #83 was congregating with other residents in the hallway without a mask. Resident #83 confirmed that she was coming from a smoke break and had not been informed Resident #105 had tested positive for COVID. <BR/>An interview with the DON on 02/07/23 at 3:52 PM revealed Resident #83 was to have smoke breaks alone and not congregate with other residents. He stated COVID negative resident (Resident #83) had been sharing a room with COVID positive resident (Resident #105) since that morning. The DON stated COVID positive and COVID negative roommates are to be separated immediately. He stated if residents were not separated immediately, it could lead to cross contamination and spread of infection from one resident to another. <BR/>4. An observation and interview with the DON on 02/08/23 at 8:56 AM revealed, 100 hallway was the hall dedicated for COVID positive residents. Observation revealed a dietary cart on 100 hall with reusable dishes loaded on the dietary cart. The DON stated residents with COVID are to use only Styrofoam plates, cups, and eating utensils when eating to prevent the risk of cross contamination. He stated clean items enter at the front entrance on 100 hall and dirty items exit through the back door on 100 hall. <BR/>An observation and interview at 02/08/23 at 9:59 AM revealed the dietary cart had been placed outside the front entrance of 100 hall. Observation also revealed Resident #59 touching the dietary cart in an attempt to enter the 100 halls. Social Worker assisted Resident #59 away from 100 hall and to her room. Interview with RN E revealed that dietary cart would be picked up by dietary staff. When asked if it was to be picked up from that location, RN E replied, yes.<BR/>An observation on 02/08/23 at 10:09 AM revealed the dietary cart from 100 hall was sprayed with Comet Cleaner with Bleach and the dietary cart was not labeled with a dedicated hall. Dietary Aide F had allowed three minutes for contact time before she had rinsed dietary cart. <BR/>An interview with Dietary Aide F on 02/08/23 at 10:13 AM revealed the Comet disinfectant contact time was five min before rinsing. She stated if the correct contact time was not done then the dietary cart would still be contaminated and could make residents sick. <BR/>Record review revealed the correct contact time for Comet Cleaner with Bleach was 10 minutes before rinsing. <BR/>Review of the facility's Dressing, soiled/contaminated policy, dated August 2009, reflected: .1. Disposable items such as bandages, applicators, gauze pads etc., that are soiled or contaminated with ineffective material, blood, or body fluids must be placed in a plastic bag and removed from the resident's room upon completion of any procedure.<BR/>Review of the facility's Blood sampling -Capillary (finger sticks) policy, dated September 2014, reflected: .Following manufacturer's instructions, clean and disinfect reusable equipment, parts and /or devices after each use. <BR/>Review of the facility's policy titled COVID-19 Response for Nursing Facilities, dated 06/27/22, reflected: Once a case of COVID-19 is identified in the NF, immediate action must be taken to isolate the resident who is positive for COVID-19 away from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for 1 (Resident #45) of 16 residents reviewed for quality of care.<BR/>The facility failed to obtain follow-up orders when Resident #45 returned to the facility from the hospital with a splint after she was diagnosed with an elbow fracture.<BR/>The failure placed residents at risk of not receiving needed treatments to prevent conditions from worsening. <BR/>Findings included:<BR/>Review of Resident #45's MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, hemiplegia (paralysis of one side of the body), respiratory failure, fracture of lower end of humerus, and acute cholecystitis (inflammation of the gallbladder). Resident #45 had a BIMS of 9, cognition moderately impaired, and was able to be understood and she understood others. <BR/>Observation and interview on 03/18/24 at 12:40 PM with Resident #45 revealed she was in her wheelchair sitting across from the nurse's station. Her left arm was covered with an ace bandage and Resident #45 said she had fallen in the bathroom over a week ago and broke her arm. The resident said she had been sent to the hospital with other issues other than her broken arm and she also said she was not in any pain at the time. The Resident said no one had taken her splint off since she re-admitted from the hospital (02/29/24) nor had she been assessed by any doctors. <BR/>Review of Resident #45 hospital records dated 02/28/24 reflected the resident had a left elbow fracture, ortho was consulted and there was a sling in place. The hospital records did not have any discharge instructions/ orders or follow-ups for her arm. <BR/>Review of Resident #45's hospital records dated 03/09/24 reflected the resident had been transferred for reasons unrelated to her arm. Further review of the records revealed Resident #45 had a left radial head fracture, a splint was in place and Resident #45 had an out patient follow-up with an ortho but there was no date added. <BR/>Interview on 03/20/24 at 4:33 PM with LVN A revealed she had re-admitted Resident #45 from the hospital on [DATE] and she did not recall seeing any orders regarding the resident's arm. The LVN said she called Resident #45's physician but did not recall if she heard back from him or if she followed up. LVN A said she did not know if Resident #45 had a cast or a splint and she have never taken the wrap off to see what was underneath. She said she would check the skin around the ace wrap and look at the resident's fingernails for any discoloration. LVN A further stated the ADON and DON knew the resident had returned with a wrapped arm and LVN let them, ADON and DON, take over . The LVN stated she should have continued to follow-up with the physician to get orders. <BR/>Interview on 03/21/24 at 10:42 AM with LVN B revealed he never looked underneath Resident #45's wrap because he believed it was a cast and he only checked her fingers for circulation. LVN B further stated if residents did not have a cast, they were expected to look under any device to check their skin integrity and make sure there was no breakdown. <BR/>Interview on 03/20/24 at 3:09 PM with the ADON revealed there should have been some type of orders to care for Resident #45's arm to check the skin integrity under the ace bandage but did not know why there was not. The ADON said the Physician was contacted (03/20/24) and ordered an xrays for the following day (03/21/24). <BR/>Observation and interview on 03/21/24 at 8:40 AM revealed the xray company had just left the facility after Resident #45's arm xray. The ADON stated the Physician had given them an order to take resident's splint off and apply a soft wrap around the resident's arm. Observation of Resident #45's skin on her fractured arm was intact and there were no skin breakdown and the resident denied having any pain. The ADON said they would send the xray results to the Physician as soon as they arrived. <BR/>Interview on 03/21/24 at 12:34 PM with the DON revealed when Resident #45 was re-admitted from the hospital it was discussed with IDT and she did notice the resident did not have any orders for her arm so they contacted the resident's Physician and he took over the care, but was not able to say what the Physician had put in place. The DON said staff were checking capillary refills on the resident's hand. The DON further stated when Resident #45 re-admitted (02/29/24), she personally would have called the hospital to get clarification or further instructions. The DON said she would have expected the admitting nurse to continue to try and reach the doctor for orders when Resident #45 returned from the hospital to get clarification and follow-up orders for her arm or they should have called the hospital to get clarification on the ortho appointments mentioned in the discharge paperwork. They interpreted the ortho appointments as mentioned that the resident had seen an ortho doctor at the hospital. <BR/>Interview on 03/21/24 at 2:23 PM with the Wound Care Nurse revealed she was making a wound care appointment for Resident #45, 03/21/24, and she went ahead and made an ortho appointment because she had not seen what was under the resident's bandage on her arm. The Wound Care Nurse looked through Resident #45's discharge paperwork from the hospital and she did not see any follow-ups related to her fractured arm. She said normally if there were no follow-ups nursing should call the surgeon for care instructions. <BR/>Attempts to contact the hospital on [DATE] for clarifications orders for Resident #45's arm were unsuccessful.<BR/>Interview on 03/21/24 at 3:34 PM with the Physician revealed he did not recall if he was ever contacted about Resident #45's arm when she was re-admitted from the hospital (02/29/24). He stated if the resident did not come back with orders for her arm, the facility should have followed up with the surgeon or provider that cared for the resident at the hospital for clarification. The Physician further stated if the facility was not able to get in touch with the hospital staff, then he would have to take over the care and gave the nurses care orders. The Physician said he did see Resident #45 the day prior, 03/20/24, but did not unwrap her arm but he had ordered some xrays to be completed. He also said he looked at the xray results and saw some osteoporosis but he would have the facility follow-up with the ortho doctor. He stated risk of not getting follow-up orders could worsen a resident's condition or health. <BR/>At the time of exit, the facility did not have a policy related to resident admission or re-admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #66) of 6 residents reviewed for care plans.<BR/>1. The facility failed to develop a care plan for Resident #66 that addressed her use of dentures.<BR/>2. The facility failed to update Resident #66's care plan to address changes in diet texture, weight loss, or health shakes at lunch and dinner.<BR/>3. The facility failed to develop a care plan that addressed Resident #66's need to have assistance for eating. <BR/>4. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #66, hospice services.<BR/>These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs.<BR/>Findings included:<BR/>Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function is disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), Anemia (blood disorder), <BR/>Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with eating, substantial/maximum assistance with dental hygiene, and supervision/touching assistance with personal hygiene. Section L - Oral/Dental status revealed none of the above were present which included: Broken or loosely fitting full or partial denture. <BR/>Record review of Resident #66's care plan reviewed on 03/18/24 did not indicate she had or required the use of dentures. Resident #66's care plan did not address her change of diet to pureed texture, weight loss or need to have health shakes at lunch and dinner. Resident #66's care plan did not address her need to have assistance with eating. Resident's #66's care plan was not updated with measurable timeframes to address Resident #66 hospice services when she admitted on [DATE].<BR/>Record review of Resident #66's Order Summary Report dated 03/21/24, reflected: <BR/>Regular diet Pureed texture, Thin liquids consistency, health shakes with lunch and dinner (prefers chocolate flavor) for difficulties chewing. Start date 03/05/24.<BR/>Activity level: bedbound. Diet: comfort feeds as tolerated. Start date 03/07/24.<BR/>May see dentist, Start date 04/03/23.<BR/>Admit to Community Healthcare of Texas for Terminal Sepsis, Report change in condition or death. Start date 03/07/24.<BR/>Record review of Resident #66 progress note, dated 02/27/24 at 9:53 PM, written by the LVN reflected Resident #66 went to dental appointment with her Family Member, she came back with no new order, she has been sleeping since she came back, respiration 18, even and unlabored, no s/s of discomfort was notes, oncoming nurse to monitor. <BR/>Record review of Resident #66's progress note dated 02/28/24 revealed Resident #66 was seen by the dietician today with recommendations to add a chocolate health shake related to weight loss. Resident and Representative made aware. <BR/>Record review of Resident #66's physician order dated 03/05/24 revealed Regular diet, Pureed Texture, Thin Liquids consistency. Health Shakes with lunch and dinner (Prefers Chocolate flavor) for difficulties chewing. <BR/>Record review of Resident #66's Dietary Profile upon readmission on [DATE] revealed current diet order: Puree as tolerated, Current Texture of food: Regular, small portions, poor appetite, Eating/Chewing: Denture Both, Eating Assistance: Total Assistance<BR/>Observation and interview on 03/18/24 at 12:20 PM, revealed Resident #66 in her room, in low bed, resting while Family Member was sitting at bedside. When Resident #66 heard voices in the room she awoke and greeted the surveyor, revealing she did not have any teeth. According to the Family Member Resident #66 entered the facility almost a year ago, recently had a decline in weight. The Family Member stated she felt Resident #66's decline started when she lost her dentures about 4 months ago. The Family Member stated she spoke with facility about Resident #66's missing dentures, however they had never received any feedback. The Family Member stated she then decided to go outside the facility to replace the missing dentures since she never got any assistance from the facility. The Family Member stated it took a while before the facility provided Resident #66 with alternate accommodations for her to eat well. The Family Member stated the facility did not provide Resident #66 with health shakes. The Family Member stated she began to bring supplemental beverages for Resident #66 to ensure she was getting proper nutrition. Observation prior to exiting Resident #66's room revealed pureed lunch tray delivered to bedside table not near resident. Observation of Resident #66's meal ticket revealed she should have a shake at meals, however there was not a shake on the tray. According to the Family Member Resident #66 is supposed to have assistance with her feeding, but since she was present staff expected her to do the feeding. <BR/>Interview and record review on 03/20/24 at 3:33 PM with MDS Coordinator #1 and MDS Coordinator #2 about Resident #66's care plan missing documentation about her being admitting to hospice upon readmission to the facility. MDS Coordinator #2 stated when Resident #66 returned from the hospital she entered a focus area for hospice on her care plan dated 03/07/24. Surveyor pointed out there was not an entry indicated on the care plan prior to 03/20/24 and now the care plan was updated with hospice as of 03/18/24 made by MDS Coordinator #2. MDS Coordinator #1 stated the care plan for hospice was started and the care plan was left open so that facility staff, nursing staff could go into the care plan to edit up until the next care plan review. MDS Coordinator #1 denied updating hospice information on 03/18/24. According to both MDS Coordinators #1 and #2 it was important to have resident's care plan updated so that staff would be knowledgeable about each resident's care. MDS Coordinator #2 stated it was the responsibility of the nursing staff to keep resident's care plan updated at all times. MDS Coordinator #2 stated not updating the care plan with new order, activities of daily living and resident care needs placed residents at risk for not receiving proper care while in the facility. MDS Coordinator #2 stated upon admission they try to capture how to care for residents in every area. <BR/>Interview on 03/20/24 at 3:43 PM with ADON revealed the facility was missing the required focus areas on the care plan when came to hospice, nutrition, and eating. According to the ADON, MDS Coordinators could do the initial hospice, nutrition and any focus areas to the care plans. The ADON stated the nursing staff was also responsible to enter updated care plan information in any areas so that the nursing staff would be able to know how to care for residents. The ADON stated the care plans are required for all residents and not having care plans updated would place residents at risk of neglect. <BR/>Interview on 03/21/24 at 12:51 PM with ADON L revealed if residents had any changes in their care, she was responsible to ensure resident's care plan was updated. ADON L stated she was asked if Resident #66's care plan addressed eating requirements and when she looked, she noticed it had not been updated. ADON L stated she knew Resident #66 had dentures before January however she was not in the ADON's role at this time to ensure the care plan was updated with her use of dentures. ADON L stated while working on the floor she could recall the Family Member handling the issue with getting the dentures fitted properly for Resident #66. ADON L stated Family Member did bring up the concern for the dentures missing and tried looking for them. ADON L stated she did not bring it to anyone's attention to complete a grievance and she did not notify the Social Worker which was in charge of dental appointments. ADON L stated she did observe Family Member bringing in softer foods and after Resident #66's hospital visit when she started pureed foods. ADON L stated upon Resident #66's return from the hospital in February, she required assistance with eating. ADON L stated when staff passed the trays whomever passed Resident #66's trays were responsible for staying in their room to assist with feedings. According to ADON L staff are trained during orientation to the floor which residents required feeding assistance. ADON L stated not doing so would place residents at risk of not knowing her needs with weight loss, proper diet requirements and her need to have assistance with eating, that she needed someone to feed her. <BR/>Interview on 03/21/24 03:09 PM with the DON revealed when a resident entered the facility the MDS Coordinators would enter information for the MDS, and that information would transmit to the care plan. The DON stated it was the responsibility of the nursing staff and ADONs to ensure the care plan was updated with focus areas, goals, and interventions for resident's care. The DON stated she was not aware Resident #66's care plan did not address her dentures, weight loss, health shakes, need for assistance for eating or her admission to hospice. DON stated she was responsible to overlook the care plans to ensure they are up to date and completed accurately. The DON stated not having an updated care plan placed the resident at risk for missed opportunities of care. <BR/>Record review of facility policy revised March 2022, titled Care Planning - Interdisciplinary Team revealed the interdisciplinary team is responsible for the development of resident care plans. <BR/>1. <BR/>Resident care plans are developed according to the time frames and criteria established by $483.21.<BR/>2. <BR/>Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). <BR/>3. <BR/>The IDT includes but is not limited to.<BR/>a. <BR/>The resident's attending physician. <BR/>b. <BR/>A registered nurse with responsibility for the resident; <BR/>c. <BR/>A nursing assistant with responsibility for the resident; <BR/>d. <BR/>A member of the food and nutrition services staff; <BR/>e. <BR/>To the extent practicable, the resident and/or the resident's representative; and <BR/>f. <BR/>Other staff as appropriate or necessary to meet the needs of the resident or as requested by the resident. <BR/>4. <BR/>The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. <BR/>5. <BR/>Care plan meetings are scheduled at the best time of the day for the resident and family when possible. <BR/>6. <BR/>If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #10 and Resident #66) reviewed for ADLs.<BR/>The facility failed to ensure Resident #10, and Resident #66 had feeding assistance for more than 30 minutes after lunch trays were delivered to their rooms. <BR/>This failure could place residents at risk for not receiving appropriate care, assistance when needed, and decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #10's face sheet reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had diagnoses which included Huntington's Disease (progressive breakdown of nerve cells in the brain), Dementia, muscle weakness, lack of coordination, speech and language deficit, contracture of muscle in both left and right hands. <BR/>Record review of Resident #10's MDS, dated [DATE], reflected a BIMS score of 03, which indicated she had severe cognitive impairment. Her Functional Status indicated she required substantial/maximum assistance with eating and oral hygiene, and she was dependent on staff for personal hygiene. Section K - weight 103 pounds, no loss of 5% or more in the last month or loss of 10% or more in the last 6 months, Mechanically altered diet - while a resident.<BR/>Record review of Resident #10's care plan reviewed on 03/18/24 revealed Resident #10 has a daily living self-care performance deficit related to disease process (Huntington's Disease) and is dependent on staff for all daily living tasks. Goal: The resident's needs will be met. Interventions: Eating: resident is totally dependent on one staff for eating. Resident has potential nutritional problems related to being dependent on staff with feeding and being underweight. Goal: The resident's nutritional needs will be met as evidence by maintaining a steady weight and or gaining weight as prescribed by physician. Intervention: Monitor/record/report to physician signs and symptoms of malnutrition: Emaciation (thinness), muscle wasting and significant weight loss. Registered Dietician to evaluate and make diet change recommendations. <BR/>Resident has a swallowing problem related to history of stroke (Huntington Disease) Goal: Resident will not have injury related to aspiration. Intervention: The resident is a feeder and requires one staff member to assist with eating. <BR/>Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function was disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), chronic obstructive pulmonary disease (lung disease), Hypothyroidism (lack of hormones), <BR/>Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with eating. Section K - weight 102 pounds, no loss of 5% or more in the last month or loss of 10% or more in the last 6 months, Mechanically altered diet - while a resident. <BR/>Record review of Resident #66's care plan reviewed on 03/18/24 revealed focus areas: Diagnosis of Hypothyroidism (lack of hormones), Use of antidepressant medication, Chronic Pain related to primary Osteoarthritis (joint disease), Fibromyalgia (condition that causes widespread pain) all with interventions to monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. Care plan did not address Resident #66's concerns with weight loss; to have a health shake with lunch and dinner; or required assistance with feedings. <BR/>Record review of Resident #66's orders revealed: Health Shake two time a day provide Chocolate Health Shake twice daily. Start 02/29/24<BR/>Observation and interview on 03/18/24 at 12:20 PM, revealed Resident #66 in her room, in low bed, resting while Family Member was sitting at bedside. Observation prior to exiting Resident #66's room staff entered the room with pureed lunch tray; delivered it to bedside table not located near resident. According to Family Member Resident #66 was supposed to have assistance with her feeding, but since she was present staff may have expected her to do the feeding. <BR/>Observation on 03/19/24 between 12:55 PM-1:30 PM revealed staff was exiting Resident #10's room. When asked if she was facility staff and was going to assist Resident #10 with eating, she responded that she was hospice and she was headed to look for staff for assisting resident with eating. Resident #10 responded Yes that she was ready to eat. Resident #66 received her lunch tray; tray was sitting on bedside table not within reach. Resident #66's tray did not include a health shake. Resident #66 stated she was ready to eat and there had not been anyone to return to assist her with eating. Surveyor observed the hall for at least 30 minutes for noticing staff walked up to the nursing station. Surveyor asked staff to observe both Resident #10's tray sitting in front of her and Resident #66's food sitting on bedside table not within reach; and no one to assist either resident with eating their lunch. <BR/>Interview on 03/19/24 at 1:35 PM CNA K stated she would assist Resident #10 with eating and would contact someone else to assist Resident #66 with eating her lunch. According to CNA K, when staff are oriented to their halls that they are working, it was then expected for staff to know which residents required assistance with eating. CNA K stated the person doing the training and orientation will alert staff which residents required assistance with eating. CNA K stated it was the responsibility of the facility staff to ensure residents are being fed, however if a family member is present and want to do the feeding, it could be ok.<BR/>Observation on 03/19/24 at 1:45 PM revealed Family Member entered Resident #66's room to find Resident #66 was alone and lunch tray had not been touched. Family Member began assisting Resident #66 with her feeding. <BR/>Interview on 03/20/24 11:32 AM with LVN C revealed she was responsible for Resident #10 and Resident #66's hall on 03/19/24 and 03/20/24. LVN C stated she had dining room duty during lunch each day which left nurse aides on the floor to ensure each resident received their lunch trays and was assisted with eating. LVN C stated she was aware Resident #10 and Resident #66 required assistance with all meals. According to LVN C, CNA J was the CNA working on the hall and was responsible for ensuring residents were assisted with lunch on 03/19/24 and 03/20/24. According to LVN C she was not aware Residents #10 and #66 were delivered their lunch tray without assistance with eating. LVN C stated she expected aides on the hall to pass trays to all residents on the hall and assist those that required assistance with eating. LVN C stated she also could help with feeding assistance, however she was scheduled to work in the dinning hall, therefore aides are expected to find someone to come assist if they needed help with more than one resident. LVN C stated not assisting residents that require help with eating placed them at risk of malnutrition, vitamin deviancies', and starvation.<BR/>Interview on 03/20/24 at 1:57 PM with CNA I revealed she did not work on the hall with Residents #10 and #66, however she used to work with Resident #10 and knew she required assistance with eating so she would often come by to check on her. CNA I stated on 03/19/24 she did come by to check on Resident #10 but when she came by Resident #10 had already eaten her lunch. CNA I stated when working your hall, nurses and aides are alerted to which residents require assistance with eating. CNA I stated aides are responsible for ensuring that every resident on the hall had eaten. CNA I stated not doing so placed residents at risk of being weak and die, if you don't eat you are not strong. CNA I stated if there was a resident on the hall that had not eaten aides should report that information to the nurse. <BR/>Interview on 03/20/24 at 2:26 PM with CNA J revealed she is currently the CNA working on Resident #10 and #66's hall. CNA J stated she also was scheduled dining room duty and was also working a different hall. CNA J stated when the carts enter the hall everyone assist with passing out food trays. CNA J stated she was not able to identify who passed the lunch trays on 03/19/24, but it was the responsibility of the aide that passed the tray to stay with residents that require feeding assistance to ensure they eat. CNA J stated when she completed her dining room duty and walked the halls to begin her feeding duties, Resident #10 was being assisted by CNA K and Resident #66 was being assisted by a Family Member, so she went on to the next hall to check on other residents that required assistance with eating. CNA J stated she was responsible on 03/19/24 to ensure Resident #10 and #66 received assistance with eating, not doing so placed them at risk of not eating to meet their nutritional needs and could present a physiological effect. <BR/>Interview on 03/20/24 at 2:46 PM with CNA K revealed she was also the staffing scheduler. CNA K stated on 03/19/24 they had an aide that called off which left aides to fill in on the hall with Resident #10 and #66's. According to CNA K the goal was to divide up the hall, at lunch time the procedure included everyone available to help pass lunch trays. CNA K stated if you pass the tray, you should stay in the room to assist residents that required assistance with eating. CNA K stated Residents #10 and #66 should have had their trays passed last so staff are able to stay in the room and not leave the tray, allowing residents to see the food sitting in front of them and having to wait until someone else returned to assist them with feedings. According to CNA K the risk included neglect, leaving resident hungry, and ready to eat, looking at it and cause a negative reaction. <BR/>Interview on 03/20/24 at 05:09 PM the DON stated she was not aware who passed Resident #10's and #66's lunch tray because all available aides were responsible for passing trays on the hall. The DON stated her expectation was for nurses to assist aides with duties on the floor, feeding residents that require assistance was priority, it was not being monitored, it was expected. The DON stated ultimately the aide that worked Resident #10 and #66's hall was responsible for ensuring they delivered trays to residents that could feed themselves first and then deliver trays to residents that require assistance with eating and staying in the room to complete the feeding. The DON stated if the aide was not able to stay and complete the feeding, they should notify another aide to assist, contact their nurse or ADON or DON, someone to come and complete the task. The DON stated the risk included residents not receiving nutrition, becoming mentally disturbed, weight loss and all sorts of things are at risk for residents that required feeding assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weigh or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 2 of 5 residents (Resident #66 and Resident #115) reviewed for nutrition status maintenance. <BR/>1.The facility failed to ensure Resident #66 had a heath shake with lunch and dinner. <BR/>2. The facility failed to measure and record Resident #115's body weight, as ordered by the resident's physician, for three weeks in November 2023.<BR/>These failures could place residents at risk of weight loss, weight gain, nutritional deficit, and adverse health consequences.<BR/>Findings included:<BR/>1. Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function was disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), chronic obstructive pulmonary disease (lung disease), Hypothyroidism (lack of hormones), <BR/>Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with eating, substantial/maximum assistance with dental hygiene, and supervision/touching assistance with personal hygiene. Section K - weight 102 pounds, no loss of 5% or more in the last month or loss of 10% or more in the last 6 months, Mechanically altered diet - while a resident. Section L - Oral/Dental status revealed none of the above were present which included: Broken or loosely fitting full or partial denture. <BR/>Record review of Resident #66's care plan reviewed on 03/18/24 revealed focus areas: Diagnosis of Hypothyroidism (lack of hormones), Use of antidepressant medication, Chronic Pain related to primary Osteoarthritis (joint disease), Fibromyalgia (condition that causes widespread pain) all with interventions to monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. Care plan did not address Resident #66 had a concerns with weight loss; to have a health shake with lunch and dinner; or required assistance with feedings. <BR/>Record review of Resident #66's Dietician Progress note, and Recommendations dated 02/28/24 reflected meal intake 26-50% & 51-75%; meals refused in one week 1-3; weight 102.0 on 02/12/24; comments: 2.8#loss x 3 weeks, 7# loss x 30 days (6.4%), 11#loss x 90 days (9.7%), 18# loss x 180 days (15%) indicating unstable weight. Usual body weight 120. <BR/>Assessment: recent hospital return: comments Diet: regular, mech soft, thin Nutrient Needs:1125 kcal, 46 grams protein, 1610 ml fluid Other Comments: Annual review/weight loss follow up. Resident was recently readmitted to facility post fall with stitches to left eyebrow area. Current weight reflects significant weight loss X 30, 90 and 180 days. Resident was noted to have 25-75% intake most recorded meals. 1000 ml fluid restriction was recently discontinued. Resident stated her appetite is great. Resident agreed to try health shake BID. Resident prefers chocolate. Goal is &gt; 50% meal intake. Will continue to monitor. <BR/>Record review of Resident #66's progress note dated 02/28/24 revealed Resident #66 seen by dietician today with recommendations to add a chocolate health shake related to weight loss. Resident and Representative made aware. <BR/>Record review of Resident #66's physician order dated 03/05/24 revealed Regular diet, Pureed Texture, Thin Liquids consistency. Health Shakes with lunch and dinner (Prefers Chocolate flavor) for difficulties chewing. <BR/>Record review of Resident #66's Dietary Profile upon readmission on [DATE] revealed current diet order: Puree as tolerated, Current Texture of food: Regular, small portions, poor appetite, Eating/Chewing: Denture Both, Eating Assistance: Total Assistance<BR/>Record review of Resident #66's Order Summary Report reviewed 03/21/24, reflected Regular diet Pureed texture, Thin liquids consistency, health shakes with lunch and dinner (prefers chocolate flavor) for difficulties chewing. Start date 03/05/24.<BR/>Activity level: bedbound. Diet: comfort feeds as tolerated. Start date 03/07/24.<BR/>Record review of Resident #66's weights:<BR/>3/7/2024 9:05 <BR/> 73.7 Lbs <BR/>Bed <BR/>2/12/2024 3:17 <BR/>102.0 Lbs <BR/>Digital/ wheelchair Scale <BR/>1/22/2024 5:23 <BR/>104.8 Lbs <BR/>Standing <BR/>1/19/2024 5:38 <BR/>109.0 Lbs <BR/>Wheelchair <BR/>1/11/2024 4:34 <BR/>109.0 Lbs <BR/>Digital/ wheelchair Scale <BR/>01/4/2024 6:09 <BR/>109.0 Lbs <BR/>Digital/ wheelchair Scale <BR/>12/11/2023 2:41 <BR/>104.8 Lbs <BR/>Standing <BR/>11/8/2023 1:41 <BR/>113.0 Lbs <BR/>Digital/ wheelchair Scale <BR/>10/15/2023 10:55 <BR/>117.6 Lbs <BR/>Standing Scale <BR/>9/21/2023 6:50 <BR/>117.0 Lbs <BR/>Wheelchair <BR/>8/16/2023 12:59 <BR/>120.0 Lbs <BR/>Wheelchair <BR/>Observation and interview on 03/18/24 at 12:20 PM, revealed Resident #66 in her room, in low bed, resting while Family Member was sitting at bedside. When Resident #66 heard voices in the room she awoke and greeted surveyor, revealing she did not have any teeth. According to Family Member Resident #66 entered the facility almost a year ago, recently had a decline in weight. The Family Member stated she felt Resident #66's decline started when she lost her dentures about 4 months ago. The Family Member stated she spoke with facility about Resident #66's missing dentures, however had never received any feedback. The Family Member stated she then decided to go outside the facility to replace the missing dentures since she never got any assistance from the facility. The Family Member stated it took a while before the facility provided Resident #66 with alternate accommodations for her to eat well. The Family Member stated the facility did not provide Resident #66 with health shakes. The Family Member stated she began to bring supplemental beverages for Resident #66 to ensure she was getting proper nutrition. Observation prior to exiting Resident #66's room revealed pureed lunch tray delivered to bedside table not near resident. Observation of Resident #66's meal ticket revealed she should have a shake at meals, however there was not shake on the tray. According to Family Member Resident #66 is supposed to have assistance with her feeding, but since she was present staff expected her to do the feeding. <BR/>Observation on 03/19/24 between 12:55 PM-1:30 PM revealed Resident #66 received her lunch tray; tray was sitting on bedside table not within reach. Resident #66's tray did not include a health shake. <BR/>Interview on 03/20/24 11:32 AM with LVN C revealed she was responsible for Resident #66's hall. LVN C stated she had dining room duty during lunch which would leave aides on the floor to ensure each resident received their lunch trays and reviewed resident tickets to ensure Resident #66's health shake was included with her lunch. According to LVN C she had noticed some decline with Resident #66's health and weight. LVN C stated the scheduler and an aide that assists on the floor was responsible for resident weight checks. LVN C stated Resident #66 recently enrolled in Hospice therefore, she had not reported any weight loss to anyone. LVN C stated the weight checks were completed by designated staff. LVN C stated not reporting weight loss placed residents at risk for malnutrition or other health concerns. <BR/>Interview on 03/20/24 at 11:40 AM with Hospice Case Manager revealed this was only her second time visiting with Resident #66. Hospice Case Manager stated Resident#66's weight was a concern and after speaking with the ADON about Resident #66's weight reading 74 pounds; she was told that reading was incorrect and Resident #66's correct weight was 96 pounds.<BR/>Interview on 03/20/24 05:09 PM with the DON revealed Resident #66 had a major decline in health and began to have several issues. The DON stated resident went to the hospital and at that time lost weight during her 2 hospital visits (4 days) . The DON stated it was discovered that a staff member was not entering weights correctly. The DON stated she reviewed Resident #66's records and identified issues with her weight recordings., The DON stated she reweighed Resident #66 on 03/19/24, and discovered her correct weight was 96 pounds. According to the DON because of Resident #66's weight loss, health shake was added to her lunch and dinner tray. The DON stated the health shakes were added after trays left the kitchen, aides on the halls were to ensure each meal ticket matched what was on each resident tray. The DON stated she could not tell who passed Resident #66's lunch tray because all available aides were responsible for passing trays on the hall. The DON stated ultimately the aide that worked Resident #66's hall was responsible for ensuring she had a health shake.DON stated health shakes and supplements were printed on the meal tickets, and staff checking the tickets and carts in the dining room were responsible for placing the shakes on the trays. DON stated she was in the dinning room helping to check those trays and did not recall missing anyone. The DON stated risk included resident not gaining weight if she was not getting the health shake which was used to promote weight gain. The DON stated not entering proper weight balances will place residents at risk of having a major change of condition. <BR/>Interview on 03/20/24 at 5:15 PM with Administrator revealed Resident #66 has been in the facility for almost a year. The Administrator stated Resident #66 had undergone recent health decline and her care plan had changed quite a bit. The Administrator stated his expectations was to have accuracy when entering resident weights so that we can have a picture of resident's health and condition. The Administrator stated the nursing staff was responsible for monitoring and reporting resident weight loss, reporting to ADON or [NAME] and following up with physician, dietitian, and family. <BR/>2. <BR/>Review of Resident #115's face sheet, dated 03/21/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/26/23. His diagnoses included anorexia (an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self- induced behaviors towards thinness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).<BR/>Review of Resident #115's quarterly MDS assessment, dated 11/07/23, reflected he had a BIMS score of 15 indicating no cognitive impairment.<BR/>Review of Resident #115's physician's orders reflected an order for weekly weights on Wednesdays starting on 10/31/23.<BR/>Review of Resident #115's care plan, dated 12/18/23, reflected the following: Focus: risk for malnutrition; goal: resident intake of nutrients will meet metabolic needs . <BR/>Review of Resident #115's weights, dated 03/21/24, reflected the following: 11/08/23 171 lbs (wheelchair). <BR/>Interview on 03/20/24 at 3:30 PM with CNA T revealed he was responsible for weighing residents back in November 2023. CNA T said he would get a list of residents on Wednesdays who needed to be weighed weekly. CNA T said he would go and weigh the residents and the write down the weight next to their names and give the list to the ADON/DON at the time. <BR/>Interview on 03/21/24 at 1:45 PM with the DON revealed the purpose of weighing a resident weekly was to try and see how a resident's weight was trending and to see if the weight the facility got was actually accurate or not. The DON said it was also to assist in closer monitoring purposes and helps to identify if the facility needed to add something to the resident's plan of care or not. The DON said back in November 2023 CNA T was responsible for weighing residents and he would receive a list weekly of which residents needed to be weighed. The DON said after the weights were added to the list CNA T would provide it to the nurse managers. The DON said she was not sure why Resident #115's weekly weights were not recorded back in November 2023.<BR/>Review of the facility's policy, revised March 2022, and titled Weight Assessment and Intervention reflected the following: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #42) of 3 residents reviewed for dialysis.<BR/>The facility failed to ensure dialysis assessments were completed for Resident #42 after return from dialysis treatment.<BR/>This failure could place residents at risk of inadequate post dialysis care.<BR/>Findings included:<BR/>Record review of Resident #42's, face sheet reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE].Resident #42 had diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis).<BR/>Record review of Resident #42's quarterly MDS assessment, dated 01/12/24, reflected a BIMS score of 9, which indicated his cognition was moderately impaired.The MDS section O related to special treatments, procedures and programs reflected Resident #42 received dialysis.<BR/>Record review of Resident #42's care plan, dated 02/24/23, reflected Resident #42 needed hemodialysis(procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean blood) rule out end stage renal failure. Resident #42 will have no signs of complication from dialysis through next review. Monitor vital signs every shift. Notify medical doctor of significant abnormalities. Monitor/document/report as needed any signs and symptoms of infection to access site: Redness, Swelling, warmth or drainage.Blood pressure documented under vitals tab in pint click care upon return from dialysis.<BR/>Record review of Resident #42's physician's order, dated 01/18/24, reflected record post-dialysis weight under weights/Vitals upon return to facility.<BR/>Record review of Resident #42's dialysis communication forms reflected dialysis communication forms with no information on the resident assessment and observation during dialysis section on 03/13/24, 03/11/24, 03/08/24, 03/04/24, 03/01/24, 02/19/24, 02/16/24, 02/14/24, 02/05/24, 01/26/24, 01/15/24, 01/14/24, 01/10/24, 01/05/24, and 01/03/24.<BR/>Interview on 03/20/24 at 11:34 AM with the DON revealed it was the nurses' responsibility to send dialysis residents with a communication form to dialysis and get the form back when the resident returned to the facility so if there were orders from dialysis or changes, it was noted. She stated her expectation was for the nurses to perform post-dialysis assessments when residents returned from dialysis and call dialysis if the communication form was received blank.She stated if there are new orders the dialysis center calls the facility.She stated if there are new orders the dialysis center calls the facility. She stated failure to call the dialysis center staff would not know whether Resident #42 got new orders or received treatment. She stated she had not been notified the forms were being received blank from dialysis. She stated the ADONs were responsible for ensuring nurses were receiving the papers from resident after dialysis and assessment is documented. The DON stated she had done training with staff and the last in-service was in October 2023. She stated they have called the dialysis center, and they had received all the vital signs for the missing days. They have come up with a plan of correction with dialysis they would be sending Resident #42 with a folder that could be easily seen by the dialysis staff.<BR/>Interview on 03/20/24 at 1:55 PM with RN E revealed he was aware he was supposed to collect the form when Resident #42 returned from dialysis. RN E stated Resident#42 returned during his shift and his communication form would be in his backpack not filled by dialysis. He stated he made attempts to call the dialysis center and phones were not going through. He stated he had not reported to the DON that Resident#42 communication form was being received blank. RN E stated he was aware of the importance of the communication form being filled out at the dialysis center., He would have known the weight post dialysis, vitals signs the dialysis center and in case there were new orders. He stated he had done training on dialysis communication form to be filled before and after dialysis and also if dialysis did not fill the form staff should call dialysis center and obtain the information and dialysis center should fax to facility the completed form.<BR/>Interview on 03/20/24 at 4:05 PM with the ADON revealed it was management's responsibility to ensure the staff completed the dialysis communication forms when Resident #42 left and returned to the facility. ADON stated she was responsible on checking what the nurses were doing. ADON stated she was not aware the form was being returned blank. ADON stated the importance of the communication form serves as a communication for changes between the facility and dialysis center. She stated the risk for not receiving a completed form there was a communication breakdown and they were not able to tell what happened at dialysis, treatment given or changes in vitals during the dialysis and any new orders, but she stated in case of new orders the nephrologist (medical doctor who specializes in kidney care and treating diseases of the kidneys ) calls the facility.<BR/>Interview with Dialysis Director through a phone call he stated he was called by the facility on the morning of 03/21/24, and he noted there was a problem with the communication form was not being filled from the dialysis center. He stated he was told by the facility nurses that the communication papers were in the resident backpack, and they have come up with a plan of correction . He stated the importance of the communication form was for updates and communication between two facilities to ensure continuity of care.<BR/>Record review of the facility's current undated dialysis policy reflected the following:<BR/> .The general medical nurse should document in the resident's medical record every shift as follows:<BR/> .4. Any part of report from dialysis nurse post dialysis being given.<BR/>5.Observation post dialysis

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #89) of 7 residents reviewed for pharmaceutical services.<BR/>1. RN D failed to follow the facility policy and physician orders for flushing Resident #89's gastrostomy tube with 5 mL of water before, between, and after medications, when she administered Tylenol to the resident<BR/>2. RN D failed to follow the Physician Orders to check gastrostomy tube placement every shift hold for residual greater than 100 mL and notify the doctor. <BR/>3. RN D failed to follow the facility policy for flushing the gastrostomy tube after stopping a continuous feeding with at least 15 mL of water.<BR/>These failures could put residents at risk, who received medications via gastrostomy tube, for tube occlusion, and displacement of the gastrostomy tube and medication interactions.<BR/>Findings included:<BR/>Review of Resident #89's MDS (a standardized tool that measures health status in nursing home residents), dated 11/25/22, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The assessment reflected Resident's #89 had severed impaired cognition and had diagnoses which included muscle weakness, feeding difficulties and pain in unspecified joint. <BR/>Review of Resident #89's February 2023 Physician Orders reflected the following: flush gastrostomy tube with 5 ml of water before, between and after medication administration. Tylenol oral tablet 325 milligrams. Give 2 tablets via gastrostomy tube every 8 hours as needed for pain.<BR/>Observation on 02/08/23 at 12:29 PM revealed RN D crushed 2 tablets of Tylenol 325 mg and put the crushed medication in a cup. RN D went to resident 89's room: RN D positioned the Resident #89. RN D sanitized don gloves and discontinued the continuous tube feeding, checked Resident #89's bowel sound. RN D did not check for the residual before administering medication and she did not flush the gastrostomy tube after stopping the feeding prior to administering medication. <BR/>Interview with RN D on 02/08/23 at 12:38 PM revealed she was aware of the order to administer medication through gastrostomy tube for Resident #89, but she was nervous and that is why she forgot to check for the residual and flush the gastrostomy tube after stopping the feeding and before medication administration. She stated failure to check for residual, she was not sure whether the resident feeding was being digested well. She also stated failure to flush the gastrostomy tube after stopping the feeding and before administering medication could lead to g-tube blockage and medication interaction with feeding formula. She stated she had received training on medication administration via gastrostomy tube.<BR/>Interview with the DON on 02/08/23 at 01:34 PM revealed his expectation was for the nurses to flush the gastrostomy tube before between and after each medication administration as per the doctor's orders and follow the facility policy. He stated failure to flush the gastrostomy tube made the tube hard to flush and over time it may cause the gastrostomy tube to clog. He stated failure to flush before medication administration and after stopping the formula feeding it might also cause medication chemical interaction that would affect the effectiveness of the administered medication. He stated he had trained the nurses on medications administration via gastrostomy tubes.<BR/>Review of the facility's current policy dated November 2018, Administering Medication through enteral tube policy and procedure, reflected the following: <BR/> .4. Tablets that must be crushed prior to administration through an enteral tube require a specific order related to crushing. <BR/> .6. Verify placement of feeding tube.<BR/>a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the charge nurse or physician.<BR/>7. Stop the feeding and flush tubing with at least 15 mL warm purified water or (another prescribed amount). <BR/>10. Administer each medication separately <BR/>13. If administering several medications, administer each one separately. The tube should be flushed with at least 15mls of water between medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 2 of 5 residents (Resident #14 and #98) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. <BR/>The facility's Pharmacist Consultant recommended Residents #14 and #98 antipsychotic medication Quetiapine required an additional consent on the Form 3713 to be completed and uploaded to the resident's chart.<BR/>These failures could place residents on psychotropic medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #14's face sheet dated 03/21/24 revealed the resident was a [AGE] year-old male who originally admitted to the facility 04/05/2023.The diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), delusional disorders and adjustment disorder with mixed disturbance of emotions.<BR/>Record review of Resident #14's quarterly MDS dated [DATE] revealed a BIMS score of 09 indicating he was moderately cognitive impaired. <BR/>Review of Resident #14's physician's orders reflected an order for: Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors, with a start date of 02/13/24.<BR/>Review of Resident #14's January 2024 MAR reflected the following: <BR/>Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors and indicated Resident #14 received the medication the entire month of January 2024.<BR/>Review of Resident #14's February 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors and indicated Resident #14 received the medication the entire month of February 2024.<BR/>Review of Resident #14's March 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 50MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for antipsychotic behaviors and indicated Resident #14 received the medication the entire month of March 2024.<BR/>Review of Resident #14's care plan, revised on 08/29/23, reflected: The resident uses psychotropic medications (Seroquel .) rule out behavior management.<BR/>Review of Resident #14's Medication Regimen Review, dated 01/30/24, reflected the following: Resident has an order for the antipsychotic medication, Quetiapine. Effective January 2022 consent is required to on Form 3713 provided by Texas Health and Human Services. Please ensure form is completed and uploaded to resident's chart.<BR/>2. Review of Resident #98's face sheet, dated 03/21/24, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included persistent mood disorders (a continuous, long-term form of depression), unspecified dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), and generalized anxiety disorder (a common mental disorder that makes you worry excessively about everyday thing).<BR/>Review of Resident #98's quarterly MDS Assessment, dated 02/15/24, reflected she had a BIMS of 14 indicating no cognitive impairment. <BR/>Review of Resident #98's physician's orders reflected an order for: Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders with a start date of 02/13/24.<BR/>Review of Resident #98's January 2024 MAR reflected the following: <BR/>Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders and indicated Resident #98 received the medication the entire month of January 2024.<BR/>Review of Resident #98's February 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders and indicated Resident #98 received the medication the entire month of February 2024.<BR/>Review of Resident #98's March 2024 MAR reflected the following:<BR/>Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for psychosis related to other specified persistent mood disorders and indicated Resident #98 received the medication the entire month of March 2024.<BR/>Review of Resident #98's care plan, revised on 03/05/24, reflected: The resident uses psychotropic medications (Seroquel .) r/t behavior management.<BR/>Review of Resident #98's Medication Regimen Review, dated 01/29/24, reflected the following: Resident has an order for the antipsychotic medication, Quetiapine. Effective January 2022 consent is required on Form 3713 provided by Texas Health and Human Services. Please ensure form is completed and uploaded to resident's chart.<BR/>Interview on 03/21/24 at 4:08 PM with the DON revealed she was not aware Form 3713 was a requirement for psychotropic medications. The DON said regarding the pharmacy consultant recommendations that she was primarily responsible for following up on them but the ADON's also assisted. The DON said the Pharmacy Consultant was at the facility yesterday (03/20/24) and asked them about the Form 3713 and said it was for consents which the facility already had so the DON thought the facility had everything already . The DON said she had a chance to glance at the form and the purpose of it was for the doctor to evaluate the resident, give a diagnosis, and that the family has confirmed they had been notified and were aware of the medication being given. The DON said it was a separate version of the consent form already signed off for the medications the resident was receiving. The DON said it appeared to be a form the doctor would complete.<BR/>Record review of the antipsychotic medication use policy revised December 2016 did not address Form 3713.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one of 4 residents (Resident #66) reviewed for dental services. <BR/>The facility failed to assist in providing dental services for Resident #66.<BR/>This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. <BR/>Findings included: <BR/>Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function is disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), Anemia (blood disorder), <BR/>Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with eating, substantial/maximum assistance with dental hygiene, and supervision/touching assistance with personal hygiene. Section L - Oral/Dental status revealed none of the above were present which included: Broken or loosely fitting full or partial denture. <BR/>Record review of Resident #66's care plan reviewed on 03/18/24 did not indicate she had or required the use of dentures. <BR/>Record review of Resident #66's Order Summary Report dated 03/21/24, reflected Regular diet Pureed texture, Thin liquids consistency, health shakes with lunch and dinner (prefers chocolate flavor) for difficulties chewing. Start date 03/05/24.<BR/>Activity level: bedbound. Diet: comfort feeds as tolerated. Start date 03/07/24.<BR/>May see dentist, Start date 04/03/23.<BR/>Record review of Resident #66 progress note, dated 02/27/24 at 9:53 PM, written by the LVN reflected Resident #66 went to a dental appointment with her Family Member, she came back with no new order, she has been sleeping since she came back, respiration 18, even and unlabored, no signs and symptoms of discomfort was notes, oncoming nurse to monitor. <BR/>Observation and interview on 03/18/24 at 12:20 PM, revealed Resident #66 in her room, in low bed, resting while Family Member was sitting at bedside. When Resident #66 heard voices in the room she awoke and greeted surveyor, revealing she did not have any teeth. According to Family Member Resident #66 entered the facility almost a year ago, recently had a decline in weight. Family Member stated she felt Resident #66's decline started when she lost her dentures about 4 months ago. Family Member stated it took a while before Resident #66's tray provided pureed accommodations for her to eat well. Family Member stated she began to bring supplemental beverages for Resident #66 to ensure she was getting proper nutrition. Family Member stated she spoke with facility about Resident #66's missing dentures, however had never received any feedback. Family Member stated she then decided to go outside the facility to replace the missing dentures. Observation prior to exiting Resident #66's room revealed pureed lunch tray. <BR/>Interview on 03/19/24 at 3:59 PM with the Social Worker revealed she began at the facility in December 2023, she was not notified of any dental concerns by the facility staff, Resident #66, or Family Member. Social Worker stated she could not recall the last time she saw Resident #66 with her dentures. Social Worker stated Resident #66's last dental visit by facility dental provider was on 08/25/24 recommending fabrications of full upper and lower dentures. Social Worker stated the facility procedure for dental services were to have both the resident or responsible party and the physician to sign consent forms to move forward with the dental recommendations, which were provided to the Dental Provider to move forward. The Social Worker stated Resident #66 went out with on 02/27/24 for a dental appointment, indicating the family went through an outside dental provider. Social Worker stated she did not follow up with Family Member about the dental appointment neither did she offer any resources. Social Worker stated she was responsible for ensuring residents received the required dental services while in the facility. Social Worker stated if she had known about the dental recommendations, she could have notified Family Member and followed up to see how Family Member would have like to move forward, however the dental visit was prior to her employment. Social Worker stated not assisting residents with follow-ups to dental recommendations placed residents at risk of not getting their dental needs met. Social Worker stated she relied on the residents or staff to inform her of any concerns, otherwise the facility provided annual dental checks and cleanings to all residents. <BR/>Interview on 03/20/24 at 5:09 PM, with the DON, revealed Resident #66 was full of life and would wander the facility all the time. DON stated Resident #66 would eat plenty of snacks and can drinks, she would enter resident room and facility offices looking for things to eat and drink. DON stated Resident #66 had a major decline, she began having behavioral issues and would be hard to redirect for example she lost her purse, phone, and dentures. DON stated when you would try to redirect her to put her purse in her room, she would not listen to you, so it resulted in missing items. DON stated she was not able to recall the last time Resident #66 had her dentures because she would move things all the time and would take her personal items in and out of other resident rooms so there was no way to keep up with her items. According to the DON it was the responsibility of the nursing staff to alert the family that Resident #66's dentures were missing. According to the DON not having dentures could place residents at risk of not being able to eat, weight loss, or decline in health. The DON stated the Social Worker was responsible for working with resident and resident power of attorney to ensure residents were seen by dental provider and follow up on any dental appointments. <BR/>Interview on 03/21/24 at 12:33 PM with Occupational Therapist revealed she did work with Resident #66., The Occupational Therapist stated as far as she could remember it was around January 2024, she noticed Resident #66 was without her dentures. Occupational Therapist stated there was a time when she was able to ambulate and would move her things around resulting with her losing her personal items. Occupational Therapist stated she found the dentures one time in her bed and another in the drawer. Occupational Therapist stated she had lost the dentures several times but about January was when she lost the dentures for good. Occupational Therapist stated that Resident #66 continued eating but it was about this time she was having a change in condition with behaviors, falls and health decline. Occupational Therapist stated she did not report to anyone that Resident #66 was missing her dentures. Occupational Therapist stated the discussion never came up, Social Service Office was responsible for ensuring residents were having dental services as needed, without dentures or dental services this placed residents at risks of not being able to eat and weight loss. <BR/>Interview on 03/21/24 at 3:39 PM with the Administrator revealed Social Services was responsible for assisting residents with dental services. The Administrator wanted to point out to surveyor that Resident #66 had a dental appointment on 08/24/23 and was due her next annual appointment on 08/24/24. The Administrator stated upon his review in Resident #66's progress notes he saw Resident #66 had a dental appointment outside the facility made by family. The Administrator stated he was not made aware of Resident #66 dental recommendations for new dentures or concern that her dentures were missing. The Administrator stated not having dentures could place resident at risk of not being able to eat and weight loss, however he stated after reviewing diet status, Resident #66 was on a puree diet therefore did not need the dentures. The Administrator advised the family scheduled outside dental services, no one followed up to ensure services were completed. <BR/>Record review of facility policy revised February 2014 titled Medication and Treatment Orders, Dental Services revealed Orders for the treatment of the resident's dental problems must be signed by the attending dentist.

Based on observation, interview, and record review the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for one (lunch meal) of one meal services reviewed. <BR/>The facility failed to ensure [NAME] A prepared the pureed lunch meal in a manner to conserve nutrition, flavor, and palatability on 02/08/23.<BR/>The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.<BR/>Findings included:<BR/>Observation of [NAME] A pureeing food items for lunch on 02/08/23 beginning at 10:45 AM revealed [NAME] A used tap water to thin out pureed breaded chicken patties. The pureed chicken patties had a mashed potato consistency. <BR/>Interview on 02/08/23 at 10:52 AM with [NAME] A revealed she had worked as a cook for the facility for about 6 months. [NAME] A stated she had been trained on following recipes when preparing all diets; however, she did not follow recipes because they had never been provided to her. [NAME] A showed surveyor a binder that only contained the weekly menus. [NAME] A stated she had already pureed the lima beans and cheesy cauliflower, and that she used tap water to thin out those food items as well. She recalled the RDN informing kitchen staff to use potato flakes as a thickener and liquids such as water, broth or juice as a thinner. When asked why she chose to use tap water, [NAME] A stated because she was close to the sink and nervous from being watched by surveyor; although she admitted to using tap water in the food items prepared outside of the presence of the surveyor. [NAME] A stated the risk of using tap water as a thinner could be watering down the flavor which could cause the residents to be dissatisfied with their food. <BR/>Interview on 02/08/23 at 11:15 PM with the Dietary Manager revealed he had worked at the facility for about 6 months. He stated that all cooks had been trained on how to properly prepare all meals, including specialized diets. The Dietary Manager stated the cooks knew to use pasta water, broths or juice to thin out pureed foods. He stated pasta water and broths would be used for meat and juice would be used for certain desserts. The Dietary Manager stated the RDN talked to them about using recipes, but he did not know where the recipes were. He was aware that the cooks did not have recipes to follow when preparing meals. He stated that even without recipes, they knew not to use tap water as a thinner based on the in-services they had received. The Dietary Manager stated the risk of using tap water as a thinner could be decreasing the nutrition and taste of the food. <BR/>Interview on 02/08/23 at 4:33 PM with the RDN revealed she had worked at the facility for over a year. The RDN stated she had trained the Dietary Manager and the cooks on how to properly thin and thicken pureed foods. The RDN stated using tap water as a thinner was an old method and no longer an appropriate way of obtaining the proper consistency for pureed foods as it diluted the flavor and nutritive value in the food items. The RDN stated she informed the cooks and the Dietary Manager to used broths, milk, and juice as appropriate. The RDN stated the risk of diluting the flavor and nutritive value in food with tap water could be the residents disliking the food which could lead to loss of appetite and weight loss. The RDN stated this was not likely and would take a long period of time to take effect, if so, but it was a possibility. <BR/>Interview on 02/09/23 at 5:15 PM with the Administrator revealed the RDN was responsible for monitoring the menus and ensuring that the kitchen staff understood the importance of properly preparing all meals. He stated it was his expectation for the Dietary Manager to ensure that kitchen staff were following the RDN's recommendations. The Administrator stated that not following the RDN's recommendations on properly preparing meals could have a negative impact on the residents' health. <BR/>Record review of the facility's recipe for breaded chicken breasts (pureed), lima beans (pureed), and cauliflower with cheese (pureed) revealed the following:<BR/>1. To get the actual serving size, puree the number or portions needed, adding adequate liquid needed to achieve the desired consistency as appropriate for resident .<BR/>Record review of an in-service titled Puree additives you can add for nutritional value, dated 12/05/22, revealed the following:<BR/>Do not use thickener powder. <BR/>Liquids: gravy, stock, pasta water.<BR/>Thickener: breadcrumbs, bread, potato pellets.<BR/>Record review of the facility's policy titled Therapeutic Diet Orders, revised January 2020, reflected the following:<BR/>Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. <BR/>Definitions: <BR/>Mechanically Altered Diet-one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat and thickened liquids. <BR/> .Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.<BR/>A policy on standardized recipes was requested form the Administrator on 02/09/23 and was not provided at the time of exit. Administrator stated the facility did not have a specific policy on recipes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #115) of 5 residents reviewed for clinical records.<BR/>1. The facility failed to ensure staff accurately documented on Resident #115's October 2023 MAR that he received his medications.<BR/>2. The facility failed to ensure staff kept copies of Resident #115's shower sheets from September and October 2023.<BR/>These failures could affect residents and place them at risk of inaccurate or incomplete clinical records.<BR/>Findings included:<BR/>1. Review of Resident #115's face sheet, dated 03/21/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/26/23. His diagnoses included anorexia (an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self induced behaviors towards thinness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).<BR/>Review of Resident #115's quarterly MDS assessment, dated 11/07/23, reflected he had a BIMS score of 15 indicating no cognitive impairment. <BR/>Review of Resident #115's physician's orders reflected the following: <BR/>- <BR/>Morphine sulfate ER tablet extended release 15 MG, Give 1 tablet by mouth at bedtime for pain ***do not crush*** with a start date of 09/30/23<BR/>- <BR/>Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa), Give 1 tablet by mouth four times a day for Parkinson's Disease ***do not crush*** with a start date of 09/14/23<BR/>Review of Resident #115's care plan, closed on 12/18/23, reflected the resident had a diagnosis of Parkinson's disease and was taking carbidopa-levodopa and also had chronic pain .<BR/>Review of Resident #115's October 2024 MAR revealed blank spots for the following orders: Morphine sulfate ER tablet extended release 15 MG, Give 1 tablet by mouth at bedtime for pain ***do not crush***; on the following date: 10/07/23. Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa), Give 1 tablet by mouth four times a day for Parkinson's Disease ***do not crush*** on the following date: 10/13/23 for the 12:00 PM dose.<BR/>Interview on 03/21/24 at 1:45 PM with the DON revealed staff should document when they administer a medication or treatment due to nursing standard practices on the resident's MAR/TAR . The DON said the purpose of this was nursing 101 and if they did not document a medication or treatment administered then it was not done. <BR/>Review of the facility's policy, revised April 2019, and titled Administering Medications reflected the following: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.<BR/>2. Review of shower sheets provided by the facility for Resident #115 revealed there were only two for the entire month of September 2023 (dated 09/08/23 and 09/15/23) and none dated for October 2023. <BR/>Interview on 03/20/24 at 2:12 PM with CNA S revealed he cared for Resident #115 and provided him baths while he was working with him. CNA S said Resident #115's shower days were Mondays, Wednesdays, and Fridays. CNA S said when a resident received a shower he would fill out a shower sheet and give it to the nurse to look over. CNA S said he was not sure what happened to the shower sheets after that. <BR/>Interview on 03/21/24 at 4:05 PM with the Administrator revealed he was not able to locate any additional shower sheets for Resident #115 for September and October 2023.<BR/>Interview on 03/21/24 at 4:08 PM with the DON revealed she was unable to locate any additional shower sheets for Resident #115 for the months of September and October 2023. The DON said the shower sheets were pulled at the end of the month and sent to medical records to be kept for the resident's records. The DON said the CNA's were responsible for providing showers and filling out the shower sheet and then showing it to the Nurse and placing it in a specific place to be held until the end of the month.<BR/>Follow-up interview on 03/21/24 at 4:29 PM with the DON revealed the purpose of keeping shower sheets was to prove that the resident was provided a shower on that date. <BR/>Review of the facility's policy, revised February 2018, and titled Bath, Shower/Tub reflected: Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment date (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two (Resident #2 and #4) of four residents reviewed for accidents and supervision.<BR/>1. The facility staff DA M allowed Resident #2 to leave behind her without ensuring he was not a resident.<BR/>2. The facility failed to ensure Resident #2 did not elope from the facility and staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. <BR/>3. The facility staff including MA R, LVN P, LVN Q and CNA B and CNA X failed to check on Resident #2 on the 2-10PM, 10PM-6AM, AND 6AM-2PM shifts from 08/19/23 through 08/20/23 to ensure he was present in the facility. <BR/>4. The facility nurses failed to check on Resident #2 every shift per the physician's order to monitor for increased signs and symptoms of exit-seeking and/or wandering on the 10pm-6am shift from 08/19/23 through 08/20/23. <BR/>5. The facility failed to ensure the wander guard system was effective as Resident #4's wander guard did not alarm on 08/22/23 when she approached the front exit door and the side emergency exit door on Hall 700.<BR/>An Immediate Jeopardy (IJ) situation was identified on 08/22/23 at 4:50 PM. While the Immediate Jeopardy was removed on 08/24/23, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of their plan of corrective systems .<BR/>These failures could place residents at risk for injury and/or death from elopement related harm, including vehicular accidents, falls, missing medications, and extreme heat exposure.<BR/>Findings include:<BR/>1. Record review of Resident #2's quarterly MDS assessment, dated 06/22/23, reflected a [AGE] year old male who was admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Vascular dementia can develop after a stroke blocks an artery in your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2 did not have an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. <BR/>Record review of Resident #2's care plan, dated 03/17/23 and last revised 08/21/23, reflected the following:<BR/>- Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed.<BR/>- Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed.<BR/>- Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others.<BR/>Record review of Resident #2's Elopement Evaluation at his time of admission, dated 03/17/23, reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. <BR/>Record review of Resident #2's facility progress notes, pertinent to his use of a wander guard and elopement, incident included:<BR/>-03/17/2023- Behavior: Resident noted wandering on the hallways, other resident rooms and exit doors. Resident easily redirected back into his room and comes out of the room immediately. MD was notified and gave order to monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. RP present at the facility, notified and agreed with order. Family Member confirmed resident behavior.<BR/>-06/09/2023-Nursing: This nurse notified the MD that the resident has pitting edema +3. MD has a new order of reduce salt intake, no excessive liquids and elevate legs for one hour three times a day. MD will re-evaluate resident.<BR/>-06/11/2023-Nursing: Resident #2's family member asked nurse to encourage resident to have a shower. This nurse went to try and assist resident with shower, resident refused. Family notified. Nurse attempted multiple ways to encourage resident to shower, resident keeps telling nurse that you don't know what you're talking about. Also, nurse noticed that resident removed wander guard, family notified, admin notified. Resident keeps stating that the wander guard fell off in the shower. Unable to locate in resident's room, admin notified.<BR/>-06/28/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I)<BR/>-06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A)<BR/>-06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. <BR/>-07/07/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A)<BR/>-07/10/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. The resident does not have a wander guard in place.<BR/>-07/11/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard is not in place of the resident.<BR/>-07/12/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard not in place.<BR/>-07/13/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place.<BR/>-07/18/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident has removed wander guard (signed by LVN A)<BR/>-07/19/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident Removed (signed by LVN A)<BR/>- 07/20/2023- Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I)<BR/>-07/24/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed, DON aware (signed by LVN A)<BR/>-07/25/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/26/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/20/23-Review of a Multidisciplinary Care Conference: (ADM and RP checked as only participants) reflected, Problems/needs-CP meeting held with Administrator and RP to discuss behaviors of resident cutting wander guard off. Discussed recent elopement assessment reflecting resident is not at risk for elopement. Based off initial elopement assessment resident has not shown exit seeking behavior and therefore not considered elopement risk. Family, Nursing administration, and Administrator that wander guard is not necessary. However, if exit seeking behavior begins, alternate placement will be discussed.<BR/>-Note: Review of a Resident #2's physician order dated 07/27/23 reflected, Monitor for increased S/S of exit seeking and/or wandering every shift (Active 07/27/2023).<BR/>-07/28/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A)<BR/>-07/31/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A)<BR/>-08/02/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A)<BR/>-08/03/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A)<BR/>-08/07/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A)<BR/>-08/08/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A)<BR/>An interview with LVN A on 08/24/23 at 12:05 PM revealed she was no longer employed at the facility. LVN A stated she was one of the charge nurses for Resident #2 and she had not been working very long at the facility when she was told Resident #2 had a wander guard in the past but he had cut it off or pulled it off. LVN A stated Resident #2 did not display exit-seeking behavior and at point, she tried to put a wander guard on his wrist one time only, but he removed it on the same shift. She said she did not see him remove it and after that, someone tried his ankle, and he took it off unwitnessed. She said it was in the 24-hour report that he removed it and no staff had seen it happen. LVN A stated the wander guard was not located and she did not know if it was ever found. Aside from placing a wander guard on his wrist that one time, LVN A stated she did not try to place another one on him after that. LVN A stated, I kept saying resident removed in my notes and asked the DON if she wanted me to get the order discontinued and she said let me see if I can have it replaced with metal band or get with family to figure it out.<BR/>Record review of Resident #2's nursing progress notes, for 08/19/23 and 08/20/23, did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: [hospital] notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [family member] notified via VM.<BR/>Record review of the facility's incident for Resident #2, dated 08/20/23 at 12:10 PM, reflected Incident description: Resident noted to be missing from room at approximately 12 PM. Search conducted at facility. Admin notified ASAP. Approximately 6 PM police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and [hospital] notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside.<BR/>Review of website: https://www.accuweather.com (retrieved 08/22/23) revealed the temperature high for the location Resident #2 was found on 08/20/23 was 109 degrees Fahrenheit.<BR/>Review of Resident #2's August 2023 MAR reflected he missed the following prescribed medications during the time he was missing from the facility on 08/20/23 were Aspirin Oral Capsule 81 MG (blood thinner), Calcium-Vitamin D Oral Tablet 500 MG Protein Oral Liquid 30 ml (supplement).<BR/>An observation of the facility video footage, dated 08/19/23 at approximately 7:38 PM, showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. <BR/>An interview with Resident #2's RP on 08/22/23 at 6:30 AM revealed when Resident #1 was located by the Police, she went to see him and transport him back to the facility. The RP stated she observed Resident #1 to be extremely confused and scared. He was covered from head to toe in dirt and had a trash bag full of garbage one would find in a dumpster. The RP stated she was a RN and was able to assess her father and noted that he had 4+pitting edema. <BR/>An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth , he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, police had already started process for silver alert and approximately. 30 minutes later, I got a call from sergeant saying he had been found in a hotel lobby in Grapevine. The ADM stated the police notified the family who were on their way to pick Resident #1 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and stated the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and Resident #2 kept removing it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by the family request because the family told him Resident #2 had a criminal history in the past where he had to wear and ankle monitor and having one on his leg in the nursing home may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not interview him. He stated, I want to say someone [name unknown] from our nursing staff talked to him [name unknown] . The ADM admitted the overnight staff working 08/19/23 into 08/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he was told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, [Resident #2] does not like to be bothered at night and gets agitated, so that was why he had less rounds. If he doesn't require incontinent care, then it would be opening his door to make sure he was there as rounding. He does not have a roommate. It could be done quietly and that was my conversation with them yesterday when we started the in-service. The ADM stated the elopement incident could have been prevented by staff ensuring when they left the facility exits, to make sure there were no residents trying to leave and if they were unsure who a resident was, to stop and ask them. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards .<BR/>An interview with MD D on 08/23/23 at 1:00 PM revealed he did not know Resident #1 was on his caseload until the incident with the elopement. He stated he did not know he was missing for over 18 hours and only got notified when he was located. <BR/>An interview with DA M on 08/22/23 at 10:12 AM revealed she did not interact much with residents and 95% of the time she was in the kitchen and at other times, she was delivering meal carts to CNAs or nurses. She said she did not know who Resident #2 was and could not recall seeing him before. DA M stated, When I let him out, I saw him standing the door, I had my head down and ready to head out, I typed in code and he followed right behind me, he said thank you so much, clear as day, and I thought he was family member. I didn't think much of it. DA M stated she had not been informed by the facility who were potential exit-seekers or what to do if she saw one of those residents attempting to elope. She stated, 'I didn't think I would be in a situation where I would be dealing one-on-one with a resident. I had not been informed on what to do if one wanted to leave. If I had seen him around and knew him, I would have grabbed a CNA or nurse and told them he was trying to leave, but it was the end of my shift, I clocked out and wasn't thinking much of it, I thought he was a visitor of a resident here. I walked out and my mom who was in a car picking me up, said she had seen a man walk out behind me but didn't think much of it . He was dressed in casual clothing, I glimpsed at him. DA M stated when she came to work Sunday 08/20/23, the kitchen staff were telling her about a resident who had eloped the day before and it was then she realized through their description of him, that it might be the man she let out the day before. DA M said she ran to the ADM's office and the police were there and she told them what happened the night before and they were able to then pull it up on surveillance camera and verify Resident #2 went out the door behind her around 7:38 PM. <BR/>An interview with ADON I on 08/22/23 at 10:41AM revealed she was at the facility on 08/19/23 until 5:00 PM and was at the facility on 08/20/23 from 6:00 AM until 11:00PM. ADON I stated when she came into work on 08/20/23, no one mentioned Resident #2 was missing. She said the CNA that worked with him (CNA B), went to pick up his breakfast tray around 12:10 PM and it had not been eaten and she then asked ADON I if she had seen him around. ADON I said the CNA B would have delivered the breakfast tray around 7:45AM-8:30AM. ADON I stated they immediately checked all the resident rooms and bathroom, his friends' rooms and he was not present. Then someone drove the perimeter outside, down to the nearby shopping strip and did not see him. Then ADON I called the family and asked them if Resident #2 was with them and they said no. At that point ADON I stated she called the DON, called ADM and called the staff who worked the night shift before. She said there was an agency nurse (LVN P) who said she remembered checking on Resident #2 during her overnight shift. ADON I also stated she called the overnight CNA, who also remembered checking on Resident #2 during the overnight shift. Once ADON I was informed by the ADM Resident #2 was seen through video surveillance leaving the facility on 08/19/23 at approximately 7:40 PM, she stated, That made me question staff that told me they had seen him that night. ADON I said by the time Resident #2 was found and returned to the facility, he had missed three shifts of medications over two days. ADON I stated Resident #2 did not have a wander guard on because he kept cutting them off and the facility had been through about 10 or 12 of them. She said Resident #2 had never tried to exit-seek before, I have never even heard him ask, he is usually very pleasant and interactive. She stated, When we have done a wander guard in past, it was on his ankle. We have never tried one on his wrist that I can remember, don't know if it was tried. ADON I stated, Plan now for him is he has been so far one on one and I think they are going to place him in a more secured facility. That I can't say for sure. ADON I stated there were photos in a binder of the residents who exit-seeked and that binder was at each nurses station and the front desk. She said Resident #2 was not in the binder. ADON I stated most of the staff understand that during the day, the front desk receptionist let people out through the front door with a code, but staff would also let them in and out too but most of them knew who the residents were and who was not supposed to leave. She said if a staff member was not sure if a person was a resident, they should not let them out and check with the charge nurses or other direct care staff. ADON I stated LVN N was the weekend supervisor who worked until 10:00 PM on 08/19/23. <BR/>An interview with LVN N on 08/22/23 at 11:09 AM revealed he was the weekend supervisor on 08/19/23 and he left the facility around 11:00 PM and was off work on 08/20/23. He said he got a call from one of the ADONs on 08/20/23 and she told him Resident #2 was missing and they were in the process of looking for him. He remembered seeing Resident #2 on 08/19/23 around 3:45 PM in the hallway, He normally comes out and stands in the hallway then comes back to his room. As far as I know, he hasn't tried to get out of the door before. <BR/>A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. The ADM stated, I do want to touch on and I am not saying everything was handled perfectly. As soon as we noticed he [Resident #1] was not here, all parties notified. We had police at facility in and out 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 &frac12; hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure , we followed all the necessary steps and we found him . The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons . <BR/>An interview with MA O on 08/22/23 at 12:52 PM revealed he was working a double shift on 08/19/23 from 6:00AM to 10:00 PM, but not on Resident #2's hall. He stated the nurse for Resident #2 on the 2-10PM shift was LVN Q. MA O stated he knew who Resident #2 was and he had eloped from the facility. The resident usually had a wander guard on him. He remembered seeing Resident #2 on his 08/19/23 shift because he normally came to the nurses' station for snacks and MA O remembered him coming to get one after dinner on 08/19/23, but there were no snacks left because they had all been passed out already. He stated Resident #2 was okay with it and not upset. MA O stated Resident #2 usually went to bed and would come out during the evening around 8-9PM most nights. The next morning, 08/20/23, MA O stated he worked Resident #2's hall from 6AM-2PM and was told by CNA B around lunch time that she had not seen him and could not find him. They began looking in each residents' room and around the hall, and then some staff went outside to look for him and that was when everyone realized he was missing and the police and family were notified. <BR/>An interview with LVN P on 08/22/23 at 1:06 PM revealed she was the agency nurse who worked the overnight shift on Resident #2's hall on 08/19/23 into 08/20/23 and it was her first time working at the facility. She stated that night she was the charge nurse for four halls. She stated she came into the facility to work around 10:00 PM and left around 6:45 AM the next morning. When she arrived at her shift that night, LVN P stated, When I got there, I can't really say I was oriented, but I did make rounds while the 2-10PM nurse was finishing up stuff. LVN P stated no one told her who was exit-seeking on her halls or who wore a wander guard. She stated she rounded on her own with no one else. LVN P stated she had rooms 507-510 (where Resident #2 resided) and she opened up each door when she started her shift to make sure there was a body in each bed. LVN P stated she remembered seeing a body in each bed; she did not go into the rooms and touch the residents but when she opened each door, she saw a body and assumed each resident was asleep. She stated she did not turn the lights on. Around 11:30 PM, the off-going nurse came back around and gave LVN P a report and then LVN P took over from there. LVN P stated she did not know who the residents were and a nurse named (LVN N) gave her a login to chart in the residents' e-chart. LVN P could not remember if she gave Resident #2 any medications or treatments during the overnight shift because there were two residents in the facility with the same last name, Resident #2 and Resident #7. She stated, So I don't remember which one I saw. I think one was on 500 and one on 700, I could be mistaken. After she left the next morning, she got a call from the facility around 12:30 PM on 08/20/23, asking questions about Resident #2.<BR/>Review of Resident #2's clinical chart revealed no documentation in his care plan or progress notes that he did not want to be disturbed at night.<BR/>An interview with CNA B on 08/22/23 at 1:20 PM revealed she was Resident #2's CNA on the 6AM-2PM shift 08/20/23 and got to the facility around 6:15 AM. CNA B did not remember who the nurse was on her hall that shift. She said Resident #2 liked to walk around, so when she did not see him in his room that morning, she initially did not think anything of it. She put his breakfast tray in his room because she thought he was visiting with another resident at that time. CNA B then proceeded to get some more residents up for the day and fed a resident, then at some point went to pick up Resident #2's breakfast tray and he still was not in his room and his food had not been eaten. She said she did not panic but tried to look for him and around 9:45 AM and checked one of his friend's rooms but he was not there. CNA B stated, I figured he would pop back up. I went to dress another resident. He wasn't in his doorway asking me for a penny like he normally does and I am thinking that is not like him. I thought maybe he went out with the [family member]. At that time, CNA B said she looked at the piano in the dining room because he played sometimes, but nothing, I am thinking he will pop back up. I got up another resident then went back, not there. CNA B said she asked ADON I if she had seen him and they checked the sign out sheet. CNA B stated there was sign out for Resident #7, but not Resident #2, they both had the same last name. She asked the front desk receptionist what time Resident #7 left and she had it mixed up with Resident #2, so she asked another staff member when did Resident #2 leave, to which she was told he did not leave, he was in his room. CNA B stated, I started to panic and told [ADON I] and she and I started looking for him, did a wide search everywhere in the facility, looked outside, drove around McDonalds, grocery store, the neighborhood. Everyone in all departments looking for him. He was nowhere to be found. We just kept looking and then [ADON I] made calls. CNA B stated she was present when Resident #2 was found [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for one (Resident #2) of three residents reviewed for intravenous fluids. <BR/>1. The facility failed to date and maintain the integrity of the PICC/CVC line dressing per professional standards for Resident #2. <BR/>2. The facility failed to ensure LVN C had training on IV administration and IV dressing changes.<BR/>This failure could affect residents by placing them at risk for infections and cross-contamination.<BR/>Findings included:<BR/>Review of Resident #2's MDS assessment, dated 09/09/23, revealed the resident was admitted to the facility on [DATE], and she had severe cognitive impairement with a BIMS score of 7. The resident had diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and encephalopathy (a broad term for any brain diseases that alters brain function or structure). The MDS did not address the need for IV therapy. <BR/>Care plan on PICC/CVC not reviewed.<BR/>Review of Resident #2's physician orders, dated 12/13/23, revealed an order to change the resident's PICC line dressing every day shift every Wednesday for wound infection.<BR/>Review of Resident #2's December 2023 TAR/MAR revealed she was required to receive intravenous antibiotics, Piperacillin-Tazobactam intravenous solution 3-0.375 gm/50 mL every 8 hours for infection, through her PICC line in her upper extremity. A PICC line is a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is requred over a long period. <BR/>Observation on 12/19/23 at 12:08 PM revealed Resident #2's PICC line had an undated dressing that was peeling off on her right upper extremity. The PICC line insertion site was not open to air, the dressing was still intact with no signs of infection, but it was rolled up. <BR/>Interview on 12/19/23 at 12:38 PM with LVN C revealed nurses were responsible for the PICC/midline dressings. She stated the dressing change for Resident #2 was not known since it did not have a date. LVN C stated the dressing needed a change because it was rolled up and did not have a date. She stated she understood if the dressing change was not scheduled the resident was at risk of becoming infected. LVN C stated she knew the dressing change was supposed to be done weekly and as needed. She denied seeing the date on the dressing since it was rolled up. She stated she had worked two days with Resident #2, and she was aware it was her responsibility to check on the insertion site for infection, redness , date, and status of the dressing. She stated she forgot to check on the date on the dressing both shifts that she had worked with Resident #2. LVN C also revealed she was not IV certified, and she was not aware that she had to be certified to administer IV medication to Resident #2. She stated she had not done training on IV administration and dressing changes in this facility since she was a new hire. LVN C stated the importance of putting the date on the dressing was to verify the date of changing the dressing to prevent infection. She stated the dressing was rolled up, and she knew if the dressing was not dated as scheduled the resident was at risk of becoming infected. Other interviewed staff knew the dressing need to be dated and changed weekly.<BR/>Interview on 12/19/23 at 1:37 PM with the DON revealed her expectation was for the nurses to change the PICC/midline every seven days and as needed. The DON stated her expectation was that when the nurses noted there was no date, they should have notified her, the ADON or any RN on duty to change the undated dressing from hospital immediately and put a new dressing with a date. The DON stated she was not notified about the dressing until today when it was noted by the surveyor. She stated the RN and the LVNs were the ones that administered intravenous medication and changed the dressings on PICC/midlines. She stated LVN C was oriented by RN, and she took a position for an RN and she did not know she was not certified, though IV certification was not facility policy requirement but for the best standard of practice she had offered IV classes to her staff, but LVN C was a new hire and had not done certification training. She stated failure to have a date on the dressing predisposed the residents to infection. She stated whoever changed the dressing should put a date and the purpose of putting a date was to notify other staff when the next change was due. She stated she had done training on PICC/midline care with staff but in-service training records were not provided. <BR/>Record review of the facility's current Central Vascular Access Device Dressing Changes policy, dated July 2020, reflected the following: <BR/>It is the policy of this facility to change peripherally inserted central catheter (PICC),midline or central venous access device (CVAD) dressing ,weekly or if soiled ,in a manner to decrease potential for infection and /or cross-contamination. Physicians orders will specify type of dressing and frequency of changes.<BR/>20.Label the dressing with the date and time and your initials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs were provided for 1 (Resident #1) of 5 residents reviewed for accommodation of needs.<BR/>The facility failed to ensure Resident #1's call light was placed within his reach. <BR/>This failure could place dependent residents at risk of injuries and unmet needs. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet, printed on 12/07/23, revealed Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis on the right side of the body due to tissue damage to the brain or spinal cord), chronic allergic conjunctivitis (inflammation of the conjunctiva caused by an allergic reaction), and vascular dementia (problem with thought processes caused by brain damage from impaired blood flow to the brain).<BR/>Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 02 which indicated Resident #1 had a severe cognitive impairment. Section GG -Functional Abilities and Goals revealed Resident #1 required two-person physical assistance with ADLs of Eating, toileting, bathing, dressing and personal hygiene. <BR/>Record review of Resident #1's care plan, initiated on 03/01/23 and revised on 05/08/23, revealed the following: <BR/>- A focus of the resident has an ADL self-care performance deficit r/t Dementia, hemiplegia, [and] stroke, with interventions to include encourage the resident to use bell to call for assistance.<BR/>- A focus of The resident has a communication problem r/t Selective Mutism, with interventions to include Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation.<BR/>- A focus of the resident is at risk for Falls r/t muscle weakness, incontinence, impaired mobility, with interventions to include Ensure call light is available to Resident.<BR/>In an observation on 12/07/23 at 2:47 PM, Resident #1 was observed laying in his bed, which was in the lowest setting and floor mat in place. Resident #1's call light was observed to be wrapped around the wall plug which was roughly three feet away form the resident. A hand written sign was observed on the wall which read Do not give dad the call light, he can see the call light. <BR/>In an interview on 12/07/23 at 3:33 PM, CNA B stated she had worked in the facility since August 2023, and she was Resident #1's aide for the current shift. CNA B stated Resident #1 was visually impaired and he did not use his call light. She stated Resident #1's family placed a sign in the room to not give him the call light, so she checked on Resident #1 more often than every two hours to ensure he received the care he needed. CNA B stated if the sign was not on the wall, she would ensure Resident #1's call light was in reach whenever he was in his room. <BR/>In and interview on 12/07/23 at 3:52 PM, LVN C stated she worked at the facility for roughly three months, and she was Resident #1's nurse for the current shift. LVN C stated Resident #1 was legally blind and very quiet. LVN C stated she was not aware that Resident #1's call light was not in reach. LVN C stated it was the responsibility off any staff member who entered a resident's room to ensure the residents call light is in reach. LVN C stated Resident #1 was able to make his needs known to staff and staff knew to check on him more often because he was visually impaired. LVN C stated Resident #1's call light should have been in reach and not having a residents call light in place could delay the residents' care. <BR/>In an interview on 12/07/23 at 4:07 PM, the DON stated she had worked int the facility since 9/11/23. The DON stated Resident #1 was not able to see the call light and he would often tangle himself in the call light wire and the family requested he not been given a call light. The DON stated staff knew to check on Resident #1 every hour to ensure he received the care he needed timely. Surveyor reviewed Resident #1's current and historical care plans with the DON and the DON acknowledged the care plan had several interventions to state Resident #1's call light should be accessible. The DON stated based on the care plan, Resident #1's call light should have been in place. The DON stated it was the responsibility of all staff to ensure call lights were in place while residents were in their rooms. The DON stated a resident would not be able to call for assistance if their call light was not in place. The DON stated to ensure this act would not happen again, she would begin to Inservice staff on call light placement and have an additional care plan meeting with Resident #1's family to ensure their call light placement preferences were included. <BR/>In an interview on 12/07/23 at 4:44 PM, the ADMIN stated call lights should be in reach at all times when a resident was in their rooms. The ADMIN stated all staff were responsible to ensure call lights were in place. The ADMIN stated residents would not be able to use the call light if it were not in reach. The ADMIN stated he was not aware that Resident #1's call light was observed not in reach or that his family placed the sign in his room. The ADMIN stated he would have the DON start in-services on call light placement immediately and he planned to have a meeting to update Resident #1's care plan with any preferences. <BR/>A related policy was requested from the DON on 12/07/23 at 4:07 PM and was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident/RP has the right to be informed of, and participate in, his or her treatment for one (Resident #2) of ten individuals reviewed for resident and RP rights. <BR/>Resident #2's RP was not notified or provided any information of a doctor's appointment to which she needed to attend due to the resident having vascular dementia and having recently eloped when he was let out of the facility unknowingly by a staff member. The RP was denied the opportunity to attend the doctor's appointment post-elopement to help be a part of the treatment decisions.<BR/>Findings included:<BR/>Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2's MDS did not indicate he used an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard.<BR/>An interview with Resident #2's RP on 08/24/23 at 11:15 AM revealed she was currently at the facility and had just gone to Resident #2's room and he was not there . The RP stated he/she was very upset and worried. The RP then asked staff where he was and they told her Resident #2 had gone to a doctor's appointment at the [hospital]. The RP stated he/she had not been notified of the doctor's appointment and was not given the chance to accompany Resident #2, which was something the RP had told nursing staff (names unknown) during the last doctor's appointment because Resident #2 had been scared to leave the facility. The RP stated he/she told the nursing staff multiple times that when Resident #2 had an appointment scheduled, to notify the RP so he/she could be present, but it did not happen. The RP stated he/she was worried about Resident #2 being out in the community in lieu of the recent elopement due to facility lack of supervision and did not know if anyone went with him. The RP stated after the past weekend's events of Resident #2's elopement from the facility, he/she should have been notified if Resident #2 was leaving the facility so the RP could be there to provide emotional support.<BR/>An interview with the Front Desk Receptionist (with the ADM and RP present) on 08/24/23 at 11:20 AM revealed the front desk receptionist did not have Resident #2 on her hand-written list of family to contact for an appointment. She stated she had a list of about four residents whose families needed to be notified when an appointment was made, but Resident #2 was not on that list. The front desk receptionist stated she knew which families to call because someone from nursing staff would just tell her.<BR/>An interview with the ADM on 08/24/23 at 11:23 AM revealed he was not sure what the communication process was to ensure the RP/MPOA's of residents were notified of doctor's appointments so they could attend or who was responsible for monitoring staff to ensure family/RP were involved with resident activities. The ADM stated the [hospital] required a person to be with any of their residents (to include Resident #2) for any appointments, so the facility had sent 1:1 staff with him so he was not alone. <BR/>An interview with the charge nurse LVN Y for Resident #2 on 08/24/23 at 1:38 PM revealed the resident had an appointment earlier that morning. LVN Y stated in the past there was a scheduler, front desk receptionist or medical records who would handle the transportation and escort to doctor appointments, but when the [hospital] made an appointment, they organized transport and the facility was responsible for providing an escort and any clinical documentation. LVN Y stated the escort was done by the scheduler. He stated, We have the front desk lady, medical records and then scheduler and they work together. In the past it was the front desk who scheduled but since she quit, I can't say who does it. Like now, this morning I know the scheduler was responsible by telling who to go with him. I don't know actually who has that responsibility fully for that job. LVN Y stated when the facility makes an appointment, they were supposed to call and notify the RP and let them know and ask if they wanted to transport or attend, but he did not know the protocol if the [hospital] made the appointment. LVN Y said as a nurse, when there was a resident who went to a [hospital] appointment, the nurse made sure they provided the needed documentation, the resident leaves with the escort, and came back and if they had any results, the nurse would call the family and let them know what changes were made and the outcome of the appointment. <BR/> A follow-up interview with the front desk receptionist on 08/24/23 at 2:49 PM revealed for doctors' appointments, her role was that she was responsible to put the residents with appointments on the transport shuttle that were listed on the daily transportation list, other than that, I don't do anything else, the nurses call families, but I was doing it for certain families but from now on, I am calling them all. Like for tomorrow I will call the family members today so there won't be a discrepancy. The front desk receptionist stated with Resident #2, she did not know what happened that morning and had never heard anything about his RP needing to be notified for appointments. She said the nurses would have told her and maybe there was a miscommunication, but usually nurses call the relatives, that is not what I do, I just put them on the shuttles and let transport know who to pick up.<BR/>The facility ADM was asked on 08/24/23 for a policy related to RP accompaniment to doctor's appointments but did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #2) of ten residents reviewed for neglect. <BR/>The facility failed to ensure Resident #2 did not elope from the facility. The facility staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. The resident was located around 6:00 pm 12 miles away from the facility after police became involved and a Silver Alert had been issued.<BR/>An Immediate Jeopardy was identified on 08/22/23. The IJ Template was provided to the facility on [DATE] at 5:03 PM. While the Immediate Jeopardy was removed on 08/24/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems.<BR/>This failure could affect residents and place them at risk of further abuse/neglect with exit-seeking behaviors by placing them at risk for injury and/or death from elopement-related harm, including vehicular accidents, falls, missing medications, and extreme heat exposure.<BR/>Findings included:<BR/>Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Vascular dementia can develop after a stroke blocks an artery in your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one- person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one-person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2 did not have an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. <BR/>Review of Resident #2's care plan dated 03/17/23 and last revised 08/21/23 reflected the following:<BR/>- Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed.<BR/>- Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed.<BR/>- Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others.<BR/>-Date initiated: 08/21/23- Resident elopement from facility 8/19/23; returned 8/20/23. Resident will remain 1:1 until alternate placement is found; Interventions: Assess resident's coping skills and support system, Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation.<BR/>Review of Resident #2's Elopement Evaluation at his time of admission dated 03/17/23 reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. <BR/>Review of Resident #2's nursing progress notes for 08/19/23 and 08/20/23 did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: [hospital] notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [RP] notified via VM.<BR/>Record review of the facility's incident report for Resident #2 dated 08/20/23 at 12:10 PM and completed by ADON I reflected, Incident description: Resident noted to be missing from room at approximately 12pm. Search conducted at facility. Admin notified ASAP. Approximately 6pm police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and [hospital] notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside. <BR/>Review of Resident #2's August 2023 physician orders reflected they were ordered by MD D. Resident #2 had two discontinued orders that reflected, Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift [Verbal Discontinued 03/17/2023], and Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift [Verbal Discontinued 07/14/2023].<BR/>Review of Resident #2's August 2023 MAR reflected he missed the following prescribed medications during the time he was missing from the facility on 08/20/23 were Aspirin Oral Capsule 81 MG (blood thinner), Calcium-Vitamin D Oral Tablet 500 MG Protein Oral Liquid 30 ml (supplement).<BR/>An interview with MD D on 08/23/23 at 1:00 PM revealed he did not know Resident #2 was on his caseload until the incident with the elopement. He stated he did not know he was missing for over 18 hours and only got notified when he was located . <BR/>Review of website: https://www.accuweather.com (retrieved 08/22/23) revealed the temperature high for the location Resident #2 was found on 08/20/23 was 109 degrees fahrenheit.<BR/>An interview with Resident #2's RP on 08/22/23 at 6:30 AM revealed when Resident #1 was located by the Police, she went to see him and transport him back to the facility. The RP stated she observed Resident #1 to be extremely confused and scared. He was covered from head to toe in dirt and had a trash bag full of garbage one would find in a dumpster. The RP stated she was a RN and was able to assess her father and noted that he had 4+pitting edema. <BR/>An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had just searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday, 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth, he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, the police had already started the process for a silver alert and approx. 30 minutes later, I got a call from a sergeant saying he had been found in a hotel lobby in [city name]. The ADM stated the police notified the family who were on their way to pick Resident #2 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and confirmed the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and he stated Resident #2 kept removing it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by family request because the family told him Resident #2 had a criminal history with ankle monitors and having one on his leg may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not interview him. He stated, I want to say someone from our nursing staff talked to him. The ADM admitted the overnight staff working 08/19/23 into 08/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he had been told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, He does not like to be bothered at night and gets agitated, so that was why he had less rounds. If he doesn't require incontinent care, then it would be opening his door to make sure he was there as rounding. He does not have a roommate. It could be done quietly and that was my conversation with them yesterday when we started the in-service. The ADM stated the elopement incident could have been prevented by staff ensuring when they left the facility exits, to make sure there were no residents trying to leave and if they were unsure who a resident was, to stop and ask them. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards.<BR/>An observation of the facility video footage dated 08/19/23 at approximately 7:38 PM showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. <BR/>An interview with DA M on 08/22/23 at 10:12 AM revealed she did not interact much with residents and 95% of the time she was in the kitchen and at other times, she was delivering meal carts to CNAs or nurses. She said she did not know who Resident #2 was and could not recall seeing him before. DA M stated, When I let him out, I saw him standing the door, I had my head down and was ready to head out, I typed in the code and he followed right behind me, he said thank you so much, clear as day, and I thought he was family member. I didn't think much of it. DA M stated she had not been informed by the facility who were potential exit-seekers or what to do if she saw one of those residents attempting to elope. She stated, 'I didn't think I would be in a situation where I would be dealing one-on-one with a resident. I had not been informed on what to do if one wanted to leave. If I had seen him around and knew him, I would have grabbed a CNA or nurse and told them he was trying to leave, but it was the end of my shift, I clocked out and wasn't thinking much of it, I thought he was a visitor of a resident here. I walked out and my mom who was in a car picking me up, said she had seen a man walk out behind me but didn't think much of it. He spoke clear as day and said thank you very much, he was dressed in casual clothing, I glimpsed at him. DA M stated when she came to work Sunday 08/20/23, the kitchen staff were telling her about a resident who had eloped the day before and it was then she realized through their description of him, that it might be the man she let out the day before. DA M said she ran to the ADM's office and police were there and she told them what had happened the night before and they were able to then pull it up on surveillance camera and verify Resident #2 went out the door behind her around 7:38 PM. <BR/>An interview with ADON I on 08/22/23 at 10:41AM revealed she was at the facility on 08/19/23 until 5:00 PM and was at the facility on 08/20/23 from 6:00 AM until 11:00PM. ADON I stated when she came into work on 08/20/23, no one mentioned Resident #2 was missing. She said the CNA that worked with him [CNA B], went to pick up is breakfast tray around 12:10 PM and it had not been eaten and she then asked ADON I if she had seen him around. ADON I said the CNA B would have delivered the breakfast tray around 7:45AM-8:30AM. ADON I stated they immediately checked all the resident rooms and bathroom, his friends' rooms and he was not present. Then someone drove the perimeter outside, down to the nearby shopping strip and did not see him. Then ADON I called the family and asked them if Resident #2 was with them and they said no. At that point ADON I stated she called the DON, called ADM and called the staff who worked the night shift before. She said there was an agency nurse [LVN P] who said she remembered checking on Resident #2 during her overnight shift. ADON I also stated she called the overnight CNA, who also remembered checking on Resident #2 during the overnight shift. Once ADON I was informed by the ADM that Resident #2 was seen through video surveillance leaving the facility on 08/19/23 at approximately 7:40 PM, she stated, That made me question staff that told me they had seen him that night. ADON I said by the time Resident #2 was found and returned to the facility, he had missed three shifts of medications over two days. ADON I stated Resident #2 did not have a wander guard on because he kept cutting them off and the facility had been through about 10 or 12 of them. She said Resident #2 had never tried to exit-seek before, I have never even heard him ask, he is usually very pleasant and interactive. She stated, When we have done a wander guard in past, it was on his ankle. We have never tried one on his wrist that I can remember, don't know if it was tried. ADON I stated, Plan now for him is he has been so far one on one and I think they are going to place him in a more secured facility. That I can't say for sure. ADON I stated there were photos in a binder of the residents who exit-seeked and that binder was at each nurses station and the front desk. She said Resident #2 was not in the binder. ADON I stated most of the staff understand that during the day, the front desk receptionist let people out through the front door with a code, but staff would also let them in and out too but most of them knew who the residents were and who was not supposed to leave. She said if a staff member was not sure if a person was a resident, they should not let them out and check with the charge nurses or other direct care staff. ADON I stated LVN N was the weekend supervisor who worked until 10:00 PM on 08/19/23. <BR/>An interview with LVN N on 08/22/23 at 11:09 AM revealed he was the weekend supervisor on 08/19/23 and he left the facility around 11:00 PM and was off work on 08/20/23. He said he got a call from one of the ADONs on 08/20/23 and she told him Resident #2 was missing and they were in the process of looking for him. He remembered seeing Resident #2 on 08/19/23 around 3:45 PM in the hallway, He normally comes out and stands in the hallway then comes back to his room. As far as I know, he hasn't tried to get out of the door before. <BR/>A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. The ADM stated, I do want to touch on and I am not saying everything was handled perfectly . As soon as we noticed he [Resident #1] was not here, all were parties notified. We had police at the facility in and out about 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 &frac12; hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure, we followed all the necessary steps and we found him. The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons. <BR/>An interview with MA O on 08/22/23 at 12:52 PM revealed he was working a double shift on 08/19/23 from 6:00AM to 10:00 PM, but not on Resident #2's hall. He stated the nurse for Resident #2 on the 2-10PM shift was LVN Q. MA O stated he knew who Resident #2 was and that he had eloped from the facility and he usually had a wander guard on him. He remembered seeing Resident #2 on his 08/19/23 shift because he normally came to the nurses' station for snacks and MA O remembered him coming to get one after dinner on 08/19/23, but there were no snacks left because they had all been passed out already. He stated Resident #2 was okay with it and not upset. MA O stated Resident #2 usually went to bed and would come out during the evening around 8-9PM most nights. The next morning, 08/20/23, MA O stated he worked Resident #2's hall from 6AM-2PM and was told by CNA B around lunch time that she had not seen him and could not find him. They began looking in each residents' room and around the hall, and then some staff went outside to look for him and that was when everyone realized he was missing and the police and family were notified. <BR/>An interview with LVN P on 08/22/23 at 1:06 PM revealed she was the agency nurse who worked the overnight shift on Resident #2's hall on 08/19/23 into 08/20/23 and it was her first time working at the facility. She stated that night she was the charge nurse for four halls. She stated she came into the facility to work around 10:00 PM and left around 6:45 AM the next morning. When she arrived at her shift that night, LVN P stated, When I got there, I can't really say I was oriented, but I did make rounds while the 2-10 nurse was finishing up stuff. LVN P stated no one told her who was exit-seeking on her halls or who wore a wander guard. She stated she rounded on her own with no one else. LVN P stated she had rooms 507-510 (where Resident #2 resided) and she opened up each door when she started her shift to make sure there was a body in each bed. LVN P stated she remembered seeing a body in each bed; she did not go into the rooms and touch the residents but when she opened each door, she saw a body and assumed each resident was asleep . She stated she did not turn the lights on. Around 11:30 PM, the off-going nurse came back around and gave LVN P a report and then LVN P took over from there. LVN P stated she did not know who the residents were and a nurse named [LVN N] gave her a login to chart in the residents' e-chart. LVN P could not remember if she gave Resident #2 any medications or treatments during that overnight shift because there were two residents in the facility with the same last name, Resident #2 and Resident #7. She stated, So I don't remember which one I saw. I think one was on 500 and one on 700, I could be mistaken. After she left the next morning, she got a call from the facility around 12:30 PM on 08/20/23, asking questions about Resident #2.<BR/>Review of Resident #2's clinical chart revealed no documentation in his care plan or progress notes that he did not want to be disturbed at night.<BR/>An interview with CNA B on 08/22/23 at 1:20 PM revealed she was Resident #2's CNA on the 6AM-2PM shift 08/20/23 and got to the facility around 6:15 AM. She said she clocked in, looked at the assignment sheet, made sure her linens were stocked and all the CNAs were present and started to get the heavy-care residents up, which was not Resident #2. CNA B did not remember who the nurse was on her hall that shift. She said Resident #2 liked to walk around, so when she did not see him in his room that morning, she initially did not think anything of it. She put his breakfast tray in his room because she thought he was visiting with another resident at that time. CNA B then proceeded to get some more residents up for the day and fed a resident, then at some point went to pick up Resident #2's breakfast tray and he still was not in his room and his food had not been eaten. She said she did not panic but tried to look for him and around 9:45 AM and checked one of his friend's rooms but he was not there. CNA B stated, I figured he would pop back up. I went to dress another resident. He wasn't in his doorway asking me for a penny like he normally does and I am thinking that is not like him. I thought maybe he went out with the [family member]. At that time, CNA B said she looked at the piano in the dining room because he played sometimes, but nothing, I am thinking he will pop back up. I got up another resident then went back, not there. CNA B said she asked ADON I if she had seen him and they checked the sign out sheet. CNA B stated there was sign out for Resident #7, but not Resident #2, they both had the same last name. She asked the front desk receptionist what time Resident #7 left and she had it mixed up with Resident #2, so she asked another staff member when did Resident #2 leave, to which she was told he did not leave, he was in his room. CNA B stated, I started to panic and told [ADON I] and she and I started looking for him, did a wide search everywhere in the facility, looked outside, drove around McDonalds, grocery store, the neighborhood. Everyone in all departments looking for him. He was nowhere to be found. We just kept looking and then [ADON I] made calls. CNA B stated she was present when Resident #2 was found and brought back to the facility, it was after dinner on 08/20/23. She said she gave him his dinner tray and he looked normal but a little upset because there was a staff doing 1:1 with him and he was asking why they were in his room. CNA B stated Resident #2 did not have any recollection of what happened. CNA B stated she had never seen Resident #2 wear a wander guard when she worked with him prior to the elopement incident and he was not someone who she ever witnessed wanting to leave the facility. CNA B stated since he had been placed on 1:1, he was kind of quiet and reserved, like in a shell. He just keeps saying he doesn't want to leave this place.<BR/>An interview with LVN Q on 08/22/23 at 1:41 PM revealed she worked a double shift 08/19/23 from 6AM-10PM and was the charge nurse for 500, 600, and 700 halls and was relieved by the agency nurse [LVN P]. LVN Q stated she saw Resident #2 on her shifts and the last time she saw him was around 6-7 PM when she was at the nurses station and he was walking from one nurses' station to the other one. She stated she did not pass medications for him on her shift, MA R did, but MA R never came and told her that she could not locate Resident #2 for 9PM med pass. LVN Q was not aware MA R was giving Resident #2 his medications early by MA R. LVN Q stated she did not round with the oncoming nurse for the overnight shift [LVN P] and most times, when she rounded with a nurse, it would be to give report at the nurses' station, not go room to room. LVN Q stated Resident #2 wore a wander guard but he kept cutting it off. She said Resident #2 wore one because he wandered around the building but he had never tried to leave and she had never seen him take a wander guard off or found a wander guard in his room, it was just what she had heard. She did not know if the facility ever tried to place one on his wrist. <BR/>An interview and observation of Resident #2 on 08/23/23 at 10:50 AM revealed he was in his room with a staff member sitting on a chair in the corner of his room. Resident #2 was interviewed privately and he stated he did not like the staff member being in his room all the time and did not know why she was there and liked his privacy. Resident #2 was able to talk, but when asked about the elopement incident when he left the facility, he was surprised and said he did not leave. He could not recall being found by the police and being gone all night and day. Resident #2 said he liked living at the facility and they understood his kind of person. He said he liked to watch television and denied that he wanted to leave. He talked about loving God and being right with him. Resident #2's cognition did not remember the incident and had trouble with recall/memory .<BR/>An interview with MA R on 08/23/23 at 12:27 PM revealed she worked a double shift on 08/19/23 from 6AM-10PM and was in charge of passing medications for about 50 residents on four different halls. She said there was one other medication aide for the other halls in the building. MA R stated no one notified her that Resident #2 was missing and she remembered last seeing him around 4:00 PM between smoke break and dinner time because she saw him when dinner trays were coming out and a resident had made a comment about his cowboy that he was wearing. MA R stated she told Resident #2 hello as she was wheeling another resident down the hall, and she had just administered Resident #2 his medications a few minutes earlier. MA R said the way she was trained was to give Resident #2 his medications when he was in a good mood, even if it was outside of his medication pass time and order time frame, because he tended to attack people and she was told he had balled up his first once to a staff in the past. MA R stated Resident #2 was usually in a good mood right after he ate dinner, so that was when she gave him his medications on 08/19/23, which was around 4-5PM, not at 9:00 PM as she had documented on his MAR/TAR. She stated the next morning she was working (08/20/23), she had asked other staff where he was because she went to pass his morning medication and he was not in the room, which was not unusual because he walked around a lot. Someone told her that he was out on pass with his a family member, and I was like cool, I'll catch him when he gets back. Around noon, MA R stated she walked past one of the aides who asked her where he was and MA R told her he had gone out on pass. They both looked in the sign out book and realized it was the other resident with the same last name who left [Resident #7], not Resident #2. MA R stated, I guess that was the confusion on where he was. She said once staff realized that it was a mistake, they started looking around, informed the nurses and then that was when phone calls started to be made and the police got involved. MA R stated in hindsight, knowing there were two residents with the same last name, she thought the facility should have made sure it was the correct person who signed out on pass. MA R stated, I feel like someone had to have gone in the room and noticed he was missing because two shifts went by. They say he left at 7:30 Saturday night, so the nurse rounding should have noticed, any of us should have noticed that he was gone but then again, it was not unlike him to not be in his room, but no one could pinpoint when they last saw him. I do think that if people had been rounding and laying eyes on him, we probably would have caught on to it earlier. MA R stated she made a comment to a police officer that even if Resident #2 had the code to get out of the facility, he would not know how to come back in because it the entry code to come in was different. MA R stated the shift on 08/20/23 she worked was crazy, no one initially knew what to do once they realized Resident #2 was missing, and it was frightening, like where did he go? MA R stated there were residents who looked completely normal, like they did not belong in the nursing home and god forbid, something could have happened and this could have gone a lot worse. Interviews with nursing staff and medication aides from 08/22/23 through 08/24/23 that worked with Resident #2 did not indicate they had any issues with administering his medications to him at the times prescribed, except for MA R. <BR/>An interview with CNA X on 08/23/23 at 3:24 PM revealed she was the CNA assigned to Resident #2's hall on the overnight shift on 08/19/20 into 08/20/23 but was working a double shift that day. CNA X stated the facility was short-staffed that night and that was why she was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for one (Resident #2) of ten residents reviewed for neglect policies. <BR/>The facility failed to ensure their abuse and neglect policy was implemented for Resident #1 when he eloped from the facility. The facility staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. The resident was located around 6:00 pm 12 miles away from the facility after police became involved and a Silver Alert had been issued.<BR/>An Immediate Jeopardy was identified on 08/22/23. The IJ Template was provided to the facility on [DATE] at 5:03 PM. While the Immediate Jeopardy was removed on 08/24/23, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of pattern due to the facility's need to implement and monitor the effectiveness of its corrective systems.<BR/>This failure could affect residents and place them at risk of further abuse/neglect due to policy not being developed/implemented. <BR/>Findings included:<BR/>Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised March 2018, reflected, .2. 'Neglect', as defined at 483.5, means 'the failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress'; .Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.<BR/>Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Vascular dementia can develop after a stroke blocks an artery in your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one-person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one-person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2 did not have an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. <BR/>Resident #2's care plan dated 03/17/23 and last revised 08/21/23 reflected the following:<BR/>- Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed.<BR/>- Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed.<BR/>- Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others.<BR/>-Date initiated: 08/21/23- Resident elopement from facility 8/19/23; returned 8/20/23. Resident will remain 1:1 until alternate placement is found; Interventions: Assess resident's coping skills and support system, Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation.<BR/>Review of Resident #2's Elopement Evaluation at his time of admission dated 03/17/23 reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. <BR/>Review of Resident #2's nursing progress notes for 08/19/23 and 08/20/23 did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: VA notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [RP] notified via VM.<BR/>Review of the facility's incident for Resident #2 dated 08/20/23 at 12:10 PM completed by ADON I reflected Incident description: Resident noted to be missing from room at approximately 12pm. Search conducted at facility. Admin notified ASAP. Approximately 6pm police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and VA notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside. <BR/>Review of website: https://www.accuweather.com (retrieved 08/22/23) revealed the temperature high for the location Resident #2 was found on 08/20/23 was 109 degrees fahrenheit.<BR/>Review of Resident #2's August 2023 physician orders reflected they were ordered by MD D. Resident #2 had two discontinued orders that reflected, Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift [Verbal Discontinued 03/17/2023], and Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift [Verbal Discontinued 07/14/2023].<BR/>Review of Resident #2's August 2023 MAR reflected he missed the following prescribed medications during the time he was missing from the facility on 08/20/23 were Aspirin Oral Capsule 81 MG (blood thinner), Calcium-Vitamin D Oral Tablet 500 MG Protein Oral Liquid 30 ml (supplement).<BR/>An interview with Resident #2's RP on 08/22/23 at 6:30 AM revealed when Resident #1 was located by the Police, she went to see him and transport him back to the facility. The RP stated she observed Resident #1 to be extremely confused and scared. He was covered from head to toe in dirt and had a trash bag full of garbage one would find in a dumpster. The RP stated she was a RN and was able to assess her father and noted that he had 4+pitting edema. <BR/>An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had just searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth, he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, police had already started process for silver alert and approx. 30 minutes later, I got a call from sergeant saying he had been found in a hotel lobby in Grapevine. The ADM stated the police notified the family who were on their way to pick Resident #2 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and confirmed the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and he stated Resident #2 kept removing it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by family request because the family told him Resident #2 had a criminal history with ankle monitors and having one on his leg may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not interview him. He stated, I want to say someone from our nursing staff talked to him. The ADM admitted the overnight staff working 06/19/23 into 06/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he had been told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, He does not like to be bothered at night and gets agitated, so that was why he had less rounds. If he doesn't require incontinent care, then it would be opening his door to make sure he was there as rounding. He does not have a roommate. It could be done quietly and that was my conversation with them yesterday when we started the in-service. The ADM stated the elopement incident could have been prevented by staff ensuring when they left the facility exits, to make sure there were no residents trying to leave and if they were unsure who a resident was, to stop and ask them. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards. <BR/>An observation of the facility video footage dated 08/19/23 at approximately 7:38 PM showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. <BR/>An interview with DA M on 08/22/23 at 10:12 AM revealed she did not interact much with residents and 95% of the time she was in the kitchen and at other times, she was delivering meal carts to CNAs or nurses. She said she did not know who Resident #2 was and could not recall seeing him before. DA M stated, When I let him out, I saw him standing the door, I had my head down and ready to head out, I typed in code and he followed right behind me, he said thank you so much, clear as day, and I thought he was family member. I didn't think much of it. DA M stated she had not been informed by the facility who were potential exit-seekers or what to do if she saw one of those residents attempting to elope. She stated, 'I didn't think I would be in a situation where I would be dealing one-on-one with a resident. I had not been informed on what to do if one wanted to leave. If I had seen him around and knew him, I would have grabbed a CNA or nurse and told them he was trying to leave, but it was the end of my shift, I clocked out and wasn't thinking much of it, I thought he was a visitor of a resident here. I walked out and my mom who was in a car picking me up, said she had seen a man walk out behind me but didn't think much of it. He spoke clear as day and said thank you very much, he was dressed in casual clothing, I glimpsed at him. DA M stated when she came to work Sunday 08/20/23, the kitchen staff were telling her about a resident who had eloped the day before and it was then she realized through their description of him, that it might be the man she let out the day before. DA M said she ran to the ADM's office and police were there and she told them what had happened the night before and they were able to then pull it up on surveillance camera and verify Resident #2 went out the door behind her around 7:38 PM . <BR/>An interview with ADON I on 08/22/23 at 10:41AM revealed she was at the facility on 08/19/23 until 5:00 PM and was at the facility on 08/20/23 from 6:00 AM until 11:00PM. ADON I stated when she came into work on 08/20/23, no one mentioned Resident #2 was missing. She said the CNA that worked with him [CNA B], went to pick up is breakfast tray around 12:10 PM and it had not been eaten and she then asked ADON I if she had seen him around. ADON I said the CNA B would have delivered the breakfast tray around 7:45AM-8:30AM. ADON I stated they immediately checked all the resident rooms and bathroom, his friends' rooms and he was not present. Then someone drove the perimeter outside, down to the nearby shopping strip and did not see him. Then ADON I called the family and asked them if Resident #2 was with them and they said no. At that point ADON I stated she called the DON, called ADM and called the staff who worked the night shift before. She said there was an agency nurse [LVN P] who said she remembered checking on Resident #2 during her overnight shift. ADON I also stated she called the overnight CNA, who also remembered checking on Resident #2 during the overnight shift. Once ADON I was informed by the ADM that Resident #2 was seen through video surveillance leaving the facility on 08/19/23 at approximately 7:40 PM, she stated, That made me question staff that told me they had seen him that night. ADON I said by the time Resident #2 was found and returned to the facility, he had missed three shifts of medications over two days. ADON I stated Resident #2 did not have a wander guard on because he kept cutting them off and the facility had been through about 10 or 12 of them. She said Resident #2 had never tried to exit-seek before, I have never even heard him ask, he is usually very pleasant and interactive. She stated, When we have done a wander guard in past, it was on his ankle. We have never tried one on his wrist that I can remember, don't know if it was tried. ADON I stated, Plan now for him is he has been so far one on one and I think they are going to place him in a more secured facility. That I can't say for sure. ADON I stated there were photos in a binder of the residents who exit-seeked and that binder was at each nurses station and the front desk. She said Resident #2 was not in the binder. ADON I stated most of the staff understand that during the day, the front desk receptionist let people out through the front door with a code, but staff would also let them in and out too but most of them knew who the residents were and who was not supposed to leave. She said if a staff member was not sure if a person was a resident, they should not let them out and check with the charge nurses or other direct care staff. ADON I stated LVN N was the weekend supervisor who worked until 10:00 PM on 08/19/23. <BR/>A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. ADM stated, I do want to touch on and I am not saying everything was handled perfectly. As soon as we noticed he [Resident #1] was not here, all parties notified. We had police at facility in and out 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 &frac12; hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure, we followed all the necessary steps and we found him. The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons. <BR/>An interview with MA O on 08/22/23 at 12:52 PM revealed he was working a double shift on 08/19/23 from 6:00AM to 10:00 PM, but not on Resident #2's hall. He stated the nurse for Resident #2 on the 2-10PM shift was LVN Q. MA O stated he knew who Resident #2 was and that he had eloped from the facility and he usually had a wander guard on him. He remembered seeing Resident #2 on his 08/19/23 shift because he normally came to the nurses' station for snacks and MA O remembered him coming to get one after dinner on 08/19/23, but there were no snacks left because they had all been passed out already. He stated Resident #2 was okay with it and not upset. MA O stated Resident #2 usually went to bed and would come out during the evening around 8-9PM most nights. The next morning, 08/20/23, MA O stated he worked Resident #2's hall from 6AM-2PM and was told by CNA B around lunch time that she had not seen him and could not find him. They began looking in each residents' room and around the hall, and then some staff went outside to look for him and that was when everyone realized he was missing and the police and family were notified. <BR/>An interview with LVN P on 08/22/23 at 1:06 PM revealed she was the agency nurse who worked the overnight shift on Resident #2's hall on 08/19/23 into 08/20/23 and it was her first time working at the facility. She stated that night she was the charge nurse for four halls. She stated she came into the facility to work around 10:00 PM and left around 6:45 AM the next morning. When she arrived at her shift that night, LVN P stated, When I got there, I can't really say I was oriented, but I did make rounds while the 2-10 nurse was finishing up stuff. LVN P stated no one told her who was exit-seeking on her halls or who wore a wander guard. She stated she rounded on her own with no one else. LVN P stated she had rooms 507-510 (where Resident #2 resided) and she opened up each door when she started her shift to make sure there was a body in each bed. LVN P stated she remembered seeing a body in each bed; she did not go into the rooms and touch the residents but when she opened each door, she saw a body and assumed each resident was asleep . She stated she did not turn the lights on. Around 11:30 PM, the off-going nurse came back around and gave LVN P a report and then LVN P took over from there. LVN P stated she did not know who the residents were and a nurse named [LVN N] gave her a login to chart in the residents' e-chart. LVN P could not remember if she gave Resident #2 any medications or treatments during that overnight shift because there were two residents in the facility with the same last name, Resident #2 and Resident #7. She stated, So I don't remember which one I saw. I think one was on 500 and one on 700, I could be mistaken. After she left the next morning, she got a call from the facility around 12:30 PM on 08/20/23, asking questions about Resident #2.<BR/>An interview with CNA B on 08/22/23 at 1:20 PM revealed she was Resident #2's CNA on the 6AM-2PM shift 08/20/23 and got to the facility around 6:15 AM. She said she clocked in, looked at the assignment sheet, made sure her linens were stocked and all the CNAs were present and started to get the heavy-care residents up, which was not Resident #2. CNA B did not remember who the nurse was on her hall that shift. She said Resident #2 liked to walk around, so when she did not see him in his room that morning, she initially did not think anything of it. She put his breakfast tray in his room because she thought he was visiting with another resident at that time. CNA B then proceeded to get some more residents up for the day and fed a resident, then at some point went to pick up Resident #2's breakfast tray and he still was not in his room and his food had not been eaten. She said she did not panic but tried to look for him and around 9:45 AM and checked one of his friend's rooms but he was not there. CNA B stated, I figured he would pop back up. I went to dress another resident. He wasn't in his doorway asking me for a penny like he normally does and I am thinking that is not like him. I thought maybe he went out with the [family member]. At that time, CNA B said she looked at the piano in the dining room because he played sometimes, but nothing, I am thinking he will pop back up. I got up another resident then went back, not there. CNA B said she asked ADON I if she had seen him and they checked the sign out sheet. CNA B stated there was sign out for Resident #7, but not Resident #2, they both had the same last name. She asked the front desk receptionist what time Resident #7 left and she had it mixed up with Resident #2, so she asked another staff member when did Resident #2 leave, to which she was told he did not leave, he was in his room. CNA B stated, I started to panic and told [ADON I] and she and I started looking for him, did a wide search everywhere in the facility, looked outside, drove around McDonalds, grocery store, the neighborhood. Everyone in all departments looking for him. He was nowhere to be found. We just kept looking and then [ADON I] made calls. CNA B stated she was present when Resident #2 was found and brought back to the facility, it was after dinner on 08/20/23. She said she gave him his dinner tray and he looked normal but a little upset because there was a staff doing 1:1 with him and he was asking why they were in his room. CNA B stated Resident #2 did not have any recollection of what happened. CNA B stated she had never seen Resident #2 wear a wander guard when she worked with him prior to the elopement incident and he was not someone who she ever witnessed wanting to leave the facility. CNA B stated since he had been placed on 1:1, he was kind of quiet and reserved, like in a shell. He just keeps saying he doesn't want to leave this place.<BR/>An interview and observation of Resident #2 on 08/23/23 at 10:50 AM revealed he was in his room with a staff member sitting on a chair in the corner of his room. Resident #2 was interviewed privately and he stated he did not like the staff member being in his room all the time and did not know why she was there and liked his privacy. Resident #2 was able to talk, but when asked about the elopement incident when he left the facility, he was surprised and said he did not leave. He could not recall being found by the police and being gone all night and day. Resident #2 said he liked living at the facility and they understood his kind of person. He said he liked to watch television and denied that he wanted to leave. He talked about loving God and being right with him. Resident #2's could not remember the incident and had trouble with recall/memory. <BR/>An interview with MA R on 08/23/23 at 12:27 PM revealed she worked a double shift on 08/19/23 from 6AM-10PM and was in charge of passing medications for about 50 residents on four different halls. She said there was one other medication aide for the other halls in the building. MA R stated no one notified Resident #2 was missing and she remembered last seeing him around 4:00 PM between smoke break and dinner time because she saw him when dinner trays were coming out and a resident had made a comment about his cowboy that he was wearing. MA R stated she told Resident #2 hello as she was wheeling another resident down the hall, and she had just administered Resident #2 his medications a few minutes earlier. She stated the next morning she was working (08/20/23), she had asked other staff where he was because she went to pass his morning medication and he was not in the room, which was not unusual because he walked around a lot. Someone told her that he was out on pass with his [family member] and I was like cool, I'll catch him when he gets back. Around noon, MA R stated she walked past one of the aides who asked her where he was and MA R told her he had gone out on pass. They both looked in the sign out book and realized it was the other resident with the same last name who left [Resident #7], not Resident #2. MA R stated, I guess that was the confusion on where he was. She said once staff realized that it was a mistake, they started looking around, informed the nurses and then that was when phone calls started to be made and the police got involved. MA R stated in hindsight, knowing there were two residents with the same last name, she thought the facility should have made sure it was the correct person who signed out on pass. MA R stated, I feel like someone had to have gone in the room and noticed he was missing because two shifts went by. They say he left at 7:30 Saturday night, so the nurse rounding should have noticed, any of us should have noticed that he was gone but then again, it was not unlike him to not be in his room, but no one could pinpoint when they last saw him. I do think that if people had been rounding and laying eyes on him, we probably would have caught on to it earlier. MA R stated she made a comment to a police officer that even if Resident #2 had the code to get out of the facility, he would know how to come back in because it the entry code to come in was different. MA R stated the shift on 08/20/23 she worked was crazy, no one initially knew what to do once they realized Resident #2 was missing, and it was frightening, like where did he go? MA R stated there were residents who looked completely normal, like they did not belong in the nursing home and god forbid, something could have happened and this could have gone a lot worse. Interviews with nursing staff and medication aides from 08/22/23 through 08/24/23 that worked with Resident #2 did not indicate they had any issues with administering his medications to him at the times prescribed, except for MA R. <BR/>An interview with CNA X on 08/23/23 at 3:24 PM revealed she was the CNA assigned to Resident #2's hall on the overnight shift on 08/19/20 into 08/20/23 but was working a double shift that day. CNA X stated the facility was short-staffed that night and that was why she was assigned Resident #2's hall as well as all of 500 and 600 halls and one on 400 hall and some on 500 hall. She stated in total it was about 26 residents. CNA X stated she was newer to the facility about three months and was not used to faces and names yet. What she did know of Resident #2 was that he liked to be independent and did most of his ADLs by himself. CNA X remembered seeing Resident #2 eat dinner on 08/19/23 and she picked up his room tray from him around 6:30 PM. Then around 7:00 PM, CNA X remembered seeing him pushing a resident in a wheelchair to the nurses' station and then she did not see him again. On the overnight shift, CNA X stated she went to open his bedroom at 5:00 AM in the morning, but she remembered he was independent and did not want his room opened when he was sleeping. CNA X stated, I knew he didn't want us to opening the door because in the past he will tell me not to open it at night when he is sleeping. CNA X stated rounding was supposed to occur every two hours but she did not go into his room to check on him on the overnight shift because of the aforementioned reason. CNA X stated she left the next morning 08/20/23 around 6:00 AM and did not complete a final round on Resident #2. CNA X stated, I didn't try to check on him at all, not even quietly. I never knew he left until someone told me around noon the next day, I was at home. I talked to [ADON I] who asked when I last saw him and I told her I removed his tray at dinner time. CNA X confirmed again that she did not round on Resident #1 at the change of shift 08/20/23 when the 6:00 AM CNA and nurse came to work. CNA X stated now she felt like she should have done things differently, like even though Resident #2 was independent, she still should have opened his room to see if he was okay or needed anything, not just assume he was fine. She realized a resident could have fallen or have a serious injury and not be able to use the call light or call out for help, so rounding was crucial to check on the residents. <BR/>An interview with Resident #2's family member on 08/24/23 at 10:20 AM revealed she was the RP/MPOA and was very upset over the lack of supervision and response by the facility, which allowed Resident #2 to be let out of the building by a staff member with[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #66) of 6 residents reviewed for care plans.<BR/>1. The facility failed to develop a care plan for Resident #66 that addressed her use of dentures.<BR/>2. The facility failed to update Resident #66's care plan to address changes in diet texture, weight loss, or health shakes at lunch and dinner.<BR/>3. The facility failed to develop a care plan that addressed Resident #66's need to have assistance for eating. <BR/>4. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #66, hospice services.<BR/>These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs.<BR/>Findings included:<BR/>Record review of Resident #66's face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #66 had diagnoses which included Metabolic Encephalopathy (condition in which brain function is disturbed), acute respiratory infection with hypoxia (low oxygen tension in the arterial blood), Anemia (blood disorder), <BR/>Record review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 04, which indicated she had severe cognitive impairment. Her Functional Status indicated she required partial/moderate assistance with eating, substantial/maximum assistance with dental hygiene, and supervision/touching assistance with personal hygiene. Section L - Oral/Dental status revealed none of the above were present which included: Broken or loosely fitting full or partial denture. <BR/>Record review of Resident #66's care plan reviewed on 03/18/24 did not indicate she had or required the use of dentures. Resident #66's care plan did not address her change of diet to pureed texture, weight loss or need to have health shakes at lunch and dinner. Resident #66's care plan did not address her need to have assistance with eating. Resident's #66's care plan was not updated with measurable timeframes to address Resident #66 hospice services when she admitted on [DATE].<BR/>Record review of Resident #66's Order Summary Report dated 03/21/24, reflected: <BR/>Regular diet Pureed texture, Thin liquids consistency, health shakes with lunch and dinner (prefers chocolate flavor) for difficulties chewing. Start date 03/05/24.<BR/>Activity level: bedbound. Diet: comfort feeds as tolerated. Start date 03/07/24.<BR/>May see dentist, Start date 04/03/23.<BR/>Admit to Community Healthcare of Texas for Terminal Sepsis, Report change in condition or death. Start date 03/07/24.<BR/>Record review of Resident #66 progress note, dated 02/27/24 at 9:53 PM, written by the LVN reflected Resident #66 went to dental appointment with her Family Member, she came back with no new order, she has been sleeping since she came back, respiration 18, even and unlabored, no s/s of discomfort was notes, oncoming nurse to monitor. <BR/>Record review of Resident #66's progress note dated 02/28/24 revealed Resident #66 was seen by the dietician today with recommendations to add a chocolate health shake related to weight loss. Resident and Representative made aware. <BR/>Record review of Resident #66's physician order dated 03/05/24 revealed Regular diet, Pureed Texture, Thin Liquids consistency. Health Shakes with lunch and dinner (Prefers Chocolate flavor) for difficulties chewing. <BR/>Record review of Resident #66's Dietary Profile upon readmission on [DATE] revealed current diet order: Puree as tolerated, Current Texture of food: Regular, small portions, poor appetite, Eating/Chewing: Denture Both, Eating Assistance: Total Assistance<BR/>Observation and interview on 03/18/24 at 12:20 PM, revealed Resident #66 in her room, in low bed, resting while Family Member was sitting at bedside. When Resident #66 heard voices in the room she awoke and greeted the surveyor, revealing she did not have any teeth. According to the Family Member Resident #66 entered the facility almost a year ago, recently had a decline in weight. The Family Member stated she felt Resident #66's decline started when she lost her dentures about 4 months ago. The Family Member stated she spoke with facility about Resident #66's missing dentures, however they had never received any feedback. The Family Member stated she then decided to go outside the facility to replace the missing dentures since she never got any assistance from the facility. The Family Member stated it took a while before the facility provided Resident #66 with alternate accommodations for her to eat well. The Family Member stated the facility did not provide Resident #66 with health shakes. The Family Member stated she began to bring supplemental beverages for Resident #66 to ensure she was getting proper nutrition. Observation prior to exiting Resident #66's room revealed pureed lunch tray delivered to bedside table not near resident. Observation of Resident #66's meal ticket revealed she should have a shake at meals, however there was not a shake on the tray. According to the Family Member Resident #66 is supposed to have assistance with her feeding, but since she was present staff expected her to do the feeding. <BR/>Interview and record review on 03/20/24 at 3:33 PM with MDS Coordinator #1 and MDS Coordinator #2 about Resident #66's care plan missing documentation about her being admitting to hospice upon readmission to the facility. MDS Coordinator #2 stated when Resident #66 returned from the hospital she entered a focus area for hospice on her care plan dated 03/07/24. Surveyor pointed out there was not an entry indicated on the care plan prior to 03/20/24 and now the care plan was updated with hospice as of 03/18/24 made by MDS Coordinator #2. MDS Coordinator #1 stated the care plan for hospice was started and the care plan was left open so that facility staff, nursing staff could go into the care plan to edit up until the next care plan review. MDS Coordinator #1 denied updating hospice information on 03/18/24. According to both MDS Coordinators #1 and #2 it was important to have resident's care plan updated so that staff would be knowledgeable about each resident's care. MDS Coordinator #2 stated it was the responsibility of the nursing staff to keep resident's care plan updated at all times. MDS Coordinator #2 stated not updating the care plan with new order, activities of daily living and resident care needs placed residents at risk for not receiving proper care while in the facility. MDS Coordinator #2 stated upon admission they try to capture how to care for residents in every area. <BR/>Interview on 03/20/24 at 3:43 PM with ADON revealed the facility was missing the required focus areas on the care plan when came to hospice, nutrition, and eating. According to the ADON, MDS Coordinators could do the initial hospice, nutrition and any focus areas to the care plans. The ADON stated the nursing staff was also responsible to enter updated care plan information in any areas so that the nursing staff would be able to know how to care for residents. The ADON stated the care plans are required for all residents and not having care plans updated would place residents at risk of neglect. <BR/>Interview on 03/21/24 at 12:51 PM with ADON L revealed if residents had any changes in their care, she was responsible to ensure resident's care plan was updated. ADON L stated she was asked if Resident #66's care plan addressed eating requirements and when she looked, she noticed it had not been updated. ADON L stated she knew Resident #66 had dentures before January however she was not in the ADON's role at this time to ensure the care plan was updated with her use of dentures. ADON L stated while working on the floor she could recall the Family Member handling the issue with getting the dentures fitted properly for Resident #66. ADON L stated Family Member did bring up the concern for the dentures missing and tried looking for them. ADON L stated she did not bring it to anyone's attention to complete a grievance and she did not notify the Social Worker which was in charge of dental appointments. ADON L stated she did observe Family Member bringing in softer foods and after Resident #66's hospital visit when she started pureed foods. ADON L stated upon Resident #66's return from the hospital in February, she required assistance with eating. ADON L stated when staff passed the trays whomever passed Resident #66's trays were responsible for staying in their room to assist with feedings. According to ADON L staff are trained during orientation to the floor which residents required feeding assistance. ADON L stated not doing so would place residents at risk of not knowing her needs with weight loss, proper diet requirements and her need to have assistance with eating, that she needed someone to feed her. <BR/>Interview on 03/21/24 03:09 PM with the DON revealed when a resident entered the facility the MDS Coordinators would enter information for the MDS, and that information would transmit to the care plan. The DON stated it was the responsibility of the nursing staff and ADONs to ensure the care plan was updated with focus areas, goals, and interventions for resident's care. The DON stated she was not aware Resident #66's care plan did not address her dentures, weight loss, health shakes, need for assistance for eating or her admission to hospice. DON stated she was responsible to overlook the care plans to ensure they are up to date and completed accurately. The DON stated not having an updated care plan placed the resident at risk for missed opportunities of care. <BR/>Record review of facility policy revised March 2022, titled Care Planning - Interdisciplinary Team revealed the interdisciplinary team is responsible for the development of resident care plans. <BR/>1. <BR/>Resident care plans are developed according to the time frames and criteria established by $483.21.<BR/>2. <BR/>Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). <BR/>3. <BR/>The IDT includes but is not limited to.<BR/>a. <BR/>The resident's attending physician. <BR/>b. <BR/>A registered nurse with responsibility for the resident; <BR/>c. <BR/>A nursing assistant with responsibility for the resident; <BR/>d. <BR/>A member of the food and nutrition services staff; <BR/>e. <BR/>To the extent practicable, the resident and/or the resident's representative; and <BR/>f. <BR/>Other staff as appropriate or necessary to meet the needs of the resident or as requested by the resident. <BR/>4. <BR/>The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. <BR/>5. <BR/>Care plan meetings are scheduled at the best time of the day for the resident and family when possible. <BR/>6. <BR/>If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #2) of one residents reviewed for discharge planning. <BR/>The facility failed to implement an effective discharge plan for Resident #2 that made him and his RP an active partner in the process and prepared him when he was discharged to the [hospital] hospital after an elopement from the facility. <BR/>This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.<BR/>Findings included:<BR/>Review of Resident #2's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one-person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one-person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2's MDS did not indicate he used an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. Resident #2's MDS reflected no discharge planning was in effect. <BR/>Review of Resident #2's care plan dated 03/17/23 and last revised 08/21/23 reflected the following:<BR/>- Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed.<BR/>- Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed.<BR/>- Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others.<BR/>-Date initiated: 08/21/23- Resident elopement from facility 8/19/23; returned 8/20/23. Resident will remain 1:1 until alternate placement is found; Interventions: Assess resident's coping skills and support system, Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation.<BR/>Review of Resident #2's Elopement Evaluation at his time of admission dated 03/17/23 reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. <BR/>Review of the facility's incident report for Resident #2 dated 08/20/23 completed by ADON I at 12:10 PM reflected Incident description: Resident noted to be missing from room at approximately 12pm. Search conducted at facility. Admin notified ASAP. Approximately 6pm police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and [hospital] notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside. <BR/>Review of Resident #2's nursing progress notes for 08/19/23 and 08/20/23 did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: [hospital] notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [RP] notified via VM.<BR/>An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had just searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth, he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, police had already started process for silver alert and approx. 30 minutes later, I got a call from sergeant saying he had been found in a hotel lobby in Grapevine. The ADM stated the police notified the family who were on their way to pick Resident #1 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and confirmed the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and he stated Resident #2 kept removing it, but did not have any observations of staff seeing him do it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by family request because the family told him Resident #2 had a criminal history with ankle monitors and having one on his leg may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not attempt to interview him. He stated, I want to say someone from our nursing staff talked to him. The ADM admitted the overnight staff working 06/19/23 into 06/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he had been told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards. Regarding Resident #2's emergency discharge, the ADM stated skilled nursing facilities could not provide one on one care to residents so what the resident needed was a locked unit because he showed exit-seeking behavior and removed wander guards. The ADM stated if Resident #2 did not remove his wander guard(s), he could stay. The ADM stated he initially wanted to send Resident #2 to the [hospital] post-elopement and he needed to talk to the [hospital] social worker because he could not keep him on one-on-one long term. He said the RP told him no, that Resident #2 got agitated and confused and did not want him sent to the hospital and sent the ADM a long text message to that fact on 08/21/23. The ADM said he then told the RP the facility would not send Resident #2 to the [hospital] hospital but they would have to find another placement. The ADM stated the RP understood and the facility was already sending Resident #2's clinicals to other facilities. <BR/>Review of the facility's clinical records, including care plans, MDS assessments, elopement evaluations, behavior monitoring logs and nursing notes from March 2023 through 08/18/23 reflected Resident #2 had not shown exit-seeking behavior. <BR/>An observation of the facility video footage dated 08/19/23 at approximately 7:38 PM showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. <BR/>Review of Resident #2's facility progress notes pertinent to his use of a wander guard and elopement incident included:<BR/>-03/17/2023- Behavior: Resident noted wondering on the hallways, other resident rooms and exit doors. Resident easily redirected back into his room and comes out of the room immediately. MD was notified and gave order to monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. RP present at the facility, notified and agreed with order. [RP] confirmed resident behavior.<BR/>-06/11/2023-Nursing: Resident #2's family member asked nurse to encourage resident to have a shower. This nurse went to try and assist resident with shower, resident refused. Family notified. Nurse attempted multiple ways to encourage resident to shower, resident keeps telling nurse that you don't know what you're talking about. Also, nurse noticed that resident was removed wander guard, family notified, admin notified. Resident keeps stating that the wander guard fell off in the shower. Unable to locate in resident's room, admin notified.<BR/>-06/28/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I)<BR/>-06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A)<BR/>-06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place <BR/>-07/07/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A)<BR/>-07/10/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. The resident does not have a wander guard in place<BR/>-07/11/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard is not in place of the resident<BR/>-07/12/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard not in place<BR/>-07/13/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place<BR/>-07/18/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident has removed wander guard (signed by LVN A)<BR/>-07/19/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident Removed (signed by LVN A)<BR/>- 07/20/2023- Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I)<BR/>-07/24/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed, DON aware (signed by LVN A)<BR/>-07/25/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/26/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/20/23-Review of a Multidisciplinary Care Conference: (ADM and RP checked as only participants) reflected, Problems/needs-CP meeting held with Administrator and RP to discuss behaviors of resident cutting wander guard off. Discussed recent elopement assessment reflecting resident is not at risk for elopement. Based off initial elopement assessment resident has not shown exit seeking behavior and therefore not considered elopement risk. Family, Nursing administration, and Administrator that wander guard is not necessary. However, if exit seeking behavior begins, alternate placement will be discussed.<BR/>-Note: Review of a Resident #2's physician order dated 07/27/23 reflected, Monitor for increased S/S of exit seeking and/or wandering every shift (Active 07/27/2023).<BR/>-07/28/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A)<BR/>-07/31/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A)<BR/>-08/02/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A)<BR/>-08/03/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A)<BR/>-08/07/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A)<BR/>-08/08/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A)<BR/>A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. ADM stated, I do want to touch on and I am not saying everything was handled perfectly [related to staff response to Resident #2 missing] . As soon as we noticed he [Resident #1] was not here, all parties were notified. We had police at the facility in and out about 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 &frac12; hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure, we followed all the necessary steps and we found him. The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons.<BR/>An interview with Resident #2's family member on 08/24/23 at 10:20 AM revealed she was the RP/MPOA and was very upset over the lack of supervision and response by the facility, which allowed Resident #2 to be let out of the building by a staff member without anyone knowing until the next day. During the interview, the RP was also upset because she had just met with the ADM a few minutes prior (08/24/23) and he told the RP that Resident #2 was going to be discharged because he kept cutting off his wander guard. The RP was incredulous that Resident #2 had cut a wander guard off because the staff had told her there were never any scissors or knives located in his room, and staff never saw him take a wander guard off, so how could the facility management know when they were placing one on him and when it was coming off, since no one could account for them. She stated the ADM told her Resident #2 was going to be issued an emergency discharge and he was the only resident that did not have a wander guard and hence, because of the elopement, they could not care for him anymore. The RP stated the ADM told her she was being uncooperative and she told him he was being uncooperative for not trying other modalities and not allowing the RP to be present when the wander guard was being put on his body by the staff, which was something she had requested several times months prior when they told her he had removed it. The RP stated the ADM gave verbal notice of an emergency discharge via the RP's cell phone at 8:27 AM on 08/21/23 and told her he had gone through his channels and knew his rights and was letting the RP know he had applied for an emergency discharge and the local ombudsman was aware. The RP stated when Resident #2 first removed the wander guard, no one notified her, and she did not know what date or shift it occurred on. The RP stated it was herself that found the wander guard the first time on Resident #2's table in his room around April 2023. The RP asked the staff to place it on him because it was just sitting in his room and Resident #2 did not know what it was. Resident #2 did not know if they had already put it on him, or if it was going to be placed on him. The RP asked the ADM why did he not call her because he had agreed in their previous discussion that the RP would be there to place it on Resident #2, but he didn't and no one did, his excuse was nurses did it, they didn't tell me and he claimed he had bought a metal zip type wander guard and used a pair of scissors and was able to cut it off, so he never attempted to put it on [Resident #2]. The RP stated she told the ADM she was supposed to be present for the wander guard placement and he told her the nurses were busy and they did not have a chance to call her and the ADM had cut through the new one ordered do he did not bother trying it on Resident #2. The RP stated she was not part of the communications when they initially placed the wander guard on Resident #2 or when they first saw that it had been removed. The RP stated the facility did not attempt to place a new wander guard on Resident #2 when she brought him back to the facility after the elopement incident on 08/20/23. kThe RP also stated she had asked during a care plan meeting four months prior, to have Resident #2's Aricept increased. The RP followed up with the facility about three to four times, but they said he needed to be evaluated by psyche, which the RP gave consent to and also pre-authorized an increase in the Aricept. After a couple of weeks, the RP contacted the psychiatrist who told her he had been seeing Resident #2 and they were getting the increase in Aricept taken care of, but two weeks later, she talked to the facility SW (no longer employed), who told her she would follow up to see if the order was written and would let the doctor know. The RP stated this was important to know because she found out now that the Aricept medication was never increased and she told the ADM after the elopement incident on 08/23/23. After that, the ADM sent her a text message stating Resident #2's had just been increased, to which she replied to him, This could have helped him from elopement and my four attempts to get it increased were not addressed. The RP stated the ADM had not provided a written letter of emergency discharge and stated they just met with her that morning to tell her they could not care for Resident #2 because he took the wander guard off. The RP stated a woman contacted her on 08/23/23 from another facility stating Resident #2's clinicals had been sent to them. The RP told that woman she did not give permission to send his clinical to that facility to which the woman responded that she was going to be assisting with Resident #2's discharge and that the facility did not take his insurance, but they could still accept him. Then the SW called the RP stating she was trying to find placement and the RP told the SW, I already told you right now is not a good time to move him due to your negligence of an employee letting him out, it is not fair and I haven't had the chance to look at the these places and no one has provided me a list and random people have been calling me. The RP stated the way the ADM had put it, it sounded like Resident #2 was being discharged asap. The RP stated, I have said no every move and he has said I am being uncooperative. He said he was putting on his transfer orders he would need to be on a locked unit and I said that is not fair. I told him this happened to my [Resident #2], my [Resident #2] didn't cause this. The RP said she was still waiting for the ADM to provide her something in writing related to a discharge. <BR/>An interview with the CEO of the company (with ADM present) on 08/24/23 at 11:11 AM revealed the facility dropped the ball and he apologized to the RP and stated Resident #2 should have been found sooner. The CEO stated the RP were incredulous on how Resident #2 had taken off the wander guard if no one saw him do it and he did not have the means to cut it off. <BR/>An interview with the ADM 08/24/23 at 11:15 AM stated he told the RP he had gone into Resident #2's room after the wander guard was removed (not date given) and did not see anything that could have cut a wander guard off and no one know how it happened or when. The ADM stated during a meeting that morning (08/24/23), he told the RP he would reach out to the company they purchased their wander guards from to see if there was a more tamper-resistant band, which he felt there would not be. The ADM stated for each instance of Resident #2 removing his wander guard, there were at least a couple of progress notes saying he removed it. The ADM stated in July 2023 was when he met with the RP and they decided to discontinue the wander guard. The ADM did confirm that the RP had asked to be present when Resident #2's wander guard was being placed on him prior to that, but he did not know if she was contacted. The ADM stated, She is saying it didn't happen, whether it is true or not, I can say. The ADM stated there was only one brand of wander guards that would work with the connectivity of the facility's system and the facility did try different straps (not documented in clinical chart) and the last time they tried to place a wander guard on him (did not know which staff tried), it was a tamper resistant one and he was still able to remove it, so when he called the supplier that morning to see if there were any other straps that could be more effective, they said no. The ADM confirmed no one had witnessed Resident #2 remove his wander guard, But he is a very resourceful man. The ADM was asked who applied the replacement tamper resistant wander guard on the resident a few months prior which did not work and he responded he did not know and he did not know if family was present for it. The ADM was asked if there were any incident reports from when Resident #2 was known to remove his wander guard and he responded no, but he thought the nurses wrote some notes about it. The ADM then stated when he had talked to the RP over the phone the morning of 08/24/23, she was did not want to re-traumatize Resident #2 and move him and because she was not in a rush to move him. The ADM stated, I said he could get out of the facility again and that safety took precedent of him having to be relocated more than once. She explained she was going to do it her way, I explained we would have to issue an emergency discharge notice and then she drove up here. I didn't get a chance to tell her that we were not kicking him out on curb right at that moment. The ADM said he then told the RP in a meeting on 08/24/23 that he would reach out to the wander guard provider and try to get a more tamper-resistant band, but he did not think there would be one. The ADM then stated, This is what may be triggered [the RP], I said there has been some uncooperation to facilitate timely discharge to another facility and I gave the example of today and yesterday when [RP] told the social worker [he/she] did not want him moved. [The RP] was being unreasonable. I did not provide [the RP] a written emergency discharge notice, I was giving [the RP] the courtesy of saying that was the direction we are heading, nothing has been issued yet. It has been verbally communicated, but [discharge notice] document has not been sent. The ADM stated they had not started the discharge process yet. The ADM stated, We don't know for sure if [Resident #2] is able to remove it or not [wander guard], even if he was allowed to stay, there would still be gaps in supervision where the nurses were not checking on him if he was not on 1:1 where he could exit from the facility, which puts us back at square one. The ADM the reason he told the RP it was going to be an emergency discharge was because he felt the RP understood post-elopement that the facility could not provide one-on-one placement. The ADM stated, So it had been four days and I just find out yesterday [the RP] is not open to a locked unit. Those are the only facilities that will accept this man. The ADM confirmed prior to the recent incident, Resident #2 had never exit-seeked before. The ADM stated, We don't give him another chance [to stay at the facility after he eloped] .<BR/>A follow up interview with the CEO on 08/24/23 at 11:20 AM revealed the facility was not doing anything other than putting outing feelers out there for possible placement, which he felt was being proactive about the situation. <BR/>An interview with the CEO on 08/24/23 at 11:29 AM revealed he and the ADM were trying to get in touch with the local Ombudsman because they wanted her professional judgement on Resident #2's safety and follow her recommendation and do the right thing for Resident #2. The CEO stated, We know this man is going to remove his wander guard and potentially elope because of the situation we are going through, so that logically tells us this is not the right place for him, now getting that through everyone's head, we are going to do 1:1 until we can get that through everyone's head. We have the right to do an emergency discharge for his safety. The CEO stated the only reason the facility started talking about an expedited discharge was because the RP had stated she was in no rush to find an alternate placement and was going against agreeing to place Resident #2 in a locked unit, Which we have determined is a safe placement for him.<BR/>An interview with ADON C on 08/24/23 at 2:36 PM revealed the facility did not ensure the safety of Resident #2. ADON C stated, As nurses, we are taught we make our rounds . truthfully, it is an error in our system.<BR/>An interview with the SW on 08/24/23 at 2:08 PM revealed she had not met Resident #2 yet and it was only her second week working at the facility. The SW stated from what she had heard, the facility had previously tried to place a wander guard on Resident #2 about five times and he cut them off himself but no one had seen him do it. The SW stated during a meeting that morning with the RP and ADM (08/24/23), the RP said she had been waiting to come up to the facility and place the wander guard on the resident herself. The SW did not know if she was ever allowed that opportunity and did not know if there were any incident reports each time the wander guard was removed. She stated she had not been involved with the RP and facility in any care plan meetings about the wander guard. The SW stated she talked to the RP the day before (08/23/23) because she needed permission from the RP to send clinicals to other facilities for placement and the RP told the SW that she was not in agreement and did not feel the resident needed to be in a locked unit. The SW stated the RP did not actually agree that clinicals could be sent to new facilities, but she did not tell me verbally to stop sending clinicals. The SW stated she gave the RP a list of all [hospital] contracted facilities and em[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two (Resident #2 and #4) of four residents reviewed for accidents and supervision.<BR/>1. The facility staff DA M allowed Resident #2 to leave behind her without ensuring he was not a resident.<BR/>2. The facility failed to ensure Resident #2 did not elope from the facility and staff did not notice the resident was missing from Saturday, 08/19/23 at approximately 7:40 PM to the following Sunday, 08/20/23 around noon. <BR/>3. The facility staff including MA R, LVN P, LVN Q and CNA B and CNA X failed to check on Resident #2 on the 2-10PM, 10PM-6AM, AND 6AM-2PM shifts from 08/19/23 through 08/20/23 to ensure he was present in the facility. <BR/>4. The facility nurses failed to check on Resident #2 every shift per the physician's order to monitor for increased signs and symptoms of exit-seeking and/or wandering on the 10pm-6am shift from 08/19/23 through 08/20/23. <BR/>5. The facility failed to ensure the wander guard system was effective as Resident #4's wander guard did not alarm on 08/22/23 when she approached the front exit door and the side emergency exit door on Hall 700.<BR/>An Immediate Jeopardy (IJ) situation was identified on 08/22/23 at 4:50 PM. While the Immediate Jeopardy was removed on 08/24/23, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of their plan of corrective systems .<BR/>These failures could place residents at risk for injury and/or death from elopement related harm, including vehicular accidents, falls, missing medications, and extreme heat exposure.<BR/>Findings include:<BR/>1. Record review of Resident #2's quarterly MDS assessment, dated 06/22/23, reflected a [AGE] year old male who was admitted to the facility on [DATE]. His active diagnoses included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain. Vascular dementia can develop after a stroke blocks an artery in your brain), dysphagia (swallowing difficulties) and cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 had no hearing, speech or vision issues, and his BIMS score was 08, which indicated he was moderately impaired cognitively. Resident #2 had no symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no behavioral symptoms, no rejection of care and no wandering behaviors. Resident #2 required one person physical assistance for all ADLs, with the exception of eating, which he only required supervision. Resident #2 required one person physical assistance for transfers, bed mobility, walking in his room and in the facility per the MDS assessment. Resident #2 was not steady in his balance during transitions and walking, but able to stabilize without staff assistance. He did not have any range of motion impairments and did not use any mobility devices. Resident #2 was frequently incontinent of bowel and bladder. He required a mechanically altered diet and was administered antipsychotic and antidepressant medications. Resident #2 did not have an alarm, which included any physical or electronic device that monitored his movement and alerted the staff when movement was detected, such as a wander guard. <BR/>Record review of Resident #2's care plan, dated 03/17/23 and last revised 08/21/23, reflected the following:<BR/>- Date initiated 03/17/23: The resident has Dx of Vascular Dementia unspecified severity without behavioral disturbance. Resident is taking Aricept; Interventions: Cue, orient and supervise as needed.<BR/>- Date Initiated: 06/11/2023- Resident removed wander guard (not found in room); Interventions: Encourage resident to participate in activities of choice, Notify MD of increase wandering behavior if needed.<BR/>- Date initiated: 07/20/23- Wander guard removed related to no exit seeking; Interventions: Educate Resident / Representative on the necessity of care attempted to provide, Ensure the safety of Resident and others.<BR/>Record review of Resident #2's Elopement Evaluation at his time of admission, dated 03/17/23, reflected he had no prior history of elopement at home no wandering behavior that was a pattern or goal-directed, no wandering that was likely to affect the safety or well-being of self/others and his elopement score was a 0 (zero). As a result, no interventions were checked on the assessment as being needed to prevent elopement. No other elopement evaluations were completed until after Resident #2's elopement incident on 08/19/23. <BR/>Record review of Resident #2's facility progress notes, pertinent to his use of a wander guard and elopement, incident included:<BR/>-03/17/2023- Behavior: Resident noted wandering on the hallways, other resident rooms and exit doors. Resident easily redirected back into his room and comes out of the room immediately. MD was notified and gave order to monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. RP present at the facility, notified and agreed with order. Family Member confirmed resident behavior.<BR/>-06/09/2023-Nursing: This nurse notified the MD that the resident has pitting edema +3. MD has a new order of reduce salt intake, no excessive liquids and elevate legs for one hour three times a day. MD will re-evaluate resident.<BR/>-06/11/2023-Nursing: Resident #2's family member asked nurse to encourage resident to have a shower. This nurse went to try and assist resident with shower, resident refused. Family notified. Nurse attempted multiple ways to encourage resident to shower, resident keeps telling nurse that you don't know what you're talking about. Also, nurse noticed that resident removed wander guard, family notified, admin notified. Resident keeps stating that the wander guard fell off in the shower. Unable to locate in resident's room, admin notified.<BR/>-06/28/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I)<BR/>-06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A)<BR/>-06/29/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place. <BR/>-07/07/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. On order (signed by LVN A)<BR/>-07/10/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. The resident does not have a wander guard in place.<BR/>-07/11/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard is not in place of the resident.<BR/>-07/12/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. Wander guard not in place.<BR/>-07/13/2023-Medication Administration Note: Monitor wander guard to left ankle and monitor skin under wander guard for irritation q shift. No wander guard in place.<BR/>-07/18/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident has removed wander guard (signed by LVN A)<BR/>-07/19/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident Removed (signed by LVN A)<BR/>- 07/20/2023- Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/21/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. No wander guard in place. (signed by ADON I)<BR/>-07/24/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed, DON aware (signed by LVN A)<BR/>-07/25/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/26/2023-Medication Administration Note: Monitor wander guard to right wrist and monitor skin under wander guard for irritation q shift. Resident removed (signed by LVN A)<BR/>-07/20/23-Review of a Multidisciplinary Care Conference: (ADM and RP checked as only participants) reflected, Problems/needs-CP meeting held with Administrator and RP to discuss behaviors of resident cutting wander guard off. Discussed recent elopement assessment reflecting resident is not at risk for elopement. Based off initial elopement assessment resident has not shown exit seeking behavior and therefore not considered elopement risk. Family, Nursing administration, and Administrator that wander guard is not necessary. However, if exit seeking behavior begins, alternate placement will be discussed.<BR/>-Note: Review of a Resident #2's physician order dated 07/27/23 reflected, Monitor for increased S/S of exit seeking and/or wandering every shift (Active 07/27/2023).<BR/>-07/28/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A)<BR/>-07/31/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A)<BR/>-08/02/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (signed by LVN A)<BR/>-08/03/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A)<BR/>-08/07/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed. (Signed by LVN A)<BR/>-08/08/2023-Medication Administration Note: Monitor for increased S/S of exit seeking and/or wandering every shift. Resident removed (Signed by LVN A)<BR/>An interview with LVN A on 08/24/23 at 12:05 PM revealed she was no longer employed at the facility. LVN A stated she was one of the charge nurses for Resident #2 and she had not been working very long at the facility when she was told Resident #2 had a wander guard in the past but he had cut it off or pulled it off. LVN A stated Resident #2 did not display exit-seeking behavior and at point, she tried to put a wander guard on his wrist one time only, but he removed it on the same shift. She said she did not see him remove it and after that, someone tried his ankle, and he took it off unwitnessed. She said it was in the 24-hour report that he removed it and no staff had seen it happen. LVN A stated the wander guard was not located and she did not know if it was ever found. Aside from placing a wander guard on his wrist that one time, LVN A stated she did not try to place another one on him after that. LVN A stated, I kept saying resident removed in my notes and asked the DON if she wanted me to get the order discontinued and she said let me see if I can have it replaced with metal band or get with family to figure it out.<BR/>Record review of Resident #2's nursing progress notes, for 08/19/23 and 08/20/23, did not reflect he was missing or eloped from the facility. The only nursing notes for those dates reflected, 08/20/2023-Nursing: MD notified that resident was found [signed by ADON I]; 08/20/2023-Nursing: Called MD and notified him that family, responsible party was in facility with resident at this time and requests that he has his night medications at this time. MD gave N/O to give meds now. [signed by ADON I]; 08/20/2023-Nursing: [hospital] notified that resident was found [Signed by ADON I]; 08/20/2023-Nursing: Resident returns to the building with family at bedside. Head to toe assessment and VS done. VS: BP 130/92, 02 96% RA, HR 96, RR 17, and no c/o pain. No injuries or tears noted to skin. Dry scaly heels bilaterally. Resident is calm, friendly and engaging in conversation; 08/20/2023-Nursing: Resident currently resting in bed. He is on 1 to 1 observation; 08/21/2023 Nursing: MD notified of the resident increased confusion and gave order to increase Donepezil HCl Oral Tablet to 10 MG at bedtime. MD also gave dx of Psychosis with Dementia for Seroquel. [family member] notified via VM.<BR/>Record review of the facility's incident for Resident #2, dated 08/20/23 at 12:10 PM, reflected Incident description: Resident noted to be missing from room at approximately 12 PM. Search conducted at facility. Admin notified ASAP. Approximately 6 PM police notified facility that resident was found. Immediate Action Taken: Facility was searched and administration, responsible party, physician, DON, and [hospital] notified. Police department notified. MD notified of missed medications, no new orders given. Upon return to facility, head to toe assessment and pain assessment done. Resident placed on one on one care, sitter at bedside.<BR/>Review of website: https://www.accuweather.com (retrieved 08/22/23) revealed the temperature high for the location Resident #2 was found on 08/20/23 was 109 degrees Fahrenheit.<BR/>Review of Resident #2's August 2023 MAR reflected he missed the following prescribed medications during the time he was missing from the facility on 08/20/23 were Aspirin Oral Capsule 81 MG (blood thinner), Calcium-Vitamin D Oral Tablet 500 MG Protein Oral Liquid 30 ml (supplement).<BR/>An observation of the facility video footage, dated 08/19/23 at approximately 7:38 PM, showed Resident #2 walking down the hallway casually towards the front lobby. DA M was also observed coming down a different hallway to the front entrance. No other staff, family members or residents were observed. DA M went to the keyed alarm panel to the left side of the front door and while she was putting in the code, Resident #2 walked towards her and was standing behind her. When she opened the door, she held it open for him and he walked out through the door after her. Then there was a second sliding door that automatically opened without a code and they both proceeded out of that door together out into the parking lot. <BR/>An interview with Resident #2's RP on 08/22/23 at 6:30 AM revealed when Resident #1 was located by the Police, she went to see him and transport him back to the facility. The RP stated she observed Resident #1 to be extremely confused and scared. He was covered from head to toe in dirt and had a trash bag full of garbage one would find in a dumpster. The RP stated she was a RN and was able to assess her father and noted that he had 4+pitting edema. <BR/>An interview with the ADM on 08/22/23 at 9:40 AM revealed he was notified on 08/20/23 at approximately 1:00 PM that Resident #2 was missing by ADON I. He asked her what happened and she said staff had searched the entire facility to verify Resident #2 was not there, so the ADM drove to the facility and on his way called the local police department and filed a report. The police arrived at the same time he arrived at the facility. Then the ADM started going through surveillance footage in the facility with police and while he was doing that, DA M came to his office and said she thought she may have known what happened. DA M told him on her way out the door the evening before on Saturday 08/19/23, at approximately 7:38 PM, someone had slipped out the front door behind her and she thought it was a family member of a resident; she didn't recognize the person. The ADM said he went to that part of the surveillance footage and sure enough, it was [Resident #2] that went outside, walked out. In her defense, it was very smooth , he has dementia but you wouldn't know that, you would have to have a conversation to determine that. The ADM stated there would not have been a front desk staff at 7:40 PM the evening of the incident. The ADM stated he then checked the outside surveillance footage and was able to see Resident #2 coming around the side of the building walking down the sidewalk to the left of the facility. He stated, At that point, by the time I found that footage, police had already started process for silver alert and approximately. 30 minutes later, I got a call from sergeant saying he had been found in a hotel lobby in Grapevine. The ADM stated the police notified the family who were on their way to pick Resident #1 up. He stated the family had been notified around 1:00 PM that afternoon that Resident #2 was missing and he was found around 6:00 PM. The ADM stated he was told Resident #2 was found with a trash bag and a water bottle, a banana and a couple rachet straps and surmised the resident may have gotten a ride due to the distance. He was brought back to the facility, placed on 1:1 supervision and had been on 1:1 since then. The ADM stated, So this was the confusion, I had a couple of statements from staff saying he was identified later that night of when he eloped around 11:00 PM asking for snacks at the nurses station. Number one, it is very common for him to not be in his room, he has no history of exit seeking, just walking around the facility. The ADM stated Resident #2 would not have known how to get back into the facility if he was locked outside and stated the front exit door locked after the door closed. The ADM further stated Resident #2 was not wearing a wander guard anymore because he was a low-elopement risk and just walked around the facility and had dementia. The ADM stated he ordered a tamper-resistant wander guard bracelet, but did not have any evidence of it, and Resident #2 kept removing it. The ADM stated Resident #2 had cut through four to five wander guards off his wrists, even though he had no evidence of it, did not know when the wander guards were attempted to be placed, was not present for the placement and no one ever saw the resident remove them. He stated he met with Resident #2's family in July 2023 and told them Resident #2 was not exit-seeking and was cutting the wander guard off, so we need it removed or if they want him to keep it on, he needed to move. He stated the resolution was to take it off his ankle and move it to his wrist by the family request because the family told him Resident #2 had a criminal history in the past where he had to wear and ankle monitor and having one on his leg in the nursing home may have triggered him. The ADM stated, We agreed to have it discontinued because he has never tried to elope before. The [family member] was okay with that and we were all on the same page. It was in a way a perfect storm for this to happen. We had the wander guard removed because of no exit seeking and he doesn't come across as having dementia and looks like a family member. The ADM stated once Resident #2 was located post-elopement and brought back to the facility, he did not interview him. He stated, I want to say someone [name unknown] from our nursing staff talked to him [name unknown] . The ADM admitted the overnight staff working 08/19/23 into 08/20/23 did not round on Resident #1. He said he was still conducting his facility investigation, but from what he could tell thus far, he was told CNA X rounded on Resident #2 at midnight but then later said maybe she got the resident rooms mixed up. The ADM stated, [Resident #2] does not like to be bothered at night and gets agitated, so that was why he had less rounds. If he doesn't require incontinent care, then it would be opening his door to make sure he was there as rounding. He does not have a roommate. It could be done quietly and that was my conversation with them yesterday when we started the in-service. The ADM stated the elopement incident could have been prevented by staff ensuring when they left the facility exits, to make sure there were no residents trying to leave and if they were unsure who a resident was, to stop and ask them. The ADM stated, This goes back to us not being equipped to care for his needs. He is not the type of resident appropriate for this care, but we would not have known that. A wander guard would have solved this problem. He removed four or five wander guards .<BR/>An interview with MD D on 08/23/23 at 1:00 PM revealed he did not know Resident #1 was on his caseload until the incident with the elopement. He stated he did not know he was missing for over 18 hours and only got notified when he was located. <BR/>An interview with DA M on 08/22/23 at 10:12 AM revealed she did not interact much with residents and 95% of the time she was in the kitchen and at other times, she was delivering meal carts to CNAs or nurses. She said she did not know who Resident #2 was and could not recall seeing him before. DA M stated, When I let him out, I saw him standing the door, I had my head down and ready to head out, I typed in code and he followed right behind me, he said thank you so much, clear as day, and I thought he was family member. I didn't think much of it. DA M stated she had not been informed by the facility who were potential exit-seekers or what to do if she saw one of those residents attempting to elope. She stated, 'I didn't think I would be in a situation where I would be dealing one-on-one with a resident. I had not been informed on what to do if one wanted to leave. If I had seen him around and knew him, I would have grabbed a CNA or nurse and told them he was trying to leave, but it was the end of my shift, I clocked out and wasn't thinking much of it, I thought he was a visitor of a resident here. I walked out and my mom who was in a car picking me up, said she had seen a man walk out behind me but didn't think much of it . He was dressed in casual clothing, I glimpsed at him. DA M stated when she came to work Sunday 08/20/23, the kitchen staff were telling her about a resident who had eloped the day before and it was then she realized through their description of him, that it might be the man she let out the day before. DA M said she ran to the ADM's office and the police were there and she told them what happened the night before and they were able to then pull it up on surveillance camera and verify Resident #2 went out the door behind her around 7:38 PM. <BR/>An interview with ADON I on 08/22/23 at 10:41AM revealed she was at the facility on 08/19/23 until 5:00 PM and was at the facility on 08/20/23 from 6:00 AM until 11:00PM. ADON I stated when she came into work on 08/20/23, no one mentioned Resident #2 was missing. She said the CNA that worked with him (CNA B), went to pick up his breakfast tray around 12:10 PM and it had not been eaten and she then asked ADON I if she had seen him around. ADON I said the CNA B would have delivered the breakfast tray around 7:45AM-8:30AM. ADON I stated they immediately checked all the resident rooms and bathroom, his friends' rooms and he was not present. Then someone drove the perimeter outside, down to the nearby shopping strip and did not see him. Then ADON I called the family and asked them if Resident #2 was with them and they said no. At that point ADON I stated she called the DON, called ADM and called the staff who worked the night shift before. She said there was an agency nurse (LVN P) who said she remembered checking on Resident #2 during her overnight shift. ADON I also stated she called the overnight CNA, who also remembered checking on Resident #2 during the overnight shift. Once ADON I was informed by the ADM Resident #2 was seen through video surveillance leaving the facility on 08/19/23 at approximately 7:40 PM, she stated, That made me question staff that told me they had seen him that night. ADON I said by the time Resident #2 was found and returned to the facility, he had missed three shifts of medications over two days. ADON I stated Resident #2 did not have a wander guard on because he kept cutting them off and the facility had been through about 10 or 12 of them. She said Resident #2 had never tried to exit-seek before, I have never even heard him ask, he is usually very pleasant and interactive. She stated, When we have done a wander guard in past, it was on his ankle. We have never tried one on his wrist that I can remember, don't know if it was tried. ADON I stated, Plan now for him is he has been so far one on one and I think they are going to place him in a more secured facility. That I can't say for sure. ADON I stated there were photos in a binder of the residents who exit-seeked and that binder was at each nurses station and the front desk. She said Resident #2 was not in the binder. ADON I stated most of the staff understand that during the day, the front desk receptionist let people out through the front door with a code, but staff would also let them in and out too but most of them knew who the residents were and who was not supposed to leave. She said if a staff member was not sure if a person was a resident, they should not let them out and check with the charge nurses or other direct care staff. ADON I stated LVN N was the weekend supervisor who worked until 10:00 PM on 08/19/23. <BR/>An interview with LVN N on 08/22/23 at 11:09 AM revealed he was the weekend supervisor on 08/19/23 and he left the facility around 11:00 PM and was off work on 08/20/23. He said he got a call from one of the ADONs on 08/20/23 and she told him Resident #2 was missing and they were in the process of looking for him. He remembered seeing Resident #2 on 08/19/23 around 3:45 PM in the hallway, He normally comes out and stands in the hallway then comes back to his room. As far as I know, he hasn't tried to get out of the door before. <BR/>A follow up interview with the ADM on 08/22/23 at 12:16 PM revealed he did not have a policy for wander guards. The ADM stated, I do want to touch on and I am not saying everything was handled perfectly. As soon as we noticed he [Resident #1] was not here, all parties notified. We had police at facility in and out 30 minutes, camera reviewed, silver alert approved and issued by the state within 2 &frac12; hours and he was found unharmed about 30 minutes after that was issued. At the end of the day, when it comes to our elopement procedure , we followed all the necessary steps and we found him . The ADM said he QAPI'ed the incident and also terminated the DON on 08/21/23 for a number of reasons . <BR/>An interview with MA O on 08/22/23 at 12:52 PM revealed he was working a double shift on 08/19/23 from 6:00AM to 10:00 PM, but not on Resident #2's hall. He stated the nurse for Resident #2 on the 2-10PM shift was LVN Q. MA O stated he knew who Resident #2 was and he had eloped from the facility. The resident usually had a wander guard on him. He remembered seeing Resident #2 on his 08/19/23 shift because he normally came to the nurses' station for snacks and MA O remembered him coming to get one after dinner on 08/19/23, but there were no snacks left because they had all been passed out already. He stated Resident #2 was okay with it and not upset. MA O stated Resident #2 usually went to bed and would come out during the evening around 8-9PM most nights. The next morning, 08/20/23, MA O stated he worked Resident #2's hall from 6AM-2PM and was told by CNA B around lunch time that she had not seen him and could not find him. They began looking in each residents' room and around the hall, and then some staff went outside to look for him and that was when everyone realized he was missing and the police and family were notified. <BR/>An interview with LVN P on 08/22/23 at 1:06 PM revealed she was the agency nurse who worked the overnight shift on Resident #2's hall on 08/19/23 into 08/20/23 and it was her first time working at the facility. She stated that night she was the charge nurse for four halls. She stated she came into the facility to work around 10:00 PM and left around 6:45 AM the next morning. When she arrived at her shift that night, LVN P stated, When I got there, I can't really say I was oriented, but I did make rounds while the 2-10PM nurse was finishing up stuff. LVN P stated no one told her who was exit-seeking on her halls or who wore a wander guard. She stated she rounded on her own with no one else. LVN P stated she had rooms 507-510 (where Resident #2 resided) and she opened up each door when she started her shift to make sure there was a body in each bed. LVN P stated she remembered seeing a body in each bed; she did not go into the rooms and touch the residents but when she opened each door, she saw a body and assumed each resident was asleep. She stated she did not turn the lights on. Around 11:30 PM, the off-going nurse came back around and gave LVN P a report and then LVN P took over from there. LVN P stated she did not know who the residents were and a nurse named (LVN N) gave her a login to chart in the residents' e-chart. LVN P could not remember if she gave Resident #2 any medications or treatments during the overnight shift because there were two residents in the facility with the same last name, Resident #2 and Resident #7. She stated, So I don't remember which one I saw. I think one was on 500 and one on 700, I could be mistaken. After she left the next morning, she got a call from the facility around 12:30 PM on 08/20/23, asking questions about Resident #2.<BR/>Review of Resident #2's clinical chart revealed no documentation in his care plan or progress notes that he did not want to be disturbed at night.<BR/>An interview with CNA B on 08/22/23 at 1:20 PM revealed she was Resident #2's CNA on the 6AM-2PM shift 08/20/23 and got to the facility around 6:15 AM. CNA B did not remember who the nurse was on her hall that shift. She said Resident #2 liked to walk around, so when she did not see him in his room that morning, she initially did not think anything of it. She put his breakfast tray in his room because she thought he was visiting with another resident at that time. CNA B then proceeded to get some more residents up for the day and fed a resident, then at some point went to pick up Resident #2's breakfast tray and he still was not in his room and his food had not been eaten. She said she did not panic but tried to look for him and around 9:45 AM and checked one of his friend's rooms but he was not there. CNA B stated, I figured he would pop back up. I went to dress another resident. He wasn't in his doorway asking me for a penny like he normally does and I am thinking that is not like him. I thought maybe he went out with the [family member]. At that time, CNA B said she looked at the piano in the dining room because he played sometimes, but nothing, I am thinking he will pop back up. I got up another resident then went back, not there. CNA B said she asked ADON I if she had seen him and they checked the sign out sheet. CNA B stated there was sign out for Resident #7, but not Resident #2, they both had the same last name. She asked the front desk receptionist what time Resident #7 left and she had it mixed up with Resident #2, so she asked another staff member when did Resident #2 leave, to which she was told he did not leave, he was in his room. CNA B stated, I started to panic and told [ADON I] and she and I started looking for him, did a wide search everywhere in the facility, looked outside, drove around McDonalds, grocery store, the neighborhood. Everyone in all departments looking for him. He was nowhere to be found. We just kept looking and then [ADON I] made calls. CNA B stated she was present when Resident #2 was found [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician reviewed the resident's total program of care, including medication and treatments, at each visit and wrote, signed and dated progress notes at each visit for five (Residents #1, #3, #5, #9 and #10) of 10 residents reviewed for physician visits. <BR/>The facility failed to ensure there were physician progress notes available for Residents #1, #3, #5, #9 and #10 that were signed and dated by the physician(s) for each visit via the physical charts or electronic record. The physicians were, however, consulted about critical lab values and changes in condition.<BR/>These failures could place residents at risk of not receiving the appropriate care as ordered by the physician and a lack of oversight by the physician, which could place the residents at risk of harm and health decline. <BR/>Findings included:<BR/>1. Review of Resident #1's quarterly MDS assessment dated [DATE], reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her active diagnoses included non-Alzheimer's dementia (the loss of cognitive functioning-thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech), cerebrovascular accident (an interruption in the flow of blood to cells in the brain), multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), anxiety, depression and hypertension (is when the pressure in your blood vessels is too high). Resident #1 had unclear speech, was usually understood by others and she sometimes understood others (responds to simple, direct communication only) and had a BIMS score of 07 which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium (inattention, disorganized thinking or altered level of consciousness), no mood issues, and no behaviors which included psychosis (hallucinations and delusions), no physical and verbal behaviors, no rejection or care or wandering. Resident #1 required limited assistance with her ADLs of one person and used a walker and wheelchair for ambulation. Resident #1 received antidepressant medication as the only psychoactive medication at the time of the MDS assessment and she was not on hospice care.<BR/>Review of Resident #1's care plan initiated on 03/23/23 and last revised 05/17/23 reflected only four care planned areas: 1) Risk for Harm: Self Directed or Other- Directed r/t Mood Disorders Secondary to clinical diagnosis of depression; 2) Acute pain/Chronic Pain; 3) Limited physical mobility related to multiple sclerosis; and 4) a fall on 03/11/23. <BR/>Review of Resident #1's face sheet dated 08/15/23 reflected her current physician was MD D as of 07/31/23. Prior to that date, her previous attending physician was noted in her chart to be PHY DD who was her physician since 03/09/23. <BR/>Review of Resident #1's clinical chart reflected no evidence of any visits or physician progress notes from PHY DD or subsequently MD D, since her admission to the facility. <BR/>Review of Resident #1's Hospice Certification and Plan of Care dated 03/17/23 reflected she entered into hospice on 03/17/23. <BR/>Review of Resident #1's nursing progress notes from reflected the following medical/health issues:<BR/>-03/18/23-Resident #1 had a critical lab for Potassium with a value of 6.6 (reference range is 3.5-5.1) and a Glucose value of 699 (reference range is 74-109). (Note: High potassium levels may be a sign of kidney disease; too much potassium may mean the kidneys are not working well; Blood sugar more than 600 can cause a coma. Dangerously high blood sugar levels cause ketoacidosis which is a serious diabetic complication where the body produces excess blood acids-ketones)<BR/>-06/11/23-Resident #1 had a fall which resulted her being sent to the ER. Resident #1 had a hematoma in the center of forehead her measuring 5x5 cm and under her right eye with a laceration measuring 3cm x 1 cm that was glued in the ER. <BR/>-06/11/23-Resident #1's blood sugar was noted to be 600, and her attending physician was notified (PHY DD) and stated to administer one time order of 3 units of insulin. <BR/>-07/14/23- Nurse was notified of Resident #1 attempting to leave facility (front entrance). Resident stated, I want to leave why am I here Nurse contacted hospice for PRN medication. <BR/>-07/27/23- Hospice RN ordered Seroquel for Resident #1 at bedtime due to agitation.<BR/>-07/31/23- A new order was received to change Resident #1's primary physician to MD D.<BR/>-08/07/23- Resident #1 was showing signs of hypoglycemia [low blood sugar] was sweaty and slumped over in her walker. A finger stick blood sugar reflected her blood glucose was 40.The nurse administered Glucagon 1mg IM. Resident #1 was able to get back to baseline and her fsbs was 87. <BR/>-08/17/23- Resident experienced change of condition (dizziness, slowly eating and speaking). MD order implemented for rehydration and insulin monitoring ongoing. Stat Cath UA, CBC, and CMP, Doxycycline 100 mg BID for seven days for Sepsis; IV NS @ 70 ML/Hr. x 3 liters. <BR/>Review of Resident #1's clinical chart reflected neither MD D or PHY DD wrote any progress notes over the course of her stay at the facility to show they were monitoring her health conditions and medications. <BR/>2. Review of Resident #5's annual MDS dated [DATE] reflected she was a [AGE] year old female admitted to the facility on [DATE]. Resident #5's active diagnoses included aphasia (loss of ability to understand or express speech), dysphagia (swallowing difficulties), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and arm contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Resident #5 had unclear speech, was rarely understood and had short/long term memory deficits. Resident #5 required one person physical assistance for all ADLs and had range of motion impairment on one side of her upper extremity. She used a wheelchair for mobility. <BR/>Review of Resident #5's care plan care plan initiated 05/15/23 and last revised on 08/14/23 had three focus areas: 1) Resident #5 was resistive to care and would refuse care such as medications, ADL care, lab draws; 2) Resident #5 had an actual fall related to poor safety awareness and unsteady gait; and 3) Resident #5 used an anti-depressant.<BR/>Review of Resident #5's face sheet dated 08/15/23 reflected her current physician was PHY BB as of 07/31/23. Prior to that date, her previous attending physician was noted in her chart to be PHY DD.<BR/>Review of Resident #5's clinical chart reflected no evidence of any visits or physician progress notes from PHY DD from 03/21/23 to 08/01/23, when she was seen by her new doctor, PHY BB.<BR/>Review of Resident #5's nursing progress notes from reflected the following medical/health issue prior to PHY DD seeing her on 08/01/23:<BR/>-03/23/23-Resident #5 had a change of condition- She was noted to have numerous cavities to top and bottom teeth and was in pain. Resident #5 ended up having a dental infection and required antibiotics for ten days.<BR/>-04/20/23-Resident #5 noted to have decline in weight possibly indicating malnutrition. PHY DD notified received order for labs: CMP and Albumin.<BR/>-05/02/23- BMP results for Resident #5 provided to PHY DD who stated, Not bad but poor kidney function-no new orders.<BR/>-0709/23-Resident #5 fell in her room, no injuries. <BR/>-07/31/23-Resident #5's primary attending physician changed from PHY DD to PHY BB. <BR/>-08/05/23- Resident #5's new attending physician (PHY BB) ordered STAT - CBC and CMP<BR/>-08/06/23-Resident #5 had a critical calcium value of 5.9 and was sent to the ER for further evaluation and was diagnosed with a UTI.<BR/>Review of Resident #5's clinical chart reflected neither PHY DD did not write any progress notes over the course him being her attending physician from March 2023 through July 2023 to show he was monitoring her health conditions and medications.<BR/>3. Review of Resident #9's quarterly MDS assessment reflected he was a [AGE] year old male admitted to the facility on [DATE]. Resident #9's active diagnoses included Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), insomnia (trouble falling asleep, staying asleep, or getting good quality sleep), essential tremors (a type of involuntary shaking movement), hyperlipidemia (An excess of fats or lipids in the blood), peripheral vascular disease (a slow and progressive circulation disorder) and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). Resident #9 had short/long term memory deficits and moderately impaired cognitive skills for daily decision making. Resident #9 had signs and symptoms of delirium as evidenced by continuously present inattention, as well as mood issues that involved trouble with concentration. Resident #9 required one person physical assistance for all ADLs, was always incontinent of bowel and bladder and used a wheelchair for mobility. <BR/>Resident #9's care plan dated 02/01/23 and last revised on 03/29/23, reflected the following care areas: 1) High risk for falls, 2) Requires staff assist for ADLs, 3) Behavior of sleeping on the floor, 4) Impaired cognitive function and thought processes due to dementia, 5) Diagnosis of hypertension related to lifestyle choices, 6) Use of anti-depressant medication due to sleep disturbances, 7) Resident is on anti-Parkinson medication therapy, 8) Risk of skin integrity impairment due to incontinence, and 9) Impaired visual function related to cataracts.<BR/>Resident #9's face sheet dated 08/15/23 reflected his current physician was PHY BB as of 07/31/23. Prior to that date, his previous attending physician was noted in his chart to be PHY DD.<BR/>Review of Resident #9's clinical chart reflected no evidence of any visits or physician progress notes from PHY DD from 03/01/23 to 08/01/23, when he was seen by his new doctor, PHY BB.<BR/>4. Review of Resident #10's quarterly MDS assessment dated [DATE], reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses of macular degeneration [an eye disease that can blur your central vision], polyneuropathy [the simultaneous malfunction of many peripheral nerves throughout the body], peripheral vascular disease [reduced circulation of blood to a body part other than the brain or heart], hypertension [(high blood pressure) is when the pressure in your blood vessels is too high (140/90 mmHg or higher)] and hyperlipidemia [an elevated level of lipids- like cholesterol and triglycerides in the blood]. Resident #10 had a BIMS score of 10, which indicted no cognitive impairment. Resident #10 required one person physical assistance for all ADLs except eating, which she required supervision only. Resident #1 used a walker for mobility, had frequent pain present that was mild and was on a scheduled pain regimen. Resident #10 received a diuretic medication. <BR/>Review of Resident #10's care plan initiated and dated 08/11/23, reflected the following care areas: 1) Resident #10 had a diagnosis of hypertension, 2) Resident #10 had a diagnosis of hyperlipidemia, 3) At risk for falls related to vision/hearing problems and unsteady gait, 4) On diuretic therapy related to edema, 5) Potential for nutritional problem related to obesity, 6) Had chronic pain, 7) At risk for breakdown in skin integrity, and 8) Impaired visual function due to macular degeneration.<BR/>Resident #10's face sheet dated 08/15/23 reflected her current physician was PHY BB as of 07/31/23. Prior to that date, her previous attending physician was noted in his chart to be PHY DD.<BR/>Review of Resident #10's clinical chart reflected no evidence of any visits or physician progress notes from PHY DD from 03/01/23 to 08/01/23.<BR/>5. An interview with ADON C on 08/11/23 at 2:26 revealed she had been employed at the facility for a few weeks and she did not know how often the attending physicians were supposed to see their residents. She stated that usually MDS and medical records staff would remind the doctors when their visits were due. ADON C stated the importance of physician visits and documentation were to make sure the residents were being followed up on and medications were verified during those visits. She said the physicians were supposed review medication during their face-to face visits, make sure everything was good and that nothing was being missed and it also gave the resident a chance to talk to them directly. ADON C stated, It is critical.<BR/>An interview with MR on 08/11/23 at 4:22 PM revealed he had some issues with PHY DD and a couple other physicians getting his notes to the facility. MR stated he was supposed to reach out to PHY DD and he had been having some problems with him providing those progress notes from his visits. He said, So I guess when the new ADM started, I guess he got rid of them. MR stated he tried to keep track of the when each physician was due to visit and if he saw the physicians in the facility, he would get progress notes from some of them. He said there was one physician, an older doctor, who never gave the facility progress notes, he could not remember his name. He said he wanted to do all of his notes hand-written. <BR/>An interview with the ADM on 08/11/23 at 4:38 PM revealed when he started working at the facility (which he claimed was a month prior), he had heard through the DON that there were some doctors not turning in their notes or doing visits, so her terminated three of their contracts. He said he knew it was an issues and even though he was a newer Administrator, he was on it and the facility was trying to get new processes in place. The ADM stated he had not had a QAPI on that issue yet or completed a PIP, but he was working on it and knew it was already an issue. <BR/>Interview with NP K on 08/15/23 at 12:55 PM revealed she was the nurse practitioner for the medical director (MD D) and they had recently picked up about 25 residents on their caseload at the end of July 2023 due to some issues with the other attending physicians. She said she was still in the process of making sure everyone had been seen and reviewing orders and labs. NP K said she did not know what was going on with the other physicians and did not know about any concerns, only that they are gone and she and MD D have new residents as a result. <BR/>An interview with LVN H on 8/15/23 at 1:47 PM revealed he was told some of the attending physicians did not have residents on their caseload anymore, and he did not know why. He said that he did see them come out to visit their residents, including PHY DD. LVN H stated he did not know how the physician progress notes worked, some write it directly into the computer, some write their notes on paper and then all of them were supposed to turn them in and they went to medical records. LVN H stated the importance of having physician notes was to see if there were any new orders, see what was wrong with the resident and check for any new updates. <BR/>An interview with the ADM and DON on 08/15/23 at 2:19 PM revealed medical records staff was supposed to oversee the physician visits and ensure they were turning in their progress notes and completing their visits. She said as far as care issues and concerns, the DON would contact the doctor. The DON was not sure when the physicians were supposed to complete a face-to-face visit with their resident but stated that the three physicians who were transitioned away from working at the facility (which included PHY DD) had chronic issues and warnings from previous administrators and she and the current administrator inherited the issue. The DON said they had now switched over and between MD D and his NP K, who were in the facility once a week, they were getting everyone caught up on their visits and progress notes. The ADM stated that the physicians (to include PHY DD) did come to the facility, text and call the nurses, but the follow up was slower with the nurses and receiving orders. The DON then stated the risk of the physicians not visiting the residents face to face and providing progress notes at those visits was, Just poor outcome, not reviewing medications for necessary changes, not having progress notes for review, it could affect how the interdisciplinary team is approaching care. We need communication.<BR/>An interview with MD D on 08/23/23 at 1:00 PM revealed he was the medical director for about a year and he had been aware that the attending physicians were not keeping up, answering phone calls and the facility finally made the decision to dismiss three of them in July 2023 (to included PHY DD). MD D stated he would see the physicians in the facility, such as PHY DD and word of mouth is that they were seeing the residents, just not doing documentation, I don't know how they got paid. I was actually seeing them and saying hi to them and I wasn't aware of their lack of documentation., I heard through the grapevine one of the doctors has everything hand-written at home. <BR/>6. Review of the facility's policy titled, Physician Services, revised February 2021, reflected, .6. Physician orders and progress notes are maintained in accordance with current OBRA regulations and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #89) of 7 residents reviewed for pharmaceutical services.<BR/>1. RN D failed to follow the facility policy and physician orders for flushing Resident #89's gastrostomy tube with 5 mL of water before, between, and after medications, when she administered Tylenol to the resident<BR/>2. RN D failed to follow the Physician Orders to check gastrostomy tube placement every shift hold for residual greater than 100 mL and notify the doctor. <BR/>3. RN D failed to follow the facility policy for flushing the gastrostomy tube after stopping a continuous feeding with at least 15 mL of water.<BR/>These failures could put residents at risk, who received medications via gastrostomy tube, for tube occlusion, and displacement of the gastrostomy tube and medication interactions.<BR/>Findings included:<BR/>Review of Resident #89's MDS (a standardized tool that measures health status in nursing home residents), dated 11/25/22, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The assessment reflected Resident's #89 had severed impaired cognition and had diagnoses which included muscle weakness, feeding difficulties and pain in unspecified joint. <BR/>Review of Resident #89's February 2023 Physician Orders reflected the following: flush gastrostomy tube with 5 ml of water before, between and after medication administration. Tylenol oral tablet 325 milligrams. Give 2 tablets via gastrostomy tube every 8 hours as needed for pain.<BR/>Observation on 02/08/23 at 12:29 PM revealed RN D crushed 2 tablets of Tylenol 325 mg and put the crushed medication in a cup. RN D went to resident 89's room: RN D positioned the Resident #89. RN D sanitized don gloves and discontinued the continuous tube feeding, checked Resident #89's bowel sound. RN D did not check for the residual before administering medication and she did not flush the gastrostomy tube after stopping the feeding prior to administering medication. <BR/>Interview with RN D on 02/08/23 at 12:38 PM revealed she was aware of the order to administer medication through gastrostomy tube for Resident #89, but she was nervous and that is why she forgot to check for the residual and flush the gastrostomy tube after stopping the feeding and before medication administration. She stated failure to check for residual, she was not sure whether the resident feeding was being digested well. She also stated failure to flush the gastrostomy tube after stopping the feeding and before administering medication could lead to g-tube blockage and medication interaction with feeding formula. She stated she had received training on medication administration via gastrostomy tube.<BR/>Interview with the DON on 02/08/23 at 01:34 PM revealed his expectation was for the nurses to flush the gastrostomy tube before between and after each medication administration as per the doctor's orders and follow the facility policy. He stated failure to flush the gastrostomy tube made the tube hard to flush and over time it may cause the gastrostomy tube to clog. He stated failure to flush before medication administration and after stopping the formula feeding it might also cause medication chemical interaction that would affect the effectiveness of the administered medication. He stated he had trained the nurses on medications administration via gastrostomy tubes.<BR/>Review of the facility's current policy dated November 2018, Administering Medication through enteral tube policy and procedure, reflected the following: <BR/> .4. Tablets that must be crushed prior to administration through an enteral tube require a specific order related to crushing. <BR/> .6. Verify placement of feeding tube.<BR/>a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the charge nurse or physician.<BR/>7. Stop the feeding and flush tubing with at least 15 mL warm purified water or (another prescribed amount). <BR/>10. Administer each medication separately <BR/>13. If administering several medications, administer each one separately. The tube should be flushed with at least 15mls of water between medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #40) reviewed for unnecessary medications. <BR/>The facility failed to ensure Resident #40 had an appropriate diagnosis for her prescribed Seroquel (used to treat depression).<BR/>This failure could place residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.<BR/>Findings included:<BR/>Record review of Resident #40's admission Record, dated 04/10/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE].<BR/>Record review of Resident #40's Quarterly MDS Assessment, dated 03/24/25, reflected she had a BIMS score of 12 indicating no cognitive impairment. Her active diagnoses included cerebrovascular accident/transient ischemic attack/stroke, non-alzheimer's dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), anxiety disorder (refers to a group of specific psychiatric disorders characterized by extreme fear or worry), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). For the medication review, it was noted Resident #40 received antipsychotics on a routine basis. <BR/>Record review of Resident #40's care plan, revised 01/24/25, reflected the following: Focus: [Resident #40] uses psychotropic medications -Resident takes Seroquel .Goal: [Resident #40] will reduce the use of psychotropic medication through the review date .Interventions: Administer PSYCHOTROPIC [sic] medications as ordered by physician.<BR/>Record review of Resident #40's Order Summary Report, dated 04/10/25, reflected the following :<BR/>- Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth two times a day for ANTIPSYCHOTICS/ANTIMANIC AGENTS [sic], Take one tablet by mouth in the morning<BR/>Record review of Resident #40's April 2025 MAR reflected she received Seroquel every day as ordered.<BR/>Record review of Resident #40's Consultant Pharmacist/Physician Communication Report, dated 10/13/24, reflected: Dear [Physician A], This resident was admitted on an antipsychotic, Quetiapine. Please ensure approved psych diagnosis has been documented to support continued use .Physician/Prescriber Response 'acute on [illegible] psychosis'. The report was signed by Physician A on 10/17/24.<BR/>Record review of Resident #40's Medication Regimen Record review Report, dated 11/13/24, reflected: Resident has an order for the following medication. I recommend including a diagnosis to the medication order to support therapy. Quetipaine.<BR/>Observation and interview on 04/08/25 at 12:00 PM with Resident #40 revealed she was in her room with a family member. Resident #40 said she was doing okay today. <BR/>Interview on 04/10/25 at 3:27 PM with LVN B revealed she was caring for Resident #40. LVN B said she reviewed Resident #40's Seroquel order and saw that a diagnosis was missing. LVN B said there should be a diagnosis listed with the medication which would come from the doctor. <BR/>Interview on 04/10/25 at 3:50 PM with the Interim DON revealed normally the Charge Nurse would put an order for an antipsychotic medication into a resident's chart with the indications for use and a nurse manager, such as herself, would add the diagnosis. The Interim DON said Resident #40 should have had a diagnosis associated with her antipsychotic medication and staff should have caught that. The Interim DON said she just stepped into her role last week and the previous DON would have been responsible for ensuring the Pharmacist's recommendations were followed up on. The Interim DON said she was now responsible for them going forward, however. The Interim DON said the purpose was to complete or respond to the recommendations based on the regulations and to allow for communication between the pharmacist and the doctor to occur. The Interim DON said the previous DON was the only one following up on the recommendations and there was not anyone going behind her to ensure they were completed. The Interim DON said the previous DON was expected to complete the recommendations herself.<BR/>Interview on 04/10/25 at 4:15 PM with the Interim DON revealed the facility did not have a policy regarding pharmacy recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide laboratory services to meet the needs of its residents for one of 10 residents (Resident #3) reviewed for laboratory services.<BR/>The facility failed to ensure Resident #3's Keppra lab was completed as ordered. <BR/>The failure could place residents at risk for delays in the provision of treatment for laboratory abnormalities and acute exacerbation of clinical conditions.<BR/>Findings include:<BR/>Record review of Resident #3's quarterly MDS assessment, dated 06/15/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had active diagnoses which included seizure disorder (a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain), hypertension (when the pressure in the blood vessels is too high (140/90 mmHg or higher)), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and depression (serious medical health disorder that negatively affects how you feel, the way you think and how you act). Resident #3 had a BIMS score of 08, which indicated she was moderately impaired. <BR/>Record review of Resident #3's care plan, date initiated 02/02/23 and last revised on 03/14/23, reflected she had a seizure disorder and her goal was to remain free from injury related to seizure activity through the next review date. Resident #3's care planned interventions were to give seizure medication as ordered by doctor, monitor/document side effects and effectiveness; obtain and monitor lab/diagnostic work as ordered; report results to MD and follow up as indicated.<BR/>Record review of Resident #3's current August 2023 physician's orders reflected she was prescribed Keppra Oral Tablet 500 MG (Levetiracetam) one tablet twice a day for anticonvulsants (start date 02/01/23). Resident #1 was also ordered, Keppra Level Q 3 month; Next lab Feb, May, Aug, November. (start date 03/12/23). <BR/>Record review of Resident #3's MARs from 03/01/23 through 08/22/23 reflected she was administered Keppra as ordered. <BR/>Record review of Resident #3's clinical record reflected no Keppra labs were completed after the order was written on 03/12/23. <BR/>Record review of Resident #3's nursing progress notes reflected she had no seizure activity since her admission to the facility on [DATE].<BR/>Record review of Resident #3's clinical record reflected only one visit from her attending physician (PHY CC) since admission, which occurred on 07/15/23, PHY CC did not review her Keppra lab(s) or lack thereof. <BR/>Record review of a change in physician form, dated 07/31/23, reflected Resident #3's RP gave consent to change her doctor from PHY CC to PHY BB. <BR/>Record review of Resident #3's MAR/TARs for March 2023 through August 2023 reflected there was an entry every month for Keppra Level q 3 month. Next lab Feb, May, Aug, November. None of the MAR were initiated that the lab had been completed. <BR/>An interview with the ADM on 08/22/23 at 4:50 PM revealed the previous DON was terminated the previous week and presently he had two ADONs assisting with clinical issues. He stated there were no Keppra labs available for Resident #3, but the facility was in the process of getting it done and had contacted MD D to get an order. The ADM stated he thought what happened was, when the facility switched over to a new e-charting system company in February 2023, the system did not pull over routine labs ordered and put it on the e-MAR. As a result, he thought the labs were not showing up on the e-MAR, which would mean the nurses would not have known to order a lab and put it on the lab requisition form. <BR/>An interview with Resident #3 on 08/23/23 at 9:25 AM revealed she did have a seizure when she first admitted to the facility but had not had one since, that she could remember. She stated she took medication to control her seizures. <BR/>An interview with LVN H on 08/23/23 at 10:00 AM revealed for routine labs, the nurse who received the order was supposed to fill out a form when the lab was initially ordered and fax it to the lab company so they could put it into their system. LVN H stated once the routine lab order was sent to the lab company, the nurse was then supposed to put a note on the 24-hour report that it was done and then from that point, the lab company would know when the lab was due on their end and at the same time, the nurses would see it as an order that popped up under the nurse MAR. LVN H stated any nurse could follow up on a lab, and when he came into work in the mornings, he usually looked at the labs that were completed and labs that needed to be followed up on. With Resident #3, LVN H stated he had just started working on her hall so he did not know what the nurses were doing before him. He stated the stat Keppra lab that had just been completed the day before, and the results came back on 08/23/23. LVN H stated the values were on the low side, but not critical. LVN H stated a low Keppra value meant there was not enough of the medication in Resident #3's system. He denied seeing Resident #3 have a seizure at the facility. LVN H stated he notified the doctor and was waiting for a call back on her abnormal Keppra lab. <BR/>An interview with ADON C on 08/23/23 at 10:10 AM revealed she was a newer hire at the facility from a month ago and was in the process of auditing labs and putting in new lab orders. She stated, for example, with Resident #3, the lab order was on her monthly MAR, but there was not an exact date specified to complete it on the MAR, all of the days on the MARs were crossed out with an X. ADON C stated Resident #3 had a stat Keppra lab completed the day before (08/22/23). ADON C stated, I think it is a consistency issue honestly . She said ADON I knew the building but she was recently a floor nurse, so ADON C was trying to show her the systems/processes and now the new DON was no longer employed. ADON C stated, I just don't think there great consistency in nursing management. ADON C stated the potential harm of not completing labs as ordered, in particular Keppra, was to make sure the medication was working appropriately and if not, the resident could be in harm's way with seizures and decrease of brain function. ADON C stated, So if we are not sure Keppra levels are not right, we could see increased activity [of seizures] . ADON C stated she talked to MD D and he told her he saw labs were not getting done across the board with residents at the facility. ADON C stated she assured him she was on it and started the lab auditing process. <BR/>An interview with MD D on 08/23/23 at 1:00 PM revealed he was the medical director and PHY BB was new to long term care, so he was helping her with the processes and protocols at the facility. MD D stated with Resident #3, he was not sure if she was on his new caseload or not. He stated about six months ago, one of the previous DONs asked him as the medical director if the facility could do routine labs for Keppra every three months. MD D stated he did not see the clinical benefit of doing it and told the DON it was okay with him, but the neurologist had told him they did not recommend routine Keppra labs and they should only be done based off if the resident was having seizure activity or side effects of the medication. MD D stated he reviewed the stat Keppra lab the facility had just completed for Resident #3 and stated, It came back low today. He stated he told the facility he would see her for a visit, but also once again, low doesn't mean too much to me unless she has had a seizure. <BR/>Record review of Resident #3's Keppra stat lab completed after State Surveyor intervention, on 08/23/23, reflected her therapeutic drug monitoring for levetiracetam (Keppra) was low at 6.6 (reference range is 10.0-40.0). <BR/>Record review of the facility's Lab and Diagnostic Test results-Clinical Protocol Policy, revised September 2012, reflected, 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring need.; 2. The staff will arrange for tests; 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #115) of 5 residents reviewed for clinical records.<BR/>1. The facility failed to ensure staff accurately documented on Resident #115's October 2023 MAR that he received his medications.<BR/>2. The facility failed to ensure staff kept copies of Resident #115's shower sheets from September and October 2023.<BR/>These failures could affect residents and place them at risk of inaccurate or incomplete clinical records.<BR/>Findings included:<BR/>1. Review of Resident #115's face sheet, dated 03/21/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 11/26/23. His diagnoses included anorexia (an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self induced behaviors towards thinness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).<BR/>Review of Resident #115's quarterly MDS assessment, dated 11/07/23, reflected he had a BIMS score of 15 indicating no cognitive impairment. <BR/>Review of Resident #115's physician's orders reflected the following: <BR/>- <BR/>Morphine sulfate ER tablet extended release 15 MG, Give 1 tablet by mouth at bedtime for pain ***do not crush*** with a start date of 09/30/23<BR/>- <BR/>Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa), Give 1 tablet by mouth four times a day for Parkinson's Disease ***do not crush*** with a start date of 09/14/23<BR/>Review of Resident #115's care plan, closed on 12/18/23, reflected the resident had a diagnosis of Parkinson's disease and was taking carbidopa-levodopa and also had chronic pain .<BR/>Review of Resident #115's October 2024 MAR revealed blank spots for the following orders: Morphine sulfate ER tablet extended release 15 MG, Give 1 tablet by mouth at bedtime for pain ***do not crush***; on the following date: 10/07/23. Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa), Give 1 tablet by mouth four times a day for Parkinson's Disease ***do not crush*** on the following date: 10/13/23 for the 12:00 PM dose.<BR/>Interview on 03/21/24 at 1:45 PM with the DON revealed staff should document when they administer a medication or treatment due to nursing standard practices on the resident's MAR/TAR . The DON said the purpose of this was nursing 101 and if they did not document a medication or treatment administered then it was not done. <BR/>Review of the facility's policy, revised April 2019, and titled Administering Medications reflected the following: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.<BR/>2. Review of shower sheets provided by the facility for Resident #115 revealed there were only two for the entire month of September 2023 (dated 09/08/23 and 09/15/23) and none dated for October 2023. <BR/>Interview on 03/20/24 at 2:12 PM with CNA S revealed he cared for Resident #115 and provided him baths while he was working with him. CNA S said Resident #115's shower days were Mondays, Wednesdays, and Fridays. CNA S said when a resident received a shower he would fill out a shower sheet and give it to the nurse to look over. CNA S said he was not sure what happened to the shower sheets after that. <BR/>Interview on 03/21/24 at 4:05 PM with the Administrator revealed he was not able to locate any additional shower sheets for Resident #115 for September and October 2023.<BR/>Interview on 03/21/24 at 4:08 PM with the DON revealed she was unable to locate any additional shower sheets for Resident #115 for the months of September and October 2023. The DON said the shower sheets were pulled at the end of the month and sent to medical records to be kept for the resident's records. The DON said the CNA's were responsible for providing showers and filling out the shower sheet and then showing it to the Nurse and placing it in a specific place to be held until the end of the month.<BR/>Follow-up interview on 03/21/24 at 4:29 PM with the DON revealed the purpose of keeping shower sheets was to prove that the resident was provided a shower on that date. <BR/>Review of the facility's policy, revised February 2018, and titled Bath, Shower/Tub reflected: Documentation: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment date (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. <BR/>The facility failed to follow the physician orders to complete follow-up with the surgeon for staple removal for Resident #1's surgical wound. <BR/>This failure could place residents with wounds at risk for a deterioration in the condition of their wounds or additional wounds. <BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, dated 08/19/23, revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses orthopedic aftercare following surgical amputation, osteomyelitis of the left ankle and foot, muscle weakness, pain, hypertensive heart disease with heart failure, peripheral vascular disease. <BR/>Review of Resident #1's discharge MDS assessment, dated 08/04/23, reflected the resident's BIMS score was not indicated. The MDS assessment reflected Resident #1 received wound care. <BR/>Review of Resident #1's Care Plan, revised on 07/29/23, reflected the resident had a surgical wound to the left lower extremity. The goal was for the resident to be pain free and intervention was to provide treatment as ordered by the doctor. <BR/>Review of Resident #1's physician wound treatment orders and treatment administration record dated 08/19/23 reflected to clean the wound with wound cleanser, apply gauze soaked in betadine to wound bed and cover with dry dressing, wrap with kerlix (bandaged roll) and cover with ace bandage every other day. <BR/>Review of Resident #1 treatment administration record for the month of July 2023 reflected an order to monitor staples at the left above knee amputation for placement and incision site for signs and symptoms of infection every shift. <BR/>Resident #1 was not at the facility at the time of the investigation, he was transferred to the hospital on [DATE]. <BR/>Review of Resident # 1's discharge orders dated 07/04/23 reflected the resident was to follow up with the surgeon after two weeks of discharge for staple removal. <BR/>In an interview on 08/19/23 at 12:09 pm with the treatment nurse, she stated she had been in the facility for slightly more than one month. Treatment nurse stated Resident #1 had a surgical site above left knee due to amputation and the surgical site had staples. Treatment nurse stated, the facility monitored the stump for signs and symptoms of infection, and she was not aware of the follow up with the surgeon. The treatment nurse stated she contacted the surgeon office on 08/04/23 after the resident developed a wound to the knee where it looked like the bone was pressing against the skin. She stated the surgical site was intact and the wound was on a different area on the knee. Treatment nurse stated she contacted the office on a Friday (08/04/23) and the resident was schedule to see the doctor on a Monday, and when she explained that the resident was actively bleeding from the wound, she was instructed for the resident to be transferred to the local hospital. <BR/>In an interview on 08/19/23 at 12:30pm with ADON stated she oversaw Resident #1's care. ADON stated the Resident #1 has had surgery and he had staples to the stump. After she reviewed the resident's hospital record, she stated the resident required to follow up with surgeon after two weeks of discharge, but he did not. She stated the resident was to follow up with the surgeon so he could be assessed for any complications after surgery, for infection and if the surgical site was healing well. <BR/>In an interview on 08/19/23 at 1:13 pm with the DON she stated she was not aware the resident had staples. DON stated if there was recommendation from the hospital for the resident to follow up with the surgeon then the facility was supposed to schedule the follow up appointment, and the staples were to be removed per the hospital recommendations. <BR/>In an interview on 08/19/23 at 2:25 pm with Administrator he stated from Resident #1's record it reflected the staples were to be removed and the resident to be seen by the surgeon, but it was not completed. Administrator stated no one scheduled the appointment upon resident discharge from the hospital. Administrator stated there was no adverse effects from the staples, but the facility was to follow the hospital recommendations and making sure the staples were removed timely. <BR/>Review of the facility policy revised April 2018 and titled Pressure ulcer/Skin Breakdown - Clinical Protocol reflected, 2. The Physician will help identify medical interventions related to wound management; for example treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #89) of 7 residents reviewed for pharmaceutical services.<BR/>1. RN D failed to follow the facility policy and physician orders for flushing Resident #89's gastrostomy tube with 5 mL of water before, between, and after medications, when she administered Tylenol to the resident<BR/>2. RN D failed to follow the Physician Orders to check gastrostomy tube placement every shift hold for residual greater than 100 mL and notify the doctor. <BR/>3. RN D failed to follow the facility policy for flushing the gastrostomy tube after stopping a continuous feeding with at least 15 mL of water.<BR/>These failures could put residents at risk, who received medications via gastrostomy tube, for tube occlusion, and displacement of the gastrostomy tube and medication interactions.<BR/>Findings included:<BR/>Review of Resident #89's MDS (a standardized tool that measures health status in nursing home residents), dated 11/25/22, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The assessment reflected Resident's #89 had severed impaired cognition and had diagnoses which included muscle weakness, feeding difficulties and pain in unspecified joint. <BR/>Review of Resident #89's February 2023 Physician Orders reflected the following: flush gastrostomy tube with 5 ml of water before, between and after medication administration. Tylenol oral tablet 325 milligrams. Give 2 tablets via gastrostomy tube every 8 hours as needed for pain.<BR/>Observation on 02/08/23 at 12:29 PM revealed RN D crushed 2 tablets of Tylenol 325 mg and put the crushed medication in a cup. RN D went to resident 89's room: RN D positioned the Resident #89. RN D sanitized don gloves and discontinued the continuous tube feeding, checked Resident #89's bowel sound. RN D did not check for the residual before administering medication and she did not flush the gastrostomy tube after stopping the feeding prior to administering medication. <BR/>Interview with RN D on 02/08/23 at 12:38 PM revealed she was aware of the order to administer medication through gastrostomy tube for Resident #89, but she was nervous and that is why she forgot to check for the residual and flush the gastrostomy tube after stopping the feeding and before medication administration. She stated failure to check for residual, she was not sure whether the resident feeding was being digested well. She also stated failure to flush the gastrostomy tube after stopping the feeding and before administering medication could lead to g-tube blockage and medication interaction with feeding formula. She stated she had received training on medication administration via gastrostomy tube.<BR/>Interview with the DON on 02/08/23 at 01:34 PM revealed his expectation was for the nurses to flush the gastrostomy tube before between and after each medication administration as per the doctor's orders and follow the facility policy. He stated failure to flush the gastrostomy tube made the tube hard to flush and over time it may cause the gastrostomy tube to clog. He stated failure to flush before medication administration and after stopping the formula feeding it might also cause medication chemical interaction that would affect the effectiveness of the administered medication. He stated he had trained the nurses on medications administration via gastrostomy tubes.<BR/>Review of the facility's current policy dated November 2018, Administering Medication through enteral tube policy and procedure, reflected the following: <BR/> .4. Tablets that must be crushed prior to administration through an enteral tube require a specific order related to crushing. <BR/> .6. Verify placement of feeding tube.<BR/>a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the charge nurse or physician.<BR/>7. Stop the feeding and flush tubing with at least 15 mL warm purified water or (another prescribed amount). <BR/>10. Administer each medication separately <BR/>13. If administering several medications, administer each one separately. The tube should be flushed with at least 15mls of water between medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #2) of three residents reviewed for catheter care.<BR/>The facility failed to have appropriate orders transcribed in the MAR/TAR for the months of April, May and June 2023, and interventions in place for routine catheter care including cleaning and changing for Resident #2's Foley catheter and Foley catheter drainage bag.<BR/>This failure could place residents with foley catheters at risk of urinary infection and improper catheter care.<BR/>Findings included:<BR/>Review of Resident #2's face sheet dated 06/28/23 revealed Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses the included: hypertension (high blood pressure) and sepsis (a potentially life-threatening, systemic response of the immune system that results fro the spread of pathogenic agents such as bacteria or viruses).<BR/>Review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact with a BIMS score of 15 out of 15. Section M of the MDS assessment related to skin conditions, reflected Resident#2 had one Stage 4 pressure ulcer. Section H of the MDS assessment related to bladder and bowel, reflected Resident#2 had an indwelling catheter.<BR/>Review of Resident #2's physician's orders dated 04/05/23 revealed Resident #2 had orders to irrigate her Foley catheter with 60-100 ml normal saline for occlusion and to change the foley catheter every month and when needed for occlusion.<BR/>Review of Resident #2 April, May and June 2023 MARs/TARs revealed no evidence that orders were transcribed related to Foley catheter care or dates to change the Foley catheter and Foley catheter drainage bag. <BR/>Record review of Resident #2's progress notes and the TARs for the months of April, May, and June of 2023 revealed there was no documentation of Resident #2's catheter being cleaned, changed, or of her being offered or refusing catheter care. The nurse only commented that the Foley was patent on all notes.<BR/>Interview on 06/28/23 at 4:33 PM, the ADON revealed Resident#2 was re-admitted with an indwelling urinary catheter. The ADON stated he was able to see the physician order on admission, but he could not tell how the order was not transferred to the MAR and TAR for the staff to be able to access and perform the Foley catheter care. The ADON stated the admitting nurse was responsible for putting the orders in their electronic chart when Resident#2 was re-admitted to the facility, and the DON was responsible for ensuring the appropriate orders were in place. The ADON stated if Resident #2 did not have orders for specific catheter care and dates for changing the Foley catheter and Foley bag on the MARs/TARs, Resident #2 was at risk of infections such as a urinary tract infection.<BR/>Interview on 06/28/23 at 5:05 PM, the DON revealed her expectation was when Resident #2 came back from the hospital the orders were supposed to be put in the system by the admitting nurse. The DON stated the orders should elaborate on monitoring of the changes and notifying the physician, date when to change the Foley catheter and Foley bag every month. The DON stated she was new in the facility, and she did not understand why orders were not put in the system and nobody noted the orders were missing. The DON stated failure to change the Foley catheter placed Resident #2 at risk of infection and the catheter being clogged.<BR/>Interview on 06/28/23 at 5:27 PM with RN A revealed she was the admitting nurse when Resident #2 was re-admitted to the facility. RN A stated Resident #2 came back with a Foley catheter due to a sacral wound (located at the end of the spine in the pelvic area) and a coccyx (tailbone) wound. RN A stated she was supposed to put the orders in the system so that they were reflected on the MARs and TARs for staff to access and perform Foley catheter care. RN A stated she did not know what happened to the orders for the dates on when to change the Foley catheter and Foley bag or how they got skipped. RN A stated somebody in management was supposed to follow-up on the orders after admission to ensure all orders were put in the system. RN A stated failure to have Foley catheter care orders transcribed in MARs/TARs predisposed Resident #2 to infections. She stated she had done training on catheter care.<BR/>Record review of the facility's current Catheter Care, Urinary policy and procdure, revised September 2014, revealed the purpose of this procedure was to prevent urinary catheter-associated urinary tract infections and reflected: <BR/> .a Do not clean the periurethral area with antiseptics to prevent catheter associated urinary tract infections while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.<BR/> .d .Empty the collection bag at least every 8 hours.<BR/> Rather, it was suggested to change catheters and drainage bags based on clinical indications such as infections, obstruction, or when the closed system is compromised.

Based on observation, interview, and record review the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for one (lunch meal) of one meal services reviewed. <BR/>The facility failed to ensure [NAME] A prepared the pureed lunch meal in a manner to conserve nutrition, flavor, and palatability on 02/08/23.<BR/>The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.<BR/>Findings included:<BR/>Observation of [NAME] A pureeing food items for lunch on 02/08/23 beginning at 10:45 AM revealed [NAME] A used tap water to thin out pureed breaded chicken patties. The pureed chicken patties had a mashed potato consistency. <BR/>Interview on 02/08/23 at 10:52 AM with [NAME] A revealed she had worked as a cook for the facility for about 6 months. [NAME] A stated she had been trained on following recipes when preparing all diets; however, she did not follow recipes because they had never been provided to her. [NAME] A showed surveyor a binder that only contained the weekly menus. [NAME] A stated she had already pureed the lima beans and cheesy cauliflower, and that she used tap water to thin out those food items as well. She recalled the RDN informing kitchen staff to use potato flakes as a thickener and liquids such as water, broth or juice as a thinner. When asked why she chose to use tap water, [NAME] A stated because she was close to the sink and nervous from being watched by surveyor; although she admitted to using tap water in the food items prepared outside of the presence of the surveyor. [NAME] A stated the risk of using tap water as a thinner could be watering down the flavor which could cause the residents to be dissatisfied with their food. <BR/>Interview on 02/08/23 at 11:15 PM with the Dietary Manager revealed he had worked at the facility for about 6 months. He stated that all cooks had been trained on how to properly prepare all meals, including specialized diets. The Dietary Manager stated the cooks knew to use pasta water, broths or juice to thin out pureed foods. He stated pasta water and broths would be used for meat and juice would be used for certain desserts. The Dietary Manager stated the RDN talked to them about using recipes, but he did not know where the recipes were. He was aware that the cooks did not have recipes to follow when preparing meals. He stated that even without recipes, they knew not to use tap water as a thinner based on the in-services they had received. The Dietary Manager stated the risk of using tap water as a thinner could be decreasing the nutrition and taste of the food. <BR/>Interview on 02/08/23 at 4:33 PM with the RDN revealed she had worked at the facility for over a year. The RDN stated she had trained the Dietary Manager and the cooks on how to properly thin and thicken pureed foods. The RDN stated using tap water as a thinner was an old method and no longer an appropriate way of obtaining the proper consistency for pureed foods as it diluted the flavor and nutritive value in the food items. The RDN stated she informed the cooks and the Dietary Manager to used broths, milk, and juice as appropriate. The RDN stated the risk of diluting the flavor and nutritive value in food with tap water could be the residents disliking the food which could lead to loss of appetite and weight loss. The RDN stated this was not likely and would take a long period of time to take effect, if so, but it was a possibility. <BR/>Interview on 02/09/23 at 5:15 PM with the Administrator revealed the RDN was responsible for monitoring the menus and ensuring that the kitchen staff understood the importance of properly preparing all meals. He stated it was his expectation for the Dietary Manager to ensure that kitchen staff were following the RDN's recommendations. The Administrator stated that not following the RDN's recommendations on properly preparing meals could have a negative impact on the residents' health. <BR/>Record review of the facility's recipe for breaded chicken breasts (pureed), lima beans (pureed), and cauliflower with cheese (pureed) revealed the following:<BR/>1. To get the actual serving size, puree the number or portions needed, adding adequate liquid needed to achieve the desired consistency as appropriate for resident .<BR/>Record review of an in-service titled Puree additives you can add for nutritional value, dated 12/05/22, revealed the following:<BR/>Do not use thickener powder. <BR/>Liquids: gravy, stock, pasta water.<BR/>Thickener: breadcrumbs, bread, potato pellets.<BR/>Record review of the facility's policy titled Therapeutic Diet Orders, revised January 2020, reflected the following:<BR/>Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. <BR/>Definitions: <BR/>Mechanically Altered Diet-one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat and thickened liquids. <BR/> .Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.<BR/>A policy on standardized recipes was requested form the Administrator on 02/09/23 and was not provided at the time of exit. Administrator stated the facility did not have a specific policy on recipes.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Residents #41, #28, #59, #83 and #105) of 20 residents observed for infection control.<BR/>1. LVN C failed to perform proper disposal of dressing materials after performing wound care for Resident #41.<BR/>2. LVN B failed to perform proper sanitization of equipment during blood sugar check for Resident #41 and Resident #28.<BR/>3. The facility failed to ensure Resident #105, who shared a room with Resident #83, was immediately isolated when the resident tested positive for COVID-19. <BR/>4. The facility failed to properly disinfect and handle the dietary cart and dishes used on the isolation hall and failed to ensure the dietary cart was properly disinfected after it was touched by Resident #59. <BR/>These failures placed all residents at risk of cross-contamination and infections leading to illness.<BR/>Findings included:<BR/>Observation on 02/07/23 at 12:31 PM during facility initial tour, revealed a soiled wound dressing discarded in the trash can that was left exposed with some of the dressing stuck on the edge of the trash can, in Resident #41's room.<BR/>Interview on 02/07/23 at 12:35 PM with LVN C, who was the charge nurse, revealed he had provided wound care to Resident #41 at around 11:00 AM. He stated he was aware he was supposed to use a biohazard bag while performing wound care or use a plastic bag and after procedure dispose soiled materials on the biohazard box in the biohazard room. He stated he did not have the biohazard bag on the nurse's cart, and he was in a hurry. He stated he forgot to dispose of the dressing materials properly by removing them from the room. He stated failure to dispose soiled dressing materials properly could lead to cross contamination then spread of infection. He stated he is aware of the right procedure, but he forgot. He stated he is from agency, and he had not received training in this facility on wound dressing and care of soiled dressings materials. <BR/>Interview with DON on 02/07/23 at 4:14 PM revealed his expectation was for nurses to discard the soiled dressing materials on biohazard bag or plastic bags. He stated he expected the nurse to use the plastic bags and after the procedure they should remove the bag from the resident room and discard in the biohazard box. He stated failure to discard the soiled materials properly could cause contamination and spread of infection. He stated he had done training on infection control with the facility staff but not with agency nurses, because he expected them to have basic knowledge from their companies. He stated he only orient the agency nurses on the unit on their first day.<BR/>Observation on 02/08/23 at 11:35 AM revealed LVN B perform hand hygiene and don gloves and prepared to check blood glucose level on Resident #41. She was observed cleansing the finger with alcohol pad and she pricked the resident finger and got the sample. She discarded the sharps on the sharp container and the soiled alcohol pad. She removed the gloves sanitized and recorded the readings. She did not disinfect the glucometer, and she wheeled her cart to another hall to check blood sugar levels for Resident #28.<BR/>Observation on 02/08/23 at 11:43 AM revealed LVN B perform hand hygiene and removed gloves and prepared to check blood glucose level on Resident #28. She took the glucometer machine from the top of her cart without disinfecting it. She was observed cleansing the finger with alcohol pad, she pricked the resident finger, and got the sample. She was observed using the same glucometer without disinfecting on Resident #28. She discarded the needle on the sharp container and the soiled alcohol pad. She removed the gloves sanitized and recorded the readings.<BR/>Interview with LVN B on 02/08/23 at 11:47 AM revealed she knew she was supposed to disinfect the glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in blood) between each resident and with every use to prevent contamination and spread of infection. She stated she was supposed to use the disinfectant wipes but she did not have some on her cart. She stated she did not have enough reason why she did not disinfect the glucometer machine because she had alcohol pads that she could have used. She stated she is an agency nurse and had not received training on infection control in this facility but she had been trained in another facility. She stated failure to disinfect the glucometer machine could lead to spread of infection from one resident to another.<BR/>Interview with DON on 02/08/23 at 1:30 PM revealed his expectation was the nurse to disinfect the glucometer after each use and between the residents. He stated if the nurses were not disinfecting the glucometer machine it could lead to cross contamination and spread of infection from one resident to another. He stated he had not trained the agency nurse because he expected them to have the basic knowledge on infection control.<BR/>3. An observation on 02/07/23 at 11:18 AM revealed Resident #105 was symptomatic with a cough and tested positive for COVID while sharing room with Resident #83.<BR/>An observation on 02/07/23 at 11:52 AM revealed Resident #83 was observed in the hall with no mask. Resident #83 put other residents at risk for COVID transmission.<BR/>An observation on 02/07/23 at 1:01 PM revealed Resident #83 was congregating with other residents in the hallway without a mask. Resident #83 confirmed that she was coming from a smoke break and had not been informed Resident #105 had tested positive for COVID. <BR/>An interview with the DON on 02/07/23 at 3:52 PM revealed Resident #83 was to have smoke breaks alone and not congregate with other residents. He stated COVID negative resident (Resident #83) had been sharing a room with COVID positive resident (Resident #105) since that morning. The DON stated COVID positive and COVID negative roommates are to be separated immediately. He stated if residents were not separated immediately, it could lead to cross contamination and spread of infection from one resident to another. <BR/>4. An observation and interview with the DON on 02/08/23 at 8:56 AM revealed, 100 hallway was the hall dedicated for COVID positive residents. Observation revealed a dietary cart on 100 hall with reusable dishes loaded on the dietary cart. The DON stated residents with COVID are to use only Styrofoam plates, cups, and eating utensils when eating to prevent the risk of cross contamination. He stated clean items enter at the front entrance on 100 hall and dirty items exit through the back door on 100 hall. <BR/>An observation and interview at 02/08/23 at 9:59 AM revealed the dietary cart had been placed outside the front entrance of 100 hall. Observation also revealed Resident #59 touching the dietary cart in an attempt to enter the 100 halls. Social Worker assisted Resident #59 away from 100 hall and to her room. Interview with RN E revealed that dietary cart would be picked up by dietary staff. When asked if it was to be picked up from that location, RN E replied, yes.<BR/>An observation on 02/08/23 at 10:09 AM revealed the dietary cart from 100 hall was sprayed with Comet Cleaner with Bleach and the dietary cart was not labeled with a dedicated hall. Dietary Aide F had allowed three minutes for contact time before she had rinsed dietary cart. <BR/>An interview with Dietary Aide F on 02/08/23 at 10:13 AM revealed the Comet disinfectant contact time was five min before rinsing. She stated if the correct contact time was not done then the dietary cart would still be contaminated and could make residents sick. <BR/>Record review revealed the correct contact time for Comet Cleaner with Bleach was 10 minutes before rinsing. <BR/>Review of the facility's Dressing, soiled/contaminated policy, dated August 2009, reflected: .1. Disposable items such as bandages, applicators, gauze pads etc., that are soiled or contaminated with ineffective material, blood, or body fluids must be placed in a plastic bag and removed from the resident's room upon completion of any procedure.<BR/>Review of the facility's Blood sampling -Capillary (finger sticks) policy, dated September 2014, reflected: .Following manufacturer's instructions, clean and disinfect reusable equipment, parts and /or devices after each use. <BR/>Review of the facility's policy titled COVID-19 Response for Nursing Facilities, dated 06/27/22, reflected: Once a case of COVID-19 is identified in the NF, immediate action must be taken to isolate the resident who is positive for COVID-19 away from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #89) of 7 residents reviewed for pharmaceutical services.<BR/>1. RN D failed to follow the facility policy and physician orders for flushing Resident #89's gastrostomy tube with 5 mL of water before, between, and after medications, when she administered Tylenol to the resident<BR/>2. RN D failed to follow the Physician Orders to check gastrostomy tube placement every shift hold for residual greater than 100 mL and notify the doctor. <BR/>3. RN D failed to follow the facility policy for flushing the gastrostomy tube after stopping a continuous feeding with at least 15 mL of water.<BR/>These failures could put residents at risk, who received medications via gastrostomy tube, for tube occlusion, and displacement of the gastrostomy tube and medication interactions.<BR/>Findings included:<BR/>Review of Resident #89's MDS (a standardized tool that measures health status in nursing home residents), dated 11/25/22, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The assessment reflected Resident's #89 had severed impaired cognition and had diagnoses which included muscle weakness, feeding difficulties and pain in unspecified joint. <BR/>Review of Resident #89's February 2023 Physician Orders reflected the following: flush gastrostomy tube with 5 ml of water before, between and after medication administration. Tylenol oral tablet 325 milligrams. Give 2 tablets via gastrostomy tube every 8 hours as needed for pain.<BR/>Observation on 02/08/23 at 12:29 PM revealed RN D crushed 2 tablets of Tylenol 325 mg and put the crushed medication in a cup. RN D went to resident 89's room: RN D positioned the Resident #89. RN D sanitized don gloves and discontinued the continuous tube feeding, checked Resident #89's bowel sound. RN D did not check for the residual before administering medication and she did not flush the gastrostomy tube after stopping the feeding prior to administering medication. <BR/>Interview with RN D on 02/08/23 at 12:38 PM revealed she was aware of the order to administer medication through gastrostomy tube for Resident #89, but she was nervous and that is why she forgot to check for the residual and flush the gastrostomy tube after stopping the feeding and before medication administration. She stated failure to check for residual, she was not sure whether the resident feeding was being digested well. She also stated failure to flush the gastrostomy tube after stopping the feeding and before administering medication could lead to g-tube blockage and medication interaction with feeding formula. She stated she had received training on medication administration via gastrostomy tube.<BR/>Interview with the DON on 02/08/23 at 01:34 PM revealed his expectation was for the nurses to flush the gastrostomy tube before between and after each medication administration as per the doctor's orders and follow the facility policy. He stated failure to flush the gastrostomy tube made the tube hard to flush and over time it may cause the gastrostomy tube to clog. He stated failure to flush before medication administration and after stopping the formula feeding it might also cause medication chemical interaction that would affect the effectiveness of the administered medication. He stated he had trained the nurses on medications administration via gastrostomy tubes.<BR/>Review of the facility's current policy dated November 2018, Administering Medication through enteral tube policy and procedure, reflected the following: <BR/> .4. Tablets that must be crushed prior to administration through an enteral tube require a specific order related to crushing. <BR/> .6. Verify placement of feeding tube.<BR/>a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the charge nurse or physician.<BR/>7. Stop the feeding and flush tubing with at least 15 mL warm purified water or (another prescribed amount). <BR/>10. Administer each medication separately <BR/>13. If administering several medications, administer each one separately. The tube should be flushed with at least 15mls of water between medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 5 (Administrator, [NAME] Z, Dietary Aide X, Dietary Aide W, and Dietary Aide V) of 5 staff and 1 of 1 kitchen reviewed for kitchen sanitation, in that:<BR/>1. [NAME] Z placed food containers of the lunch meal in the steamtable that contained contaminated water.<BR/>2. The Administrator, Dietary Aide X, Dietary Aide W, and Dietary Aide V failed to wear a hair restraint while in the kitchen. <BR/>These failures could place residents at risk for food contamination and foodborne illness.<BR/>Findings included:<BR/>1. In a continuous observation on 03/19/24 from 11:08 AM to 11:11 AM of the kitchen's steamtable revealed of the five compartments, the second compartment from the left side had a few inches of brown tinted water in it as well as food particles. [NAME] Z placed a tray of cooked mashed potatoes in the dirty steamtable compartment. [NAME] Z a tray of cooked carrots in the third compartment from the left side that had a few inches of brown tinted water in it as well as food particles. [NAME] Z placed a container of mechanical soft chicken nuggets, a container of pureed carrots, and a container of pureed chicken nuggets into the fourth compartment form the left side that had a few inches of brown tinted water in it as well as food particles. <BR/>Observation on 03/19/24 at 11:30 AM revealed [NAME] Z placed a container of creamed gravy into the fourth compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Observation on 03/19/24 at 11:32 AM revealed [NAME] Z placed a container of chicken fried steaks in the first compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Observation on 03/19/24 at 11:38 AM revealed [NAME] Z placed a container of French fries in the fifth compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Observation on 03/19/24 at 11:58 AM revealed [NAME] Z placed a container of mechanical soft burger patties and a container of burger patties into the fifth compartment from the left side which had a few inches of brown tinted water in it as well as food particles.<BR/>Interview on 03/19/24 at 1:09 PM with the Dietary Manager revealed the steamtables appeared to have brown water because of the rust inside of the compartments. The Dietary Manager said the steamtables also had food particles from breakfast in each of them. The Dietary Manager said the night shift staff were responsible for emptying and refilling the water in each of the steamtable compartments. The Dietary Manager said if the dietary staff noticed the steamtables were dirty between meals they could stop and clean it but it was usually done at night. The Dietary Manager said the purpose of having clean compartments was related to bacteria and germs. The Dietary Manager said [NAME] Z was responsible for ensuring the compartments were cleaned before placing cooked food on the line. The Dietary Manager said [NAME] Z had already gone home for the day. <BR/>Review of the Federal Food Code 2022 reflected: 4-602.11 Equipment Food-Contact Surfaces and Utensils .3) Containers in serving situations such as salad bars, [NAME], and cafeteria lines hold READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is maintained at the temperatures specified under Chapter 3, are intermittently combined with additional supplies of the same FOOD that is at the required temperature, and the containers are cleaned at least every 24 hours.<BR/>Interview on 03/21/24 at 5:30 PM revealed the facility did not have a policy addressing kitchen equipment.<BR/>2. Observation on 03/19/24 at 10:26 AM revealed Dietary Aide X was sitting at a prep table in the kitchen rolling silverware and not wearing a hair restraint. <BR/>Interview on 03/19/24 at 10:27 AM with Dietary Aide X revealed she knew she was supposed to have a hair restraint on while in the kitchen. Dietary Aide X said she left the kitchen earlier and forgot to put one back on. Dietary Aide X said the reason to wear a hair restraint was to keep the food safe. <BR/>Observation on 03/19/24 at 10:50 AM revealed the Administrator walked into the kitchen without a hair restraint on. <BR/>Observation on 03/19/24 at 11:15 AM revealed Dietary Aide W walked through the kitchen from the back area without a hair restraint on.<BR/>Interview on 03/19/24 at 11:16 AM with Dietary Aide W revealed she came from outside of the kitchen in the back area and walked through the kitchen area without a hair restraint on. Dietary Aide W said she had to walk through the kitchen because there were not any hair restraints available at the back door. <BR/>Observation on 03/19/24 at 12:13 PM with Dietary Aide V revealed he walked into the kitchen without a hair restraint on or beard restraint to cover his facial hair on his chin. <BR/>Interview on 03/19/24 at 1:09 PM with the Dietary Manager revealed she saw that multiple staff had not been wearing hair restraints while in the kitchen. The Dietary Manager said the purpose of wearing hair and beard restraints was to avoid hair falling in the food. The Dietary Manager said it was the responsibility of each staff and her as well to make sure they were wearing hair and beard restraints. The Dietary Manager said she needed to stock some more at each of the entrance doors to the kitchen so staff did not have to walk through the kitchen to get hair restraints. <BR/>Record review of the Federal Food Code 2022 reflected: <BR/>2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints.(8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions <BR/>Review of the facility's policy, revised October 2017, and titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices reflected: 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 (the lunch meal on 03/19/24) of 4 lunches reviewed for food and nutrition services. <BR/>The facility failed to ensure the seven residents (Residents #9, #10, #46, #66, #75, #79, and #159) on a pureed diet were served pureed bread and pureed chicken fried steak during the lunch meal on 03/19/24.<BR/>This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances.<BR/>Findings included: <BR/>Review of an undated list of residents served a pureed diet revealed the facility had a total of seven residents (Residents #9, #10, #46, #66, #75, #79, and #159) on a pureed diet.<BR/>Review of the facility's menu for the lunch meal on 03/19/24 reflected country fired steak, cream gravy, garlic mashed potatoes, buttered carrots, dinner roll, cookies and cream mousse. <BR/>Observation and interview on 03/19/24 at 11:00 AM revealed [NAME] Z was using a food processer to puree cooked chicken nuggets instead of chicken fried steak. [NAME] Z said since the chicken nuggets were breaded she was not going to add any bread slices to the mix. <BR/>Interview on 03/19/24 at 1:09 PM with the Dietary Manager revealed she was not aware [NAME] Z used chicken nuggets instead of chicken fried steak for the pureed meat option today during lunch. The Dietary Manager said she was also not aware that [NAME] Z did not add bread to the chicken nuggets while pureeing them because that was what they normally did to ensure residents got each component of their meal. The Dietary Manager said [NAME] Z was responsible for making the pureed items during the lunch service and knew better. The Dietary Manager said the purpose of serving what was on the menu and including all meal components was that all residents were supposed to get the same items on the menu. The Dietary Manager said this put residents at risk of weight loss if they were not receiving the same or all the menu items. The Dietary Manager said [NAME] Z had already left for the day. <BR/>Review of the facility's recipe card for pureed chicken fried steak revealed serve 1 each, beef steak fritter 4 ounces, shortening clear fry liquid.<BR/>Interview on 03/21/24 at 5:30 PM with the Administrator revealed the facility did not have a policy addressing menus.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 12 of 12 confidential residents reviewed for resident council. <BR/>The facility failed to provide a private space for resident council meetings.<BR/>This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. <BR/>Findings included:<BR/>Observation and interview on 03/19/24 at 10:00 AM during a confidential resident group meeting with 12 residents, revealed the resident council meeting were held once a month in the dining room. The meeting was held in a TV room that was closed off to the staff and private. The residents stated normally the resident council meetings were being held in the dining room, which was an open space and no way to keep staff from walking by or overhearing. The resident further stated they really liked the privacy of the current meeting because they felt like they could speak freely without feeling like they were being overheard by staff. <BR/>Interview on 03/21/24 at 2:47 PM with the Activity Director revealed they had been having the resident council meetings in the dining room for the past two years. She stated they were having the meetings in a private room but they moved to the dining room because that private room did not fit all the residents that wanted to attend. The residents were asked if they had any problems having the resident council meetings in the dining room and she said they all said no. The Activity Director further stated they had a bigger room and she had no problem moving the council meetings there. She also stated by having meetings out in the open, staff could potentially listen in and residents would be more hesitant to complain about certain staff members. <BR/>Interview on 03/21/24 at 3:06 PM with the Administrator revealed resident council meetings were being held in the dining room and per the Activity Director, she had asked the residents if the location was ok and they had all said yes. The Administrator was asked if there were any risks of having the resident council meetings in the dining area he stated it was the resident's rights to have it where they wanted. <BR/>Review of the facility's undated policy titled Resident Council reflected the following:<BR/> .3. The resident council group is provided with space, privacy, and support to conduct meetings

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 5 residents (Resident #13) reviewed for PASRR assessments. <BR/>The facility did not refer Resident #13 to the appropriate state-designated mental health authority for review when he received a new diagnosis of major depressive disorder. <BR/>This failure could place residents at risk of not being evaluated and receive needed PASRR services.<BR/>Findings included:<BR/>Record review of Resident #13's face sheet dated 04/10/25 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #13 was diagnosed with major depressive disorder on 03/14/25. <BR/>Record review of Resident #13's MDS Assessment, dated 04/03/25, reflected the resident had an active diagnosis of depressive disorder, and the resident had severe cognitive impairment with a BIMS score of 07. <BR/>Record review of Resident #13's undated Care Plan reflected [Resident #13] uses psychotropic medications (Seroquel) r/t Behavior management.<BR/>Record review of Resident #13's PASRR Level 1 Screening, dated 05/15/24, reflected he did not have a mental illness. PASARR Level 1 screening did not indicate Resident #13 had primary diagnosis of dementia. <BR/>Interview on 04/10/25 at 9:47 AM, the MDS Coordinator revealed she was aware Resident #13 was given a diagnosis of major depressive disorder on 03/14/25. The MDS Coordinator stated Resident #13 had a primary diagnosis of dementia and did not require another PASRR Level 1. The MDS Coordinator stated a 1012 Form (Mental Illness/Dementia Resident Review) should had been completed but needed time to locate it. <BR/>Follow up interview on 04/10/25 at 10:42 AM, the MDS Coordinator revealed a Form 1012 was not completed until today (04/10/25). The MDS Coordinator reviewed Resident #13 PASRR Level 1 and stated she was not aware Resident #13 primary diagnosis was not Dementia. She stated a PASRR Level 1 should have been completed when the new diagnosis of major depressive disorder was given. She stated it was the responsibility of the MDS Coordinators to review PASRRs. She stated she had been employed for 8 years, she stated Resident #13's PASRR was missed. She stated there was no harm to the resident. The MDS Coordinator stated they did not have a PASRR policy, they followed state regulation. <BR/>Interview on 04/10/25 at 1:50 PM with the Interim DON revealed the MDS Coordinators were responsible for updating the PASRR assessments and submitting them timely and complete new ones when a new diagnosis was given. The Interim DON stated by not reviewing resident PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to implement an admission policy that did not request or require residents to waive potential facility liability for losses of personal property for one (Resident #1) of one residents reviewed for loss of personal property. <BR/>Resident #1's admission paperwork included the facility assumed no liability for the security of personal items. Resident #1's necklace was lost, and Resident #1's family was informed by the Administrator that the facility assumed no liability. <BR/>This failure placed residents at risk of misappropriation of their personal property. <BR/>Findings included:<BR/>Review of Resident #1's admission paperwork, date 10/04/22, revealed under Personal Property: Resident/Resident Representative may complete and sign an inventory of personal belongings at or near the time of admission. An original inventory will be retained by the Resident/Resident Representative as a receipt and a copy will be kept with the Resident's records. Additions and deletions to the inventory shall be brought to the attention of Facility's administrator so that records are kept current. Facility assumes no liability for the security of personal items retained by the resident of kept in the resident's room. All articles retained by the resident (including dentures, hearing aids, eyeglasses, jewelry, and documents) shall be the responsibility of the Resident. <BR/>Interview on 01/04/22 at 9:10 AM, Resident #1's family member stated they had reported to the facility on [DATE] the resident had a missing necklace. The family member stated they met with the Administrator who informed them the facility was not responsible for lost or stolen property. The family member stated the Administrator informed them the family should not have brought something so valuable to the facility. The family member stated no inventory list of the resident's property had been completed at admission.<BR/>Observation and interview on 01/04/23 at 9:40 AM, Resident #1 was in his bed eating breakfast. Resident #1 was unable to comprehend questions, he answered all questions with Yes, yes or Sure. <BR/>Interview on 01/04/23 at 2:00 PM, LVN A she stated she had not seen Resident #1 with a necklace or any type of jewelry during his stay. <BR/>Interview on 01/04/23 at 2:10 PM, RA B stated she was in Resident #1's room quite often, and she did not recall seeing any type of jewelry on the resident. <BR/>Interview on 01/04/22 at 2:25 PM, the Activity Director stated she had not seen Resident #1 with a necklace during his stay. She stated she did bedside activities with the resident since he did not attend community activities, and she did not recall the necklace described. <BR/>Interview on 01/04/23 at 3:40 PM, the Administrator stated he had been notified of Resident #1's necklace reported as missing. He stated laundry staff had searched the linen for the necklace and did not find it. Interviews with staff had revealed none of them recalled seeing the necklace. He stated he was not sure the necklace was ever in the facility. The Administrator stated he had informed the family that the facility was not responsible for lost property. The Administrator was unable to provide an inventory list of Resident #1's personal property from his admission. He stated there was most likely not one completed by the family. The facility policy was for the family to complete an inventory, not the facility.<BR/>The facility had no policy on inventorying personal property, only what was in their admission packet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals had acceptable labeling for one (400 and 500 Hall Nurse Medication Cart) of three medication carts reviewed for labeling and storage.<BR/>The facility failed to ensure insulin vials were dated after they were opened. <BR/>The failure could place residents at risk of receiving medications that were ineffective due to not labeling with opening dates. <BR/>Findings included:<BR/>Observation on [DATE] at 1:56 PM of the 400 and 500 halls Medication Cart with LVN C revealed two insulin pens, Humalog insulin injection, and one Levemir insulin injections and 2 vials of Levemir and Lantus were opened, partially used, and not labeled with the open date.<BR/>Interviewed on [DATE] at 02:06 PM with LVN C, who was the 400 and 500 Hall Charge Nurse, revealed he knew insulin pens were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. He stated he knew he was supposed to check his cart to ensure insulins were labeled and dated, but he did not check that morning because he forgot. He stated the side effects of not putting the opening date was that a nurse would not know when the insulins expired, and the insulins might not be effective leading to residents having high blood sugar readings. He stated he was trained on labeling and dating medications but not in this facility, and it was all nurses' responsibility to check the carts to ensure medications and insulins were labeled and had an opening date before administering.<BR/>Interview with the DON on [DATE] at 3:59 PM revealed it was his expectation that staff date the insulin pens once they pulled them from the refrigerator. He stated it was also the responsibility of the staff to check daily on the expiration dates and labeling. He stated if the staff were not putting the opening dates on the insulin pens and vials that required an open date it placed residents at risk of receiving expired medication, having reactions, and the medication being ineffective leading to high blood sugar levels. He stated it was the responsibility of the ADON and him to monitor the carts but since the ADON resigned he has not been able to check the carts stating he has no excuse he failed to. He stated he has not trained the agency nurses because he expected them to have basic knowledge, he only oriented them on records and the facility.<BR/>Review of the facility's General dose Preparation and Medication Administration policy, dated [DATE], reflected: <BR/> .3.11.Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.).<BR/>3.11.1. Facility staff may record the expiration date based on the date opened on the label of medications with shortened expiration dates.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 meals (lunch) reviewed for food meeting residents' needs.<BR/>The facility failed to prepare and serve pureed turkey tetrazzini as a pudding consistency for residents who required pureed diets during the lunch meal on 04/09/25.<BR/>This deficient practice could place residents at risk of not receiving meals that meet their needs.<BR/>Findings included:<BR/>Record review of the lunch menu ticket for 04/09/2025 revealed the menu for the lunch service was Turkey Tetrazzini, Vegetable Medley, Breadstick, Fruit Cup.<BR/>Observation on 04/09/25 at 11:02 AM revealed the [NAME] prepared turkey tetrazzini with a food processor and then placed it on the steam table. The Dietary Manager did not check the consistency or ensure it was all blended to a pudding smooth consistency. <BR/>Observation and interview with the Dietary Manager on 04/09/25 beginning at 1:05 PM revealed the test tray included the regular textured menu items and the pureed menu items. The Dietary Manager stated the pureed turkey tetrazzini did not have a smooth, pudding consistency. He also said the turkey tetrazzini had chunks of turkey and noodles throughout the entree.<BR/>Interview on 04/09/25 at 1:07 PM with the Dietary Manager revealed his expectation was for pureed food to have a smooth, pudding consistency. The Dietary Manager stated the turkey tetrazzini was not the correct consistency. The Dietary Manager stated residents could choke if dietary items were not blended to a smooth pudding texture. <BR/>Interview on 04/10/25 at 1:44 PM with the Administrator revealed the facility did not have a policy for pureed foods. The Administrator stated the Dietary Manager had completed an in-service with the dietary staff on 04/09/25. The Administrator provided the in-service that included directions on preparing purees.<BR/>Record review of the Facility In-Service dated 04/09/25 reflected:<BR/>1. <BR/>The desired thickness should be smooth mashed potato or pudding. There should be no large lumps<BR/> or particles. <BR/>2. <BR/>Do not add water to pureed food.<BR/>3. <BR/>Add liquid, if needed (ex. reserved liquid, broth, sauces, gravy, milk or juice<BR/>4. <BR/>If needed, gradually add thickener. Ex mashed potato flakes, cream of rice, or commercial thickener)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident rooms were equipped with privacy curtains the assured full visual privacy for 11 of 53 rooms (Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409) reviewed for visual privacy.<BR/>1. LVN C and CNA D failed to ensure Resident #2 had full visual privacy while providing care.<BR/>2. The facility failed to ensure the residents in the A beds in Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409 had privacy curtains to assure full visual privacy. <BR/>This failure could place residents at risk of being exposed to the hallway during cares.<BR/>Findings included:<BR/>Review of Resident #2's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain chemical imbalance), muscle weakness, and reduced mobility. <BR/>Review of Resident #2's quarterly MDS, dated [DATE]. revealed a BIMS score of 3 indicating severe cognitive impairment. Her Functional Status indicated she required total assistance with all of her ADLs. <BR/>Review of Resident #2's care plan, dated 02/20/24, revealed she had a self-care deficit requiring assistance with her ADLs, impaired cognitive function and impaired thought processes, and was a high fall risk. <BR/>Observation on 06/06/24 at 1:40 PM revealed LVN C and CNA D were assisting Resident #2 back to bed from her wheelchair, using the lift device. LVN C closed the resident's door, blocking the view from the hallway. After the resident was in bed, during her skin assessment, the door to the hallway popped open slightly. There was not a privacy curtain around Resident #2's bed. <BR/>Interview on 06/06/24 at 1:50 PM LVN C stated privacy for residents in A bed was created by closing the door and pulling the curtain between the beds. LVN C agreed the door was not secured to prevent someone from walking in during care when the resident was exposed. LVN C stated they yelled Cares! when someone knocked on the door or walked in, but that would not stop another resident from coming in. LVN C stated being exposed during care could lead to decreased feelings of self-worth by the resident. <BR/>Observation on 06/06/24 from 1:55 PM-2:20 PM of Halls 100, 200, 300, and 400 revealed 11 (Rooms 201, 202, 205, 207, 211, 302, 305, 306, 307, 406, and 409) of 53 rooms had no privacy curtain for residents of the A bed. Residents of the B bed only had a curtain between the beds, no curtain across the end of the bed. <BR/>Interview on 06/06/24 at 3:15 PM with the DON revealed residents needed privacy when they were receiving care. She was not aware the rooms did not have the appropriate privacy curtains installed. She stated it was a dignity issue for the residents. <BR/>Interview on 06/06/24 at 3:30 PM with the Administrator revealed he was not aware there were not appropriate curtains for the resident's privacy. He stated it was a dignity issue of someone walked in on a resident receiving care. <BR/>Interview on 06/06/24 at 4:00 PM with the Administrator revealed the facility did not have a policy addressing privacy curtains specifically.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 meals (lunch) reviewed for food meeting residents' needs.<BR/>The facility failed to prepare and serve pureed turkey tetrazzini as a pudding consistency for residents who required pureed diets during the lunch meal on 04/09/25.<BR/>This deficient practice could place residents at risk of not receiving meals that meet their needs.<BR/>Findings included:<BR/>Record review of the lunch menu ticket for 04/09/2025 revealed the menu for the lunch service was Turkey Tetrazzini, Vegetable Medley, Breadstick, Fruit Cup.<BR/>Observation on 04/09/25 at 11:02 AM revealed the [NAME] prepared turkey tetrazzini with a food processor and then placed it on the steam table. The Dietary Manager did not check the consistency or ensure it was all blended to a pudding smooth consistency. <BR/>Observation and interview with the Dietary Manager on 04/09/25 beginning at 1:05 PM revealed the test tray included the regular textured menu items and the pureed menu items. The Dietary Manager stated the pureed turkey tetrazzini did not have a smooth, pudding consistency. He also said the turkey tetrazzini had chunks of turkey and noodles throughout the entree.<BR/>Interview on 04/09/25 at 1:07 PM with the Dietary Manager revealed his expectation was for pureed food to have a smooth, pudding consistency. The Dietary Manager stated the turkey tetrazzini was not the correct consistency. The Dietary Manager stated residents could choke if dietary items were not blended to a smooth pudding texture. <BR/>Interview on 04/10/25 at 1:44 PM with the Administrator revealed the facility did not have a policy for pureed foods. The Administrator stated the Dietary Manager had completed an in-service with the dietary staff on 04/09/25. The Administrator provided the in-service that included directions on preparing purees.<BR/>Record review of the Facility In-Service dated 04/09/25 reflected:<BR/>1. <BR/>The desired thickness should be smooth mashed potato or pudding. There should be no large lumps<BR/> or particles. <BR/>2. <BR/>Do not add water to pureed food.<BR/>3. <BR/>Add liquid, if needed (ex. reserved liquid, broth, sauces, gravy, milk or juice<BR/>4. <BR/>If needed, gradually add thickener. Ex mashed potato flakes, cream of rice, or commercial thickener)