South Dallas Nursing & Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for two of nine residents (Residents #1 and #2) reviewed for elopement.<BR/>1. The facility failed to ensure Resident #1 did not elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train.<BR/>2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized .<BR/>An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on 5/29/24 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>These failures resulted in one arrest due to obstructing traffic and one hospitalization due to being found lying on the ground and had suffered a stroke.<BR/>Findings included:<BR/>1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of 05/14/24.<BR/>Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care.<BR/>Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. <BR/>Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM, written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back.<BR/>Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM, written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him.<BR/>Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM, written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. <BR/>Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property.<BR/>Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker.<BR/>Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested/checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. <BR/>Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train.<BR/>Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM, she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they have not found Resident #1, and the SW stopped communicating with her. <BR/>Interview with the ADM on 05/23/24 at 10:30 AM, she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested.<BR/>Interview with the DON on 05/23/24 at 10:40 AM, she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him.<BR/>Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he woke up around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoke and visit other residents. Resident #3 stated Resident #1 never showed any signs that he was leaving or that he did not like it here.<BR/>Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 would follow him outside and he may have seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1.<BR/>Interview with DET A on 5/23/24 at 01:35 PM, he stated it was believed Resident #1 was arrested in [City] , but then it was determined he had been arrested by the DTP. DET A stated when he was assigned to locate Resident #1, he was not missing as he had already been arrested. DET A stated when he located Resident #1 in jail, his case was closed as Resident #1 was no longer considered a missing person.<BR/>Interview with the MD on 5/23/24 at 01:50 PM, he stated he was made aware that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated he had not been made aware that there were any concerns for Resident #1 smoking on his own. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently.<BR/>Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated they are not supposed to give the door code to any residents. LVN H stated the door codes are now changed once a month. LVN H stated you must make sure the door was fully closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you must notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, they would notify the police. LVN H stated if the resident was found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer.<BR/>Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he did not see Resident #1 up and walking around prior to taking his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room around 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 was probably outside smoking. CNA K stated he told LVN J that Resident #1 was not in his room, and LVN J said he may be smoking. CNA K stated around 9:00 AM, it was discovered Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours but now it was every 1 hour. CNA K stated when you complete the checks, you must chart in PCC any care provided. CNA K stated if you are just laying eyes on a Resident, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List only after physically laying eyes on them. CNA K stated he has never known for a resident to go missing. CNA K stated previously residents that were authorized to enter and exit with the door code, had the freedom to go as they please if they signed in and out. CNA K stated the door code was now changed once a month and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed and locked so no resident follows them out.<BR/>Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on Monday (5/13), Resident #1 tried to go out front to smoke by himself when the ADM was entering the building and she explained to Resident #1 that he must sign out first. The ADON stated Resident #1 complied and then went out and returned, and everything was fine. The ADON stated the next morning on 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the ADM had Management driving throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she does not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated they are making sure any resident that leaves the facility signs out and informs the nurse. The ADON stated the aides and nurses now completes rounds every hour. The ADON stated Resident #1 could have been hit by a vehicle, ended up in the hospital, or even killed. <BR/>Interview with the ADM on 05/23/24 at 03:25 PM, she stated they have completed re-assessments on all residents to make sure the assessments were accurate. The ADM stated all residents that were already exit-seeking had a doctor's order to wear a wander guard. The ADM stated the SW had recently reassessed the residents that are allowed to sign themselves out. The ADM stated they completed in-services on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses must print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all the residents that are allowed to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they are having another in-service tomorrow on 05/24/24 on the same items.<BR/>During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility.<BR/>Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she looked Resident #1 up on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #1's friend, Resident #4 most likely gave Resident #1 the door code. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. <BR/>Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 could not be found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process has changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would tell you if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if it was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. <BR/>Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, and CNA K took Resident #1 his breakfast tray, he was still not in his room. CNA L stated LVN J asked her if Resident #1 was in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and did not see Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must make sure the wander guard was working by observing the light taking the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must walk the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope.<BR/>Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM, Surveyor left a voicemail and sent a text requesting a callback.<BR/>Record review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked his halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During his last round at 4:00 AM, he assumed Resident #1 was asleep and did not disturb him nor his roommate.<BR/>Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback.<BR/>Record review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications.<BR/>2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. <BR/>Review of Resident #2's Order Summary Report for May 2024 reflected:<BR/>-04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. <BR/>-04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. <BR/>Review of Resident #2's Care Plans reflected: <BR/>-05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. <BR/>Facility interventions included: <BR/>Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. <BR/>Identify pattern of wandering.<BR/>Provide structured activities.<BR/>Wander alert on left ankle. Monitor function and skin integrity every shift.<BR/>Review of Resident #2's Progress Notes reflected:<BR/>-05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A<BR/>-05/22/24 2:30 PM Type: Behavior Note<BR/>Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON<BR/>-05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW<BR/>-05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A<BR/>-05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON<BR/>-05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON<BR/>-05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON <BR/>-05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A<BR/>-05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A<BR/>-05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B<BR/>-05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B<BR/>-05/26/24 5:20 PM, Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside in the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B<BR/>Review of Resident #2's Ambulance Record, dated 05/26/24, reflected:<BR/>Dispatch notified: 7:31 PM<BR/>On scene: 7:36 PM<BR/>Resident transferred: 8:10 PM<BR/>Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. <BR/>Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected:<BR/>Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. <BR/>Final Diagnosis: Stroke<BR/>Review of website: timeanddate.com on 05/29/24 reflected the following temperatures:<BR/>[NAME] TX temperature:<BR/>5/26/24 4:53 PM 97 degrees<BR/>5/26/24 6:53 PM 97 degrees<BR/>Dallas TX temperature:<BR/>5/26/24 4:53 PM 97 degrees<BR/>5/26/24 6:53 PM 98 degrees<BR/>Observation of Resident #2 on 05/25/25 at 1:20 PM, revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional.<BR/>Observation of Resident #2 on 05/25/24 at 03:15 PM, revealed the DM sitting one-on-one with Resident #2 in the facility's lobby with his wander-guard transmitter still visible on the left lower extremity and the presence of the LED light indicated it was functional.<BR/>An interview on 05/25/24 at 01:00 PM, with the MTD he stated he adjusted the front door to make the door close faster and changed the door code. The MTD stated the front door was monitored by the wander-guard system. The MTD stated normally, [Company] instructed him over the phone how to change the door code, but this time, he had [Company] come to the facility and [Company] installed a button under the receptionist's desk in order to open the door remotely and provided him a manual on how to change the door code himself. The MTD stated there had not been any concerns and everything was working properly. The MTD stated he monitored the doors as needed to ensure they are closing properly. The MTD stated he completed door checks three times a day and completed Tail Logs for documentation purposes. The MTD stated he had never been aware of any residents being in possession of the door code.<BR/>On 05/25/24 at 01:20 PM, Surveyor observed the five residents identified for placement of a Wander Guard. Surveyor observed the five residents in their rooms with their Wander Guard placed according to their individual Care Plans and Orders. Surveyor also conducted testing with the ADON at the front door to ensure the Wander Guards were functioning properly.<BR/>An interview on 05/25/24 at 02:15 PM, with the DM, he stated he drove around looking for Resident #1 when he was reported missing. The DM stated he was in-serviced on not giving the door code out or allowing residents to follow anyone outside. The DM stated the door codes were changed and a remote access button was installed under the receptionist's desk. <BR/>An interview on 05/25/24 at 02:30 PM, with HR, she stated she was in-serviced on making sure all residents know they must be buzzed in and out. HR stated no residents nor visitors should have access to the door code. HR stated the approved residents must sign in and out of the facility and let staff know they are leaving. HR stated the MTD changed the door codes last on Thursday, 05/23/24. HR stated when she ends her shift at 5:00 PM and over the weekend, various staff members would cover the front door.<BR/>An interview on 05/25/24 at 02:45 PM, HK O stated she was in-serviced on being more concerned when entering and exiting the front door. HK O stated she was informed the door code would be changed once a month. HK O stated she was informed to keep an eye on the residents that wear a Wander Guard.<BR/>Interviews were conducted with facility staff across multiple shifts on 05/23/24, 05/24/24, and 05/25/24. Staff interviewed were LVN H, LVN J, CNA L, CNA K, CNA F, CNA G, CNA C, HK O, LVN B, LVN J and MA A.<BR/>Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated into the TARS. They stated they had been in-serviced on checking to ensure the wander guard was functional every shift by observing that the light was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administrator of the facility and to other officials which included the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of neglect. <BR/>The facility failed to ensure a report for an allegation of neglect was submitted within 2 hours to the State Agency after Hospice RN D reported a fall with possible injury to LVN E. <BR/>This failure could place residents at risk of abuse, physical harm, mental anguish and emotional distress.<BR/>Findings include:<BR/>Record review of Resident#1's face sheet, dated 05/28/25, revealed a [AGE] year-old male with an initial admission date of 11/27/24. Resident #1 had diagnoses which included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes) and Aphasia (Language disorder caused by brain damage).<BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS of 12, which indicated mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required Substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. <BR/>Record review of Resident #1's Significant Change MDS, dated [DATE], reflected Resident #1 had a BIMS of 12, which indicated Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step.<BR/>Record review of Resident #1's Care Plan, dated 03/06/25, reflected Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy, dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are made to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery.<BR/>Record review of Resident #1's Active Orders as of 06/08/25 reflected Resident #1 had 2 active orders for pain medications prior to the left humerus comminuted fracture of 02/10/25 listed as the following:<BR/>1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite.<BR/>2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite.<BR/>Record review of Resident #1's Active orders as of 06/08/25 reflected Resident #1 had 4 active orders for pain after to the right humorous comminated fracture of 02/10/25 listed as the following:<BR/>1. Orders reflected Gabapentin 400 mg. Give 1 capsule by mouth three times per day for pain. Order start date 11/27/24, End Date: Indefinite.<BR/>2. Tylenol Oral tablet 325 mg. Give 1 tablet by moth every 4 hours as needed for Pain. Order start date 11/27/24, End Date: Indefinite.<BR/>3. Tramadol HCL Oral Tablet 50 mg, Give 50 mg by mouth three times a day for pain. Start Date: 02/10/25, Revision Date: 03/10/25, New orders, give 50 mg by mouth every 8 hours as needed for pain. End Date: Indefinite <BR/>4. Hydrocodone-Acetaminophen Oral tablet 5-325 mg, Give 1 tablet by mouth three times a day for pain. Start Date: 03/06/2025. End Date: Indefinite.<BR/>Record review of the Facility, PIR dated 02/25/25, reflected on 02/10/25, CNA A and CNA B stated Resident #1 had a slip in the shower chair while transferring from a shower chair to a wheelchair. Resident #1 stated to the facility that Resident #1 had slipped and hit his shoulder while he was in the shower. Resident #1 did not report the incident to the facility until 02/21/25. The PIR Investigation Summary reflected on 02/10/25 CNA A had taken Resident #1 to the shower room and Resident #1 started to slip out of the shower chair. CNA A then called for LVN B who helped to assist the resident immediately by placing their arms (CNA A and LVN B) under Resident #1's arms and pulled Resident #1 back up into the shower chair. LVN B reported Resident #1 did not report any injuries and subsequent skin assessments found no injuries, bruises, or skin integrity issues. Both CNA A and LVN B stated here was no fall or change of plan as they prevented Resident #1 from having a fall.<BR/>Record review of CNA A's witness statement included in the PIR, dated 02/24/25, and signed by CNA A, reflected CNA A assisted the nurse with a transfer in the shower room, shower was given to Resident #1, nurse assisted with transferring Resident #1 back to the wheelchair from the shower chair. <BR/>Record review of LVN B's witness statement included in the PIR, dated 02/24/25, and signed by LVN B, reflected LVN B assisted CNA A with a transfer of Resident #1 from a wheelchair to a shower chair and then from a shower chair to wheelchair on 02/10/25. She stated Resident #1 had no complaint of pain upon transferring of Resident #1 to a wheelchair.<BR/>Record review of a document entitled Radiology Report for Resident #1, dated 02/21/25, reflected Left Shoulder X-ray Complete 2 or more views .Significant Findings .Multiple views of the left shoulder show a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral head/neck (top part of the arm bone). Fracture of the glenoid (where the head of the arm bone connects to the shoulder) is also noted .No soft tissue swelling is seen. <BR/>Record review of Resident #1's EHR from 02/04/25 to 2/11/25 found no evidence of a fall being reported, no documentation of skin or pain assessments. No documentation of Resident #1 slipping from a shower chair. Two progress notes related to the incident of 02/10/25 were found (1) denoting a pain medication ordered and (2) When the facility first found out about the incident: <BR/>1. A Progress Note was found, dated 02/10/25 at 9:17 PM, written by LVN E, ordering tramadol HCL Oral tablet 50 mg, give 50 mg by mouth three times a day for pain. <BR/>2. A Progress Note, dated 02/21/25 at 9:36 AM, by the DON, reflected Resident (#1's) family reported to this nurse, he (Resident #1) still had pain from the fall that happened Monday before last. Skin assessment pain assessment and stat left shoulder x-ray. Notified hospice, family present, notified MD and administrator.<BR/>Record review of the facility Incident Accident Log reflected no evidence of Resident #1 having a fall, near fall or injury for the dates of 02/04/25 to 02/21/25.<BR/>Interview on 05/28/25 at 9:45 AM with Resident #1 revealed Resident #1 was able to speak with some difficulty but was able to make his needs known. Resident #1 stated he had his arm broken several months ago. He identified the CNA as the facility CNA not his hospice CNA, and he stated it was just CNA A in the shower room with him when the fall occurred. He stated he hit his shoulder when the fall happened and he had less movement in his left arm and hand than he did before. He indicated with his right arm and hand to his left shoulder and indicated his left hand where it was observed he could still move his pinky and ring finger.<BR/>Interview on 05/28/25 at 9:58 AM with the Hospice SW C revealed she was in the building that morning to visit with Resident #1 to discuss care plan options with Resident #1 since the resident had come under her hospice agency care on 02/04/25. She stated Resident #1 told her he was in pain and he had a fall in the shower room earlier that morning and he indicated his left shoulder was where the pain was the worst. Hospice SW C stated she contacted Hospice RN D and reported to her Resident #1 was complaining of 5/10 pain in his left shoulder and Resident #1 had told her he had a fall earlier that morning in the shower. <BR/>Interview on 05/28/25 at 9:58 AM with Hospice RN D revealed Resident #1 reported to her he had a fall in the shower room earlier that day (02/10/25). Hospice RN D stated she did an assessment on Resident #1, she stated Resident #1 complained of pain in his left shoulder at 5/10 on a pain scale and Resident #1 had no swelling, no redness no bruising. Hospice RN D stated she notified the hospice physician and ordered 50 mg Tramadol three times a day. Hospice RN D stated she informed facility nurse, LVN E, about the new order, fall and pain and that another Hospice RN had assessed Resident #1 on 02/13/25 and Resident #1 did not complain of pain that day.<BR/>Interview on 05/29/25 at 10:58 AM with LVN E revealed she had been working on Resident #1's hall on 02/10/25. She stated she remembered speaking with Hospice RN D that day and Hospice RN D told her Resident #1 had complained of 5/10 pain in his left shoulder, that he reported to her that he had a fall earlier that day in the shower and she ordered Tramadol 50 mg three times a day for Resident #1. LVN E stated she was a brand-new nurse at the time and assumed LVN B, who was at the facility much longer, told the DON about the fall in the shower room, and assessed Resident #1. LVN E stated she first learned of Resident #1's fracture on 02/23/25 when the DON asked if she knew anything about Resident #1's fracture.<BR/>Interview on 6/2/25 at 5:59 PM with the DON revealed she defined a fall as anytime a resident stumbled, loses balance or their knees touch the floor. She stated staff were always expected to report any accidents incidents to the DON or the ADM as soon as possible so residents could receive the services they required.<BR/>Interview on 6/2/25 at 6:08 PM, the ADM stated a fall was defined as anyone who lost balance or for example knees gave out and had to be lowered to the floor would be a fall. Also, even if they lost balance of gave out and caught themselves and the staff had to assist them in any manner was considered a fall according to the policy/procedure. He stated staff were always expected to report any accidents incidents to the DON or the ADM as soon as possible so residents could receive the services they required. He stated that a former ADM had been notified of he incident on 02/21/25, and he was unsure why the original incident of 02/10/25 had not been reported properly.<BR/>Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting, dated 2001 and revised July 2017, reflected:<BR/>Policy Statement. All accidents or incidents involving residents, employees, visitors, etc., occurring on our premises shall be investigated and reported to the Administrator.<BR/>Policy Interpretation and Guidelines. <BR/>1. The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .<BR/>5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident.<BR/>6. The Director of nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #3) of 66 residents reviewed for assistive devices.<BR/>A portable heater was found in use in Resident #3's room without direct supervision.<BR/>This failure could place residents at risk for accidents or injuries.<BR/>Findings include:<BR/>Record review of Resident #3's Face sheet dated 01/28/2025 revealed that Resident #3 was a [AGE] year-old male that was initially admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, Age-Related Cognitive Decline and Partial traumatic Amputation of left foot at Ankle Level.<BR/>Record Review of Resident #3's Quarterly MDS Assessment and Care Screening dated 11/07/2024 revealed that Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. The resident required the use of a wheelchair and required supervision or touching assistance for all transfers and personal hygiene. <BR/>Record review of Resident #'3 Care Plan, dated 11/13/2024 revealed that Resident #3 has an Activity of Daily Living self-care deficit related to osteomyelitis [infection of the bone] of left foot post-surgical intervention, impaired cognition and makes poor decisions.<BR/>In an observation and interview on 01/28/2025 at 11:24 AM revealed Resident #3 was observed in his room, seated comfortably in a wheelchair. A portable heater was noted to be operating behind the resident within 2 feet of the resident's bed and privacy curtain. The resident stated that the facility had given him the portable heater to use because his in-wall unit was not working for the last two days. He stated that the air conditioning part of the in-wall unit worked fine but that the heat was not working. He stated that he liked it warm in his room.<BR/>In a set of observations from 01/28/2025 at 11:42 AM to 01/28/2025 to 11:42 AM revealed all other resident rooms were checked for portable heaters. No other portable heaters were found. <BR/>In an observation and interview on 01/28/2025 at 1:45 PM revealed the Maintenance Supervisor was observed removing the wall air conditioning/heater unit from Resident #3's room. The portable heater was no longer present in Resident #3's room. The Maintenance Supervisor stated that he had taken the portable heater out of Resident #3's room and he was in the process of replacing Resident #3's in-wall air conditioner/heater unit. He stated that Resident # 3 had been using the portable heater for the last 2 days and that the heater had an automatic turn-off switch if the portable heater fell over or was tipped. <BR/>In an interview on 01/28/2025 at 2:09 PM LVN A stated that she was not aware of anyone doing fire watches in the facility. She stated that fire watches meant that the staff had to check the entire facility every 15 minutes to make sure there were no fires in case the fire alarm system stopped or a power outage.<BR/>In an interview on 01/28/2025 at 2:29 PM LVN B stated that she had not heard anything about the facility having to do any fire watches or that Resident #3 had a portable heater in his room. She stated that she had been working for the last three days and that she had been unaware of any portable heaters in the building. She stated that she had thought portable heaters were not allowed in nursing facilities. <BR/>In an interview on 01/28/2025 at 3:30 PM the ADM stated that a portable heater could pose a fire risk to residents if a blanket, curtain or pillow got too close to it for a period of time. He stated that he had not done any fire watches while the portable heater was in use in Resident #3's room, and that the portable heater had been in use for the last two days.<BR/>In an interview on 01/28/2025 at 3:34 PM Maintenance Supervisor stated that portable heaters could cause fires if left unmonitored because something flammable could get next to a heater and possibly start a fire. He stated that he had replaced the in-wall unit in Resident #3's room and had meant too the day before but had not been able to get to it. He stated that he had replaced it a few hours ago and that there were no other portable heaters in use in the facility.<BR/>A policy for Portable Heaters in Nursing facilities was requested on 01/28/2025 at 3:17 PM but was not presented before the conclusion of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the designated interdisciplinary team member was responsible for collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services and communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family for 1 (Resident #1) of 8 residents reviewed for hospice services. <BR/>The facility failed to ensure a staff member was designated to communicate with a hospice agency.<BR/>This deficient practice could place residents at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers. <BR/>The findings were: <BR/>Record review of Resident#1's face sheet dated 05/28/25 revealed he was a [AGE] year-old male resident with an initial admission date of 11/27/24 with diagnosis that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Non-Dominant side (paralysis of the left side of the residents body due to a stroke), Vascular Dementia (Brain damage caused by multiple strokes), and Aphasia (Language disorder caused by brain damage).<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12, meaning mildly impaired or moderate cognitive impairment. Resident #1 had impairment to one side. Resident #1 required Substantial/maximal assistance (help of 1-2 staff members) with showers and sitting to standing and was totally dependent (help of 2 or more staff members) for toileting. <BR/>Record review of Resident #1's Significant Change MDS dated [DATE] reflected that Resident #1 had a BIMS (Brief Interview for Mental Status) of 12 meaning Resident #1 was mildly impaired or had moderate cognitive impairment. Resident #1 was dependent and required the assistance of 2 or more or more helpers for tub/shower transfer, toilet transfer and chair to bed transfer. Resident #1 was listed as Not applicable (due to current injury/illness) for the ability to go up and down a curb and/or up and down one step.<BR/>Record Review of Resident #1's Care Plan dated 03/06/25 reflected that Focus: The resident has an ADL self-care Performance deficit CVA with left hemiplegia, diabetes with neuropathy, dementia and muscle weakness. Bed mobility: partial assist of 1-2, Transfers: partial to substantial assist 1-2, Eating: set-up to supervision of 1, Toileting: partial assist of 1-2. Provisions are mad to care as needed. Level of assistance may vary depending on my condition. Goal: The resident will maintain or improve current level of function in bed partial to substantial assist of 1-2 by the next review date. Interventions/Tasks: Provide sponge bath when a full bath or shower cannot be tolerated .Allow sufficient time for ADL tasks .Make sure are comfortable and not slippery.<BR/>Record review of Resident #1's orders as of 06/02/25 revealed that Resident #1 had orders that stated Admit to Hospice, call for any change of condition .Admit to Facility under hospice custodial services. admission orders have been reviewed, verified and changes have been made. Physical Therapy/Occupational Therapy/Speech Therapy to screen and treat as indicated.<BR/>During an interview with the Administrator on 06/02/2025 at 5:50 p.m., the Administrator stated there was no specific person designated to communicate with hospice, but the nurse who received the resident would communicate with hospice. When a resident was received to the facility with orders, the nurse who received the resident was their responsibility to ensure the orders were carried out. The Administrator stated his expectation was if a resident came in on weekend it was the responsibility of the nurse who accepted the resident to ensure their orders were carried out and communicated with any third-party agency. <BR/>During an interview with the DON on 06/02/2025 at 6:18 p.m., the DON stated the facility did not have one person who was designated to speak with hospice, but the Social Worker, Nursing Staff to include ,the DON and the Administrator, were able to speak to hospice on behalf of the residents. <BR/>During an interview with the Hospice SW on 06/4/25 at 3:23 PM, the Hospice SW stated that she had never been notified by the facility that Resident #1 had any follow up appointments. She stated that her hospice agency had never received any discharge paperwork from the facility for Resident #1's hospital visit on 02/21/25. She stated that she would have been the person that would have coordinated follow up appointment, and that she was unsure which facility staff should have contacted her but it usually the facility Social Worker that was generally responsible for communicating with the hospice agency.<BR/>Record review of the facility's policy titled, Residents with Hospice Services, revised 7/2018, revealed 12. Our facility has designated Name (left blank), Title (left blank) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the State scope of practice act). He or she is responsible for the following: 12Aa. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for resident receiving services; 12b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, relation conditions, and other conditions, to ensure quality of care for the residents and family; 12c. Ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. <BR/>The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings Include:<BR/>Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room.<BR/>Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room .<BR/>An interview on 03/07/24 at 9:20 a.m., Resident #6 revealed that he had seen many black small flies and roaches all over the facility.<BR/>An interview on 03/07/24 at 9:24 a.m., Resident # 6 stated that he had seen flying black gnats and roaches in many areas of the facility. He did not state how long he had been seeing the insects/pest or if he had seen pest control at the facility. <BR/>Observation on 03/07/24 at 9:37 a.m. in the 300-hall shower room revealed 15-20 small black flies or gnats either alighted on the shower curtain to shower stall #1 or flying near a large plastic bag filled with wet towels near shower stall #1. Four dead roaches were observed on the floor underneath the shower curtain for shower stall #1.<BR/>An interview on 03/07/24 at 2:57 p.m., MA A stated that she had seen gnats and roaches all over the facility and in resident rooms. She stated that the staff were supposed to write down bug sightings in some book, but she did not know where the book was, and she denied knowing what a pest sighting log was. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:33 p.m., CNA B revealed she had seen many roaches and gnats in room [ROOM NUMBER] and she had seen gnats and roaches in room [ROOM NUMBER] room that day (03/07/24). She stated hat she had never seen a pest sighting log, and she was not sure where the staff were supposed to write those things down. She stated that the staff just reports bugs to the maintenance manager. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:40 p.m., Housekeeper C stated that he did sometimes see gnats and that he was not sure how to report insects at the facility. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:50 p.m., CNA D revealed that she had seen gnats and roaches at the facility and denied knowing that she had to log them in the pest sighting log.<BR/>An interview on 03/07/24 at 4:00 p.m., RN E revealed that he had seen gnats and roaches in the facility and that he thought there was a book somewhere to write them down (insect sightings) but he did not know where the book was. <BR/>An interview on 03/07/24 at 4:06 p.m. CNA F stated that she had seen many gnats and roaches at the facility. She stated that she tells the maintenance manager about insects when she sees him. She stated that she had never heard of a pest sighting log.<BR/>An interview on 03/07/24 at 4:14 p.m., the Administrator stated that the staff were supposed to use the pest sighting log and that the staff had been trained on using the pest sighting log but that they just tell the maintenance manager instead. She stated that having gnats in the facility could affect residents negatively and mentally and could pose a risk of cross contamination.<BR/>An interview on 03/07/24 at 6:17 p.m., the DON revealed she had seen some gnats around the facility and that she thought staff were supposed to log insects in the pest sighting log. She stated that it could be very annoying for residents to have to deal with gnats and that it could affect their mental health and could possibly cause cross contamination. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the Facility's Pest Sighting Log/Pest Control Binder revealed: that the last pest sighting logged in the pest sighting log was 08/09/23 for flies, no other more recent entries could be found.<BR/>Review of Pest Control Service Inspection Report dated 02/15/24 revealed taget pest treated were rodents (rodent bait stations), german cockroaches in the kitchen and laundry area. This was the last inspection/service report in the binder. <BR/>Record review of the facility's policy dated May 2008, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for one (Resident #1) of seven residents reviewed for self-determination.<BR/>The facility failed to promote Resident #1's self-determination by not honoring his choice to receive medications at a later time on 1/24/2025.<BR/>This failure could place residents at risk for poor self-esteem and decreased self-worth due to their needs and preferences not being met.<BR/>Findings included:<BR/>Record review of Resident #1's MDS (type indicated option selected was none of the above) dated 1/23/2025 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. No BIMS score was listed on the assessment to indicate if the resident had any cognitive impairment.<BR/>Record review of Resident #1's face sheet dated 1/28/2025 revealed Resident #1 had diagnoses of sepsis (infection that has spread to multiple organs), polyneuropathy (multiple nerves are damaged), muscle spasm, and paraplegia (weakness of both legs or arms).<BR/>Record review of Resident #1's care plan with a revision date of 1/24/2025 revealed Resident #1 was resistive to care, and interventions included allowing the resident to make decisions about treatment regime. <BR/>Record review of Resident #1's physician order with a revision date of 1/27/2025 for trazodone 25 mg revealed the physician ordered trazodone 25mg one tablet by mouth at bedtime for insomnia (difficulty sleeping).<BR/>Record review of Resident #1's January 2025 MAR revealed trazodone was scheduled for 9:00 p.m.<BR/>In an interview on 1/28/2025 at 3:11 p.m., Resident #1 stated that a nurse tried to give him his other medications (not pain medications) on 1/24/2025 around 8:00 p.m., and he refused because he did not want them that early. Resident #1 stated he told them to bring his medications later, and they did not. Resident #1 stated it made him upset, and he cursed at the staff. Resident #1 stated the staff did not need to bring his medications that early because he was not ready to go to bed.<BR/>Record review of Resident #1's progress note dated 1/24/2025 at 9:41 p.m., LVN A documented Resident #1 refused to take his medication because the hospital always brought them at 10:00 p.m. LVN A documented that the MA would not be there at 10:00 p.m., and she told Resident #1 that she would bring the medications at 9:00 p.m. <BR/>In an interview on 1/28/2025 at 5:00 p.m., LVN A stated a MA attempted to give Resident #1 his medications on 1/24/2025, but Resident #1 refused. LVN A reported she then spoke with Resident #1, and he told her to bring his medications later. LVN A stated she did not go back to Resident #1's room to give his medications because he was angry. LVN A stated the medication was trazodone, and there was no risk to the resident for missing one dose. <BR/>In an interview on 1/28/2025 at 3:28 p.m., the DON reported she was responsible for monitoring and ensuring medications were administered as ordered. The DON stated she checked the MARs once a week to ensure they were completed, and medications were administered. The DON stated the risks to the residents if medications were not received timely could be uncontrolled blood pressure or behaviors. The DON did not state the risk to the residents if they were unable to use their own self-determination in their care.<BR/>Review of facility policy titled Resident Rights, with a revision date of December 2016, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . e. self-determination.

**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 acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two residents (Resident #1 and Resident #2) of four residents reviewed for pharmaceutical services in that:<BR/>1. <BR/>The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident requested pain medication on 1/23/2025. The facility also failed to return and administer Trazodone to Resident #1 as ordered on 1/24/2025. <BR/>2. <BR/>The facility failed to acquire, administer, and accurately document two scheduled doses of gabapentin on 1/24/25 to Resident #1 as ordered. <BR/>3. <BR/>The facility failed to acquire and administer intravenous antibiotic medications to Resident #2 as ordered upon admission for the dose scheduled on 1/9/25. <BR/>4. <BR/>The facility failed to obtain a pharmacy delivery receipt for Resident #2's medications per facility policy. <BR/>5. <BR/>The facility failed to administer and accurately document medications for Resident #2 on the facility MAR for January 2025.<BR/>These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, and uncontrolled pain.<BR/>Findings included:<BR/>1. Record review of Resident #1's MDS (type indicated option selected was none of the above) dated 1/23/2025 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. No BIMS score was listed on the assessment to indicate if the resident had any cognitive impairment.<BR/>Record review of Resident #1's face sheet dated 1/28/2025 revealed Resident #1 had diagnoses of sepsis (infection that has spread to multiple organs), polyneuropathy (multiple nerves are damaged), muscle spasm, and paraplegia (weakness of both legs or arms).<BR/>Record review of Resident #1's care plan with a revision date of 1/24/2025 revealed Resident #1 was resistive to care, and interventions included allowing the resident to make decisions about treatment regime. <BR/>Record review of Resident #1's physician order with a revision date of 1/23/2025 for oxycodone 10mg revealed the physician ordered oxycodone 10mg one tablet by mouth every four hours as needed for pain.<BR/>Record review of Resident #1's physician order with a revision date of 1/27/2025 for trazodone 25 mg revealed the physician ordered trazodone 25mg one tablet by mouth at bedtime for insomnia (difficulty sleeping).<BR/>In an interview on 1/28/2025 at 10:18 a.m., Resident #1 reported he did not receive any medications until 24 hours after he had arrived at the facility. Resident #1 stated he requested pain medication from the nurse around 9:30 p.m. on 1/23/2025, and the nurse told him they did not have any narcotics available. Resident #1 stated he needed his pain medication because he had pressure sores and was unable to sleep without them. Resident #1 stated the facility had obtained all of his medications and currently were giving them to him like they were supposed to.<BR/>Record review of Resident #1's progress note dated 1/23/2025 at 11:30 p.m., revealed LVN A documented Resident #1 arrived at the facility at 9:00 p.m., and stated he needed a pain pill before he could be assessed.<BR/>Record review of the pharmacy manifest dated 1/24/2025 revealed gabapentin, methocarbamol, trazodone, and oxycodone for Resident #1 was not delivered until 1/24/2025 at 10:37 p.m.<BR/>In an interview on 1/28/2025 at 2:01 p.m., the DON reported medications were automatically ordered from the pharmacy when the medication orders were entered into their electronic medical records system. The DON reported that orders were entered as soon as a resident was admitted and was physically in the building. The DON reported the pharmacy delivered medications twice a day at 10:00 a.m. and 10:00 p.m.<BR/>In an interview on 1/28/2025 at 3:06 p.m., LVN A stated Resident #1 was admitted to the facility late on 1/23/2025 and requested specifically oxycodone. LVN A reported the medication was not available in the emergency medication kit, so she asked Resident #1 if he would take a different pain medication. LVN A reported Resident #1 declined the other pain medications and refused to allow her to assess him. LVN A stated Resident #1 did not state a pain level and cursed at her when she told him she did not have his specific pain medication available. LVN A stated she contacted the pharmacy but did not contact the DON or doctor, and the pharmacy told her they would send the medication that night. LVN A stated she documented the incident in the progress notes. LVN A reported when medications were needed prior to being delivered by the pharmacy then some medications could be found in the emergency medication kit but not oxycodone. LVN A also stated if the facility was unable to obtain scheduled medications, then the doctor should be notified, and it should be documented on the MAR. LVN A stated the risks to the residents if they did not receive their medications as ordered varied depending on the medication. LVN A did not state any further risks.<BR/>In an interview on 1/28/2025 at 2:01 p.m., the DON stated they did not have oxycodone in the emergency medication kit, but there was Tylenol #3 or tramadol in the emergency medication kit that could be offered. The DON stated if a new admission required a narcotic then the hospital would have to send a prescription or the resident would have to wait until the medication was delivered by their pharmacy. The DON stated she had requested stronger pain medications from the pharmacy and their nurse consultant for the emergency medication kit but was told the facility would need a hardwired internet connection which they did not have at this time. The DON stated a hardwired internet connection was needed for narcotics to be stored in the emergency medication kit but did not explain why. The DON stated the resident could be at risk for pain if pain medications were not available, but that they had other pain medicine that could be used until the resident's medications were delivered.<BR/>In an interview on 1/28/2025 at 3:11 p.m., Resident #1 stated the nurse offered him tramadol but that was pointless because it did not work. Resident #1 stated he went out on pass the next day (1/24/2025) and did not discuss his pain medication with anyone else until that night. Resident #1 stated they brought his pain medication just after midnight on 1/25/2025. Resident #1 stated that a nurse tried to give him his other medications (not pain medications) on 1/24/2025 around 8:00 p.m., and he refused because he did not want them that early. Resident #1 stated he told them to bring his medications later, and they did not.<BR/>Record review of Resident #1's January 2025 MAR revealed trazodone was scheduled for 9:00 p.m.<BR/>Record review of Resident #1's progress note dated 1/24/2025 at 9:41 p.m., LVN A documented Resident #1 refused to take his medication because the hospital always brought them at 10:00 p.m. LVN A documented that the MA would not be there at 10:00 p.m., and she told Resident #1 that she would bring the medications at 9:00 p.m. <BR/>In an interview on 1/28/2025 at 5:00 p.m., LVN A stated a MA attempted to give Resident #1 his medications on 1/24/2025, but Resident #1 refused. LVN A reported she spoke with Resident #1, and he told her to bring his medications later. LVN A stated she did not go back to Resident #1's room because he was angry, and she did not administer his medications. LVN A did not state if she reported the incident to anyone. LVN A stated the medication was trazodone, and there was no risk to the resident for missing a dose. <BR/>Record review of Resident #1's MAR dated 1/28/2025 revealed gabapentin (medication to treat nerve pain) was marked as refused on 1/24/2025 at 8:00 a.m. and 2:00 p.m.<BR/>Record review of the undated inventory list for the emergency medication kit revealed gabapentin was not a medication provided in the emergency medication kit.<BR/>2. Record review of Resident #2's admission MDS dated [DATE] revealed Resident #2 was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses of multidrug-resistant organism (bacteria resistant to several antibiotics), septicemia (infection in blood), and diabetes. Section O revealed Resident #2 was receiving intravenous antibiotics, and the BIMS assessment revealed a score of 15 (indicating no cognitive impairment).<BR/>Record review of Resident #2's baseline care plan with a signed date of 1/09/2025 revealed Resident #2 was receiving intravenous medications and antibiotics.<BR/>Record review of Resident #2's orders on 1/28/2025 revealed orders for the following medications:<BR/>Daptomycin (intravenous antibiotic) use 800mg intravenously one time a day <BR/>ferrous sulfate (iron) give one 325mg tablet by mouth in the morning<BR/>fluconazole (antifungal) give four 200mg tablets by mouth one time a day<BR/>furosemide (treats heart failure) 20mg give 0.5 tablet by mouth in the morning<BR/>Jardiance (treats diabetes) give one 10mg tablet by mouth in the morning<BR/>carvedilol (treats blood pressure) give one 6.25 mg tablet by mouth two times a day<BR/>gabapentin (treats nerve pain) give one 300mg capsule by mouth two times a day<BR/>llacosamide (anticonvulsant) give one 150 mg tablet by mouth two times a day<BR/>pantoprazole (treats indigestion) give one 40mg DR tablet by mouth two times a day<BR/>miralax (treats constipation) give one scoop by mouth in the morning for constipation<BR/>sennosides (treats constipation) give two 8.6mg tablets by mouth two times a day for constipation<BR/>methocarbamol (treats muscle spasms) give one 500mg tablet by mouth three times a day<BR/>atorvastatin (treats high cholesterol) give one 40mg tablet by mouth at bedtime.<BR/>Record review of Resident #2's progress note dated 1/06/2025 at 10:41 p.m., LVN A documented Resident #2 was admitted to the facility with a left foot wound infection and had an order to continue daptomycin (intravenous antibiotic).<BR/>Record review of Resident #2's progress note dated 1/07/2025 at 12:36 p.m., LVN B documented Resident #2 was on daptomycin (intravenous antibiotic).<BR/>Record review of Resident #2's progress note dated 1/08/2025 at 2:22 p.m., LVN B documented Resident #2 continued to take intravenous antibiotics.<BR/>Record review of Resident #2's MAR dated 1/28/2025 revealed blanks on the MAR for the following medications on 1/07/2025:<BR/>Daptomycin (intravenous antibiotic), ferrous sulfate (iron), fluconazole (antifungal), furosemide (treats heart failure), Jardiance (treats diabetes), carvedilol (treats blood pressure), gabapentin (treats nerve pain), lacosamide (anticonvulsant), pantoprazole (treats indigestion), miralax (treats constipation), sennosides (treats constipation), methocarbamol (treats muscle spasms). <BR/>The MAR also revealed blanks on the MAR for the following medications on 1/08/2025: Atorvastatin (treats high cholesterol), pantoprazole, miralax (treats constipation), sennosides (treats constipation), methocarbamol (treats muscle spasms), and lacosamide (anticonvulsant). The MAR also revealed daptomycin was scheduled every day at 12:00 p.m. from 1/07/2025 until 1/10/2025, but only one dose of the daptomycin (intravenous antibiotic) was documented as administered and that was on 1/08/2025. <BR/>In an interview on 1/28/2025 at 9:31 a.m., a family member for Resident #2 reported the facility did not give Resident #2 any medications for a day and a half after he was admitted on [DATE] and did not provide his intravenous antibiotics as ordered. The family member reported it took two days to get the antibiotics, and the facility ran out before they were completed. The family member reported the facility told her the antibiotic was too expensive, so they could not order the required amount. The family member stated Resident #2 chose to go to the hospital in order to get his intravenous antibiotics.<BR/>In an interview on 1/28/2025 at 1:24 p.m., LVN B stated she administered Resident #2's daptomycin (intravenous antibiotics) every day as ordered except on 1/09/2025. LVN B stated she documented administering the medication on the MAR. LVN B stated the pharmacy was unable to deliver the medication due to the weather, so she notified the doctor. LVN B stated the doctor told her to extend the number of days the medication was supposed to be given. LVN B stated she documented in the progress notes that the physician was notified. LVN B stated there was no harm in missing one dose of intravenous antibiotics.<BR/>Record review of Resident #2's progress note dated 1/09/2025 at 11:33 a.m., LVN B documented daptomycin had not been delivered, and the pharmacy stated the medication was delayed due to the weather. LVN B documented the pharmacy reported the medication would be delivered the next business day. LVN B documented that she contacted the doctor and received orders to administer the dose as soon as it was delivered and to extend the stop date by one day.<BR/>In an interview on 1/28/2025 at 2:01 p.m., the DON stated if there was a blank on the MAR then the medication must have been missed. The DON reported the pharmacy delivered medications twice a day, and it could take up to 12 hours to get medications after a resident was admitted because they did not order medications until after the resident was admitted to the facility. The DON stated medications were automatically ordered from the pharmacy when the orders were entered into their electronic monitoring system which would be done when the resident admitted to the facility.<BR/>In an interview and observation on 1/28/2025 at 3:28 p.m., the DON reviewed the pharmacy receipt binder but was unable to find any records for Resident #2's daptomycin being delivered. The DON stated there was a record because it reflected there were five more doses delivered, but they were not received by the facility. The DON stated Resident #2 received two doses of daptomycin, but the pharmacy was unable to deliver the additional five doses because of the weather. The DON stated they initially only ordered two doses because the medication was very expensive and required authorization from their corporate team. The DON stated Resident #2 chose to discharge to a hospital instead of waiting for the antibiotics to be delivered later that day. The DON reported she was responsible for monitoring and ensuring medications were administered as ordered. The DON stated she checked the MARs once a week to ensure they were completed, and medications were administered. The DON stated her expectation was for the MARs to be accurate and for medications to be delivered within 24 hours for a new admission. The DON stated the risks to the residents if medications were not received timely could be uncontrolled blood pressure or behaviors. The DON reported the risks to the residents if their MARs were not completed was that medications could appear to not be given and another nurse could administer the medication again causing the resident to be overmedicated. The DON stated there was no risk to the residents if pharmacy receipts were not kept because the records could be obtained from the pharmacy. The DON stated she would request the pharmacy's delivery manifest and provide it.<BR/>Record review of the pharmacy manifest dated 1/07/2025 revealed two doses of daptomycin were delivered at 11:29 a.m. on 1/07/2025.<BR/>Record review of the pharmacy manifest dated 1/9/2025 revealed five doses of daptomycin were delivered at 1:39 a.m. on 1/9/2025.<BR/>In an interview on 1/28/2025 at 5:12 p.m., NP C reported if oxycodone was unavailable then tramadol could be given to assist with pain control until oxycodone was received. NP C stated it was not ideal for oxycodone to be missed for more than 24 hours, but it depended on the pharmacy. NP C stated she expected the facility to get the medicine as soon as possible and notify the doctor or NP if they were unable to obtain the medications. NP C stated the facility was at the mercy of the pharmacy to deliver the medications and did not give a time frame that she expected new admissions to have medications within. NP C stated the nurses could call and obtain an order to hold a medication until it came in. NP C stated there was not usually any harm to a resident if they missed medications for one day or missed one dose of intravenous antibiotics. NP C did not state if she was notified that anyone had missed any medications.<BR/>Review of facility policy titled Administering Medications, with a revision date of December 2012, revealed Medications shall be administered in a safe and timely manner, and as prescribed. The policy also revealed Medications must be administered in accordance with the orders, including any required time frame, and medications must be administered within one (1) hour of their prescribed time.<BR/>Review of facility policy titled Pharmacy Services Overview, with a revision date of April 2007, revealed The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals. The policy also revealed The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs . help the facility to assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers.<BR/>Review of facility policy titled Charting Errors and/or Omissions, with a revision date of December 2006, revealed Accurate medical records shall be maintained by this facility.<BR/>Review of facility policy titled Charting and Documentation, with a revision date of July 2017, revealed The following information is to be documented in the resident medical record: . b. Medications administered, and documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.<BR/>Review of facility policy titled Accepting Delivery of Medications, with a revision date of April 2007, revealed A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket, and the delivery ticket shall be archived in a designated location.<BR/>Review of facility policy titled Medication Orders and Receipt Record, with a revision date of April 2007, revealed The facility shall document all medications that it orders and receives, and the facility shall retain medication order/receipt records for at least one year or as otherwise required.<BR/>Review of facility policy titled Pharmacy Services - Role of the Provider Pharmacy, with a revision date of April 2010, revealed The provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional stands of practice, and laws and regulations, including . provide routine pharmacy service seven days a week . deliver medications to the facility, and help ensure that all deliveries are correct and proper documentation related to delivery is provided.<BR/>Review of facility policy titled Pharmacy Services - Role of the Infusion Therapy Provider, with a revision date of April 2007, revealed the facility shall ensure that infusion therapy services are available, if it accepts and/or manages individuals who require infusion therapy products.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure they had promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #28) of 10 residents reviewed for Keppra (antiseizure medication) lab levels and notifications.<BR/>Resident #28 had abnormal Keppra lab results on 8/27/24, and the facility failed to follow up to ensure prompt notification was received by the ordering physician.<BR/>This failure could result in the physician not being fully aware of the resident's clinical condition and response to Keppra for 10 residents currently prescribed Keppra.<BR/>Findings included:<BR/>Record review of Resident #28's Annual MDS dated [DATE], revealed the resident was [AGE] years old, admitted on [DATE], had a diagnosis of a seizure disorder, and a BIMS score of 08 (suggested moderate cognitive impairment).<BR/>Record review of Resident #28's care plan dated 7/10/2024 revealed Keppra levels would be monitored monthly, lab values would be monitored, and abnormal results would be reported.<BR/>Record review of Resident #28's physician order dated 11/21/2019 revealed an order to check Keppra levels every month.<BR/>Record review of Resident #28's lab results with a reported date of 8/27/2024 revealed the Keppra level was out of range at 48.9ug/mL and marked high. Normal range listed on lab was 10.0-40.0 ug/mL. <BR/>Record review of Resident #28's progress notes revealed the last seizure documented for Resident #28 was on 6/7/2023.<BR/>In an interview on 9/09/24 at 2:10 p.m., the DON stated this lab was missed. The DON stated that lab values were flagged different colors in their electronic medical record system when they were abnormal, but the Keppra labs were not flagged. The DON stated that the staff notified the physician as soon as they get the results or during their shift and she would notify the physician of the results now.<BR/>In an interview on 9/10/2024 at 9:34 a.m., ADON A stated lab and x-ray results were faxed to them from the lab, and the results were available in their electronic medical records system. ADON A stated that all nurses had access to the fax machine and to the results on their computers. ADON A stated the expectation was for the nurses to communicate in report with the next nurse that labs were pending and monitor for results. ADON A stated that if a lab result was a critical level (dangerously too high or too low) then the lab would call the facility and speak with a nurse. ADON A stated Resident #28 had not had any neurological symptoms. ADON A did not state what the failure could cause.<BR/>In an interview on 9/10/24 at 9:48 a.m., the DON stated the expectation was for labs not to be missed and should be monitored by the nurses. The DON did not state how this failure could affect the residents.<BR/>In an interview on 9/10/2024 at 11:02 a.m., Physician E stated that routine levels on patients receiving Keppra were not necessary unless they were symptomatic and experiencing symptoms such as somnolence, dizziness, tiredness, or any other neurological symptoms. Physician E stated that the Keppra lab was ordered by a previous physician, but she expected all labs to be reported to the current physician.<BR/>Record review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol with a revision date of September 2012, stated If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 2 Resident's (Resident #49 and #57) of 5 residents reviewed for dignity.<BR/>The facility failed to provide dignity and respect for Residents #49 and #57 by leaving the Residents' privacy bags off their foley bags exposing the full urinary bag to the doorways.<BR/>This failure placed residents at risk for embarrassment and low self-esteem.<BR/>Findings included:<BR/>Record Review of Resident #49's Face Sheet revealed a [AGE] year-old male who had been initially admitted on [DATE] with diagnosis of cerebral infarction (Stroke), hemiplegia and hemiparesis affecting right dominant side (paralysis of one side of the body), and mid cognitive impairment.<BR/>Record Review of Resident #49's quarterly MDS dated [DATE] revealed a BIMS score of 06 out of 15 indicating the resident was severely cognitively impaired. Resident #49 required extensive to total assistance with bed mobility, transfers, dressing, and toileting with 2-person assistance. Section H of the MDS noted an indwelling catheter.<BR/>Record Review of Resident #49's Care Plan dated 06/13/2024 revealed that . risk for infection related to indwelling catheter. Staff to maintain barrier precautions related to indwelling catheter, chronic wound .Goal .will remain free of infection through next review .Interventions .Staff will maintain .enhanced barrier precautions .<BR/>Record review of Resident #57's Face Sheet revealed he was a [AGE] year-old male who had been initially admitted on [DATE] with diagnosis of encounter for palliative care (care focused on relieving pain), chronic obstructive pulmonary disease (difficulty in breathing), chronic heart failure, rheumatoid arthritis, and age-related physical debility.<BR/>Record Review of Resident #57's quarterly MDS dated [DATE] revealed an MDS score of 14 out of 15 indicating the resident was cognitively intact. Resident #57 completely dependent and required total assistance with eating, showering, bed mobility, transfers dressing, and toileting. Section H noted an external catheter.<BR/>Record Review of Resident #57's Care Plan dated 07/23/2024 revealed . has an external condom catheter at times .Goal .resident will be/remain free from catheter-related trauma through review date .Interventions .monitor for signs and symptoms of discomfort on urination and frequency .<BR/>An observaion on 09/08/2024 at 9:23 AM revealed Resident #49's catheter bag without a privacy bag covering it. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway.<BR/>An observation on 09/08/2024 at 12:31 PM revealed Resident #57's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway.<BR/>An observation on 09/08/2024 at 1:10 PM revealed Resident #49's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway.<BR/>An observation on 09/08/2024 at 2:40 PM revealed Resident #57's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway.<BR/>An observation on 09/09/2024 at 9:32 AM revealed Resident #49's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway.<BR/>An observatiojn on 09/09/2024 at 9:36 AM revealed Resident #49's catheter bag without a privacy bag on. The catheter bag was secured to the bottom railing of the residents' bed observable from the doorway.<BR/>In an interview on 09/09/2024 at 10:01 AM with CNA D she revealed that she knew privacy covers for resident catheter bags were important for the dignity and well being of the resident. She stated that she was unaware of any residents missing privacy covers for their catheter bags. She stated that sometime the facility might run out of catheter bags but that the facility ordered supplies weekly but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues.<BR/>In an interview on 09/09/2024 at 10:17 AM with CNA I she stated that privacy covers for catheter bags were important for the dignity of the resident because if they had visitors no one wanted to see their urine on the side of their bed but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues.<BR/>An observsation on 09/10/2024 at 10:00 AM revealed both Residents #49 and #57 now had privacy covers on their catheter bags.<BR/>In an interview on 9/10/24 at 3:02 PM with LVN H she stated that it was important for the dignity of the residents to have privacy covers on their catheter bag. She stated that all residents when in bed should always have privacy covers on their catheter bags, but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues.<BR/>In an interview on 09/10/24 at 3:48 PM the DON stated that all residents that have catheter bags should have a privacy cover on their catheter bags. She stated that not having the privacy covers it could affect the wellbeing and dignity of the residents that have catheters. She stated that she had been unaware that any residents did not have catheter bag privacy covers and she stated that there had been no shortage in supplies, but that CNA's and Nursing staff should keep the nurse in charge of medical supplies informed of any shortage issues.<BR/>Record review of facilities policy titled, Promoting/Maintaining Resident Dignity read in part . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Maintain resident privacy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Residents #1 and #2) of six residents' rooms reviewed for Environment. <BR/>The facility failed to ensure Residents #1 and #2's bathroom floors and walls were in good repair and sanitary. <BR/>These failures could place all residents at risk of falls which could result in injuries leading to a decreased quality of life and psycho-social well-being. <BR/>Findings included: <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 14 (no cognitive impairment) and impaired upper and lower one-sided extremities and used a wheelchair. He also needed partial to moderate assistance with toileting and had other neurological conditions. <BR/>Interview and observation on 03/07/24 at 9:20 am, Resident #1's room had approximately 8 or 9 articles of clothing on the floor against the wall, he said were dirty clothes, and his trash can was full. He stated well this place is Kind of yucky (disgusting), they half ass clean my room daily. In his bathroom there was 1 &frac12; foot wood tile that was separated from the floor and under it was white cement and several layers of blackish colored dirt. There was 2 feet of wood tile was loose and a 1-inch gap with blackish colored grime was between the wood tile next to it. And the border and white caulk was separated from the wall and white caulk had separated from the wall and floor in the back corner of the toilet had an accumulation of blackish colored dirt and debris. The ac unit had approximately 2 &frac12; feet of white caulk 1 inch over the AC unit and had a 4 in long crack on the left upper side on the other side the AC unit appear not attached completely to the wall. And the white overhead light over the resident's bed appeared to have several layers of blackish dirt. <BR/>Record review of Resident#2's Annual MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 07 (moderate impairment) and both sides lower impairment. He used a wheelchair. He was dependent with toileting and had medically complex conditions. <BR/>Interview and observation on 03/07/24 at 10:30 am, Resident #2's room had seven to eight articles of clothing on the floor next to the wall. The resident said they were his dirty clothes. He stated the holes had been in his bathroom wall since being in this room. The bathroom had a 1 &frac12; foot hole above the floorboard that was separated from the wall and there was whitish bubbly caulk on it and the floor. The bathroom door had several areas of rust stains and the flooring next to the shower was jagged and uneven and broken in some areas. The corner next to the shower had rust stains and several layers of caulk on the wall and floor. And the resident's room flooring had several areas of scrap marks from door scrubbing the floor and as it was opened and closed it made a very loud and screeching noise. <BR/>Interview on 03/07/24 at 3:30 pm, [Anonymous] stated the facility's housekeepers did not do a good job cleaning the facility and fixing broken things. They stated speaking to the Maintenance/Housekeeping Supervisor and by putting the repairs needed into the Maintenance book up front. They stated if the facility was not cleaned properly, it could cause residents to get infections and probably get sick and also cause injuries like falls. They stated not being sure why they had not mentioned the maintenance and housekeeping issues to the Administrator. <BR/>Interview on 03/07/24 at 4:41 pm, the ADON stated sometimes the housekeepers did a good job cleaning but sometimes on Mondays, the floors were dirty. She stated the Department Heads had assigned halls, they checked the resident's rooms and common areas for cleanliness. She stated the Maintenance/Housekeeper Supervisor was responsible for ensuring the house keeping was done properly. <BR/>Interview on 03/07/24 at 5:28 pm, the SW stated the residents in the February 2024 Resident Council meeting said they felt like the housekeepers were not cleaning good enough. She stated Resident #9 complained about housekeeping services last January 2024. She stated the housekeeping issues should have been addressed by the Maintenance/Housekeeper and was not sure if the complaints were resolved. She stated the Maintenance/Housekeeper Supervisor should have spoken with the weekend housekeeper to clean and pick up trash properly. She stated she was responsible for ensuring the complaints were follow-up on and she said she was not sure why she had not done so. She added the facility's floors were a continuous battle because the glue rose up and dried on top of the flooring tiles. She stated the Maintenance/Housekeeping Supervisor did his best to make sure the facility was cleaned and in good repair. She stated she reported the hole in Resident #2's bathroom wall to the Maintenance Housekeeping Supervisor. She stated she noticed the flooring tile around Resident #1's toilet was loose last week. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she tried some best practice trainings with the housekeepers because she noticed some areas being missed. She stated she noticed the barrier door grab bars were rusty and Housekeeping/Maintenance Supervisor had a to do list to fix them. She stated they just hired a Maintenance Assistant, but he did not know how to repair much yet. She stated being aware of Resident #2's holes in his bathroom and Resident #1's loose flooring tiles in his bathroom for about two weeks. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the facility's Grievance form dated 01/17/24 revealed, Resident #9 - housekeeping needs .<BR/>Record review of the Resident Council minutes dated 02/17/24 revealed, C. Housekeeping & Laundry Department .feels like some of the housekeepers do bare min. when asked to clean their rooms. <BR/>Record review of the last 2 months (02/26/24 - 03/06/24) maintenance log sheets did not reveal any requests for Resident #1 flooring issue and Resident #2's wall hole and flooring issue. <BR/>Record review of the Facility's Cleaning and disinfection of Environmental Surfaces policy dated 2001 revised 2009 revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected, according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens Standard .Policy Interpretation and implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Critical items, semi critical items and non-critical items .9. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . <BR/>Record review of the Facility's Maintenance Service policy dated 2001 and revised 2009 revealed, Policy Statement: Maintenance services should be provided to all areas of the building, grounds and equipment .Policy interpretation:2. b. Maintaining the building in good repair and free from hazards .i. providing routinely scheduled maintenance services to all areas .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, equipment are maintained in a safe and operable manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #3) of 66 residents reviewed for assistive devices.<BR/>A portable heater was found in use in Resident #3's room without direct supervision.<BR/>This failure could place residents at risk for accidents or injuries.<BR/>Findings include:<BR/>Record review of Resident #3's Face sheet dated 01/28/2025 revealed that Resident #3 was a [AGE] year-old male that was initially admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, Age-Related Cognitive Decline and Partial traumatic Amputation of left foot at Ankle Level.<BR/>Record Review of Resident #3's Quarterly MDS Assessment and Care Screening dated 11/07/2024 revealed that Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. The resident required the use of a wheelchair and required supervision or touching assistance for all transfers and personal hygiene. <BR/>Record review of Resident #'3 Care Plan, dated 11/13/2024 revealed that Resident #3 has an Activity of Daily Living self-care deficit related to osteomyelitis [infection of the bone] of left foot post-surgical intervention, impaired cognition and makes poor decisions.<BR/>In an observation and interview on 01/28/2025 at 11:24 AM revealed Resident #3 was observed in his room, seated comfortably in a wheelchair. A portable heater was noted to be operating behind the resident within 2 feet of the resident's bed and privacy curtain. The resident stated that the facility had given him the portable heater to use because his in-wall unit was not working for the last two days. He stated that the air conditioning part of the in-wall unit worked fine but that the heat was not working. He stated that he liked it warm in his room.<BR/>In a set of observations from 01/28/2025 at 11:42 AM to 01/28/2025 to 11:42 AM revealed all other resident rooms were checked for portable heaters. No other portable heaters were found. <BR/>In an observation and interview on 01/28/2025 at 1:45 PM revealed the Maintenance Supervisor was observed removing the wall air conditioning/heater unit from Resident #3's room. The portable heater was no longer present in Resident #3's room. The Maintenance Supervisor stated that he had taken the portable heater out of Resident #3's room and he was in the process of replacing Resident #3's in-wall air conditioner/heater unit. He stated that Resident # 3 had been using the portable heater for the last 2 days and that the heater had an automatic turn-off switch if the portable heater fell over or was tipped. <BR/>In an interview on 01/28/2025 at 2:09 PM LVN A stated that she was not aware of anyone doing fire watches in the facility. She stated that fire watches meant that the staff had to check the entire facility every 15 minutes to make sure there were no fires in case the fire alarm system stopped or a power outage.<BR/>In an interview on 01/28/2025 at 2:29 PM LVN B stated that she had not heard anything about the facility having to do any fire watches or that Resident #3 had a portable heater in his room. She stated that she had been working for the last three days and that she had been unaware of any portable heaters in the building. She stated that she had thought portable heaters were not allowed in nursing facilities. <BR/>In an interview on 01/28/2025 at 3:30 PM the ADM stated that a portable heater could pose a fire risk to residents if a blanket, curtain or pillow got too close to it for a period of time. He stated that he had not done any fire watches while the portable heater was in use in Resident #3's room, and that the portable heater had been in use for the last two days.<BR/>In an interview on 01/28/2025 at 3:34 PM Maintenance Supervisor stated that portable heaters could cause fires if left unmonitored because something flammable could get next to a heater and possibly start a fire. He stated that he had replaced the in-wall unit in Resident #3's room and had meant too the day before but had not been able to get to it. He stated that he had replaced it a few hours ago and that there were no other portable heaters in use in the facility.<BR/>A policy for Portable Heaters in Nursing facilities was requested on 01/28/2025 at 3:17 PM but was not presented before the conclusion of the investigation.

**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 acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two residents (Resident #1 and Resident #2) of four residents reviewed for pharmaceutical services in that:<BR/>1. <BR/>The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident requested pain medication on 1/23/2025. The facility also failed to return and administer Trazodone to Resident #1 as ordered on 1/24/2025. <BR/>2. <BR/>The facility failed to acquire, administer, and accurately document two scheduled doses of gabapentin on 1/24/25 to Resident #1 as ordered. <BR/>3. <BR/>The facility failed to acquire and administer intravenous antibiotic medications to Resident #2 as ordered upon admission for the dose scheduled on 1/9/25. <BR/>4. <BR/>The facility failed to obtain a pharmacy delivery receipt for Resident #2's medications per facility policy. <BR/>5. <BR/>The facility failed to administer and accurately document medications for Resident #2 on the facility MAR for January 2025.<BR/>These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, and uncontrolled pain.<BR/>Findings included:<BR/>1. Record review of Resident #1's MDS (type indicated option selected was none of the above) dated 1/23/2025 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. No BIMS score was listed on the assessment to indicate if the resident had any cognitive impairment.<BR/>Record review of Resident #1's face sheet dated 1/28/2025 revealed Resident #1 had diagnoses of sepsis (infection that has spread to multiple organs), polyneuropathy (multiple nerves are damaged), muscle spasm, and paraplegia (weakness of both legs or arms).<BR/>Record review of Resident #1's care plan with a revision date of 1/24/2025 revealed Resident #1 was resistive to care, and interventions included allowing the resident to make decisions about treatment regime. <BR/>Record review of Resident #1's physician order with a revision date of 1/23/2025 for oxycodone 10mg revealed the physician ordered oxycodone 10mg one tablet by mouth every four hours as needed for pain.<BR/>Record review of Resident #1's physician order with a revision date of 1/27/2025 for trazodone 25 mg revealed the physician ordered trazodone 25mg one tablet by mouth at bedtime for insomnia (difficulty sleeping).<BR/>In an interview on 1/28/2025 at 10:18 a.m., Resident #1 reported he did not receive any medications until 24 hours after he had arrived at the facility. Resident #1 stated he requested pain medication from the nurse around 9:30 p.m. on 1/23/2025, and the nurse told him they did not have any narcotics available. Resident #1 stated he needed his pain medication because he had pressure sores and was unable to sleep without them. Resident #1 stated the facility had obtained all of his medications and currently were giving them to him like they were supposed to.<BR/>Record review of Resident #1's progress note dated 1/23/2025 at 11:30 p.m., revealed LVN A documented Resident #1 arrived at the facility at 9:00 p.m., and stated he needed a pain pill before he could be assessed.<BR/>Record review of the pharmacy manifest dated 1/24/2025 revealed gabapentin, methocarbamol, trazodone, and oxycodone for Resident #1 was not delivered until 1/24/2025 at 10:37 p.m.<BR/>In an interview on 1/28/2025 at 2:01 p.m., the DON reported medications were automatically ordered from the pharmacy when the medication orders were entered into their electronic medical records system. The DON reported that orders were entered as soon as a resident was admitted and was physically in the building. The DON reported the pharmacy delivered medications twice a day at 10:00 a.m. and 10:00 p.m.<BR/>In an interview on 1/28/2025 at 3:06 p.m., LVN A stated Resident #1 was admitted to the facility late on 1/23/2025 and requested specifically oxycodone. LVN A reported the medication was not available in the emergency medication kit, so she asked Resident #1 if he would take a different pain medication. LVN A reported Resident #1 declined the other pain medications and refused to allow her to assess him. LVN A stated Resident #1 did not state a pain level and cursed at her when she told him she did not have his specific pain medication available. LVN A stated she contacted the pharmacy but did not contact the DON or doctor, and the pharmacy told her they would send the medication that night. LVN A stated she documented the incident in the progress notes. LVN A reported when medications were needed prior to being delivered by the pharmacy then some medications could be found in the emergency medication kit but not oxycodone. LVN A also stated if the facility was unable to obtain scheduled medications, then the doctor should be notified, and it should be documented on the MAR. LVN A stated the risks to the residents if they did not receive their medications as ordered varied depending on the medication. LVN A did not state any further risks.<BR/>In an interview on 1/28/2025 at 2:01 p.m., the DON stated they did not have oxycodone in the emergency medication kit, but there was Tylenol #3 or tramadol in the emergency medication kit that could be offered. The DON stated if a new admission required a narcotic then the hospital would have to send a prescription or the resident would have to wait until the medication was delivered by their pharmacy. The DON stated she had requested stronger pain medications from the pharmacy and their nurse consultant for the emergency medication kit but was told the facility would need a hardwired internet connection which they did not have at this time. The DON stated a hardwired internet connection was needed for narcotics to be stored in the emergency medication kit but did not explain why. The DON stated the resident could be at risk for pain if pain medications were not available, but that they had other pain medicine that could be used until the resident's medications were delivered.<BR/>In an interview on 1/28/2025 at 3:11 p.m., Resident #1 stated the nurse offered him tramadol but that was pointless because it did not work. Resident #1 stated he went out on pass the next day (1/24/2025) and did not discuss his pain medication with anyone else until that night. Resident #1 stated they brought his pain medication just after midnight on 1/25/2025. Resident #1 stated that a nurse tried to give him his other medications (not pain medications) on 1/24/2025 around 8:00 p.m., and he refused because he did not want them that early. Resident #1 stated he told them to bring his medications later, and they did not.<BR/>Record review of Resident #1's January 2025 MAR revealed trazodone was scheduled for 9:00 p.m.<BR/>Record review of Resident #1's progress note dated 1/24/2025 at 9:41 p.m., LVN A documented Resident #1 refused to take his medication because the hospital always brought them at 10:00 p.m. LVN A documented that the MA would not be there at 10:00 p.m., and she told Resident #1 that she would bring the medications at 9:00 p.m. <BR/>In an interview on 1/28/2025 at 5:00 p.m., LVN A stated a MA attempted to give Resident #1 his medications on 1/24/2025, but Resident #1 refused. LVN A reported she spoke with Resident #1, and he told her to bring his medications later. LVN A stated she did not go back to Resident #1's room because he was angry, and she did not administer his medications. LVN A did not state if she reported the incident to anyone. LVN A stated the medication was trazodone, and there was no risk to the resident for missing a dose. <BR/>Record review of Resident #1's MAR dated 1/28/2025 revealed gabapentin (medication to treat nerve pain) was marked as refused on 1/24/2025 at 8:00 a.m. and 2:00 p.m.<BR/>Record review of the undated inventory list for the emergency medication kit revealed gabapentin was not a medication provided in the emergency medication kit.<BR/>2. Record review of Resident #2's admission MDS dated [DATE] revealed Resident #2 was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses of multidrug-resistant organism (bacteria resistant to several antibiotics), septicemia (infection in blood), and diabetes. Section O revealed Resident #2 was receiving intravenous antibiotics, and the BIMS assessment revealed a score of 15 (indicating no cognitive impairment).<BR/>Record review of Resident #2's baseline care plan with a signed date of 1/09/2025 revealed Resident #2 was receiving intravenous medications and antibiotics.<BR/>Record review of Resident #2's orders on 1/28/2025 revealed orders for the following medications:<BR/>Daptomycin (intravenous antibiotic) use 800mg intravenously one time a day <BR/>ferrous sulfate (iron) give one 325mg tablet by mouth in the morning<BR/>fluconazole (antifungal) give four 200mg tablets by mouth one time a day<BR/>furosemide (treats heart failure) 20mg give 0.5 tablet by mouth in the morning<BR/>Jardiance (treats diabetes) give one 10mg tablet by mouth in the morning<BR/>carvedilol (treats blood pressure) give one 6.25 mg tablet by mouth two times a day<BR/>gabapentin (treats nerve pain) give one 300mg capsule by mouth two times a day<BR/>llacosamide (anticonvulsant) give one 150 mg tablet by mouth two times a day<BR/>pantoprazole (treats indigestion) give one 40mg DR tablet by mouth two times a day<BR/>miralax (treats constipation) give one scoop by mouth in the morning for constipation<BR/>sennosides (treats constipation) give two 8.6mg tablets by mouth two times a day for constipation<BR/>methocarbamol (treats muscle spasms) give one 500mg tablet by mouth three times a day<BR/>atorvastatin (treats high cholesterol) give one 40mg tablet by mouth at bedtime.<BR/>Record review of Resident #2's progress note dated 1/06/2025 at 10:41 p.m., LVN A documented Resident #2 was admitted to the facility with a left foot wound infection and had an order to continue daptomycin (intravenous antibiotic).<BR/>Record review of Resident #2's progress note dated 1/07/2025 at 12:36 p.m., LVN B documented Resident #2 was on daptomycin (intravenous antibiotic).<BR/>Record review of Resident #2's progress note dated 1/08/2025 at 2:22 p.m., LVN B documented Resident #2 continued to take intravenous antibiotics.<BR/>Record review of Resident #2's MAR dated 1/28/2025 revealed blanks on the MAR for the following medications on 1/07/2025:<BR/>Daptomycin (intravenous antibiotic), ferrous sulfate (iron), fluconazole (antifungal), furosemide (treats heart failure), Jardiance (treats diabetes), carvedilol (treats blood pressure), gabapentin (treats nerve pain), lacosamide (anticonvulsant), pantoprazole (treats indigestion), miralax (treats constipation), sennosides (treats constipation), methocarbamol (treats muscle spasms). <BR/>The MAR also revealed blanks on the MAR for the following medications on 1/08/2025: Atorvastatin (treats high cholesterol), pantoprazole, miralax (treats constipation), sennosides (treats constipation), methocarbamol (treats muscle spasms), and lacosamide (anticonvulsant). The MAR also revealed daptomycin was scheduled every day at 12:00 p.m. from 1/07/2025 until 1/10/2025, but only one dose of the daptomycin (intravenous antibiotic) was documented as administered and that was on 1/08/2025. <BR/>In an interview on 1/28/2025 at 9:31 a.m., a family member for Resident #2 reported the facility did not give Resident #2 any medications for a day and a half after he was admitted on [DATE] and did not provide his intravenous antibiotics as ordered. The family member reported it took two days to get the antibiotics, and the facility ran out before they were completed. The family member reported the facility told her the antibiotic was too expensive, so they could not order the required amount. The family member stated Resident #2 chose to go to the hospital in order to get his intravenous antibiotics.<BR/>In an interview on 1/28/2025 at 1:24 p.m., LVN B stated she administered Resident #2's daptomycin (intravenous antibiotics) every day as ordered except on 1/09/2025. LVN B stated she documented administering the medication on the MAR. LVN B stated the pharmacy was unable to deliver the medication due to the weather, so she notified the doctor. LVN B stated the doctor told her to extend the number of days the medication was supposed to be given. LVN B stated she documented in the progress notes that the physician was notified. LVN B stated there was no harm in missing one dose of intravenous antibiotics.<BR/>Record review of Resident #2's progress note dated 1/09/2025 at 11:33 a.m., LVN B documented daptomycin had not been delivered, and the pharmacy stated the medication was delayed due to the weather. LVN B documented the pharmacy reported the medication would be delivered the next business day. LVN B documented that she contacted the doctor and received orders to administer the dose as soon as it was delivered and to extend the stop date by one day.<BR/>In an interview on 1/28/2025 at 2:01 p.m., the DON stated if there was a blank on the MAR then the medication must have been missed. The DON reported the pharmacy delivered medications twice a day, and it could take up to 12 hours to get medications after a resident was admitted because they did not order medications until after the resident was admitted to the facility. The DON stated medications were automatically ordered from the pharmacy when the orders were entered into their electronic monitoring system which would be done when the resident admitted to the facility.<BR/>In an interview and observation on 1/28/2025 at 3:28 p.m., the DON reviewed the pharmacy receipt binder but was unable to find any records for Resident #2's daptomycin being delivered. The DON stated there was a record because it reflected there were five more doses delivered, but they were not received by the facility. The DON stated Resident #2 received two doses of daptomycin, but the pharmacy was unable to deliver the additional five doses because of the weather. The DON stated they initially only ordered two doses because the medication was very expensive and required authorization from their corporate team. The DON stated Resident #2 chose to discharge to a hospital instead of waiting for the antibiotics to be delivered later that day. The DON reported she was responsible for monitoring and ensuring medications were administered as ordered. The DON stated she checked the MARs once a week to ensure they were completed, and medications were administered. The DON stated her expectation was for the MARs to be accurate and for medications to be delivered within 24 hours for a new admission. The DON stated the risks to the residents if medications were not received timely could be uncontrolled blood pressure or behaviors. The DON reported the risks to the residents if their MARs were not completed was that medications could appear to not be given and another nurse could administer the medication again causing the resident to be overmedicated. The DON stated there was no risk to the residents if pharmacy receipts were not kept because the records could be obtained from the pharmacy. The DON stated she would request the pharmacy's delivery manifest and provide it.<BR/>Record review of the pharmacy manifest dated 1/07/2025 revealed two doses of daptomycin were delivered at 11:29 a.m. on 1/07/2025.<BR/>Record review of the pharmacy manifest dated 1/9/2025 revealed five doses of daptomycin were delivered at 1:39 a.m. on 1/9/2025.<BR/>In an interview on 1/28/2025 at 5:12 p.m., NP C reported if oxycodone was unavailable then tramadol could be given to assist with pain control until oxycodone was received. NP C stated it was not ideal for oxycodone to be missed for more than 24 hours, but it depended on the pharmacy. NP C stated she expected the facility to get the medicine as soon as possible and notify the doctor or NP if they were unable to obtain the medications. NP C stated the facility was at the mercy of the pharmacy to deliver the medications and did not give a time frame that she expected new admissions to have medications within. NP C stated the nurses could call and obtain an order to hold a medication until it came in. NP C stated there was not usually any harm to a resident if they missed medications for one day or missed one dose of intravenous antibiotics. NP C did not state if she was notified that anyone had missed any medications.<BR/>Review of facility policy titled Administering Medications, with a revision date of December 2012, revealed Medications shall be administered in a safe and timely manner, and as prescribed. The policy also revealed Medications must be administered in accordance with the orders, including any required time frame, and medications must be administered within one (1) hour of their prescribed time.<BR/>Review of facility policy titled Pharmacy Services Overview, with a revision date of April 2007, revealed The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals. The policy also revealed The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs . help the facility to assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers.<BR/>Review of facility policy titled Charting Errors and/or Omissions, with a revision date of December 2006, revealed Accurate medical records shall be maintained by this facility.<BR/>Review of facility policy titled Charting and Documentation, with a revision date of July 2017, revealed The following information is to be documented in the resident medical record: . b. Medications administered, and documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.<BR/>Review of facility policy titled Accepting Delivery of Medications, with a revision date of April 2007, revealed A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket, and the delivery ticket shall be archived in a designated location.<BR/>Review of facility policy titled Medication Orders and Receipt Record, with a revision date of April 2007, revealed The facility shall document all medications that it orders and receives, and the facility shall retain medication order/receipt records for at least one year or as otherwise required.<BR/>Review of facility policy titled Pharmacy Services - Role of the Provider Pharmacy, with a revision date of April 2010, revealed The provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional stands of practice, and laws and regulations, including . provide routine pharmacy service seven days a week . deliver medications to the facility, and help ensure that all deliveries are correct and proper documentation related to delivery is provided.<BR/>Review of facility policy titled Pharmacy Services - Role of the Infusion Therapy Provider, with a revision date of April 2007, revealed the facility shall ensure that infusion therapy services are available, if it accepts and/or manages individuals who require infusion therapy products.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three (Halls 100, 400 and 500) of six halls and one (main dining room) of two dining rooms and one of one kitchen and one (facility entrance) of one reviewed for environment.<BR/>(A)The facility failed to ensure the exit door on the 100 hall and front of Resident #5's room door was clean and in good repair.<BR/>The facility failed to ensure the floors on halls 100, 400 and 500 were clean and in good repair. <BR/>The facility failed to ensure the flooring in the dining room next to the kitchen entrance and ice machine was clean and in good repair. <BR/>The facility failed to clean or replace the two rusty panic bars on hall 100 and 2 rusty panic bars on hall 500.<BR/>The facility failed to ensure Resident #9's room was cleaned thoroughly. <BR/>(B) The facility failed to ensure the floor drainage system in the kitchen was not clogged up.<BR/>The facility failed to ensure the front entrance of the facility was clean and in good repair. <BR/>These failures could affect all residents, resulting in falls and cross contamination, resulting in injury and stomach illnesses which could lead to a decline in the resident's health and physical functioning.<BR/>Findings included:<BR/>(A)Observation on 03/07/24 at 9:14 am, the floor at the entrance of Resident #5's room had assortment of colors, the flooring in the resident's room was dark brown. Around the entrance of the resident's door was one light brown tile and one grey tile. There were several layers of accumulated blackish dirt around the door and the door frame had blackish debris and chipped paint, dry rot and rust along it.<BR/>Observation on 03/07/24 at 12:49 pm, the 2 barrier door's panic bars on the 100 hall had a large amount of rust spots and scrape marks on them. <BR/>Observation on 03/07/24 at 12:50 pm, the 100 hall exit door had accumulated layers of blackish dirt, scuff marks, chipped paint, and dry rot. The corner of the door had a quarter size hole and light from the outside could be seen. The baseboards by the exit door had several layers of bumpy and chipped paint and accumulated blackish dirt. <BR/>Observation at 03/07/24 at 12:52 pm, the 2 barrier door's panic bars on the 500 hall had a large amount of rust spots and scrape marks and brownish debris particles covered most of the metal areas on the panic bars. <BR/>Observation 03/07/24 at 1:01 pm, in the main dining room, the white flooring tiles around the ice machine entrance door of kitchen appeared to have several areas of accumulated blackish dirt and grime. The drain by the ice machine had brownish rust stains and blackish dirt on and around it, the tiles were cracked and missing some areas of the tiles. The lower right side of the ice machine had yellowish colored drip stains on it and there was rust under two of the four legs. The white kitchen door had a large area of blackish smudge and the bottom of the door had bumpy/uneven paint and blackish dirt. The flooring around the door frame had brownish rust stains and blackish accumulated dirt and the corners had debris particles.<BR/>Interview on 03/07/24 at 3:30 pm, [Anonymous] stated the housekeepers did not do a good job cleaning the facility. They spoke to the Housekeeping/Maintenance Supervisor, but he had not been back to work this week. They stated when things were broken, they wrote up a repair request in the book up front. They stated noticing the rust and broken flooring and walls in the rooms and common area and had spoken to Housekeeping/Maintenance but could not remember what his response was. They stated if the facility was not cleaned properly, it could cause the residents to develop infections and probably get sick. They was not sure why They had not mentioned the housekeeping and maintenance concerns to the Administrator. They stated if things around the facility were broken it could cause the residents to trip and fall. <BR/>Interview on 03/07/24 at 4:13 pm, the Dietary Director stated the door entrance to the kitchen door needed to be painted and door frame needed to be repaired. He stated he had not really paid attention to the rust on the hallway doors but that floors were yucky and cracked. He stated the floor drain next to the kitchen front entrance was not rusted but just had paint loss and the original metal was what was exposed. He stated the Housekeeping/Maintenance Supervisor was on leave since last Monday and said their corporate office or a repair company to come out to fix stuff. He stated some areas on the flooring needed extensive repairs. <BR/>Interview on 03/07/24 at 5:28 pm, the SW stated the residents in the February 2024 Resident Council meeting said they felt like the housekeepers were not cleaning good enough. She stated Resident #9complained about housekeeping services last January 2024. She stated the housekeeping issues should have been addressed by the Maintenance/Housekeeper and was not sure if the complaints were resolved. She stated the Maintenance/Housekeeper Supervisor should have spoken with the weekend housekeeper to clean and pick up trash properly. She stated she was responsible for ensuring the complaints were follow-up on and she said she was not sure why she had not done so. She added the facility's floors were a continuous battle because the glue rose up and dried on top of the flooring tiles. She stated the Maintenance/Housekeeping Supervisor did his best to make sure the facility was cleaned and in good repair. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she tried some best practice trainings with the housekeepers because she noticed some areas were being missed. She stated she noticed the barrier door grab bars were rusty and Housekeeping/Maintenance Supervisor had a to do list to fix them. She stated their Housekeeping/Maintenance Supervisor had not worked for the past few days and they just hired a Maintenance Assistant, but he did not know how to repair much yet.<BR/>(B) Observation and interview on 03/07/24 at 9:00 AM, the floors in the facility entry area appeared to have spots of built-up black grime in the seams of the tiles. The doors around the entrance appeared to have general wear from wheelchairs. <BR/>Observation on 03/07/24 at 9:10 AM, around the RN nurses' station, the floors in this area also had built up grime in the seams. <BR/>Observation and interviews on 03/07/24 at 9:43 AM, the floor drains in the kitchen were backed up with dirty water and leveled with the floor. One drain was observed to have the hose of a wet vac inserted into the drain to drain out water. The Dietary manager stated having drainage issues for a few months. He stated there had been people at the facility to fix it a few times, but the floor drains were still backed up. <BR/>Interview on 03/07/24 at 3:40 PM, Housekeeper C stated that the problem with the floors was that the glue kept seeping through the seams. She stated they tried to mop the glue up, but it did not come off the floor. <BR/>Interview on 03/07/24 at 4:14 PM, the Administrator stated they had some issues with the floors, because there was grime build up on them . She stated they were supposed to get them redone and the owner told her the floors were really not working for this environment. She stated she agreed the floors looked Icky (disgusting) which could make the residents feel bad about their home. She stated she knew about the drainage problem in the kitchen which had been going on for a few months. She stated they tried to get some people in there to take care of it, but nothing worked so far. She stated she knew the drainage issue in the kitchen could cause a cross contamination problem. <BR/>Record review of the facility's Grievance form dated 01/17/24 revealed, Resident #9 - housekeeping needs .<BR/>Record review of the Resident Council minutes dated 02/17/24 revealed, C. Housekeeping & Laundry Department .feels like some of the housekeepers do bare min. when asked to clean their rooms.<BR/>Record review of the last two months (02/26/24 - 03/26/24) maintenance log sheets did not reveal any requests to repair the kitchen's floor drain, common areas in the hallways and main dining room.<BR/>Record review of the Facility's Cleaning and disinfection of Environmental Surfaces policy dated 2001 revised 2009 revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected, according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens Standard .Policy Interpretation and implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Critical items, semi critical items and non-critical items .9. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . <BR/>Record review of the Facility's Maintenance Service policy dated 2001 and revised 2009 revealed, Policy Statement: Maintenance services should be provided to all areas of the building, grounds and equipment .Policy interpretation:2. b. Maintaining the building in good repair and free from hazards .i. providing routinely scheduled maintenance services to all areas .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, equipment are maintained in a safe and operable manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. <BR/>The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings Include:<BR/>Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room.<BR/>Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room .<BR/>An interview on 03/07/24 at 9:20 a.m., Resident #6 revealed that he had seen many black small flies and roaches all over the facility.<BR/>An interview on 03/07/24 at 9:24 a.m., Resident # 6 stated that he had seen flying black gnats and roaches in many areas of the facility. He did not state how long he had been seeing the insects/pest or if he had seen pest control at the facility. <BR/>Observation on 03/07/24 at 9:37 a.m. in the 300-hall shower room revealed 15-20 small black flies or gnats either alighted on the shower curtain to shower stall #1 or flying near a large plastic bag filled with wet towels near shower stall #1. Four dead roaches were observed on the floor underneath the shower curtain for shower stall #1.<BR/>An interview on 03/07/24 at 2:57 p.m., MA A stated that she had seen gnats and roaches all over the facility and in resident rooms. She stated that the staff were supposed to write down bug sightings in some book, but she did not know where the book was, and she denied knowing what a pest sighting log was. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:33 p.m., CNA B revealed she had seen many roaches and gnats in room [ROOM NUMBER] and she had seen gnats and roaches in room [ROOM NUMBER] room that day (03/07/24). She stated hat she had never seen a pest sighting log, and she was not sure where the staff were supposed to write those things down. She stated that the staff just reports bugs to the maintenance manager. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:40 p.m., Housekeeper C stated that he did sometimes see gnats and that he was not sure how to report insects at the facility. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:50 p.m., CNA D revealed that she had seen gnats and roaches at the facility and denied knowing that she had to log them in the pest sighting log.<BR/>An interview on 03/07/24 at 4:00 p.m., RN E revealed that he had seen gnats and roaches in the facility and that he thought there was a book somewhere to write them down (insect sightings) but he did not know where the book was. <BR/>An interview on 03/07/24 at 4:06 p.m. CNA F stated that she had seen many gnats and roaches at the facility. She stated that she tells the maintenance manager about insects when she sees him. She stated that she had never heard of a pest sighting log.<BR/>An interview on 03/07/24 at 4:14 p.m., the Administrator stated that the staff were supposed to use the pest sighting log and that the staff had been trained on using the pest sighting log but that they just tell the maintenance manager instead. She stated that having gnats in the facility could affect residents negatively and mentally and could pose a risk of cross contamination.<BR/>An interview on 03/07/24 at 6:17 p.m., the DON revealed she had seen some gnats around the facility and that she thought staff were supposed to log insects in the pest sighting log. She stated that it could be very annoying for residents to have to deal with gnats and that it could affect their mental health and could possibly cause cross contamination. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the Facility's Pest Sighting Log/Pest Control Binder revealed: that the last pest sighting logged in the pest sighting log was 08/09/23 for flies, no other more recent entries could be found.<BR/>Review of Pest Control Service Inspection Report dated 02/15/24 revealed taget pest treated were rodents (rodent bait stations), german cockroaches in the kitchen and laundry area. This was the last inspection/service report in the binder. <BR/>Record review of the facility's policy dated May 2008, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. <BR/>The facility failed to follow physician orders for daily fasting blood sugar checks for Resident #1 on 09/03/24, 09/04/24, 09/09/24, 09/10/24, 09/15/24, and 09/16/24. <BR/>This failure could place the resident at risk of not receiving the care intended by the physician.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, printed on 09/17/24, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of legal blindness, chronic obstructive pulmonary disease (disease causing restricted airflow and breathing problems), diabetes mellitus due to underlying condition with diabetic neuropathy (a chronic disease that occurs when the body can't regulate blood sugar levels), other sequelae of cerebral infarction (Alteration of sensation following a stroke), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis that affects only one side of the body following a stroke), and chronic kidney disease (progressive damage and loss of function in the kidneys).<BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 14, which indicated Resident #1 was cognitively intact. Section GG - Functional Abilities and Goals, question GG0130. Self-Care indicated Resident #1 required moderate assistance with ADLs of toileting, showering, and personal hygiene.<BR/>Record review of Resident #1's care plan, revised on 08/28/24, reflected the following:<BR/> .FOCUS: The resident has Diabetes Mellitus with neuropathy . INTERVENTIONS: Fasting Serum Blood Sugar as ordered by doctor .<BR/>Record review of the physician orders tab of Resident #1's electronic health record revealed an order, dated 08/28/24 to CHECK FBS EVERY AM in the morning, with a start date of 08/29/24. <BR/>Record review of Resident #1's September medication administration record indicated Resident #1's blood sugar was not checked on the mornings of 09/03/24, 09/04/24, 09/09/24, 09/10/24, 09/15/24, and 09/16/24.<BR/>In an Interview on 09/17/24 at 10:40 a.m., Resident #1 stated he was aware that his blood sugar should be checked every morning, but the facility nurses do not check his sugars every morning. Resident #1 stated he had not reported the missed blood pressure checks to facility management because they should already know what their nurses aren't doing. Resident #1 stated he had a way to check his own blood sugar daily, so he was not concerned the facility failed to do so. <BR/>In an interview on 09/17/24 at 1:25 p.m., LVN A stated she was Resident #1's assigned 6:00 a.m. to 2:00 p.m., nurse. LVN A stated blood pressure checks were completed by facility nurses, while routine medications were provided to residents by facility medication aides. LVN A stated Resident #1's blood sugar check were the responsibility of the overnight nurse, because it was scheduled between 4:00 a.m. and 6:00 a.m. LVN A stated she had not received any reports from the overnight nurse that indicated Resident #1 had refused. LVN A stated she did not see the missed blood sugars because they filter the administration record to show medications and treatments to be administered during their shift.<BR/>Record review of the facility's Station One staffing schedule, dated 09/02/24 through 09/17/24, revealed that LVN B was Resident #1's assigned overnight nurse on 09/02/24, 09/03/24, 09/08/24, 09/09/24, 09/14/24, and 09/15/24. <BR/>Record review of the progress notes tab of Resident #1's electronic health record revealed no documentation that indicated Resident #1 refused his morning blood sugar checks between 09/01/24 and 09/17/24. <BR/>A telephone interview with LVN B was attempted on 09/17/24 at 1:56 p.m. but was unsuccessful. <BR/>In an interview on 09/17/24 at 2:40 p.m., the DON stated she was not aware of any missed blood sugar checks for Resident #1. The DON stated facility nurses were solely responsible for blood sugar checks and they were expected to provide all medications and treatments according to physician orders. The DON stated not completing blood sugar checks according to physician orders could cause a delay in care. The DON stated she would begin to in-service nursing staff on following physician orders and the documentation of medication and treatment orders. The DON stated she would conduct daily MAR audits to ensure medications and treatments were administered according to physician orders in the future. <BR/>In an interview on 09/17/24 at 3:32 p.m., the ADMIN stated he was not aware that Resident #1 had not received his ordered blood sugar checks. The ADMIN stated facility nurses were expected to always follow physician orders. The ADMIN stated Resident #1 could have experienced elevated blood sugar that would have not been relayed to his physician. The ADMIN stated to ensure all physician orders were followed he planned to update facility reporting procedures and in-service nursing staff on following physician orders and documentation. The ADMIN stated the DON would conduct daily MAR audits for three months and then weekly thereafter, to ensure all physician orders are followed in the future.<BR/>A related policy was requested from the DON and ADMIN on 09/17/23 at 2:40 p.m. and 3:32 p.m. but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for two of nine residents (Residents #1 and #2) reviewed for elopement.<BR/>1. The facility failed to ensure Resident #1 did not elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train.<BR/>2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized .<BR/>An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on 5/29/24 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>These failures resulted in one arrest due to obstructing traffic and one hospitalization due to being found lying on the ground and had suffered a stroke.<BR/>Findings included:<BR/>1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of 05/14/24.<BR/>Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care.<BR/>Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. <BR/>Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM, written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back.<BR/>Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM, written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him.<BR/>Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM, written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. <BR/>Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property.<BR/>Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker.<BR/>Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested/checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. <BR/>Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train.<BR/>Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM, she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they have not found Resident #1, and the SW stopped communicating with her. <BR/>Interview with the ADM on 05/23/24 at 10:30 AM, she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested.<BR/>Interview with the DON on 05/23/24 at 10:40 AM, she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him.<BR/>Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he woke up around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoke and visit other residents. Resident #3 stated Resident #1 never showed any signs that he was leaving or that he did not like it here.<BR/>Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 would follow him outside and he may have seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1.<BR/>Interview with DET A on 5/23/24 at 01:35 PM, he stated it was believed Resident #1 was arrested in [City] , but then it was determined he had been arrested by the DTP. DET A stated when he was assigned to locate Resident #1, he was not missing as he had already been arrested. DET A stated when he located Resident #1 in jail, his case was closed as Resident #1 was no longer considered a missing person.<BR/>Interview with the MD on 5/23/24 at 01:50 PM, he stated he was made aware that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated he had not been made aware that there were any concerns for Resident #1 smoking on his own. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently.<BR/>Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated they are not supposed to give the door code to any residents. LVN H stated the door codes are now changed once a month. LVN H stated you must make sure the door was fully closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you must notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, they would notify the police. LVN H stated if the resident was found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer.<BR/>Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he did not see Resident #1 up and walking around prior to taking his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room around 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 was probably outside smoking. CNA K stated he told LVN J that Resident #1 was not in his room, and LVN J said he may be smoking. CNA K stated around 9:00 AM, it was discovered Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours but now it was every 1 hour. CNA K stated when you complete the checks, you must chart in PCC any care provided. CNA K stated if you are just laying eyes on a Resident, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List only after physically laying eyes on them. CNA K stated he has never known for a resident to go missing. CNA K stated previously residents that were authorized to enter and exit with the door code, had the freedom to go as they please if they signed in and out. CNA K stated the door code was now changed once a month and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed and locked so no resident follows them out.<BR/>Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on Monday (5/13), Resident #1 tried to go out front to smoke by himself when the ADM was entering the building and she explained to Resident #1 that he must sign out first. The ADON stated Resident #1 complied and then went out and returned, and everything was fine. The ADON stated the next morning on 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the ADM had Management driving throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she does not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated they are making sure any resident that leaves the facility signs out and informs the nurse. The ADON stated the aides and nurses now completes rounds every hour. The ADON stated Resident #1 could have been hit by a vehicle, ended up in the hospital, or even killed. <BR/>Interview with the ADM on 05/23/24 at 03:25 PM, she stated they have completed re-assessments on all residents to make sure the assessments were accurate. The ADM stated all residents that were already exit-seeking had a doctor's order to wear a wander guard. The ADM stated the SW had recently reassessed the residents that are allowed to sign themselves out. The ADM stated they completed in-services on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses must print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all the residents that are allowed to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they are having another in-service tomorrow on 05/24/24 on the same items.<BR/>During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility.<BR/>Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she looked Resident #1 up on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #1's friend, Resident #4 most likely gave Resident #1 the door code. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. <BR/>Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 could not be found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process has changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would tell you if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if it was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. <BR/>Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, and CNA K took Resident #1 his breakfast tray, he was still not in his room. CNA L stated LVN J asked her if Resident #1 was in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and did not see Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must make sure the wander guard was working by observing the light taking the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must walk the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope.<BR/>Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM, Surveyor left a voicemail and sent a text requesting a callback.<BR/>Record review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked his halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During his last round at 4:00 AM, he assumed Resident #1 was asleep and did not disturb him nor his roommate.<BR/>Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback.<BR/>Record review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications.<BR/>2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. <BR/>Review of Resident #2's Order Summary Report for May 2024 reflected:<BR/>-04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. <BR/>-04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. <BR/>Review of Resident #2's Care Plans reflected: <BR/>-05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. <BR/>Facility interventions included: <BR/>Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. <BR/>Identify pattern of wandering.<BR/>Provide structured activities.<BR/>Wander alert on left ankle. Monitor function and skin integrity every shift.<BR/>Review of Resident #2's Progress Notes reflected:<BR/>-05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A<BR/>-05/22/24 2:30 PM Type: Behavior Note<BR/>Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON<BR/>-05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW<BR/>-05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A<BR/>-05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON<BR/>-05/23/24 11:09 AM Late Entry Resident being sent to hospital for evaluation. Arranging transportation. - DON<BR/>-05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON <BR/>-05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A<BR/>-05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A<BR/>-05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B<BR/>-05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B<BR/>-05/26/24 5:20 PM, Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside in the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B<BR/>Review of Resident #2's Ambulance Record, dated 05/26/24, reflected:<BR/>Dispatch notified: 7:31 PM<BR/>On scene: 7:36 PM<BR/>Resident transferred: 8:10 PM<BR/>Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. <BR/>Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected:<BR/>Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. <BR/>Final Diagnosis: Stroke<BR/>Review of website: timeanddate.com on 05/29/24 reflected the following temperatures:<BR/>[NAME] TX temperature:<BR/>5/26/24 4:53 PM 97 degrees<BR/>5/26/24 6:53 PM 97 degrees<BR/>Dallas TX temperature:<BR/>5/26/24 4:53 PM 97 degrees<BR/>5/26/24 6:53 PM 98 degrees<BR/>Observation of Resident #2 on 05/25/25 at 1:20 PM, revealed the resident was wearing a wander-guard transmitter on the left lower extremity and the presence of the LED light indicated it was functional.<BR/>Observation of Resident #2 on 05/25/24 at 03:15 PM, revealed the DM sitting one-on-one with Resident #2 in the facility's lobby with his wander-guard transmitter still visible on the left lower extremity and the presence of the LED light indicated it was functional.<BR/>An interview on 05/25/24 at 01:00 PM, with the MTD he stated he adjusted the front door to make the door close faster and changed the door code. The MTD stated the front door was monitored by the wander-guard system. The MTD stated normally, [Company] instructed him over the phone how to change the door code, but this time, he had [Company] come to the facility and [Company] installed a button under the receptionist's desk in order to open the door remotely and provided him a manual on how to change the door code himself. The MTD stated there had not been any concerns and everything was working properly. The MTD stated he monitored the doors as needed to ensure they are closing properly. The MTD stated he completed door checks three times a day and completed Tail Logs for documentation purposes. The MTD stated he had never been aware of any residents being in possession of the door code.<BR/>On 05/25/24 at 01:20 PM, Surveyor observed the five residents identified for placement of a Wander Guard. Surveyor observed the five residents in their rooms with their Wander Guard placed according to their individual Care Plans and Orders. Surveyor also conducted testing with the ADON at the front door to ensure the Wander Guards were functioning properly.<BR/>An interview on 05/25/24 at 02:15 PM, with the DM, he stated he drove around looking for Resident #1 when he was reported missing. The DM stated he was in-serviced on not giving the door code out or allowing residents to follow anyone outside. The DM stated the door codes were changed and a remote access button was installed under the receptionist's desk. <BR/>An interview on 05/25/24 at 02:30 PM, with HR, she stated she was in-serviced on making sure all residents know they must be buzzed in and out. HR stated no residents nor visitors should have access to the door code. HR stated the approved residents must sign in and out of the facility and let staff know they are leaving. HR stated the MTD changed the door codes last on Thursday, 05/23/24. HR stated when she ends her shift at 5:00 PM and over the weekend, various staff members would cover the front door.<BR/>An interview on 05/25/24 at 02:45 PM, HK O stated she was in-serviced on being more concerned when entering and exiting the front door. HK O stated she was informed the door code would be changed once a month. HK O stated she was informed to keep an eye on the residents that wear a Wander Guard.<BR/>Interviews were conducted with facility staff across multiple shifts on 05/23/24, 05/24/24, and 05/25/24. Staff interviewed were LVN H, LVN J, CNA L, CNA K, CNA F, CNA G, CNA C, HK O, LVN B, LVN J and MA A.<BR/>Interviews with the staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on obtaining orders when a resident was assessed and determined to require a wander guard to ensure the wander guard monitoring populated into the TARS. They stated they had been in-serviced on checking to ensure the wander guard was functional every shift by observing that the light was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibited and prevented abuse and neglect for two of nine residents (Resident #1 and Resident#2) reviewed for elopement.<BR/>1. The facility failed to follow the policy and procedure for neglect which allowed Resident #1 to elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train.<BR/>2. The facility failed to follow the policy and procedure for neglect which allowed Resident #2 to elope from the facility. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. Resident #2 suffered a stroke and was hospitalized .<BR/>An Immediate Jeopardy (IJ) was identified on 5/29/24 at 3:20 PM. The IJ template was provided to the facility on 5/29/24 3:25 PM and signed by the Administrator. While the IJ was removed on 05/31/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. <BR/>These failures resulted in the failure to follow the policy for neglect as well as hospitalization with stroke.<BR/>Findings included:<BR/>Review of facility's policy Abuse and Neglect Clinical Protocol, revised March 2018, reflected:<BR/>Neglect .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.<BR/>1. Review of Resident #1's quarterly MDS assessment, dated 05/02/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epilepsy (abnormal electrical brain activity), muscle weakness, lack of coordination and anxiety (feeling of fear, dread, and uneasiness). The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 10 indicating moderate cognitive impairment, moderately impaired decision-making, required cues/supervision. Under Section P - Restraints and Alarms revealed Resident #1 did not have any physical restraints (wander guard). Resident #1's undated Census Record reflected a discharge date of 05/14/24.<BR/>Review of Resident #1's care plan revised on 05/08/24 revealed Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, impaired balance was addressed. Interventions included encourage the resident to use the call light for assistance, he required extensive assistance x 1 staff for toileting and praise all efforts at self-care.<BR/>Review of Resident #1's quarterly Elopement Risk Assessments, dated 02/12/24 and 05/12/24, revealed Resident #1 was ambulatory and had no history of wandering. The assessment reflected the Resident #1 was at a low risk for wandering with a score of 2.0 and had no reported episodes of wandering in the past 6 months. <BR/>Review of Resident #1's progress notes dated 05/14/24 at 10:09 AM, written by LVN J revealed the resident is not in the building, his roommate said, he left at 1:30 AM and he has not come back.<BR/>Review of Resident #1's progress notes dated 05/14/24 at 11:30 AM, written by SW revealed there were several groups of staff that went out looking for Resident #1 to find him. The groups returned unable to locate him.<BR/>Review of Resident #1's progress notes dated 05/14/24 at 1:30 PM, written by SW revealed DPD notified the ADM that Resident #1 had been found in [. Jail]. SW called [. Jail] to find him and they were unable to locate him either in jail or in booking. SW then looked up Resident #1 in [. County Jail] and was able to find that Resident #1 had been picked up at 11:01 AM on 05/14/24 due to Obstruction of Highway Passageway. <BR/>Review of the Provider Investigation Report dated 05/21/24 revealed Resident #1 was last seen on 05/13/24 at 8:30 PM in his room when taking his evening medications. On 05/14/24, CNA L served his breakfast tray at 08:30 AM and Resident #1 could not be found after searching inside the facility. DPD was notified on 05/14/24 of missing resident and was provided with a photo and face sheet. It further stated it was confirmed Resident #1 left the facility without anyone observing him, nor him notifying anyone and Resident #1 had been given the door code by another resident to go outside and smoke off property.<BR/>Review of Resident #1's Smoking Safety Screen dated 02/01/24 and 05/01/24 revealed due to his diagnosis of dementia, Resident #1 was a supervised smoker.<BR/>Review of in-service training dated 05/14/24, after Resident #1's elopement, revealed training related to the procedure to follow when a resident was missing. The in-service did not address elopement prevention, ensuring wander-guard transmitters were routinely tested/checked to ensure they were functioning properly or training to ensure staff were able to demonstrate competency in monitoring and checking wander-guard transmitters. <BR/>Review of DTP Police Report dated 05/14/24 revealed Resident #1 was arrested on Tuesday, 05/14/24 at approximately 08:30 AM . impeding the progress of a southbound [Company] train.<BR/>Interview with a family member of Resident #1 on 05/23/24 at 9:45 AM, she stated the SW called her on 05/14/24 and informed her Resident #1 was missing. Resident #1's family member stated she had not spoken to, nor visited Resident #1 since November 2023. Resident #1's family member stated they have not found Resident #1, and the SW stopped communicating with her. <BR/>Interview with the ADM on 05/23/24 at 10:30 AM, she stated due to Resident #1 not being exit-seeking, he did not wear a wander-guard transmitter. The ADM stated during their morning meeting on 5/14, it was reported by LVN J they were unable to locate Resident #1 inside the facility. The ADM stated LVN J informed her CNA L delivered Resident #1's breakfast tray to his room and then took residents out to smoke at 8:30 AM, but Resident #1 did not partake in neither. The ADM stated a report was filed with the DPD and a couple of hours later she was informed by DPD that Resident #1 was no longer considered missing as he had been arrested.<BR/>Interview with the DON on 05/23/24 at 10:40 AM, she stated Resident #1 had not experienced a medical decline. The DON stated she believed Resident #1 had the door code because the only way you can get out without sounding the alarm, you would have to enter the door code. The DON stated Resident #1 had Dementia, but you would not know it by talking to him or looking at him.<BR/>Interview with Resident #3 (Resident #1's roommate) on 05/23/24 at 12:00 PM, he stated Resident #1 did not tell him he was leaving. Resident #3 stated he woke up around 01:00 AM and Resident #1 was not in his bed. Resident #3 stated Resident #1 never mentioned he wanted to leave. Resident #3 stated all Resident #1 did was smoke and visit other residents. Resident #3 stated Resident #1 never showed any signs that he was leaving or that he did not like it here.<BR/>Interview with Resident #4 (Resident #1's friend) on 05/23/24 at 12:20 PM, he stated Resident #1 would follow him outside and he may have seen him enter the door code to get out. Resident #4 denied intentionally providing the door code to Resident #1.<BR/>Interview with DET A on 5/23/24 at 01:35 PM, he stated it was believed Resident #1 was arrested in [City] , but then it was determined he had been arrested by the DTP. DET A stated when he was assigned to locate Resident #1, he was not missing as he had already been arrested. DET A stated when he located Resident #1 in jail, his case was closed as Resident #1 was no longer considered a missing person.<BR/>Interview with the MD on 5/23/24 at 01:50 PM, he stated he was made aware that Resident #1 eloped, and the police picked him up. The MD stated Resident #1 had never eloped before and did not exhibit any exit-seeking behaviors. The MD stated he had not been made aware that there were any concerns for Resident #1 smoking on his own. The MD stated Resident #1 had not had any change in conditions. The MD stated Resident #1 ambulated independently.<BR/>Interview with LVN H on 5/23/24 at 02:35 PM, she stated she worked on Monday, 5/13 from 2:00 PM until 10:00 PM. LVN H stated she administered Resident #1's medication before the regular smoke break at 8PM. LVN H stated she saw Resident #1 return to his room after he finished smoking. LVN H stated she never saw Resident #1 come out of his room before she ended her shift at 09:50 PM. LVN H stated Resident #1 was his normal self and had not had a change in condition. LVN H stated they are not supposed to give the door code to any residents. LVN H stated the door codes are now changed once a month. LVN H stated you must make sure the door was fully closed and locked and not allow any residents to exit behind you. LVN H stated the Residents that previously had the door code, had to be assessed by the SW. LVN H stated if a resident passed the Mental Mini-Assessment, they were allowed to sign themselves in and out. LVN H stated if you were unable to locate a resident, you must notify the ADM. LVN H stated then the ADM would instruct management to drive around the neighborhood and if they still could not find the resident, they would notify the police. LVN H stated if the resident was found, they would complete an assessment, an incident report and notify the doctor and the family. LVN H stated if the doctor gave an Order for a wander guard, they would place a wander guard on the resident. LVN H stated Resident #1 was not a wanderer.<BR/>Interview with CNA K on 5/23/24 at 02:50 PM, he stated he saw Resident #1 the day prior on Monday (5/13). CNA K stated there were no concerns CNA K stated Resident #1 walked throughout the facility independently and went outside to smoke. CNA K stated the next morning on 5/14/24, he did not see Resident #1 up and walking around prior to taking his breakfast tray to his room. CNA K stated when he arrived at Resident #1's room around 07:50 AM, Resident #1 was not in his room. CNA K stated he told CNA L that Resident #1 was not in his room, and CNA L said to leave his breakfast tray because Resident #1 was probably outside smoking. CNA K stated he told LVN J that Resident #1 was not in his room, and LVN J said he may be smoking. CNA K stated around 9:00 AM, it was discovered Resident #1 had not come out to smoke, and they started searching for him inside and outside the facility. CNA K stated you were supposed to check on residents every 2 hours but now it was every 1 hour. CNA K stated when you complete the checks, you must chart in PCC any care provided. CNA K stated if you are just laying eyes on a Resident, you do not have to enter anything in PCC. CNA K stated you must now check residents off on the Rounding List only after physically laying eyes on them. CNA K stated he has never known for a resident to go missing. CNA K stated previously residents that were authorized to enter and exit with the door code, had the freedom to go as they please if they signed in and out. CNA K stated the door code was now changed once a month and only employees are allowed the code. CNA K stated whenever an employee enters or exits the facility, they must make sure the door was closed and locked so no resident follows them out.<BR/>Interview on 05/23/24 at 03:05 PM, the ADON stated Resident #1 was quiet and kept to himself. The ADON stated Resident #1 was usually alert and oriented. The ADON stated on Monday (5/13), Resident #1 tried to go out front to smoke by himself when the ADM was entering the building and she explained to Resident #1 that he must sign out first. The ADON stated Resident #1 complied and then went out and returned, and everything was fine. The ADON stated the next morning on 05/14/24, LVN J stated Resident #1 was not in his room or the common areas. The ADON stated the ADM had Management driving throughout the community searching for Resident #1. The ADON stated the ADM called DPD and Resident #1 was located in jail. The ADON stated Resident #1 had been arrested for obstructing traffic. The ADON stated each Resident must complete a Mini Mental Exam and depending on their score determines if they are allowed to sign themselves in and out, smoke unsupervised, or leave the facility without a family member. The ADON stated she does not know if anything could have been done differently because Resident #1 was not a wanderer, and he caught the facility off guard. The ADON stated they are making sure any resident that leaves the facility signs out and informs the nurse. The ADON stated the aides and nurses now completes rounds every hour. The ADON stated Resident #1 could have been hit by a vehicle, ended up in the hospital, or even killed. <BR/>Interview with the ADM on 05/23/24 at 03:25 PM, she stated they have completed re-assessments on all residents to make sure the assessments were accurate. The ADM stated all residents that were already exit-seeking had a doctor's order to wear a wander guard. The ADM stated the SW had recently reassessed the residents that are allowed to sign themselves out. The ADM stated they completed in-services on 05/14/24 on rounding with each other and not by themselves. The ADM stated now nurses must print out the Midnight Census Report, give the report to the DON and text the ADM the headcount at midnight. The ADM stated they spoke with all the residents that are allowed to sign themselves out and informed them they must notify staff and make sure they sign in and out. The ADM stated they are having another in-service tomorrow on 05/24/24 on the same items.<BR/>During an observation on 05/24/24 at 10:30 AM, Surveyor observed several Residents across from the entrance sitting in the dining area waiting to play bingo. The residents all denied being provided or knowing the door code to exit the facility.<BR/>Interview with the SW on 05/24/24 at 11:00 AM, she stated Resident #1 did not have any change of conditions leading up to the elopement. The SW stated she drove throughout the neighborhood and could not locate Resident #1. The SW stated she looked Resident #1 up on the DPD website and confirmed that Resident #1 had been arrested for obstructing a highway passageway. The SW stated Resident #1 was not exit-seeking and did not wear a wander guard. The SW stated on 5/22/24 at 10:21 AM, Resident #1's daughter called her to get an update because she could not get through to the jail. The SW stated she looked Resident #1 up again on the DPD's website and it showed Resident #1 had been released the day prior on 5/21. The SW stated she drove downtown, around the jail and where the homeless people congregate and did not see Resident #1. The SW stated Resident #1's friend, Resident #4 most likely gave Resident #1 the door code. The SW stated Resident #4 was allowed to sign himself in and out and exit the facility using the door code. The SW stated Resident #1 was not allowed the door code due to his dementia diagnosis. The SW stated Resident #4 did not admit to giving Resident #1 the door code but suggested Resident #1 may have witnessed him entering it, or he may have given it to Resident #1 to enter. <BR/>Interview with LVN J on 05/24/24 at 01:20 PM, she stated she arrived to work late on 05/14/24. She stated while completing her rounds on 05/14/24 around 08:00 AM, she did not see anyone in Resident #1's room. LVN J stated this was around the time Resident #1 goes to smoke. LVN J stated after she completed her rounds, she went to receive the shift change report from the night nurse, LVN I. LVN J stated she went back to Resident #1's room to give him his medication, but he was not back. LVN J stated she checked the bathroom, and no one was in there. LVN J stated she went ahead and asked Resident #3 (roommate), and he responded, Resident #1 went out last night and he never came back. LVN J stated she asked CNA L if she had seen Resident #1 and she responded she had not seen him. LVN J stated she went to check his usual places, his friends' rooms and the smoking area and he was not there. LVN J stated she checked if Resident #1 signed himself out, but his name was not in the binder. LVN J stated she then requested all the CNAs to check every room, but Resident #1 could not be found. LVN J stated she then reported the information to the ADM. LVN J explained the old process for completing rounds was you would go to each room but did not have to sign anything. LVN J stated the new process has changed to hourly checks and if you arrive to a room and if the resident was not there you must look for them immediately. LVN J stated staff must now complete 15-minute door checks and someone would be stationed at the front desk 24-hours day. LVN J stated if someone were at risk for elopement you must complete an elopement assessment and the results would tell you if the resident was at risk. LVN J stated she would then inform the ADM, DON, and the ADON. LVN J explained the process for wander guards are each day on every shift, you must check to see if it was working. LVN J stated if the wander guard was not working properly, you must report it to the MD, the ADM, and the DON. LVN J stated if the wander guard were working properly, the light would be red, and it makes a continuous sound if a resident gets too close to the door. LVN J stated the alarm would have to be physically turned off at the nursing station. LVN J stated she was trained by the DON to take residents with wander guards to the front door to ensure the equipment was working properly. LVN J stated residents are not allowed to have the door code and staff must open the door for them to enter and exit the facility. LVN J stated she received a new door code, and the door code would now be changed monthly. LVN J stated Resident #1 could have been harmed, hit by a car, or even killed. <BR/>Interview with CNA L on 05/24/24 at 01:40 PM, she stated when she arrived to work 05/14/24 at 6:00 AM, she completed her rounds noticed Resident #1 was not in his room and his bed was made. CNA L stated when the breakfast trays arrived on the floor at approximately 8:30 AM, and CNA K took Resident #1 his breakfast tray, he was still not in his room. CNA L stated LVN J asked her if Resident #1 was in his room when she completed her rounds and she stated, No. CNA L stated her, and CNA K searched the inside and outside of the facility and did not see Resident #1. CNA L stated the process for completing rounds did not have a checklist at the time. CNA L stated you would inform the nurse if there were any concerns. CNA L stated now there was a checklist. CNA L stated if a resident was not in their room, they must search all rooms and they cannot wait and assume the resident was smoking. CNA L stated now CNAs complete rounds every odd hour and Nurses complete rounds every even numbered hour. CNA L stated since the elopement, if any resident signs themselves out to smoke and if the resident was not back within 15 minutes, staff must check on them. CNA L stated she had two residents on her hall that wears a wander guard, and she must make sure the wander guard was working by observing the light taking the resident to the door to sound the alarm. CNA L stated she must then sign the wander guard binder at the front desk. CNA L stated there was a sign-out binder for residents to sign out and staff must walk the resident to the door. CNA L stated staff was not allowed to share the door code with anyone. CNA L stated she was unsure how the residents previously received access to the door code. CNA L stated prior to this incident, Resident #1 had never tried to elope.<BR/>Surveyor attempted to interview CNA M on 05/24/24 at 02:00 PM, Surveyor left a voicemail and sent a text requesting a callback.<BR/>Record review of a Witness Statement dated 05/15/24 by CNA M revealed, I clocked in and walked his halls at 10:00 PM. Resident #1 was in his room. At approximately 11:00 PM, Resident #1 received ice. At midnight, Resident #1 was in his room. At 2:00 AM, another round was completed, and Resident #1 was in his room. During his last round at 4:00 AM, he assumed Resident #1 was asleep and did not disturb him nor his roommate.<BR/>Surveyor attempted to interview LVN I on 05/24/24 at 02:15 PM. Surveyor left a voicemail and sent a text requesting a callback.<BR/>Record review of a Witness Statement dated 05/15/24 sent in by LVN I revealed, I went to Resident #1's room early morning on 05/14/24 to administer medications to his roommate, Resident #3. I noticed Resident #1's bed was unmade, and Resident #3 was sitting in his wheelchair asleep in front of the television. There was light on in the restroom, the water was running, and the restroom door was closed all the way. I allowed Resident #1 to have privacy in the restroom. I left the main door unlocked per the roommate's request then moved on to the next room to continue passing medications.<BR/>2. Review of Resident #2's admission MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was moderately impaired, and he had hallucinations. He did not have wandering behaviors. His diagnoses included heart failure, diabetes, and Non-Alzheimer's Dementia, hemiplegia, and multiple sclerosis. <BR/>Review of Resident #2's Order Summary Report for May 2024 reflected:<BR/>04/24/24 Resident is wearing a wander guard device to the left ankle every shift for elopement. <BR/>04/24/24 To ensure that wander guard is functioning correctly, every shift take resident to front door to ensure that alarm sounds. If alarm does not sound, please alert Administrator as soon as possible every shift for elopement. <BR/>Review of Resident #2's Care Plans reflected: <BR/>05/24/24 Resident is an elopement risk/wanderer related to dementia. Resident has a wander guard on his left ankle. <BR/>Facility interventions included: <BR/>Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. <BR/>Identify pattern of wandering.<BR/>Provide structured activities.<BR/>Wander alert on left ankle. Monitor function and skin integrity every shift.<BR/>Review of Resident #2's Progress Notes reflected:<BR/>05/21/24 5:46 PM Resident noted packing his clothing and stating, I'm leaving I'm going home. Writer attempted to redirect resident. Unable to redirect resident. Writer called family; resident calmed down after speaking with family. - LVN A<BR/>05/22/24 2:30 PM Type: Behavior Note Resident insisted on leaving out the front door, despite receptionist attempts to redirect. Writer went outside and eventually was able to redirect resident to come back inside. Resident stated he wanted to go home. Called the wife and she said she was on the way. Resident appearing less agitated. - DON<BR/>05/22/24 5:09 PM SW spoke with resident about wanting to leave today. Resident was very agitated, upset, angry, and verbally making threats towards people. Resident verbalized that he was upset over his cigarettes and not seeing his family. SW took resident outside to smoke and talk. Resident became very agitated again and began to pace and not listen to redirection. Resident would partially deescalate and then allow himself to amp up once again. Resident Mrs. [NAME] is aware of his behaviors and actions. SW sent referral to two facilities. - SW<BR/>05/22/24 10:34 PM At approximately 7:27 PM alarm to the front door was sounding. Staff answered the alarm to discover resident was outside trying to leave the facility. Resident was stopped by staff and redirected back inside of facility. Resident placed on every 15-minute checks. - LVN A<BR/>05/23/24 9:15 AM Resident continues this morning to attempt leaving. Redirecting this behavior is getting more difficult. - DON<BR/>05/23/24 11:09 AM Late Entry<BR/>Resident being sent to hospital for evaluation. Arranging transportation. - DON<BR/>05/23/24 12:12 PM Resident noted with his belongings packed at the front door mentioning that he was leaving and didn't want to stay in this F** place no more, called the wife who is also the POA to talk to his and encourage him to wait for the social worker to get him another home, resident got very agitated and angry, threatening to leave any way notified the NP who gave an order to send resident to hospital, notified the wife transport arrived to pick up resident he refused to leave without all his belongings, cigarettes, bible, urinal he carried everything with him into the van, wife on the phone trying to convince him not to go with belongings resident was very adamant. Resident transported to hospital, Dr notified and DON aware. - ADON <BR/>05/23/24 3:06 PM Resident returned from hospital at approximately 1:27 PM with no paperwork. Resident was alert, responsive, calm, and cooperative at that time. Resident ambulating with walker ab lib in hallways. Displays no distress. Denies any pain/discomfort. - LVN A<BR/>05/23/24 10:24 PM The resident had a psych consult today with NP. New orders received to discontinue risperidone (used to treat schizophrenia) 2 and 3 mg and start risperidone 5 mg at bedtime, Depakote DR (anti-seizure medication and treats bipolar disorder) 250mg twice daily, change venlafaxine (anti-depressant) to every morning and a Valproic acid level and CBC 7 days after starting Depakote. - LVN A<BR/>05/25/24 3:01 PM Late Entry Resident forced himself out through the front door. Writer and another nurse ADON followed him and tried to redirect him, but resident did not want to listen or take directions. Resident was agitated and aggressive stating that he was going home. The ADON called resident's wife via video. Wife talked with the resident and asked him to come back into building. Wife told him that she will come to visit him today. Resident then came into the building. Resident redirected to his room. - LVN B<BR/>05/26/24 2:02 PM Resident followed another resident through the front door and forced himself outside. Writer tried to redirect resident and bring him back to the building, but resident refused and aggressively pushed the doors and got out. Writer then walked with the resident. Resident stated that he was going home, and he wanted to go buy cigarettes. Writer told resident that he had some cigarettes in the box. Resident then stated that he needed to sit down for few minutes. Writer stayed with resident outside for about 20 minutes. Resident then decided to come back into the building. Resident walked to his room and laid down on his bed. - LVN B<BR/>05/26/24 5:20 PM Writer asked the other staff member if they had seen the resident. CNA on duty stated that they were outside the smoke area with other residents, and he came back with other residents after the smoke break. Resident's walker noted at the dining hall, but resident is not there. Immediately all staff members alerted and started looking for the resident. All rooms searched but resident was not found. Administrator notified. Staff members went outside and searched around the building as some drove within the streets around, but resident was not found. Police notified and wife also called and notified. Staff members extended to search for the resident within the neighborhood, but resident was not found. Police arrived and were given description of the resident and gave the claim number. Police stated that if we find him before they do, we call them. - LVN B<BR/>Review of Resident #2's Ambulance Record, dated 05/26/24, reflected: <BR/>Dispatch notified: 7:31 PM<BR/>On scene: 7:36 PM<BR/>Resident transferred: 8:10 PM<BR/>Patient was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. EMS arrived and transfer station staff were pouring water on him in an attempt to cool him off. EMS transported patient to the hospital. <BR/>Review of Resident #2's Hospital Records, dated 05/26/24 8:30 PM, reflected:<BR/>Chief Complaint: slurred speech, extremity weakness, fall, unable to respond to questioning. Temperature 98.9 degrees Fahrenheit. <BR/>Final Diagnosis: Stroke<BR/>Review of website: timeanddate.com on 05/29/24 reflected the following temperatures:<BR/>[NAME] TX temperature:<BR/>5/26/24 4:53 PM 97 degrees<BR/>5/26/24 6:53 PM 97 degrees<BR/>Dallas TX temperature:<BR/>5/26/24 4:53 PM 97 degrees<BR/>5/26/24 6:53 PM 98 degrees<BR/>An interview on 05/28/24 at 2:00 PM with a family member of Resident #2 revealed facility staff told her the resident was trying to leave the facility prior to his elopement. She said facility staff did not say he was on any enhanced monitoring. The family member said Resident #2 had tried to leave the previous facility he was in also. She said Resident #2 moved to the current facility because the facility had the wander guard system. The facility called her on 05/26/24 between 5:30 PM and 6:00 PM to tell her the resident had eloped. On 05/27/24 a person from the hospital called her and said the resident had been found and was in the hospital. <BR/>An interview on 05/28/24 at 12:15 PM with the DON revealed she did not know how Resident #2 had eloped from the facility on 05/26/24. She said the resident was on 15-minute checks and provided a document showing 15-minute checks were completed and signed by staff. The DON said the resident kept attempting to get out of the facility and he was placed on a wander guard. She said the way the door worked was that if it was pressed on it would beep with the wander guard and then open. She said the resident was admitted on [DATE]. She said the facility staff noticed he was missing and began searching for the resident on 05/26/24. The DON said the resident was found in a gas station restroom and was taken to the hospital. The DON said the resident would not be returning to the facility. The DON said she had been working at the facility since 02/26/24. <BR/>An interview on 05/28/24 at 12:40 PM with the Administrator revealed she said Resident #2 kept trying to get out and the staff were keeping him in sight. The Administrator said the resident forced himself out earlier when visitors were coming in and he was holding the door even though the alarm sounded, and staff had to tell him in to coming back again. The Administrator said Resident #2 was on 15-minute checks.<BR/>Record review of the Resident Behavior Monitoring Log for Resident #2, dated 05-22-24 to 5-26-24 and provided by the DON, reflected 15-minute checks were documented and each entry was signed. The form showed LVN B's initials were signed for each entry on 05/26/24 from 6:00 AM to 5:45 PM. <BR/>An interview on 05/29/24 at 9:45 AM with LVN B revealed he last saw Resident #2 on 04/26/24 at 4:00 PM when he went out to smoke. His initials were on the 15-minute checks provided by the DON. He said he went back to passing medications and noticed the resident's walker was in the front area next to the kitchen. LVN B said he did not perform 15-minute monitoring checks and also did not sign a form saying that he did. He said the resident was on hourly checks. He said he was the charge nurse, and the other staff were also not performing 15-minute checks on the resident. <BR/>An interview on 05/29/24 at 11:06 AM with CNA C revealed she worked on 05/26/24 and last saw Resident #2 after smoke break between 4:00 PM and 4:30 PM. She said she was not checking on the resident every 15 minutes. She said she checked on the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #3) of 66 residents reviewed for assistive devices.<BR/>A portable heater was found in use in Resident #3's room without direct supervision.<BR/>This failure could place residents at risk for accidents or injuries.<BR/>Findings include:<BR/>Record review of Resident #3's Face sheet dated 01/28/2025 revealed that Resident #3 was a [AGE] year-old male that was initially admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, Age-Related Cognitive Decline and Partial traumatic Amputation of left foot at Ankle Level.<BR/>Record Review of Resident #3's Quarterly MDS Assessment and Care Screening dated 11/07/2024 revealed that Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. The resident required the use of a wheelchair and required supervision or touching assistance for all transfers and personal hygiene. <BR/>Record review of Resident #'3 Care Plan, dated 11/13/2024 revealed that Resident #3 has an Activity of Daily Living self-care deficit related to osteomyelitis [infection of the bone] of left foot post-surgical intervention, impaired cognition and makes poor decisions.<BR/>In an observation and interview on 01/28/2025 at 11:24 AM revealed Resident #3 was observed in his room, seated comfortably in a wheelchair. A portable heater was noted to be operating behind the resident within 2 feet of the resident's bed and privacy curtain. The resident stated that the facility had given him the portable heater to use because his in-wall unit was not working for the last two days. He stated that the air conditioning part of the in-wall unit worked fine but that the heat was not working. He stated that he liked it warm in his room.<BR/>In a set of observations from 01/28/2025 at 11:42 AM to 01/28/2025 to 11:42 AM revealed all other resident rooms were checked for portable heaters. No other portable heaters were found. <BR/>In an observation and interview on 01/28/2025 at 1:45 PM revealed the Maintenance Supervisor was observed removing the wall air conditioning/heater unit from Resident #3's room. The portable heater was no longer present in Resident #3's room. The Maintenance Supervisor stated that he had taken the portable heater out of Resident #3's room and he was in the process of replacing Resident #3's in-wall air conditioner/heater unit. He stated that Resident # 3 had been using the portable heater for the last 2 days and that the heater had an automatic turn-off switch if the portable heater fell over or was tipped. <BR/>In an interview on 01/28/2025 at 2:09 PM LVN A stated that she was not aware of anyone doing fire watches in the facility. She stated that fire watches meant that the staff had to check the entire facility every 15 minutes to make sure there were no fires in case the fire alarm system stopped or a power outage.<BR/>In an interview on 01/28/2025 at 2:29 PM LVN B stated that she had not heard anything about the facility having to do any fire watches or that Resident #3 had a portable heater in his room. She stated that she had been working for the last three days and that she had been unaware of any portable heaters in the building. She stated that she had thought portable heaters were not allowed in nursing facilities. <BR/>In an interview on 01/28/2025 at 3:30 PM the ADM stated that a portable heater could pose a fire risk to residents if a blanket, curtain or pillow got too close to it for a period of time. He stated that he had not done any fire watches while the portable heater was in use in Resident #3's room, and that the portable heater had been in use for the last two days.<BR/>In an interview on 01/28/2025 at 3:34 PM Maintenance Supervisor stated that portable heaters could cause fires if left unmonitored because something flammable could get next to a heater and possibly start a fire. He stated that he had replaced the in-wall unit in Resident #3's room and had meant too the day before but had not been able to get to it. He stated that he had replaced it a few hours ago and that there were no other portable heaters in use in the facility.<BR/>A policy for Portable Heaters in Nursing facilities was requested on 01/28/2025 at 3:17 PM but was not presented before the conclusion of the investigation.

**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 personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident #2) reviewed for privacy.<BR/>The facility failed to ensure LVN E locked the computer, which showed Resident #2's wound care information, after she walked away and left the computer unattended. <BR/>This failure could place residents at risk of having medical information exposed to others, and cause residents to feel uncomfortable and disrespected. <BR/>The findings include:<BR/>Record review of Resident #2's face sheet, printed on 05/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included sequelae of cerebral infarction (history of a stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side), Type II diabetes, atrial fibrillation (irregular and rapid heart rhythm), cellulitis of lower limb and groin, and congenital pancreatic cyst.<BR/>Record review of Resident #2's quarterly MDS assessment, dated 04/30/24, reflected Resident #2 had a BIMS score of 15, which indicated he was cognitively intact.<BR/>Record review of the physician orders tab of Resident #2's electronic health record reflected an order with a start date of 05/08/24, which read: Clean wound to the Penis with N/s or wound cleanser pat dry and apply house barrier cream twice daily for<BR/>18 days two times a day for wound care for 18 Days.<BR/>Observation on 05/17/24 at 2:30 PM through 2:38 PM revealed a computer was unlocked and displayed a wound care reminder for Resident #2. No facility nursing staff were observed at the nurse's station. Two residents and a facility visitor passed the nurses station during this time. At 2:38 PM, LVN D, LVN E and a third nurse were observed exiting Resident #2's room. LVN E returned to the computer at the nurse's station, updated the wound care note, locked the computer and left the nurse's station. <BR/>In an interview on 05/17/24 at 2:29 PM, LVN E stated she worked as the facility's 2:00 PM to 10:00 PM, station 1 nurse for roughly 2 weeks. LVN E stated the computer observed unlocked and unattended was used by her. LVN E stated the system showed a wound care reminder for Resident #2 and she left to see if the residents wound was still active. LVN E stated she walked away from the nurse's station to confirm the residents wound but had forgotten to lock the computer. LVN E stated she was trained to protect all resident's information and to lock her computer before leaving it unattended. LVN E stated her actions violated Resident #2's privacy, as his information could have been seen or recorded by individuals who should not have access to his information. <BR/>In an interview on 05/17/24 at 4:49 PM, the DON stated she was not aware Resident #2's records were left open and unattended. The DON stated it was her expectation for facility nursing staff to uphold HIPAA and lock computer screens when they were away from them. The DON stated all staff were to ensure residents charts were protected at all times. The DON stated leaving residents charts open and unattended could give unauthorized access to resident charts. The DON stated she would in-service staff on HIPAA and would do random computer sweeps. <BR/>In an interview on 05/17/24 at 5:24 PM, the ADMIN stated residents' records should be safe by coverings and locks at all times due to HIPAA, as not doing so could expose residents' records and violate their privacy. The ADMIN stated nursing staff who accessed any resident information were to ensure the records were secure and protected. The ADMIN stated she would in-service staff on HIPAA, confidentiality and privacy. <BR/>Record review of the facility's policy entitled Resident Rights, revised in December 2016, read in part:<BR/> . 3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA Compliance Officer

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for three of three residents (Residents #2 and #1) reviewed for ADL care.<BR/>The facility failed to ensure Residents #2 and #1 bathed/showered three times a week as per their shower schedule. <BR/>This failure could place residents at risk of skin breakdown, infection and loss of self-esteem. <BR/>The findings include:<BR/>1. Record review of Resident #2's face sheet, printed on 05/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included sequelae of cerebral infarction (history of a stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side), Type II diabetes, atrial fibrillation (irregular and rapid heart rhythm), cellulitis of lower limb and groin (bacterial infection), and congenital pancreatic cyst.<BR/>Record review of Resident #2's quarterly MDS assessment, dated 04/30/24, reflected Resident #2 had a BIMS score of 15, which indicated he was cognitively intact.<BR/>Record review of Resident #2's care plan, revised on 04/03/24, reflected the following:<BR/>The resident has an ADL self-care performance deficit r/t obesity. Recent CVA with right sided weakness. Provisions are made to care as needed, when patient is able to assist more, requiring less support of staff, staff allows patient to do so, at other times when<BR/>patient may not be able to assist as much, staff provides more support to ensure that all needs are met. Limited Mobility . Intervention : Bathing/Showering: The resident is totally dependent on 2 staff to provide bed bath and as necessary.<BR/>Record review of the tasks tab of Resident #2's electronic health record, showering/bathing task reflected No data found, for the past 30 days. <BR/>Record review of Resident #2's Shower Sheets from March 2024 through May 2024 reflected Resident #2 received a bed bath on 04/03/24, 04/10/24, 04/24/24, 05/07/24 and 05/13/24. <BR/>In an interview on 05/17/24 at 10:47 AM, Resident #2 stated he was well. Resident #2 stated he had issues getting his bed baths according to his scheduled days, which were Mondays, Wednesdays and Fridays. Resident #2 stated when he asked the facility staff for a shower, he was told there were not enough staff to give him a shower. Resident #2 stated he received his last bed bath on Monday, 05/13/24. Resident #2 stated he reported his shower issues to the ADMIN and DON, but nothing had changed, which upset him. <BR/>2. Record review of Resident #1's face sheet, printed on 05/17/24, reflected Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute kidney failure, gastrointestinal hemorrhage, major depressive disorder, extrarenal uremia (functional kidney disease), type 2 diabetes and essential hypertension. <BR/>Record review of Resident #1's MDS assessment, dated 04/07/24, reflected Resident #1 had a BIMS score of 08, which indicated a moderate cognitive impairment. Section GG - Functional Abilities and Goals, question GG0130, reflected Resident #1 required substantial assistance with ADLs of toileting hygiene, showering and dressing. <BR/>Record review of Resident #1's care plan, revised on 03/28/24, reflected the following:<BR/> .Focus: The resident has an ADL self-care performance deficit r/t CVA /c right side hemiparesis. Bed- partial to substantial assist of 1-2 Transfers- partial to substantial assist of 1- 2 Eating- partial assist of 1. Toileting- partial to substantial assist of 1-2 Provisions are made to care as needed, Level of assistance may vary depending on my condition. Interventions . Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated <BR/>Record review of the tasks tab of Resident #1's electronic health record, titled showering/bathing task reflected No data found, for the past 30 days.<BR/>Record review of Resident #1's Shower Sheets from March 2024 through May 2024 reflected Resident #1 received a bed bath on 04/12/24, no other shower documentation was reviewed. <BR/>In an interview on 05/17/24 at 11:37 AM, Resident #1 stated he received his showers but could not indicate when his last shower was or how often he received showers. <BR/>In an interview on 05/17/24 at 12:42 PM, LVN A stated she was the Station 1 nurse, who assigned to Halls 100, 200, and 300. LVN A stated she had not received any complaints regarding residents not receiving their showers. LVN A stated she had not received any reports of Resident #1 or Resident #2 refusing showers. <BR/>In an interview on 05/17/24 at 3:30 PM, the DON stated she was unaware of the lack of shower documentation for Residents #1 and #2. The DON stated the facility aides were responsible for all ADL care and facility nurses were to ensure ADLs were completed. The DON stated if the system showed a task as no data found, it meant the task was not schedule and the system would not alert staff the task needed to be completed. The DON check the electronic care system and confirmed showers were not scheduled, thus unable to be documented when completed. The DON stated she would immediately update the residents' systems. The DON stated aides also documented showers in the facility's shower log book at the nurse's station. The DON stated she was unaware Resident #1 had 1 shower and Resident #2 had 5 showers documented in the Shower Log book for the past month. The DON stated residents should receive showers according to their schedule and as requested. The DON stated she was certain the residents had received their showers or bed baths but possibly staff forgot to document. <BR/>In an interview on 05/17/24 at 4:08 PM, CNA F stated she was Resident #2's 2:00 PM to 10:00 PM aide. CNA F stated as the aide she was responsible for all ADL care, like incontinent care and showers. CNA F stated showers were provided to the residents in even rooms on B-bed during her shift. CNA F stated she believed Resident #2 received a bed bath on Monday, 05/13/24. CNA F stated showers were documented on shower sheets and electronically. CNA F stated she could not recall how often she provided Resident #2 with a shower. <BR/>In a follow-up interview on 05/17/24 at 4:49 PM, the DON stated it was the facility's expectation for residents to be provided showers according to schedule, upon request and the task be documented, regardless of outcome. The DON stated all nursing staff were to ensure showers were provided. The DON stated showers not received regularly could lead to an unclean appearance, behaviors, depression and infections. The DON stated he would in service staff on ADL care and she and the ADON would conduct shower sheet audits to ensure all showers were given and documented. <BR/>In an interview on 05/17/24 at 5:24 PM, the ADMIN stated she was not aware of the lack of showers provided and documented for Residents #1 and #2. She stated showers should be done according to the facility's schooled and documented. The ADMIN stated aides were to complete the showers and nurses were to ensure the shower was provided and documented correctly. She stated not receiving regular showers could lead to skin breakdown. The ADMIN stated she would begin an in service on ADL Care and documentation. The ADMIN stated the Assistant Director of Nursing would be tasked with shower documentation audits to ensure showers were provided and documented as needed. <BR/>Record review of the facility's policy entitled Activities of Daily Living (ADLs), Supporting, revised in March 2018, read in part:<BR/>Policy Statement: Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of five residents (Resident #2) reviewed for storage of medication.<BR/>The facility failed to ensure a 0.9% sodium chloride syringe was not stored at Resident #1's bedside table and failed to ensure it was secured in the medication cart or medication room.<BR/>This failure could place residents at risk of medication misuse.<BR/>The findings include:<BR/>Record review of Resident #2's face sheet, printed on 05/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included sequelae of cerebral infarction (history of a stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side), Type II diabetes, atrial fibrillation (irregular and rapid heart rhythm), cellulitis of lower limb and groin, and congenital pancreatic cyst.<BR/>Record review of Resident #2's quarterly MDS assessment, dated 04/30/24, reflected Resident #2 had a BIMS score of 15, which indicated he was cognitively intact.<BR/>Record review of the progress notes tab of Resident #2's electronic health record reflected a progress note, dated 04/23/24, and written by LVN B, reflected the following:<BR/>Resident [#2] readmitted back to facility to room [ROOM NUMBER]B, transported by [company] via stretcher, resident able to roll himself to bed x1 person assist. resident AAO x3 able to make needs known, resident reoriented to his room use of call light and bed control resident acknowledges understanding. Resident has a double lumen central line to his right upper chest flushed patent .<BR/>Record review of the physician orders tab of Resident #2's electronic health record, dated 04/24/24, revealed the following order:<BR/>Flush Central Line With 5ml Normal Saline Pre and Post Medication Administration. Flush With 5ml Of Heparin Post Med Administration Every Day and Night Shift Related to Cellulitis of Left Lower Limb<BR/>Interview and observation on 05/17/24 at 10:27 AM revealed Resident #2 in his room, lying in his bed. There was a packaged syringe labeled 0.9% sodium chloride and several alcohol swabs on Resident #2's bedside table. Resident #2 stated the facility nurses put the saline solution in his port, while pointing at the right side of his chest, and stated they always leaving something in here. Resident #2 stated he did not pay attention to when the syringe was left in his room but the last two nurses who came in his room used a syringe on his port. <BR/>In an interview and observation on 05/17/24 at 12:42 PM, LVN A stated she was the nurse for Station 1, which covered the facility's 100, 200 and 300 halls. LVN A stated she was not aware that a syringe was left in a resident's room. LVN A accompanied the State Surveyor to Resident #2's room to observe the syringe left in the room. LVN A stated the syringe was a flush used to flush the resident's central line and it should have been taken out of the room with the nurse who bought it in the room. LVN A stated she did not leave the syringe in Resident #2's room, and it must have been left by the morning or overnight nurse. As the State Surveyor was leaving Resident #2's room, he stated LVN A was not his assigned nurse but the nurse in pink(LVN D) was.<BR/>In an interview on 05/17/24 at 1:24 PM, revealed LVN D was Resident #2's assigned nurse for the 6:00 AM to 2:00 PM shift. LVN D stated the syringe observed in Resident #2's room was a saline flush. LVN D stated she flushed Resident #2's central line before and after his morning medication administration. LVN D stated she did not recall leaving a flush in Resident #2's room or seeing a flush in the room when she entered. LVN D stated it was her responsibility as the nurse to remove all medications and any biologicals from a resident's room. LVN D stated she was uncertain of how leaving the flush in a resident's room could affect them and stated a resident could use the flush inappropriately. <BR/>In an interview on 05/17/24 at 4:49 PM, the DON stated LVN D told her of the saline flush that was left in Resident #2's room prior to her interview with the State Surveyor. The DON stated it was her expectation for medication, biologicals and all medication supplies should not be left in a resident's room. The DON stated the saline syringe could be contaminated and accidentally used if left in residents' rooms. The DON stated she would in-service nursing staff on medication storage to ensure medication items were not improperly stored.<BR/>In an interview on 05/17/24 at 5:24 PM, the ADMIN stated it was the facility's expectation for medications, biologicals and supplies to never be left in a resident's room. The ADMIN stated facility nurses were to ensure medications and supplies were not left in resident's room. The ADMIN stated medications and supplies could be tampered with and harm the resident. The ADMIN stated the resident could have attempted to flush his central line himself, but she did not believe Resident #2 would do so, due to his cognition. The ADMIN stated she would in-service staff on medication storage. <BR/>Record review of the facility's policy entitled Storage of Medications, revised in April 2007, read in part:<BR/> Policy Statement: The facility shall store drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: .2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner . 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. <BR/>The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings Include:<BR/>Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room.<BR/>Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room .<BR/>An interview on 03/07/24 at 9:20 a.m., Resident #6 revealed that he had seen many black small flies and roaches all over the facility.<BR/>An interview on 03/07/24 at 9:24 a.m., Resident # 6 stated that he had seen flying black gnats and roaches in many areas of the facility. He did not state how long he had been seeing the insects/pest or if he had seen pest control at the facility. <BR/>Observation on 03/07/24 at 9:37 a.m. in the 300-hall shower room revealed 15-20 small black flies or gnats either alighted on the shower curtain to shower stall #1 or flying near a large plastic bag filled with wet towels near shower stall #1. Four dead roaches were observed on the floor underneath the shower curtain for shower stall #1.<BR/>An interview on 03/07/24 at 2:57 p.m., MA A stated that she had seen gnats and roaches all over the facility and in resident rooms. She stated that the staff were supposed to write down bug sightings in some book, but she did not know where the book was, and she denied knowing what a pest sighting log was. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:33 p.m., CNA B revealed she had seen many roaches and gnats in room [ROOM NUMBER] and she had seen gnats and roaches in room [ROOM NUMBER] room that day (03/07/24). She stated hat she had never seen a pest sighting log, and she was not sure where the staff were supposed to write those things down. She stated that the staff just reports bugs to the maintenance manager. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:40 p.m., Housekeeper C stated that he did sometimes see gnats and that he was not sure how to report insects at the facility. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:50 p.m., CNA D revealed that she had seen gnats and roaches at the facility and denied knowing that she had to log them in the pest sighting log.<BR/>An interview on 03/07/24 at 4:00 p.m., RN E revealed that he had seen gnats and roaches in the facility and that he thought there was a book somewhere to write them down (insect sightings) but he did not know where the book was. <BR/>An interview on 03/07/24 at 4:06 p.m. CNA F stated that she had seen many gnats and roaches at the facility. She stated that she tells the maintenance manager about insects when she sees him. She stated that she had never heard of a pest sighting log.<BR/>An interview on 03/07/24 at 4:14 p.m., the Administrator stated that the staff were supposed to use the pest sighting log and that the staff had been trained on using the pest sighting log but that they just tell the maintenance manager instead. She stated that having gnats in the facility could affect residents negatively and mentally and could pose a risk of cross contamination.<BR/>An interview on 03/07/24 at 6:17 p.m., the DON revealed she had seen some gnats around the facility and that she thought staff were supposed to log insects in the pest sighting log. She stated that it could be very annoying for residents to have to deal with gnats and that it could affect their mental health and could possibly cause cross contamination. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the Facility's Pest Sighting Log/Pest Control Binder revealed: that the last pest sighting logged in the pest sighting log was 08/09/23 for flies, no other more recent entries could be found.<BR/>Review of Pest Control Service Inspection Report dated 02/15/24 revealed taget pest treated were rodents (rodent bait stations), german cockroaches in the kitchen and laundry area. This was the last inspection/service report in the binder. <BR/>Record review of the facility's policy dated May 2008, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat residents with respect and dignity for one (Resident #3) of six residents reviewed for Resident rights. <BR/>The Nursing staff failed to ensure Resident #3 did not have food and drink stains on his shirt for over three hours on 03/07/24. <BR/>This failure could affect residents who require assistance with meals, which could cause their food and drinks to fall onto their clothes, resulting in a sense of diminished self-worth and psycho-social well-being. <BR/>The findings included:<BR/>Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 08 (Severe cognitive impairment), no behaviors, with upper and lower extremity impairments of both sides and used a wheelchair. He was partial/moderate assist with eating and substantial/maximum assist with mobility and had progressive neurological conditions. His diagnoses included anemia, neurogenic bladder, aphasia, hemiplegia/hemiparesis, multiple sclerosis, malnutrition, depression, dysphagia, anorexia, lack of coordination, muscle weakness, cognitive communication deficit. He was on a mechanically altered diet. <BR/>Review of Resident #3's Care Plan dated December 2023 revealed: I have a nutritional problem related to protein malnutrition. I will need a regular diet mechanical consistency with large portions with house shake .I will comply with the recommended diet daily through next review date .staff will assist Resident #3 with his diet, encourage him to eat all of his food, and encourage him to eat his fortified foods .I have left hemiparesis and Multiple Sclerosis with decreased Range of motion to my upper and lower extremities .I will remain free of complications or discomfort related to hemiplegia/hemiparesis left side through review date .Range of motion (active/passive) with am/pm care daily. <BR/>Observation on 03/07/24 at 9:10 am, Resident #3 was sitting across from the nurse's station, in a high back recliner wheelchair. He had on a light green shirt with several dried brownish stains along his chest area.<BR/>Observation on 03/07/24 at 12:47 pm, Resident #3 was sitting across from the nurse's station, in his high back recliner wheelchair. He had on a light green shirt with several brownish stains and new reddish and black stains along his chest area. <BR/>Interview on 03/07/24 at 3:49 pm, CNA D stated Resident #3 needed feeding assistance. She stated all the staff were not the same by putting a cloth around his chest, but she always did, so that his clothes would not get stained. <BR/>Interview on 03/07/24 at 4:25 pm, [Anonymous] stated most of the staff used a towel around his neck to avoid getting his clothes dirty from food dropping on him and keeping him clean.<BR/>Interview on 03/07/24 at 4:41 pm, the ADON stated whenever they fed Resident #3, they were supposed to put a paper cloth around his neck to prevent him for messing up his clothes. She stated if the staff noticed a resident with stains on their shirts, the staff should change them immediately. She stated Resident #3 had stains on his shirt at times but did not notice that today (03/07/24). She stated it was a dignity issue if resident's clothes were dirty. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she had not noticed Resident #3's shirt had stains on it today (03/07/24). She stated she would find out who cared for him today (03/07/24) to talk to them about the matter. She stated all staff were responsible for ensuring the residents looked clean and presentable. <BR/>Record review of the facility's Resident Rights policy dated 2001 revised 2016 revealed, Employees should treat all residents with kindness, respect and dignity .Policy interpretation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the rights to be free to: a dignified existence .<BR/>Record Review of the Facility's Activities of Daily Living (ADLs) supporting policy dated 2001 and revised 2018 revealed, Policy Statement: Residents will be provided with the care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three (Halls 100, 400 and 500) of six halls and one (main dining room) of two dining rooms and one of one kitchen and one (facility entrance) of one reviewed for environment.<BR/>(A)The facility failed to ensure the exit door on the 100 hall and front of Resident #5's room door was clean and in good repair.<BR/>The facility failed to ensure the floors on halls 100, 400 and 500 were clean and in good repair. <BR/>The facility failed to ensure the flooring in the dining room next to the kitchen entrance and ice machine was clean and in good repair. <BR/>The facility failed to clean or replace the two rusty panic bars on hall 100 and 2 rusty panic bars on hall 500.<BR/>The facility failed to ensure Resident #9's room was cleaned thoroughly. <BR/>(B) The facility failed to ensure the floor drainage system in the kitchen was not clogged up.<BR/>The facility failed to ensure the front entrance of the facility was clean and in good repair. <BR/>These failures could affect all residents, resulting in falls and cross contamination, resulting in injury and stomach illnesses which could lead to a decline in the resident's health and physical functioning.<BR/>Findings included:<BR/>(A)Observation on 03/07/24 at 9:14 am, the floor at the entrance of Resident #5's room had assortment of colors, the flooring in the resident's room was dark brown. Around the entrance of the resident's door was one light brown tile and one grey tile. There were several layers of accumulated blackish dirt around the door and the door frame had blackish debris and chipped paint, dry rot and rust along it.<BR/>Observation on 03/07/24 at 12:49 pm, the 2 barrier door's panic bars on the 100 hall had a large amount of rust spots and scrape marks on them. <BR/>Observation on 03/07/24 at 12:50 pm, the 100 hall exit door had accumulated layers of blackish dirt, scuff marks, chipped paint, and dry rot. The corner of the door had a quarter size hole and light from the outside could be seen. The baseboards by the exit door had several layers of bumpy and chipped paint and accumulated blackish dirt. <BR/>Observation at 03/07/24 at 12:52 pm, the 2 barrier door's panic bars on the 500 hall had a large amount of rust spots and scrape marks and brownish debris particles covered most of the metal areas on the panic bars. <BR/>Observation 03/07/24 at 1:01 pm, in the main dining room, the white flooring tiles around the ice machine entrance door of kitchen appeared to have several areas of accumulated blackish dirt and grime. The drain by the ice machine had brownish rust stains and blackish dirt on and around it, the tiles were cracked and missing some areas of the tiles. The lower right side of the ice machine had yellowish colored drip stains on it and there was rust under two of the four legs. The white kitchen door had a large area of blackish smudge and the bottom of the door had bumpy/uneven paint and blackish dirt. The flooring around the door frame had brownish rust stains and blackish accumulated dirt and the corners had debris particles.<BR/>Interview on 03/07/24 at 3:30 pm, [Anonymous] stated the housekeepers did not do a good job cleaning the facility. They spoke to the Housekeeping/Maintenance Supervisor, but he had not been back to work this week. They stated when things were broken, they wrote up a repair request in the book up front. They stated noticing the rust and broken flooring and walls in the rooms and common area and had spoken to Housekeeping/Maintenance but could not remember what his response was. They stated if the facility was not cleaned properly, it could cause the residents to develop infections and probably get sick. They was not sure why They had not mentioned the housekeeping and maintenance concerns to the Administrator. They stated if things around the facility were broken it could cause the residents to trip and fall. <BR/>Interview on 03/07/24 at 4:13 pm, the Dietary Director stated the door entrance to the kitchen door needed to be painted and door frame needed to be repaired. He stated he had not really paid attention to the rust on the hallway doors but that floors were yucky and cracked. He stated the floor drain next to the kitchen front entrance was not rusted but just had paint loss and the original metal was what was exposed. He stated the Housekeeping/Maintenance Supervisor was on leave since last Monday and said their corporate office or a repair company to come out to fix stuff. He stated some areas on the flooring needed extensive repairs. <BR/>Interview on 03/07/24 at 5:28 pm, the SW stated the residents in the February 2024 Resident Council meeting said they felt like the housekeepers were not cleaning good enough. She stated Resident #9complained about housekeeping services last January 2024. She stated the housekeeping issues should have been addressed by the Maintenance/Housekeeper and was not sure if the complaints were resolved. She stated the Maintenance/Housekeeper Supervisor should have spoken with the weekend housekeeper to clean and pick up trash properly. She stated she was responsible for ensuring the complaints were follow-up on and she said she was not sure why she had not done so. She added the facility's floors were a continuous battle because the glue rose up and dried on top of the flooring tiles. She stated the Maintenance/Housekeeping Supervisor did his best to make sure the facility was cleaned and in good repair. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she tried some best practice trainings with the housekeepers because she noticed some areas were being missed. She stated she noticed the barrier door grab bars were rusty and Housekeeping/Maintenance Supervisor had a to do list to fix them. She stated their Housekeeping/Maintenance Supervisor had not worked for the past few days and they just hired a Maintenance Assistant, but he did not know how to repair much yet.<BR/>(B) Observation and interview on 03/07/24 at 9:00 AM, the floors in the facility entry area appeared to have spots of built-up black grime in the seams of the tiles. The doors around the entrance appeared to have general wear from wheelchairs. <BR/>Observation on 03/07/24 at 9:10 AM, around the RN nurses' station, the floors in this area also had built up grime in the seams. <BR/>Observation and interviews on 03/07/24 at 9:43 AM, the floor drains in the kitchen were backed up with dirty water and leveled with the floor. One drain was observed to have the hose of a wet vac inserted into the drain to drain out water. The Dietary manager stated having drainage issues for a few months. He stated there had been people at the facility to fix it a few times, but the floor drains were still backed up. <BR/>Interview on 03/07/24 at 3:40 PM, Housekeeper C stated that the problem with the floors was that the glue kept seeping through the seams. She stated they tried to mop the glue up, but it did not come off the floor. <BR/>Interview on 03/07/24 at 4:14 PM, the Administrator stated they had some issues with the floors, because there was grime build up on them . She stated they were supposed to get them redone and the owner told her the floors were really not working for this environment. She stated she agreed the floors looked Icky (disgusting) which could make the residents feel bad about their home. She stated she knew about the drainage problem in the kitchen which had been going on for a few months. She stated they tried to get some people in there to take care of it, but nothing worked so far. She stated she knew the drainage issue in the kitchen could cause a cross contamination problem. <BR/>Record review of the facility's Grievance form dated 01/17/24 revealed, Resident #9 - housekeeping needs .<BR/>Record review of the Resident Council minutes dated 02/17/24 revealed, C. Housekeeping & Laundry Department .feels like some of the housekeepers do bare min. when asked to clean their rooms.<BR/>Record review of the last two months (02/26/24 - 03/26/24) maintenance log sheets did not reveal any requests to repair the kitchen's floor drain, common areas in the hallways and main dining room.<BR/>Record review of the Facility's Cleaning and disinfection of Environmental Surfaces policy dated 2001 revised 2009 revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected, according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens Standard .Policy Interpretation and implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Critical items, semi critical items and non-critical items .9. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . <BR/>Record review of the Facility's Maintenance Service policy dated 2001 and revised 2009 revealed, Policy Statement: Maintenance services should be provided to all areas of the building, grounds and equipment .Policy interpretation:2. b. Maintaining the building in good repair and free from hazards .i. providing routinely scheduled maintenance services to all areas .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, equipment are maintained in a safe and operable manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. <BR/>The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings Include:<BR/>Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room.<BR/>Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room .<BR/>An interview on 03/07/24 at 9:20 a.m., Resident #6 revealed that he had seen many black small flies and roaches all over the facility.<BR/>An interview on 03/07/24 at 9:24 a.m., Resident # 6 stated that he had seen flying black gnats and roaches in many areas of the facility. He did not state how long he had been seeing the insects/pest or if he had seen pest control at the facility. <BR/>Observation on 03/07/24 at 9:37 a.m. in the 300-hall shower room revealed 15-20 small black flies or gnats either alighted on the shower curtain to shower stall #1 or flying near a large plastic bag filled with wet towels near shower stall #1. Four dead roaches were observed on the floor underneath the shower curtain for shower stall #1.<BR/>An interview on 03/07/24 at 2:57 p.m., MA A stated that she had seen gnats and roaches all over the facility and in resident rooms. She stated that the staff were supposed to write down bug sightings in some book, but she did not know where the book was, and she denied knowing what a pest sighting log was. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:33 p.m., CNA B revealed she had seen many roaches and gnats in room [ROOM NUMBER] and she had seen gnats and roaches in room [ROOM NUMBER] room that day (03/07/24). She stated hat she had never seen a pest sighting log, and she was not sure where the staff were supposed to write those things down. She stated that the staff just reports bugs to the maintenance manager. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:40 p.m., Housekeeper C stated that he did sometimes see gnats and that he was not sure how to report insects at the facility. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:50 p.m., CNA D revealed that she had seen gnats and roaches at the facility and denied knowing that she had to log them in the pest sighting log.<BR/>An interview on 03/07/24 at 4:00 p.m., RN E revealed that he had seen gnats and roaches in the facility and that he thought there was a book somewhere to write them down (insect sightings) but he did not know where the book was. <BR/>An interview on 03/07/24 at 4:06 p.m. CNA F stated that she had seen many gnats and roaches at the facility. She stated that she tells the maintenance manager about insects when she sees him. She stated that she had never heard of a pest sighting log.<BR/>An interview on 03/07/24 at 4:14 p.m., the Administrator stated that the staff were supposed to use the pest sighting log and that the staff had been trained on using the pest sighting log but that they just tell the maintenance manager instead. She stated that having gnats in the facility could affect residents negatively and mentally and could pose a risk of cross contamination.<BR/>An interview on 03/07/24 at 6:17 p.m., the DON revealed she had seen some gnats around the facility and that she thought staff were supposed to log insects in the pest sighting log. She stated that it could be very annoying for residents to have to deal with gnats and that it could affect their mental health and could possibly cause cross contamination. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the Facility's Pest Sighting Log/Pest Control Binder revealed: that the last pest sighting logged in the pest sighting log was 08/09/23 for flies, no other more recent entries could be found.<BR/>Review of Pest Control Service Inspection Report dated 02/15/24 revealed taget pest treated were rodents (rodent bait stations), german cockroaches in the kitchen and laundry area. This was the last inspection/service report in the binder. <BR/>Record review of the facility's policy dated May 2008, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of five residents (Resident #2) reviewed for storage of medication.<BR/>The facility failed to ensure a 0.9% sodium chloride syringe was not stored at Resident #1's bedside table and failed to ensure it was secured in the medication cart or medication room.<BR/>This failure could place residents at risk of medication misuse.<BR/>The findings include:<BR/>Record review of Resident #2's face sheet, printed on 05/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included sequelae of cerebral infarction (history of a stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side), Type II diabetes, atrial fibrillation (irregular and rapid heart rhythm), cellulitis of lower limb and groin, and congenital pancreatic cyst.<BR/>Record review of Resident #2's quarterly MDS assessment, dated 04/30/24, reflected Resident #2 had a BIMS score of 15, which indicated he was cognitively intact.<BR/>Record review of the progress notes tab of Resident #2's electronic health record reflected a progress note, dated 04/23/24, and written by LVN B, reflected the following:<BR/>Resident [#2] readmitted back to facility to room [ROOM NUMBER]B, transported by [company] via stretcher, resident able to roll himself to bed x1 person assist. resident AAO x3 able to make needs known, resident reoriented to his room use of call light and bed control resident acknowledges understanding. Resident has a double lumen central line to his right upper chest flushed patent .<BR/>Record review of the physician orders tab of Resident #2's electronic health record, dated 04/24/24, revealed the following order:<BR/>Flush Central Line With 5ml Normal Saline Pre and Post Medication Administration. Flush With 5ml Of Heparin Post Med Administration Every Day and Night Shift Related to Cellulitis of Left Lower Limb<BR/>Interview and observation on 05/17/24 at 10:27 AM revealed Resident #2 in his room, lying in his bed. There was a packaged syringe labeled 0.9% sodium chloride and several alcohol swabs on Resident #2's bedside table. Resident #2 stated the facility nurses put the saline solution in his port, while pointing at the right side of his chest, and stated they always leaving something in here. Resident #2 stated he did not pay attention to when the syringe was left in his room but the last two nurses who came in his room used a syringe on his port. <BR/>In an interview and observation on 05/17/24 at 12:42 PM, LVN A stated she was the nurse for Station 1, which covered the facility's 100, 200 and 300 halls. LVN A stated she was not aware that a syringe was left in a resident's room. LVN A accompanied the State Surveyor to Resident #2's room to observe the syringe left in the room. LVN A stated the syringe was a flush used to flush the resident's central line and it should have been taken out of the room with the nurse who bought it in the room. LVN A stated she did not leave the syringe in Resident #2's room, and it must have been left by the morning or overnight nurse. As the State Surveyor was leaving Resident #2's room, he stated LVN A was not his assigned nurse but the nurse in pink(LVN D) was.<BR/>In an interview on 05/17/24 at 1:24 PM, revealed LVN D was Resident #2's assigned nurse for the 6:00 AM to 2:00 PM shift. LVN D stated the syringe observed in Resident #2's room was a saline flush. LVN D stated she flushed Resident #2's central line before and after his morning medication administration. LVN D stated she did not recall leaving a flush in Resident #2's room or seeing a flush in the room when she entered. LVN D stated it was her responsibility as the nurse to remove all medications and any biologicals from a resident's room. LVN D stated she was uncertain of how leaving the flush in a resident's room could affect them and stated a resident could use the flush inappropriately. <BR/>In an interview on 05/17/24 at 4:49 PM, the DON stated LVN D told her of the saline flush that was left in Resident #2's room prior to her interview with the State Surveyor. The DON stated it was her expectation for medication, biologicals and all medication supplies should not be left in a resident's room. The DON stated the saline syringe could be contaminated and accidentally used if left in residents' rooms. The DON stated she would in-service nursing staff on medication storage to ensure medication items were not improperly stored.<BR/>In an interview on 05/17/24 at 5:24 PM, the ADMIN stated it was the facility's expectation for medications, biologicals and supplies to never be left in a resident's room. The ADMIN stated facility nurses were to ensure medications and supplies were not left in resident's room. The ADMIN stated medications and supplies could be tampered with and harm the resident. The ADMIN stated the resident could have attempted to flush his central line himself, but she did not believe Resident #2 would do so, due to his cognition. The ADMIN stated she would in-service staff on medication storage. <BR/>Record review of the facility's policy entitled Storage of Medications, revised in April 2007, read in part:<BR/> Policy Statement: The facility shall store drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: .2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner . 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #12, #6, #36, #30, #42) of eight residents reviewed for infection control.<BR/>1. <BR/>RN B failed to disinfect the glucometer in between blood glucose checks for Residents #12 and #6.<BR/>2. <BR/>LVN A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #36, #30 and #42.<BR/>These failures could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>1. <BR/>Review on 06/29/22 of Resident #12 EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses that included stroke affecting unspecified side, cognitive communication deficit, diabetes, high blood pressure. <BR/>Review of Resident #12's MDS, dated [DATE], revealed a BIMS score of 6, indicating moderate impairment, mobility requiring two persons to assist. <BR/>Review of Resident #12's care plan, dated 06/27/22, revealed she was care planned for wound to her right breast.<BR/>Review on 06/29/22 of Resident #6's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, Cognitive communication deficit, and muscle weakness.<BR/>Review of Resident #6's MDS, dated [DATE], revealed a BIMS score of 8 indicating moderate impairment, mobility requiring one to two persons to assist. <BR/>Review of Resident #6's care plan, dated 05/07/21, revealed she was care planned for risk of pressure ulcers related to diabetes and she refuses for skin to be assessed most of the times.<BR/>Observation on 06/27/22 at 7:24 AM revealed RN B performing bedside finger stick glucose check on Resident #12. RN B failed to sanitize the glucometer before or after using it on Resident #12.<BR/>Observation on 06/27/22 at 7:31 AM revealed RN B performing bedside finger stick glucose check on Resident #6. RN B failed to sanitize the glucometer before or after using it on Resident #6.<BR/>Interview on 06/27/22 at 12:45 PM of RN B she stated reusable equipment, like glucometer, should be sanitized with wipes between each resident use in order to prevent transmitting an infection from one resident to another. She stated that if she forgot to wipe the glucometer because the presence of the surveyor made her more nervous.<BR/>2. <BR/>Review on 06/29/22 of Resident #36's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, chronic obstructive pulmonary disease, and hypertension. <BR/>Review of Resident #36's MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate impairment, his functional status indicated he needed setup help only with hid ADLs. <BR/>Review of Resident #36's care plan, date 11/09/21, revealed he was care planned for being at risk for pressure ulcer development related to incontinence and Parkinson's Disease.<BR/>Review of Resident #30's EHR revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included epilepsy, hypertension, muscle weakness, and age-related cognitive decline. <BR/>Review of Resident #30's MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate impairment. His mobility status indicated he needed one-person physical assist, needed assistance for his ADLs and mobility. <BR/>Review of Resident #30's care plan, dated 05/04/22, revealed he was care planned for history of testing positive for COVID-19. <BR/>Review of Resident #42's EHR revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, diabetes, delusional disorder, and hypertension. <BR/>Review of Resident #42's MDS, dated [DATE], revealed a BIMS score of 7, indicating severe impairment. His mobility status indicated that he needed limited assistance in his ADLs. He was at risk of pressure ulcers. <BR/>Review of resident #42's care plan, dated 06/27/22, had him care planned for having colostomy, he requires intravenous therapy related to urinary tract infection and intravenous antibiotic order. <BR/>Observation on 06/27/22 at 7:40 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #42. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #42.<BR/>Observation on 06/27/22 at 8:02 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #30. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #30.<BR/>Observation on 06/27/22 at 8:10 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #36. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #36.<BR/>Interview on 06/27/22 at 12:35 PM of LVN A she stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use in order to prevent transmitting an infection from one resident to another. She stated that if she forgot to wipe the cuff it was because of the presence of the surveyor made her more nervous.<BR/>Interview on 06/28/22 at 9:05 AM with the ADON she stated that her expectation was that staff will sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another.<BR/>Review of facility's Cleaning and Disinfecting Non-Critical Resident-Care Items policy, revised June 2011, reflected the following: c. No-critical items are those that come in contact with intact skin but not mucous membranes. 1) Non-critical resident-care items include bedpans, blood pressure cuffs, glucometers, crutches, and computers. 2) most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). d. Reusable items are cleaned and disinfected or sterilized between residents.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three (Halls 100, 400 and 500) of six halls and one (main dining room) of two dining rooms and one of one kitchen and one (facility entrance) of one reviewed for environment.<BR/>(A)The facility failed to ensure the exit door on the 100 hall and front of Resident #5's room door was clean and in good repair.<BR/>The facility failed to ensure the floors on halls 100, 400 and 500 were clean and in good repair. <BR/>The facility failed to ensure the flooring in the dining room next to the kitchen entrance and ice machine was clean and in good repair. <BR/>The facility failed to clean or replace the two rusty panic bars on hall 100 and 2 rusty panic bars on hall 500.<BR/>The facility failed to ensure Resident #9's room was cleaned thoroughly. <BR/>(B) The facility failed to ensure the floor drainage system in the kitchen was not clogged up.<BR/>The facility failed to ensure the front entrance of the facility was clean and in good repair. <BR/>These failures could affect all residents, resulting in falls and cross contamination, resulting in injury and stomach illnesses which could lead to a decline in the resident's health and physical functioning.<BR/>Findings included:<BR/>(A)Observation on 03/07/24 at 9:14 am, the floor at the entrance of Resident #5's room had assortment of colors, the flooring in the resident's room was dark brown. Around the entrance of the resident's door was one light brown tile and one grey tile. There were several layers of accumulated blackish dirt around the door and the door frame had blackish debris and chipped paint, dry rot and rust along it.<BR/>Observation on 03/07/24 at 12:49 pm, the 2 barrier door's panic bars on the 100 hall had a large amount of rust spots and scrape marks on them. <BR/>Observation on 03/07/24 at 12:50 pm, the 100 hall exit door had accumulated layers of blackish dirt, scuff marks, chipped paint, and dry rot. The corner of the door had a quarter size hole and light from the outside could be seen. The baseboards by the exit door had several layers of bumpy and chipped paint and accumulated blackish dirt. <BR/>Observation at 03/07/24 at 12:52 pm, the 2 barrier door's panic bars on the 500 hall had a large amount of rust spots and scrape marks and brownish debris particles covered most of the metal areas on the panic bars. <BR/>Observation 03/07/24 at 1:01 pm, in the main dining room, the white flooring tiles around the ice machine entrance door of kitchen appeared to have several areas of accumulated blackish dirt and grime. The drain by the ice machine had brownish rust stains and blackish dirt on and around it, the tiles were cracked and missing some areas of the tiles. The lower right side of the ice machine had yellowish colored drip stains on it and there was rust under two of the four legs. The white kitchen door had a large area of blackish smudge and the bottom of the door had bumpy/uneven paint and blackish dirt. The flooring around the door frame had brownish rust stains and blackish accumulated dirt and the corners had debris particles.<BR/>Interview on 03/07/24 at 3:30 pm, [Anonymous] stated the housekeepers did not do a good job cleaning the facility. They spoke to the Housekeeping/Maintenance Supervisor, but he had not been back to work this week. They stated when things were broken, they wrote up a repair request in the book up front. They stated noticing the rust and broken flooring and walls in the rooms and common area and had spoken to Housekeeping/Maintenance but could not remember what his response was. They stated if the facility was not cleaned properly, it could cause the residents to develop infections and probably get sick. They was not sure why They had not mentioned the housekeeping and maintenance concerns to the Administrator. They stated if things around the facility were broken it could cause the residents to trip and fall. <BR/>Interview on 03/07/24 at 4:13 pm, the Dietary Director stated the door entrance to the kitchen door needed to be painted and door frame needed to be repaired. He stated he had not really paid attention to the rust on the hallway doors but that floors were yucky and cracked. He stated the floor drain next to the kitchen front entrance was not rusted but just had paint loss and the original metal was what was exposed. He stated the Housekeeping/Maintenance Supervisor was on leave since last Monday and said their corporate office or a repair company to come out to fix stuff. He stated some areas on the flooring needed extensive repairs. <BR/>Interview on 03/07/24 at 5:28 pm, the SW stated the residents in the February 2024 Resident Council meeting said they felt like the housekeepers were not cleaning good enough. She stated Resident #9complained about housekeeping services last January 2024. She stated the housekeeping issues should have been addressed by the Maintenance/Housekeeper and was not sure if the complaints were resolved. She stated the Maintenance/Housekeeper Supervisor should have spoken with the weekend housekeeper to clean and pick up trash properly. She stated she was responsible for ensuring the complaints were follow-up on and she said she was not sure why she had not done so. She added the facility's floors were a continuous battle because the glue rose up and dried on top of the flooring tiles. She stated the Maintenance/Housekeeping Supervisor did his best to make sure the facility was cleaned and in good repair. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she tried some best practice trainings with the housekeepers because she noticed some areas were being missed. She stated she noticed the barrier door grab bars were rusty and Housekeeping/Maintenance Supervisor had a to do list to fix them. She stated their Housekeeping/Maintenance Supervisor had not worked for the past few days and they just hired a Maintenance Assistant, but he did not know how to repair much yet.<BR/>(B) Observation and interview on 03/07/24 at 9:00 AM, the floors in the facility entry area appeared to have spots of built-up black grime in the seams of the tiles. The doors around the entrance appeared to have general wear from wheelchairs. <BR/>Observation on 03/07/24 at 9:10 AM, around the RN nurses' station, the floors in this area also had built up grime in the seams. <BR/>Observation and interviews on 03/07/24 at 9:43 AM, the floor drains in the kitchen were backed up with dirty water and leveled with the floor. One drain was observed to have the hose of a wet vac inserted into the drain to drain out water. The Dietary manager stated having drainage issues for a few months. He stated there had been people at the facility to fix it a few times, but the floor drains were still backed up. <BR/>Interview on 03/07/24 at 3:40 PM, Housekeeper C stated that the problem with the floors was that the glue kept seeping through the seams. She stated they tried to mop the glue up, but it did not come off the floor. <BR/>Interview on 03/07/24 at 4:14 PM, the Administrator stated they had some issues with the floors, because there was grime build up on them . She stated they were supposed to get them redone and the owner told her the floors were really not working for this environment. She stated she agreed the floors looked Icky (disgusting) which could make the residents feel bad about their home. She stated she knew about the drainage problem in the kitchen which had been going on for a few months. She stated they tried to get some people in there to take care of it, but nothing worked so far. She stated she knew the drainage issue in the kitchen could cause a cross contamination problem. <BR/>Record review of the facility's Grievance form dated 01/17/24 revealed, Resident #9 - housekeeping needs .<BR/>Record review of the Resident Council minutes dated 02/17/24 revealed, C. Housekeeping & Laundry Department .feels like some of the housekeepers do bare min. when asked to clean their rooms.<BR/>Record review of the last two months (02/26/24 - 03/26/24) maintenance log sheets did not reveal any requests to repair the kitchen's floor drain, common areas in the hallways and main dining room.<BR/>Record review of the Facility's Cleaning and disinfection of Environmental Surfaces policy dated 2001 revised 2009 revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected, according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens Standard .Policy Interpretation and implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Critical items, semi critical items and non-critical items .9. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . <BR/>Record review of the Facility's Maintenance Service policy dated 2001 and revised 2009 revealed, Policy Statement: Maintenance services should be provided to all areas of the building, grounds and equipment .Policy interpretation:2. b. Maintaining the building in good repair and free from hazards .i. providing routinely scheduled maintenance services to all areas .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, equipment are maintained in a safe and operable manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. <BR/>The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings Include:<BR/>Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room.<BR/>Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room .<BR/>An interview on 03/07/24 at 9:20 a.m., Resident #6 revealed that he had seen many black small flies and roaches all over the facility.<BR/>An interview on 03/07/24 at 9:24 a.m., Resident # 6 stated that he had seen flying black gnats and roaches in many areas of the facility. He did not state how long he had been seeing the insects/pest or if he had seen pest control at the facility. <BR/>Observation on 03/07/24 at 9:37 a.m. in the 300-hall shower room revealed 15-20 small black flies or gnats either alighted on the shower curtain to shower stall #1 or flying near a large plastic bag filled with wet towels near shower stall #1. Four dead roaches were observed on the floor underneath the shower curtain for shower stall #1.<BR/>An interview on 03/07/24 at 2:57 p.m., MA A stated that she had seen gnats and roaches all over the facility and in resident rooms. She stated that the staff were supposed to write down bug sightings in some book, but she did not know where the book was, and she denied knowing what a pest sighting log was. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:33 p.m., CNA B revealed she had seen many roaches and gnats in room [ROOM NUMBER] and she had seen gnats and roaches in room [ROOM NUMBER] room that day (03/07/24). She stated hat she had never seen a pest sighting log, and she was not sure where the staff were supposed to write those things down. She stated that the staff just reports bugs to the maintenance manager. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:40 p.m., Housekeeper C stated that he did sometimes see gnats and that he was not sure how to report insects at the facility. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:50 p.m., CNA D revealed that she had seen gnats and roaches at the facility and denied knowing that she had to log them in the pest sighting log.<BR/>An interview on 03/07/24 at 4:00 p.m., RN E revealed that he had seen gnats and roaches in the facility and that he thought there was a book somewhere to write them down (insect sightings) but he did not know where the book was. <BR/>An interview on 03/07/24 at 4:06 p.m. CNA F stated that she had seen many gnats and roaches at the facility. She stated that she tells the maintenance manager about insects when she sees him. She stated that she had never heard of a pest sighting log.<BR/>An interview on 03/07/24 at 4:14 p.m., the Administrator stated that the staff were supposed to use the pest sighting log and that the staff had been trained on using the pest sighting log but that they just tell the maintenance manager instead. She stated that having gnats in the facility could affect residents negatively and mentally and could pose a risk of cross contamination.<BR/>An interview on 03/07/24 at 6:17 p.m., the DON revealed she had seen some gnats around the facility and that she thought staff were supposed to log insects in the pest sighting log. She stated that it could be very annoying for residents to have to deal with gnats and that it could affect their mental health and could possibly cause cross contamination. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the Facility's Pest Sighting Log/Pest Control Binder revealed: that the last pest sighting logged in the pest sighting log was 08/09/23 for flies, no other more recent entries could be found.<BR/>Review of Pest Control Service Inspection Report dated 02/15/24 revealed taget pest treated were rodents (rodent bait stations), german cockroaches in the kitchen and laundry area. This was the last inspection/service report in the binder. <BR/>Record review of the facility's policy dated May 2008, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Residents #1 and #2) of six residents' rooms reviewed for Environment. <BR/>The facility failed to ensure Residents #1 and #2's bathroom floors and walls were in good repair and sanitary. <BR/>These failures could place all residents at risk of falls which could result in injuries leading to a decreased quality of life and psycho-social well-being. <BR/>Findings included: <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 14 (no cognitive impairment) and impaired upper and lower one-sided extremities and used a wheelchair. He also needed partial to moderate assistance with toileting and had other neurological conditions. <BR/>Interview and observation on 03/07/24 at 9:20 am, Resident #1's room had approximately 8 or 9 articles of clothing on the floor against the wall, he said were dirty clothes, and his trash can was full. He stated well this place is Kind of yucky (disgusting), they half ass clean my room daily. In his bathroom there was 1 &frac12; foot wood tile that was separated from the floor and under it was white cement and several layers of blackish colored dirt. There was 2 feet of wood tile was loose and a 1-inch gap with blackish colored grime was between the wood tile next to it. And the border and white caulk was separated from the wall and white caulk had separated from the wall and floor in the back corner of the toilet had an accumulation of blackish colored dirt and debris. The ac unit had approximately 2 &frac12; feet of white caulk 1 inch over the AC unit and had a 4 in long crack on the left upper side on the other side the AC unit appear not attached completely to the wall. And the white overhead light over the resident's bed appeared to have several layers of blackish dirt. <BR/>Record review of Resident#2's Annual MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 07 (moderate impairment) and both sides lower impairment. He used a wheelchair. He was dependent with toileting and had medically complex conditions. <BR/>Interview and observation on 03/07/24 at 10:30 am, Resident #2's room had seven to eight articles of clothing on the floor next to the wall. The resident said they were his dirty clothes. He stated the holes had been in his bathroom wall since being in this room. The bathroom had a 1 &frac12; foot hole above the floorboard that was separated from the wall and there was whitish bubbly caulk on it and the floor. The bathroom door had several areas of rust stains and the flooring next to the shower was jagged and uneven and broken in some areas. The corner next to the shower had rust stains and several layers of caulk on the wall and floor. And the resident's room flooring had several areas of scrap marks from door scrubbing the floor and as it was opened and closed it made a very loud and screeching noise. <BR/>Interview on 03/07/24 at 3:30 pm, [Anonymous] stated the facility's housekeepers did not do a good job cleaning the facility and fixing broken things. They stated speaking to the Maintenance/Housekeeping Supervisor and by putting the repairs needed into the Maintenance book up front. They stated if the facility was not cleaned properly, it could cause residents to get infections and probably get sick and also cause injuries like falls. They stated not being sure why they had not mentioned the maintenance and housekeeping issues to the Administrator. <BR/>Interview on 03/07/24 at 4:41 pm, the ADON stated sometimes the housekeepers did a good job cleaning but sometimes on Mondays, the floors were dirty. She stated the Department Heads had assigned halls, they checked the resident's rooms and common areas for cleanliness. She stated the Maintenance/Housekeeper Supervisor was responsible for ensuring the house keeping was done properly. <BR/>Interview on 03/07/24 at 5:28 pm, the SW stated the residents in the February 2024 Resident Council meeting said they felt like the housekeepers were not cleaning good enough. She stated Resident #9 complained about housekeeping services last January 2024. She stated the housekeeping issues should have been addressed by the Maintenance/Housekeeper and was not sure if the complaints were resolved. She stated the Maintenance/Housekeeper Supervisor should have spoken with the weekend housekeeper to clean and pick up trash properly. She stated she was responsible for ensuring the complaints were follow-up on and she said she was not sure why she had not done so. She added the facility's floors were a continuous battle because the glue rose up and dried on top of the flooring tiles. She stated the Maintenance/Housekeeping Supervisor did his best to make sure the facility was cleaned and in good repair. She stated she reported the hole in Resident #2's bathroom wall to the Maintenance Housekeeping Supervisor. She stated she noticed the flooring tile around Resident #1's toilet was loose last week. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she tried some best practice trainings with the housekeepers because she noticed some areas being missed. She stated she noticed the barrier door grab bars were rusty and Housekeeping/Maintenance Supervisor had a to do list to fix them. She stated they just hired a Maintenance Assistant, but he did not know how to repair much yet. She stated being aware of Resident #2's holes in his bathroom and Resident #1's loose flooring tiles in his bathroom for about two weeks. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the facility's Grievance form dated 01/17/24 revealed, Resident #9 - housekeeping needs .<BR/>Record review of the Resident Council minutes dated 02/17/24 revealed, C. Housekeeping & Laundry Department .feels like some of the housekeepers do bare min. when asked to clean their rooms. <BR/>Record review of the last 2 months (02/26/24 - 03/06/24) maintenance log sheets did not reveal any requests for Resident #1 flooring issue and Resident #2's wall hole and flooring issue. <BR/>Record review of the Facility's Cleaning and disinfection of Environmental Surfaces policy dated 2001 revised 2009 revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected, according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens Standard .Policy Interpretation and implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Critical items, semi critical items and non-critical items .9. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . <BR/>Record review of the Facility's Maintenance Service policy dated 2001 and revised 2009 revealed, Policy Statement: Maintenance services should be provided to all areas of the building, grounds and equipment .Policy interpretation:2. b. Maintaining the building in good repair and free from hazards .i. providing routinely scheduled maintenance services to all areas .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, equipment are maintained in a safe and operable manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 resident (Resident #1) of 5 residents reviewed for abuse and neglect.<BR/>The facility failed thoroughly investigate an allegation of abuse and neglect for Resident #1.<BR/>This failure could place all residents at risk of abuse and neglect.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 10/31/23, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on 09/0923 with diagnoses that included: type II diabetes, morbid obesity, atrial fibrillation (irregular heartbeat), muscle weakness, mild cognitive impairment (decline in thinking and memory), schizoaffective disorder (mood disorder), and contracture of unspecified joint. <BR/>Record review of Resident #1's admission MDS Assessment, dated 09/16/23, reflected Resident #1:<BR/>- understood others and could make himself understood,<BR/>-was cognitively intact with a BIMS of 14,<BR/>-did not exhibit physical, verbal, or other behavioral symptoms towards others, <BR/>-required extensive assistance with two or more persons assist with transfer, <BR/>-required a mobility device (wheelchair).<BR/>Record review of Resident #1's care plan, revised 09/21/23, reflected Resident #1 was at risk for falls related to impaired mobility with interventions that included assistance of 2 as needed for mobility. <BR/>During an observation and interview on 10/31/23 at 10:12 AM, Resident #1 stated he required transfer assistance using a mechanical lift, and he was normally transferred safely when staff listened to his direction. However, he stated approximately 3 weeks ago CNA D did not listen to him and he fell back onto the bed during a transfer, which upset him. Resident #1 stated he cursed at CNA D. After that incident, Resident #1 stated CNA C, who was related to CNA D, entered his room and stated I'm not here to help you, so don't ask me anything. I'm here to see what the fuck you said to my mother and proceeded to curse at him. Resident #1 stated CNA C and CNA D normally worked together on the 2:00 PM-10:00 PM shift, and on the days they worked, he would ask the morning shift to transfer him to bed before the end of their shift, otherwise he would have to wait until late at night to be put in bed because CNA C and CNA D would refuse to assist him. Resident #1 stated prior to the incident, he did not have any problems with staff, and he got along well with CNA C and CNA D. He stated he was not afraid of any staff but was frustrated about being neglected and that the Administrator had not addressed CNA C verbally abusing him. Resident #1 stated he informed the Administrator that CNA C cursed at him right after it happened and again recently when he saw that nothing was being done. Resident #1 stated CNA C still works on his hall but will rarely come into his room to help him. Resident #1 stated CNA C will come assist him when there are no other staff available. Observation of Resident #1 revealed he had no visible marks, abuse, or other signs of abuse or neglect.<BR/>During an interview on 10/31/23 at 12:32 PM, the DON stated she was aware of the accident where Resident #1 was dropped onto his bed while being transferred using a mechanical lift on 10/9/23; however, she was not aware that there was conflict between him, CNA C and CNA D related to the accident. The DON stated Resident #1 was demanding and verbally aggressive towards staff when he could not get assistance the minute he asked for it. The DON stated CNA C reported Resident #1 verbally abused him because he had to find help before getting Resident #1 in bed. The DON stated CNA C was upset about the names Resident #1 called him and stated he did not feel comfortable working with him any longer. The DON stated Resident #1 seemed to be offended that CNA C did not want to work with him because they had previously been very friendly with each other. <BR/>During an interview on 10/31/23 at 12:45 PM, the Administrator stated CNA C came to her after he was verbally abused by Resident #1 and asked that he be removed from his care. The Administrator stated she went to Resident #1 on 10/13/23 to speak with him about his behavior and he apologized for it and stated they were joking. She stated Resident #1 also wrote CNA C an apology letter that CNA C accepted. The Administrator stated Resident #1 did not inform her that CNA C verbally abused him. The Administrator stated she spoke with other staff members to see if they had witnessed or heard anything and no one stated that they had. The Administrator stated she did not suspend CNA C or conduct a formal investigation because she did not have reason to. She stated on 10/30/23 Resident #1 was overheard by staff saying that he was going to call the State. The Administrator stated she went to speak with Resident #1, and he informed her that CNA C did not care for him over the weekend. The Administrator stated CNA C was not assigned to work with Resident #1 and this was explained to him. The Administrator stated she told Resident #1 that she would talk to the weekend staff and address him feeling neglected. The Administrator stated although CNA C was not assigned to Resident #1, there would be times when he would have to help transfer Resident #1 or help pass trays on his hall; therefore, he still had some contact with Resident #1. The Administrator stated Resident #1 seemed to prefer CNA C to help him and was upset that CNA C had chosen to distance himself as much as possible. The Administrator did not provide any statements from staff or other evidence of an investigation.<BR/>During an interview on 10/31/23 at 2:33 PM, CNA A stated he had worked at the facility for 4 months and worked the 6:00 AM to 2:00 PM shift, Monday-Friday. He stated he worked with Resident #1. CNA A stated Resident #1 required a lot of assistance due to his size, but he was able to help staff and make the task easier. CNA A stated Resident #1 liked to go out into the community and would be hurting when he returned to the facility from being in his wheelchair so long. CNA A stated this would cause Resident #1 to get upset when he could not be put in bed right away. CNA A stated he was aware that there was conflict between Resident #1 and CNA C after the incident where Resident #1 was dropped from the mechanical lift. CNA A stated Resident #1 would become verbally aggressive and frustrated and that he would try to explain to CNA C that he could not take it personally. CNA A stated Resident #1 would sometimes ask to be put in bed before the end of his shift because the afternoon shift would not help him. CNA A stated he had never observed Resident #1 being abused or neglected by any staff but Resident #1 informed him that he was being neglected. CNA A stated Resident #1 was in tears one morning, begging to be removed from the bed because he had been left there over the weekend. CNA A stated the DON and Administrator were aware of this. <BR/>Attempted interview on 10/31/23 at 3:01 PM with CNA D was unsuccessful due to no response to phone call. <BR/>During an interview on 10/31/23 at 3:35 PM, CNA C stated he had worked at the facility for about 4 months and was PRN. He stated he mostly worked weekends and used to work with Resident #1. CNA C stated he was no longer assigned to Resident #1 because he had been verbally abused by him. CNA C stated Resident #1 had asked to be put in bed one evening and became upset when he was told that he had to wait for another staff to be available. CNA C stated Resident #1 was large and required 2-3 staff to be transferred. CNA C stated Resident #1 told him he should be able to transfer him alone since he was a man, then called him a Dick sucking gay. CNA C stated he reported this to the Administrator immediately and asked to be removed from Resident #1's care. CNA C stated Resident #1 later apologized and they shook hands; however, he still did not feel comfortable working with him. CNA C stated he would still help other staff transfer Resident #1 when needed but he did not go into his room alone. CNA C stated he was never suspended or investigated for abusing or neglecting Resident #1. CNA C stated he was not worried about being investigated because he did not do anything wrong. CNA C stated he was aware that Resident #1 had been dropped while being transferred by CNA D, but he had nothing to do with the incident and was not mad at Resident #1 for anything related to it. <BR/>During an interview on 10/31/23 at 4:15 PM, CNA B stated she had worked at the facility for 1 year and worked the 2:00 PM to 10:00 PM shift, Monday-Friday. She stated she worked with Resident #1. CNA B stated Resident #1 was loud and joked a lot. She stated that staff would take him the wrong way and get offended by his jokes. CNA B stated she had never observed Resident #1 being abused or neglected by staff but Resident #1 would tell her that he was being neglected. CNA B stated everyone knew to keep CNA C and CNA D away from Resident #1 because they did not like each other. She stated Resident #1 would mostly say he did not want them in his room, especially after he blamed CNA D for dropping him from the mechanical lift. CNA B stated all staff were trained on abuse and neglect and she knew to report any concerns to the Administrator. She could not recall if she had reported any of Resident #1's concerns to the Administrator directly but she stated that everyone knew what was going on between them. <BR/>During an interview on 10/31/23 at 5:00 PM with the DON and Administrator, the DON stated if there were allegations of abuse or neglect it was her responsibility to speak with the resident(s) to see what was going on and reassign the alleged perpetrator until she could talk with the Administrator to discuss any further actions. The DON stated the risk of not thoroughly investigating alleged abuse and neglect could be the resident(s) continuing to be abused and/or neglected, and the resident(s) could continue abusing the staff. The Administrator stated in the case of alleged abuse or neglect it was her responsibility to investigate and remove the risk of residents being abused or neglected. <BR/>Record review of in-services titled Abuse and Neglect, dated 10/10/23, reflected staff were trained on identifying and reporting abuse and neglect. <BR/>Review of the facility's policy titled Abuse Prevention Program, revised December 2016, revealed in part the following:<BR/>Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint to treat the resident's symptoms. <BR/>Policy Interpretation and Implementation:<BR/>As part of the resident abuse prevention, the administration will:<BR/>1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. <BR/> .<BR/>7. Investigate and report any allegations of abuse within timeframes as required by federal requirements;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #3) of 66 residents reviewed for assistive devices.<BR/>A portable heater was found in use in Resident #3's room without direct supervision.<BR/>This failure could place residents at risk for accidents or injuries.<BR/>Findings include:<BR/>Record review of Resident #3's Face sheet dated 01/28/2025 revealed that Resident #3 was a [AGE] year-old male that was initially admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, Age-Related Cognitive Decline and Partial traumatic Amputation of left foot at Ankle Level.<BR/>Record Review of Resident #3's Quarterly MDS Assessment and Care Screening dated 11/07/2024 revealed that Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. The resident required the use of a wheelchair and required supervision or touching assistance for all transfers and personal hygiene. <BR/>Record review of Resident #'3 Care Plan, dated 11/13/2024 revealed that Resident #3 has an Activity of Daily Living self-care deficit related to osteomyelitis [infection of the bone] of left foot post-surgical intervention, impaired cognition and makes poor decisions.<BR/>In an observation and interview on 01/28/2025 at 11:24 AM revealed Resident #3 was observed in his room, seated comfortably in a wheelchair. A portable heater was noted to be operating behind the resident within 2 feet of the resident's bed and privacy curtain. The resident stated that the facility had given him the portable heater to use because his in-wall unit was not working for the last two days. He stated that the air conditioning part of the in-wall unit worked fine but that the heat was not working. He stated that he liked it warm in his room.<BR/>In a set of observations from 01/28/2025 at 11:42 AM to 01/28/2025 to 11:42 AM revealed all other resident rooms were checked for portable heaters. No other portable heaters were found. <BR/>In an observation and interview on 01/28/2025 at 1:45 PM revealed the Maintenance Supervisor was observed removing the wall air conditioning/heater unit from Resident #3's room. The portable heater was no longer present in Resident #3's room. The Maintenance Supervisor stated that he had taken the portable heater out of Resident #3's room and he was in the process of replacing Resident #3's in-wall air conditioner/heater unit. He stated that Resident # 3 had been using the portable heater for the last 2 days and that the heater had an automatic turn-off switch if the portable heater fell over or was tipped. <BR/>In an interview on 01/28/2025 at 2:09 PM LVN A stated that she was not aware of anyone doing fire watches in the facility. She stated that fire watches meant that the staff had to check the entire facility every 15 minutes to make sure there were no fires in case the fire alarm system stopped or a power outage.<BR/>In an interview on 01/28/2025 at 2:29 PM LVN B stated that she had not heard anything about the facility having to do any fire watches or that Resident #3 had a portable heater in his room. She stated that she had been working for the last three days and that she had been unaware of any portable heaters in the building. She stated that she had thought portable heaters were not allowed in nursing facilities. <BR/>In an interview on 01/28/2025 at 3:30 PM the ADM stated that a portable heater could pose a fire risk to residents if a blanket, curtain or pillow got too close to it for a period of time. He stated that he had not done any fire watches while the portable heater was in use in Resident #3's room, and that the portable heater had been in use for the last two days.<BR/>In an interview on 01/28/2025 at 3:34 PM Maintenance Supervisor stated that portable heaters could cause fires if left unmonitored because something flammable could get next to a heater and possibly start a fire. He stated that he had replaced the in-wall unit in Resident #3's room and had meant too the day before but had not been able to get to it. He stated that he had replaced it a few hours ago and that there were no other portable heaters in use in the facility.<BR/>A policy for Portable Heaters in Nursing facilities was requested on 01/28/2025 at 3:17 PM but was not presented before the conclusion of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for two of six residents (Residents #1 & #2) whose records were reviewed for accuracy. <BR/>The facility failed to document on Residents #1 & #2s' wound care treatment on the residents' Electronic Treatment Administration Records (eTARs) accurately. <BR/>This failure could result in incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions.<BR/>Findings include:<BR/>1. <BR/>Record review of Resident #1's TAR dated 03/01/23 - 03/31/23 reflected Resident #1 a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses of heart failure, high blood pressure, Parkinson's disease, glaucoma, urinary tract symptoms, and seizures. Further review reflected there was no evidence of documentation/s for treatment (blank - no check mark or initiated) on 03/06, 03/08, and 03/10/23 for his left buttock wound order Clean wound with normal saline, pat dry and apply collagen powder and anaspet (wound cleanser) and cover with gauze dressing once daily for 9 days, reposition while in bed, off- load wound in the morning for wound care for 9 days. The treatment was scheduled from 4 AM to 6 AM with a start date of 03/02/23 until 03/10/23. <BR/>Record review of Resident #1's nurses' note from 03/01/23 to 03/20/23 reflected there was no evidence of documentation about wound care for the dates of 03/06, 03/08, and 03/10/23. <BR/>Record review of Resident #1's order summary dated 03/20/23 reflected Resident #1 was ordered to receive Clean wound to the left ischium (buttock) with normal saline, pat dry, and apply collagen powder and anasept and cover with gauze dressings daily for 9 days with a start date of 03/02/23 and a discharge date of 03/10/23.<BR/>Record review of Resident #1's admission assessment dated [DATE] reflected Resident #1 had clear speech and usually understood others. Resident #1 had a BIMS score of 13 which indicated Resident #1 was cognitively intact. The MDS assessment included Resident # 1 had pressure ulcer/injury and he was required to have pressure injury care and applications of ointments and medications. <BR/>Record review of Resident #1's care plan undated reflected Resident #1 had wound on his left gluteal fold (buttock) and the intervention included to provide treatment as ordered. <BR/>Record review of Resident #1's weekly skin assessment dated [DATE] reflected Resident #1 had stage 4 pressure wound on his left buttock with a measurement of 0.6 x 0.6 x 0.3 cm (length x width x depth) cm.<BR/>Record review of Resident #1's wound evaluation and management summary dated 03/16/23 reflected Resident #1 had stage 4 pressure wound full thickness left ishium (buttock) with a measurement of 0.6 x 0.6 x 0.3 cm (length x width x depth) cm with an order of collagen powder apply once daily for 30 days and lodosob (an antimicrobial) gel apply once daily for 30 days. <BR/>On 03/20/23 at 12:43 PM, an observation and interview with Resident #1 revealed Resident #1 stated he had a wound on his buttock area and received dressing changes . Resident #1 was sitting on his wheelchair in the hallway with no distress. Resident #1 had refused before his buttock wound to be observed. Resident #1 stated he had no concern about his wound care during having conversation. <BR/>2. <BR/>Record review of Resident #2's TAR dated 03/01/23 - 03/31/23 reflected Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses of heart failure, seizure, nerve pain, depressive disorder, difficult sleeping, and left side brain injury. Firstly, further review reflected there was no evidence of documentation/s for treatment (blank - no check mark or initiated) on 03/06, 03/08, and 03/10/23 for his left heel wound order Clean the wound with normal saline, pat dry, apply skin prep three times a week for 30 days in the morning every Monday, Wednesday, and Friday for wound care for 30 days with a discharge date of 03/10/23. Secondly, there was no evidence of documentation/s of treatment (blank - no check mark or initiated) on 03/13 and 03/17/23 for his left heel wound order Clean the wound with normal saline, pat dry, apply skin prep three times a week for 20 days in the morning every Monday, Wednesday, and Friday for wound care for 20 days with a discharge date of 03/19/23. Thirdly, there was no evidence of documentation/s for treatment (blank - no check mark or initiated) on 03/12 and 03/17/23 for his right upper chest Clean the wound with normal saline, pat dry, apply alginate calcium and a dry dressing daily for 30 days in the morning for wound care for 30 days with a discharge date of 03/19/23. Resident #2's wound treatments were scheduled from 4 AM to 6 AM .<BR/>Record review of Resident #2's nurses' note from 03/01/23 to 03/20/23 reflected there was no evidence of documentation about wound care for the dates of 03/12, 03/13, and 03/17/23. <BR/>Record review of Resident #2's order summary dated 03/20/23 reflected Resident #2 was ordered to receive Clean the wound to the left heel with normal saline, pat dry, apply skin prep three times a week for 30 days with a start date of 03/03/23 and a discharge date of 03/10/23. Clean the wound to the left heel with normal saline, pat dry, apply skin prep three times a week for 20 days with a start date of 03/13/23 and a discharge date of 03/19/23. Clean wound to the right upper chest with normal saline, pat dry, and apply alginate calcium and a dry dressing daily for 30 days with a start date of 03/11/23 and a discharge date of 03/19/23.<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected Resident #2 had clear speech and understood others. Resident #2 had a BIMS score of 07 which indicated he had moderate cognitive impairment. The MDS assessment indicated Resident #2 was at risk of developing pressure injuries, had moisture associated skin damage, and required applications of ointments/medications. <BR/>Record review of Resident #2's care plan dated 01/19/23 reflected Resident #2 had potential impairment to skin integrity related to fragile skin and the intervention included monitor/document location, size and treatment of skin injury. <BR/>Record review of Resident #2's weekly skin assessment dated [DATE] reflected Resident #2 had surgical incision on his right upper chest with a measurement of 0.1 x 0.1 x 0.2 cm (length x width x depth) cm.<BR/>Record review of Resident #2's wound evaluation and management summary dated 02/28/23 reflected Resident #2 had non pressure wound of the left heel with a measurement of 0.8 x 0.7 x 0.1 cm (length x width x depth) cm and treatment order included skin prep apply three times per week for 30 days. <BR/>Record review of Resident #2's wound evaluation and management summary dated 03/16/23 reflected Resident #2 had post-surgical incision to the right upper chest with a measurement of 1.1 x 1.1 x 0.2 cm (length x width x depth) cm and treatment order included xeroform gauze apply three times per week for 30 days and triple antibiotic ointment apply three times per week for 30 days. And Resident #2 also had a resolved wound for non-pressure wound of the left heel. <BR/>On 03/20/23 at 12:51 PM, an interview with the DON revealed the DON expected all charge nurses to document correctly on the residents' TAR to follow the facility's policy on wound care documentation. The DON stated she was not aware of missing blanks or no documentations on 03/06, 03/08, and 03/10/23 for Resident #1 and 03/06, 03/08, 03/10, 03/12, 03/13, 03/17/23 for Resident #2 until inquiry. The DON stated missing documentation on the residents' TARs could interpret as treatments were not provided. She stated the residents' wounds could get an infection or get worse if wound care was not received per treatment order. At 1:50 PM, the DON stated she had been overseeing the nurses' documentation. She stated if she saw some missing or error in documentation, she made sure the nurses completed the documentation correctly. The DON stated she had initiated the in-services on documentation after completed wound care treatment on 03/20/23 after inquiry. <BR/>On 03/20/23 at 1:10 PM, an interview with Resident #2 revealed Resident #2 stated his wound on his heel was resolved and he received wound care treatments for his upper chest with no issue. <BR/>On 03/20/23 at 2:27 PM, an interview with LVN A revealed he worked at the facility for over five months. LVN A stated he was assigned to take care of Resident #2 on 03/12/23 from 10 PM to 6 AM and he remembered he provided wound care treatment to Resident #2. LVN A stated he forgot to go back and document on Resident #2's TAR since there was a computer system issue encountered right after the treatment done on 03/12/23. LVN A stated missing documentation of the treatment administration record indicated treatment might not have been completed and the resident's wound could be worsening and get an infection. <BR/>On 03/21/23 at 11:07 AM, an interview with LVN B revealed he worked at the facility for over eight months as needed for day shift as well as night shift. LVN B stated he completed wound care treatment to Residents #1 and #2 during his night shifts and he was unable to recall for exact dates for the past two weeks. LVN B also stated he documented on the residents' TARs after providing treatment, however, he was not very sure what had happened regarding the blanks for 03/06, 03/08, 03/10, 03/13, and 03/17. LVN B stated missing documentation after providing wound treatment could interpret as wound care not being provided and the residents' wounds could get an infection and get worse. <BR/>Record review of the facility policy on Wound Care dated October 2010 reflected, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. Documentation: The following information should be recorded in the residents' medical record; 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the date.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food sanitation.<BR/>The facility failed to ensure dishes were cleaned and stored under sanitary conditions.<BR/>This failure could place residents at risk for foodborne illness and a decline in health status.<BR/>The findings include:<BR/>Observation on 01/10/23 at 12:23 p.m., of the kitchen, revealed an empty rack near the 3- compartment sink. The rack was a large three tier rack used to store clean plate covers.<BR/>with water stains, a brown sticky substance and dried food particles on its trays and structure poles. <BR/>A follow-up observation on 01/10/23 at 3:09 p.m. of the kitchen, revealed the rack observed at 12:23 p.m., was filled with clean plastic plate covers. The rack still had water stains, a brown sticky substance and dried food particles on its trays and structure poles.<BR/>In an observation and interview on 01/10/23 at 3:11 p.m., [NAME] A stated the rack was used to store the food covers when not in use. [NAME] A stated the rack was previously observed empty because the covers were used to deliver lunch. [NAME] A stated the rack was supposed to be power washed but had not been because the DM was out for the day. [NAME] A stated it was the responsibility of all kitchen staff to ensure all equipment was cleaned. [NAME] A stated she did not know when the rack was last cleaned, but she could wipe down the rack. [NAME] A stated they were trained to complete cleaning tasks as scheduled and record their completion in a cleaning log binder. <BR/>In an interview on 01/10/23 at 3:25 p.m., the DM stated kitchen staff were trained to clean any mess in the kitchen, as they made it, which was his expectation for staff. The DM stated he had no knowledge of the cleaning schedule binder and he had been searching for lists to post for staff to use. The DM stated he was aware of the unsanitary condition of the rack used to store clean plate covers. The DM stated he tried to clean the rack a while ago with degreaser, but it did not come clean, and he planned to power wash the rack. The DM stated he did not recall when he attempted to clean the rack. The DM stated he did not know when the rack was last cleaned. The DM stated the plate covers did not come in direct contact with residents' food, so he was unsure of how the unsanitary storage of the covers would affect the resident's food. <BR/>In an interview and record review on 01/10/23 at 4:29 p.m., the Admin stated [NAME] A told her about the unsanitary condition of the rack used to store the plate covers. The Admin stated she believed the rack was scheduled to be cleaned monthly. The Admin stated the rack was supposed to be power washed but had not been washed yet. The Admin stated she expected all dietary equipment to be cleaned and sanitized on a regular basis. The Admin stated she believed the rack was on the monthly cleaning schedule and she was unsure of when it was last cleaned. While the Admin reviewed the cleaning tasks binder with the State Surveyor, the Admin stated she provided the binder to the DM to use and she was not aware staff were not completing the checklists. The Admin stated storing clean dishes on a dirty rack could be harmful to the residents and could lead to foodborne illness. The Admin stated to prevent this failure from happening again, kitchen staff would be in-serviced on kitchen sanitation and monitor the cleaning schedule to ensure all dietary equipment was cleaned and sanitized on a regular basis. <BR/>Record review of the Kitchen Cleaning Tasks binder revealed partially completed Daily Kitchen Cleaning Schedule checklists from August and September of 2022. The binder also housed blank checklists for weekly, monthly, quarterly and after use cleaning schedules, including to scrub the shelves, frame, handles, underside of shelves wheels and bumpers of tiered tray carts on a weekly basis. <BR/>Record review of the facility's policy entitled Sanitation, revised October 2008, reflected the following:<BR/>Policy statement: The food service area shall be maintained in a clean and sanitary manner. <BR/>Policy Interpretation and Implementation . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs for one (Resident #9) of five residents reviewed for PASRR assessments.<BR/>The facility failed to recognize Resident #9 who had diagnosis of Bipolar Disorder on admission and as a result he never received a PASRR Level II assessment Evaluation. <BR/>This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs.<BR/>Findings included:<BR/>Review of Resident #9's quarterly MDS dated [DATE] revealed, a [AGE] year-old male who admitted to the facility 11/21/19 with the diagnoses to include: bipolar disorder, cerebrovascular accident (stroke), and intermittent explosive disorder. The resident had BIMs score of 12, indicating his cognition was intact, and required assist of one staff for ADLs There was not a diagnosis of dementia. Further review of the section A for PASRR status was blank. <BR/>Review of Resident #9's Physician's Orders Summary Report dated June 2022 revealed, Bipolar disorder, Risperdal: Monitor and document any side effects related to use of antipsychotic medication. <BR/>included: <BR/>Risperdal tablet 2mg give one tab by mouth at bedtime for bipolar disorder. <BR/>Review of Resident #9's MAR dated June 2022, revealed the following orders:<BR/>Order date 11/21/19: Risperdal tablet 2mg give one tab by mouth at bedtime for bipolar disorder. Further review of the MAR revealed Resident #9 had received his Risperdal for the month of June 2022. <BR/>Review of Resident #9's PASRR Level 1 screen dated 11/21/19 revealed, Submitter information was the facility, Referring Entity: .Hospital .C. 100. Mental Illness: No . This was his only PASRR Level 1 Screen found in the SIMPLE LTC system.<BR/>In an interview on 06/28/22 at 1:00 p.m. with the Social Worker reveals she was responsible for the PASRR level 1. The Social Worker stated when a resident admits to the facility, she reviews the resident's information documenting the admission information on the PASRR level 1. She stated if the resident had a diagnosis of Mental Illness Health would answer yes to the question asking if they had a diagnosis, the LA would come to complete a PASRR level 2 to see if the resident qualifies for services. The Social Worker gave examples of diagnosis that she would check yes for: Schizophrenia, bipolar disorder, psychosis, anxiety with psychosis. She stated she had missed Resident 9's diagnosis of bipolar disorder and she would be completing a new PASRR 1 today. She stated that the follow-up for the PASRR 1 was her responsibly and the meetings were also her responsibility, if the residents qualified for services (specialized services) it would be the responsibility of that department manager to receive the orders and initiate the services. The Social Worker stated that there was no follow-up with the specialized services, except the scheduled meetings. The Social Worker stated that if the PASRR 1 assessment was not completed correctly the resident could not receive available services.<BR/>In an interview on 06/28/22 at 2:00 p.m. with the Administrator revealed the Social Worker was responsible for completing the PASRR 1. She started she was a full time Social Worker, and she could not understand how this could have been missed. The Administrator said she did not have direct involvement with the PASRR process, if the residents had qualified for specialized services she would be made aware of that by the Social Worker or the department head, and she would in assist to assure that the services were provided. <BR/>In an interview on 06/29/22 at 2:20 p.m. with the DON revealed she was not involved with PASRR, she had only been working at the facility for 6 weeks. She stated the Social Worker took care of the PASRR reports. The DON stated she did attend one of the meeting last week for one of the residents, but she did not understand any of the information. The DON stated if the assessment was not completed properly, she thought the resident might not get services.<BR/>In an interview on 06/29/22 at 3:00 p.m. with Resident #9 revealed he did not know anything about PASRR or specialized services, no one had talked to him about that. The resident said if he was entitled to something, he wanted to able to get it. <BR/>Review of the facility's policy and procedure PASRR Nursing Facility Specialized Services Policy and Procedure revised dated January 2022 reflected, It the policy of the facility to ensure NFSS Forms are submitted timely and accurately Procedure 1. PL1 is completed, 2. if PL1 is coded as suspicion of MI ID or DD, ta a PE required

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #12, #6, #36, #30, #42) of eight residents reviewed for infection control.<BR/>1. <BR/>RN B failed to disinfect the glucometer in between blood glucose checks for Residents #12 and #6.<BR/>2. <BR/>LVN A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #36, #30 and #42.<BR/>These failures could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>1. <BR/>Review on 06/29/22 of Resident #12 EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses that included stroke affecting unspecified side, cognitive communication deficit, diabetes, high blood pressure. <BR/>Review of Resident #12's MDS, dated [DATE], revealed a BIMS score of 6, indicating moderate impairment, mobility requiring two persons to assist. <BR/>Review of Resident #12's care plan, dated 06/27/22, revealed she was care planned for wound to her right breast.<BR/>Review on 06/29/22 of Resident #6's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, Cognitive communication deficit, and muscle weakness.<BR/>Review of Resident #6's MDS, dated [DATE], revealed a BIMS score of 8 indicating moderate impairment, mobility requiring one to two persons to assist. <BR/>Review of Resident #6's care plan, dated 05/07/21, revealed she was care planned for risk of pressure ulcers related to diabetes and she refuses for skin to be assessed most of the times.<BR/>Observation on 06/27/22 at 7:24 AM revealed RN B performing bedside finger stick glucose check on Resident #12. RN B failed to sanitize the glucometer before or after using it on Resident #12.<BR/>Observation on 06/27/22 at 7:31 AM revealed RN B performing bedside finger stick glucose check on Resident #6. RN B failed to sanitize the glucometer before or after using it on Resident #6.<BR/>Interview on 06/27/22 at 12:45 PM of RN B she stated reusable equipment, like glucometer, should be sanitized with wipes between each resident use in order to prevent transmitting an infection from one resident to another. She stated that if she forgot to wipe the glucometer because the presence of the surveyor made her more nervous.<BR/>2. <BR/>Review on 06/29/22 of Resident #36's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, chronic obstructive pulmonary disease, and hypertension. <BR/>Review of Resident #36's MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate impairment, his functional status indicated he needed setup help only with hid ADLs. <BR/>Review of Resident #36's care plan, date 11/09/21, revealed he was care planned for being at risk for pressure ulcer development related to incontinence and Parkinson's Disease.<BR/>Review of Resident #30's EHR revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included epilepsy, hypertension, muscle weakness, and age-related cognitive decline. <BR/>Review of Resident #30's MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate impairment. His mobility status indicated he needed one-person physical assist, needed assistance for his ADLs and mobility. <BR/>Review of Resident #30's care plan, dated 05/04/22, revealed he was care planned for history of testing positive for COVID-19. <BR/>Review of Resident #42's EHR revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, diabetes, delusional disorder, and hypertension. <BR/>Review of Resident #42's MDS, dated [DATE], revealed a BIMS score of 7, indicating severe impairment. His mobility status indicated that he needed limited assistance in his ADLs. He was at risk of pressure ulcers. <BR/>Review of resident #42's care plan, dated 06/27/22, had him care planned for having colostomy, he requires intravenous therapy related to urinary tract infection and intravenous antibiotic order. <BR/>Observation on 06/27/22 at 7:40 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #42. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #42.<BR/>Observation on 06/27/22 at 8:02 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #30. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #30.<BR/>Observation on 06/27/22 at 8:10 AM revealed LVN A performing morning medication pass, during which time she checked the blood pressures on Resident #36. LVN A failed to sanitize the blood pressure cuff before or after using it on Resident #36.<BR/>Interview on 06/27/22 at 12:35 PM of LVN A she stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use in order to prevent transmitting an infection from one resident to another. She stated that if she forgot to wipe the cuff it was because of the presence of the surveyor made her more nervous.<BR/>Interview on 06/28/22 at 9:05 AM with the ADON she stated that her expectation was that staff will sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another.<BR/>Review of facility's Cleaning and Disinfecting Non-Critical Resident-Care Items policy, revised June 2011, reflected the following: c. No-critical items are those that come in contact with intact skin but not mucous membranes. 1) Non-critical resident-care items include bedpans, blood pressure cuffs, glucometers, crutches, and computers. 2) most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). d. Reusable items are cleaned and disinfected or sterilized between residents.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three (Halls 100, 400 and 500) of six halls and one (main dining room) of two dining rooms and one of one kitchen and one (facility entrance) of one reviewed for environment.<BR/>(A)The facility failed to ensure the exit door on the 100 hall and front of Resident #5's room door was clean and in good repair.<BR/>The facility failed to ensure the floors on halls 100, 400 and 500 were clean and in good repair. <BR/>The facility failed to ensure the flooring in the dining room next to the kitchen entrance and ice machine was clean and in good repair. <BR/>The facility failed to clean or replace the two rusty panic bars on hall 100 and 2 rusty panic bars on hall 500.<BR/>The facility failed to ensure Resident #9's room was cleaned thoroughly. <BR/>(B) The facility failed to ensure the floor drainage system in the kitchen was not clogged up.<BR/>The facility failed to ensure the front entrance of the facility was clean and in good repair. <BR/>These failures could affect all residents, resulting in falls and cross contamination, resulting in injury and stomach illnesses which could lead to a decline in the resident's health and physical functioning.<BR/>Findings included:<BR/>(A)Observation on 03/07/24 at 9:14 am, the floor at the entrance of Resident #5's room had assortment of colors, the flooring in the resident's room was dark brown. Around the entrance of the resident's door was one light brown tile and one grey tile. There were several layers of accumulated blackish dirt around the door and the door frame had blackish debris and chipped paint, dry rot and rust along it.<BR/>Observation on 03/07/24 at 12:49 pm, the 2 barrier door's panic bars on the 100 hall had a large amount of rust spots and scrape marks on them. <BR/>Observation on 03/07/24 at 12:50 pm, the 100 hall exit door had accumulated layers of blackish dirt, scuff marks, chipped paint, and dry rot. The corner of the door had a quarter size hole and light from the outside could be seen. The baseboards by the exit door had several layers of bumpy and chipped paint and accumulated blackish dirt. <BR/>Observation at 03/07/24 at 12:52 pm, the 2 barrier door's panic bars on the 500 hall had a large amount of rust spots and scrape marks and brownish debris particles covered most of the metal areas on the panic bars. <BR/>Observation 03/07/24 at 1:01 pm, in the main dining room, the white flooring tiles around the ice machine entrance door of kitchen appeared to have several areas of accumulated blackish dirt and grime. The drain by the ice machine had brownish rust stains and blackish dirt on and around it, the tiles were cracked and missing some areas of the tiles. The lower right side of the ice machine had yellowish colored drip stains on it and there was rust under two of the four legs. The white kitchen door had a large area of blackish smudge and the bottom of the door had bumpy/uneven paint and blackish dirt. The flooring around the door frame had brownish rust stains and blackish accumulated dirt and the corners had debris particles.<BR/>Interview on 03/07/24 at 3:30 pm, [Anonymous] stated the housekeepers did not do a good job cleaning the facility. They spoke to the Housekeeping/Maintenance Supervisor, but he had not been back to work this week. They stated when things were broken, they wrote up a repair request in the book up front. They stated noticing the rust and broken flooring and walls in the rooms and common area and had spoken to Housekeeping/Maintenance but could not remember what his response was. They stated if the facility was not cleaned properly, it could cause the residents to develop infections and probably get sick. They was not sure why They had not mentioned the housekeeping and maintenance concerns to the Administrator. They stated if things around the facility were broken it could cause the residents to trip and fall. <BR/>Interview on 03/07/24 at 4:13 pm, the Dietary Director stated the door entrance to the kitchen door needed to be painted and door frame needed to be repaired. He stated he had not really paid attention to the rust on the hallway doors but that floors were yucky and cracked. He stated the floor drain next to the kitchen front entrance was not rusted but just had paint loss and the original metal was what was exposed. He stated the Housekeeping/Maintenance Supervisor was on leave since last Monday and said their corporate office or a repair company to come out to fix stuff. He stated some areas on the flooring needed extensive repairs. <BR/>Interview on 03/07/24 at 5:28 pm, the SW stated the residents in the February 2024 Resident Council meeting said they felt like the housekeepers were not cleaning good enough. She stated Resident #9complained about housekeeping services last January 2024. She stated the housekeeping issues should have been addressed by the Maintenance/Housekeeper and was not sure if the complaints were resolved. She stated the Maintenance/Housekeeper Supervisor should have spoken with the weekend housekeeper to clean and pick up trash properly. She stated she was responsible for ensuring the complaints were follow-up on and she said she was not sure why she had not done so. She added the facility's floors were a continuous battle because the glue rose up and dried on top of the flooring tiles. She stated the Maintenance/Housekeeping Supervisor did his best to make sure the facility was cleaned and in good repair. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she tried some best practice trainings with the housekeepers because she noticed some areas were being missed. She stated she noticed the barrier door grab bars were rusty and Housekeeping/Maintenance Supervisor had a to do list to fix them. She stated their Housekeeping/Maintenance Supervisor had not worked for the past few days and they just hired a Maintenance Assistant, but he did not know how to repair much yet.<BR/>(B) Observation and interview on 03/07/24 at 9:00 AM, the floors in the facility entry area appeared to have spots of built-up black grime in the seams of the tiles. The doors around the entrance appeared to have general wear from wheelchairs. <BR/>Observation on 03/07/24 at 9:10 AM, around the RN nurses' station, the floors in this area also had built up grime in the seams. <BR/>Observation and interviews on 03/07/24 at 9:43 AM, the floor drains in the kitchen were backed up with dirty water and leveled with the floor. One drain was observed to have the hose of a wet vac inserted into the drain to drain out water. The Dietary manager stated having drainage issues for a few months. He stated there had been people at the facility to fix it a few times, but the floor drains were still backed up. <BR/>Interview on 03/07/24 at 3:40 PM, Housekeeper C stated that the problem with the floors was that the glue kept seeping through the seams. She stated they tried to mop the glue up, but it did not come off the floor. <BR/>Interview on 03/07/24 at 4:14 PM, the Administrator stated they had some issues with the floors, because there was grime build up on them . She stated they were supposed to get them redone and the owner told her the floors were really not working for this environment. She stated she agreed the floors looked Icky (disgusting) which could make the residents feel bad about their home. She stated she knew about the drainage problem in the kitchen which had been going on for a few months. She stated they tried to get some people in there to take care of it, but nothing worked so far. She stated she knew the drainage issue in the kitchen could cause a cross contamination problem. <BR/>Record review of the facility's Grievance form dated 01/17/24 revealed, Resident #9 - housekeeping needs .<BR/>Record review of the Resident Council minutes dated 02/17/24 revealed, C. Housekeeping & Laundry Department .feels like some of the housekeepers do bare min. when asked to clean their rooms.<BR/>Record review of the last two months (02/26/24 - 03/26/24) maintenance log sheets did not reveal any requests to repair the kitchen's floor drain, common areas in the hallways and main dining room.<BR/>Record review of the Facility's Cleaning and disinfection of Environmental Surfaces policy dated 2001 revised 2009 revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected, according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens Standard .Policy Interpretation and implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Critical items, semi critical items and non-critical items .9. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . <BR/>Record review of the Facility's Maintenance Service policy dated 2001 and revised 2009 revealed, Policy Statement: Maintenance services should be provided to all areas of the building, grounds and equipment .Policy interpretation:2. b. Maintaining the building in good repair and free from hazards .i. providing routinely scheduled maintenance services to all areas .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, equipment are maintained in a safe and operable manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. <BR/>The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings Include:<BR/>Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room.<BR/>Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room .<BR/>An interview on 03/07/24 at 9:20 a.m., Resident #6 revealed that he had seen many black small flies and roaches all over the facility.<BR/>An interview on 03/07/24 at 9:24 a.m., Resident # 6 stated that he had seen flying black gnats and roaches in many areas of the facility. He did not state how long he had been seeing the insects/pest or if he had seen pest control at the facility. <BR/>Observation on 03/07/24 at 9:37 a.m. in the 300-hall shower room revealed 15-20 small black flies or gnats either alighted on the shower curtain to shower stall #1 or flying near a large plastic bag filled with wet towels near shower stall #1. Four dead roaches were observed on the floor underneath the shower curtain for shower stall #1.<BR/>An interview on 03/07/24 at 2:57 p.m., MA A stated that she had seen gnats and roaches all over the facility and in resident rooms. She stated that the staff were supposed to write down bug sightings in some book, but she did not know where the book was, and she denied knowing what a pest sighting log was. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:33 p.m., CNA B revealed she had seen many roaches and gnats in room [ROOM NUMBER] and she had seen gnats and roaches in room [ROOM NUMBER] room that day (03/07/24). She stated hat she had never seen a pest sighting log, and she was not sure where the staff were supposed to write those things down. She stated that the staff just reports bugs to the maintenance manager. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:40 p.m., Housekeeper C stated that he did sometimes see gnats and that he was not sure how to report insects at the facility. She did not indicate how often she had seen pest or if she had seen pest control in the building. <BR/>An interview on 03/07/24 at 3:50 p.m., CNA D revealed that she had seen gnats and roaches at the facility and denied knowing that she had to log them in the pest sighting log.<BR/>An interview on 03/07/24 at 4:00 p.m., RN E revealed that he had seen gnats and roaches in the facility and that he thought there was a book somewhere to write them down (insect sightings) but he did not know where the book was. <BR/>An interview on 03/07/24 at 4:06 p.m. CNA F stated that she had seen many gnats and roaches at the facility. She stated that she tells the maintenance manager about insects when she sees him. She stated that she had never heard of a pest sighting log.<BR/>An interview on 03/07/24 at 4:14 p.m., the Administrator stated that the staff were supposed to use the pest sighting log and that the staff had been trained on using the pest sighting log but that they just tell the maintenance manager instead. She stated that having gnats in the facility could affect residents negatively and mentally and could pose a risk of cross contamination.<BR/>An interview on 03/07/24 at 6:17 p.m., the DON revealed she had seen some gnats around the facility and that she thought staff were supposed to log insects in the pest sighting log. She stated that it could be very annoying for residents to have to deal with gnats and that it could affect their mental health and could possibly cause cross contamination. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the Facility's Pest Sighting Log/Pest Control Binder revealed: that the last pest sighting logged in the pest sighting log was 08/09/23 for flies, no other more recent entries could be found.<BR/>Review of Pest Control Service Inspection Report dated 02/15/24 revealed taget pest treated were rodents (rodent bait stations), german cockroaches in the kitchen and laundry area. This was the last inspection/service report in the binder. <BR/>Record review of the facility's policy dated May 2008, and titled Pest control reflected Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents

Based on observation, interview and record review the facility failed to ensure the nurse staffing information was posted on a daily basis for one of twenty-one days (05/17/24) reviewed for nursing services and postings.<BR/>The facility failed to update the posting of the daily staffing information on 05/17/24.<BR/>This failure could place residents at risk of not having access to information regarding staffing data and facility census.<BR/>The findings include:<BR/>Observation on 05/17/24 at 9:30 AM of the building revealed the daily nursing staff posting was posted near the dining room with a date of 05/16/24. <BR/>Observation on 05/17/24 at 11:50 AM of the building revealed the daily nursing staff posting was posted near the dining room with a date of 05/16/24.<BR/>Observation on 05/17/24 at 3:05 PM of the building revealed the daily nursing staff posting was posted near the dining room with a date of 05/16/24.<BR/>In an interview on 05/17/24 at 4:49 PM, the DON stated she was not aware the nurse staffing posting was not updated for 05/17/24. The DON stated the ADON was to ensure the posting was updated daily. The DON stated the ADON usually provided daily nurse staffing sheets in two-week increments, at every pay period, but she had not provided the sheets for the current pay period. The DON stated the facility residents would not be provided with nurse staffing if the posting was not updated daily. The DON stated she would in-service staff on required posting updates, train the receptionist to update the posting in the ADON's absence and check the nurse staffing post at the beginning of each shift to ensure it was updated correctly. <BR/>A telephone interview was attempted with the ADON on 05/17/24 at 5:15 PM but was unsuccessful. <BR/>In an interview on 05/17/24 at 5:24 PM, the ADMIN stated she did not know the nurse staffing posted was not updated for 05/17/24, but it should have been updated at the start of the day. The ADMIN stated the ADON and receptionist were responsible for updating the daily nurse staffing posting. The ADMIN stated the ADON worked in the facility last night (05/16/24) and did not leave the sheets for this pay period. The ADMIN stated her residents were not affected, as they did not pay attention to the posting, but they would be misinformed if the post was not updated daily. The ADMIN stated she would in-service staff on the daily posting and monitor the posting area to ensure it was updated. <BR/>A related policy was requested from the ADMIN on 05/17/24 at 5:24 PM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #3) of 66 residents reviewed for assistive devices.<BR/>A portable heater was found in use in Resident #3's room without direct supervision.<BR/>This failure could place residents at risk for accidents or injuries.<BR/>Findings include:<BR/>Record review of Resident #3's Face sheet dated 01/28/2025 revealed that Resident #3 was a [AGE] year-old male that was initially admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, Age-Related Cognitive Decline and Partial traumatic Amputation of left foot at Ankle Level.<BR/>Record Review of Resident #3's Quarterly MDS Assessment and Care Screening dated 11/07/2024 revealed that Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. The resident required the use of a wheelchair and required supervision or touching assistance for all transfers and personal hygiene. <BR/>Record review of Resident #'3 Care Plan, dated 11/13/2024 revealed that Resident #3 has an Activity of Daily Living self-care deficit related to osteomyelitis [infection of the bone] of left foot post-surgical intervention, impaired cognition and makes poor decisions.<BR/>In an observation and interview on 01/28/2025 at 11:24 AM revealed Resident #3 was observed in his room, seated comfortably in a wheelchair. A portable heater was noted to be operating behind the resident within 2 feet of the resident's bed and privacy curtain. The resident stated that the facility had given him the portable heater to use because his in-wall unit was not working for the last two days. He stated that the air conditioning part of the in-wall unit worked fine but that the heat was not working. He stated that he liked it warm in his room.<BR/>In a set of observations from 01/28/2025 at 11:42 AM to 01/28/2025 to 11:42 AM revealed all other resident rooms were checked for portable heaters. No other portable heaters were found. <BR/>In an observation and interview on 01/28/2025 at 1:45 PM revealed the Maintenance Supervisor was observed removing the wall air conditioning/heater unit from Resident #3's room. The portable heater was no longer present in Resident #3's room. The Maintenance Supervisor stated that he had taken the portable heater out of Resident #3's room and he was in the process of replacing Resident #3's in-wall air conditioner/heater unit. He stated that Resident # 3 had been using the portable heater for the last 2 days and that the heater had an automatic turn-off switch if the portable heater fell over or was tipped. <BR/>In an interview on 01/28/2025 at 2:09 PM LVN A stated that she was not aware of anyone doing fire watches in the facility. She stated that fire watches meant that the staff had to check the entire facility every 15 minutes to make sure there were no fires in case the fire alarm system stopped or a power outage.<BR/>In an interview on 01/28/2025 at 2:29 PM LVN B stated that she had not heard anything about the facility having to do any fire watches or that Resident #3 had a portable heater in his room. She stated that she had been working for the last three days and that she had been unaware of any portable heaters in the building. She stated that she had thought portable heaters were not allowed in nursing facilities. <BR/>In an interview on 01/28/2025 at 3:30 PM the ADM stated that a portable heater could pose a fire risk to residents if a blanket, curtain or pillow got too close to it for a period of time. He stated that he had not done any fire watches while the portable heater was in use in Resident #3's room, and that the portable heater had been in use for the last two days.<BR/>In an interview on 01/28/2025 at 3:34 PM Maintenance Supervisor stated that portable heaters could cause fires if left unmonitored because something flammable could get next to a heater and possibly start a fire. He stated that he had replaced the in-wall unit in Resident #3's room and had meant too the day before but had not been able to get to it. He stated that he had replaced it a few hours ago and that there were no other portable heaters in use in the facility.<BR/>A policy for Portable Heaters in Nursing facilities was requested on 01/28/2025 at 3:17 PM but was not presented before the conclusion of the investigation.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food sanitation.<BR/>The facility failed to ensure dishes were cleaned and stored under sanitary conditions.<BR/>This failure could place residents at risk for foodborne illness and a decline in health status.<BR/>The findings include:<BR/>Observation on 01/10/23 at 12:23 p.m., of the kitchen, revealed an empty rack near the 3- compartment sink. The rack was a large three tier rack used to store clean plate covers.<BR/>with water stains, a brown sticky substance and dried food particles on its trays and structure poles. <BR/>A follow-up observation on 01/10/23 at 3:09 p.m. of the kitchen, revealed the rack observed at 12:23 p.m., was filled with clean plastic plate covers. The rack still had water stains, a brown sticky substance and dried food particles on its trays and structure poles.<BR/>In an observation and interview on 01/10/23 at 3:11 p.m., [NAME] A stated the rack was used to store the food covers when not in use. [NAME] A stated the rack was previously observed empty because the covers were used to deliver lunch. [NAME] A stated the rack was supposed to be power washed but had not been because the DM was out for the day. [NAME] A stated it was the responsibility of all kitchen staff to ensure all equipment was cleaned. [NAME] A stated she did not know when the rack was last cleaned, but she could wipe down the rack. [NAME] A stated they were trained to complete cleaning tasks as scheduled and record their completion in a cleaning log binder. <BR/>In an interview on 01/10/23 at 3:25 p.m., the DM stated kitchen staff were trained to clean any mess in the kitchen, as they made it, which was his expectation for staff. The DM stated he had no knowledge of the cleaning schedule binder and he had been searching for lists to post for staff to use. The DM stated he was aware of the unsanitary condition of the rack used to store clean plate covers. The DM stated he tried to clean the rack a while ago with degreaser, but it did not come clean, and he planned to power wash the rack. The DM stated he did not recall when he attempted to clean the rack. The DM stated he did not know when the rack was last cleaned. The DM stated the plate covers did not come in direct contact with residents' food, so he was unsure of how the unsanitary storage of the covers would affect the resident's food. <BR/>In an interview and record review on 01/10/23 at 4:29 p.m., the Admin stated [NAME] A told her about the unsanitary condition of the rack used to store the plate covers. The Admin stated she believed the rack was scheduled to be cleaned monthly. The Admin stated the rack was supposed to be power washed but had not been washed yet. The Admin stated she expected all dietary equipment to be cleaned and sanitized on a regular basis. The Admin stated she believed the rack was on the monthly cleaning schedule and she was unsure of when it was last cleaned. While the Admin reviewed the cleaning tasks binder with the State Surveyor, the Admin stated she provided the binder to the DM to use and she was not aware staff were not completing the checklists. The Admin stated storing clean dishes on a dirty rack could be harmful to the residents and could lead to foodborne illness. The Admin stated to prevent this failure from happening again, kitchen staff would be in-serviced on kitchen sanitation and monitor the cleaning schedule to ensure all dietary equipment was cleaned and sanitized on a regular basis. <BR/>Record review of the Kitchen Cleaning Tasks binder revealed partially completed Daily Kitchen Cleaning Schedule checklists from August and September of 2022. The binder also housed blank checklists for weekly, monthly, quarterly and after use cleaning schedules, including to scrub the shelves, frame, handles, underside of shelves wheels and bumpers of tiered tray carts on a weekly basis. <BR/>Record review of the facility's policy entitled Sanitation, revised October 2008, reflected the following:<BR/>Policy statement: The food service area shall be maintained in a clean and sanitary manner. <BR/>Policy Interpretation and Implementation . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Residents #1 and #2) of six residents' rooms reviewed for Environment. <BR/>The facility failed to ensure Residents #1 and #2's bathroom floors and walls were in good repair and sanitary. <BR/>These failures could place all residents at risk of falls which could result in injuries leading to a decreased quality of life and psycho-social well-being. <BR/>Findings included: <BR/>Record review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 14 (no cognitive impairment) and impaired upper and lower one-sided extremities and used a wheelchair. He also needed partial to moderate assistance with toileting and had other neurological conditions. <BR/>Interview and observation on 03/07/24 at 9:20 am, Resident #1's room had approximately 8 or 9 articles of clothing on the floor against the wall, he said were dirty clothes, and his trash can was full. He stated well this place is Kind of yucky (disgusting), they half ass clean my room daily. In his bathroom there was 1 &frac12; foot wood tile that was separated from the floor and under it was white cement and several layers of blackish colored dirt. There was 2 feet of wood tile was loose and a 1-inch gap with blackish colored grime was between the wood tile next to it. And the border and white caulk was separated from the wall and white caulk had separated from the wall and floor in the back corner of the toilet had an accumulation of blackish colored dirt and debris. The ac unit had approximately 2 &frac12; feet of white caulk 1 inch over the AC unit and had a 4 in long crack on the left upper side on the other side the AC unit appear not attached completely to the wall. And the white overhead light over the resident's bed appeared to have several layers of blackish dirt. <BR/>Record review of Resident#2's Annual MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 07 (moderate impairment) and both sides lower impairment. He used a wheelchair. He was dependent with toileting and had medically complex conditions. <BR/>Interview and observation on 03/07/24 at 10:30 am, Resident #2's room had seven to eight articles of clothing on the floor next to the wall. The resident said they were his dirty clothes. He stated the holes had been in his bathroom wall since being in this room. The bathroom had a 1 &frac12; foot hole above the floorboard that was separated from the wall and there was whitish bubbly caulk on it and the floor. The bathroom door had several areas of rust stains and the flooring next to the shower was jagged and uneven and broken in some areas. The corner next to the shower had rust stains and several layers of caulk on the wall and floor. And the resident's room flooring had several areas of scrap marks from door scrubbing the floor and as it was opened and closed it made a very loud and screeching noise. <BR/>Interview on 03/07/24 at 3:30 pm, [Anonymous] stated the facility's housekeepers did not do a good job cleaning the facility and fixing broken things. They stated speaking to the Maintenance/Housekeeping Supervisor and by putting the repairs needed into the Maintenance book up front. They stated if the facility was not cleaned properly, it could cause residents to get infections and probably get sick and also cause injuries like falls. They stated not being sure why they had not mentioned the maintenance and housekeeping issues to the Administrator. <BR/>Interview on 03/07/24 at 4:41 pm, the ADON stated sometimes the housekeepers did a good job cleaning but sometimes on Mondays, the floors were dirty. She stated the Department Heads had assigned halls, they checked the resident's rooms and common areas for cleanliness. She stated the Maintenance/Housekeeper Supervisor was responsible for ensuring the house keeping was done properly. <BR/>Interview on 03/07/24 at 5:28 pm, the SW stated the residents in the February 2024 Resident Council meeting said they felt like the housekeepers were not cleaning good enough. She stated Resident #9 complained about housekeeping services last January 2024. She stated the housekeeping issues should have been addressed by the Maintenance/Housekeeper and was not sure if the complaints were resolved. She stated the Maintenance/Housekeeper Supervisor should have spoken with the weekend housekeeper to clean and pick up trash properly. She stated she was responsible for ensuring the complaints were follow-up on and she said she was not sure why she had not done so. She added the facility's floors were a continuous battle because the glue rose up and dried on top of the flooring tiles. She stated the Maintenance/Housekeeping Supervisor did his best to make sure the facility was cleaned and in good repair. She stated she reported the hole in Resident #2's bathroom wall to the Maintenance Housekeeping Supervisor. She stated she noticed the flooring tile around Resident #1's toilet was loose last week. <BR/>Interview on 03/07/24 at 6:37 pm, the Administrator stated she tried some best practice trainings with the housekeepers because she noticed some areas being missed. She stated she noticed the barrier door grab bars were rusty and Housekeeping/Maintenance Supervisor had a to do list to fix them. She stated they just hired a Maintenance Assistant, but he did not know how to repair much yet. She stated being aware of Resident #2's holes in his bathroom and Resident #1's loose flooring tiles in his bathroom for about two weeks. <BR/>Interview on Maintenance Director was attempted but was told by the Administrator, he was on leave since 03/04/24. <BR/>Record review of the facility's Grievance form dated 01/17/24 revealed, Resident #9 - housekeeping needs .<BR/>Record review of the Resident Council minutes dated 02/17/24 revealed, C. Housekeeping & Laundry Department .feels like some of the housekeepers do bare min. when asked to clean their rooms. <BR/>Record review of the last 2 months (02/26/24 - 03/06/24) maintenance log sheets did not reveal any requests for Resident #1 flooring issue and Resident #2's wall hole and flooring issue. <BR/>Record review of the Facility's Cleaning and disinfection of Environmental Surfaces policy dated 2001 revised 2009 revealed, Policy Statement: Environmental surfaces will be cleaned and disinfected, according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood borne Pathogens Standard .Policy Interpretation and implementation: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: Critical items, semi critical items and non-critical items .9. Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . <BR/>Record review of the Facility's Maintenance Service policy dated 2001 and revised 2009 revealed, Policy Statement: Maintenance services should be provided to all areas of the building, grounds and equipment .Policy interpretation:2. b. Maintaining the building in good repair and free from hazards .i. providing routinely scheduled maintenance services to all areas .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, equipment are maintained in a safe and operable manner .

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food sanitation.<BR/>The facility failed to ensure dishes were cleaned and stored under sanitary conditions.<BR/>This failure could place residents at risk for foodborne illness and a decline in health status.<BR/>The findings include:<BR/>Observation on 01/10/23 at 12:23 p.m., of the kitchen, revealed an empty rack near the 3- compartment sink. The rack was a large three tier rack used to store clean plate covers.<BR/>with water stains, a brown sticky substance and dried food particles on its trays and structure poles. <BR/>A follow-up observation on 01/10/23 at 3:09 p.m. of the kitchen, revealed the rack observed at 12:23 p.m., was filled with clean plastic plate covers. The rack still had water stains, a brown sticky substance and dried food particles on its trays and structure poles.<BR/>In an observation and interview on 01/10/23 at 3:11 p.m., [NAME] A stated the rack was used to store the food covers when not in use. [NAME] A stated the rack was previously observed empty because the covers were used to deliver lunch. [NAME] A stated the rack was supposed to be power washed but had not been because the DM was out for the day. [NAME] A stated it was the responsibility of all kitchen staff to ensure all equipment was cleaned. [NAME] A stated she did not know when the rack was last cleaned, but she could wipe down the rack. [NAME] A stated they were trained to complete cleaning tasks as scheduled and record their completion in a cleaning log binder. <BR/>In an interview on 01/10/23 at 3:25 p.m., the DM stated kitchen staff were trained to clean any mess in the kitchen, as they made it, which was his expectation for staff. The DM stated he had no knowledge of the cleaning schedule binder and he had been searching for lists to post for staff to use. The DM stated he was aware of the unsanitary condition of the rack used to store clean plate covers. The DM stated he tried to clean the rack a while ago with degreaser, but it did not come clean, and he planned to power wash the rack. The DM stated he did not recall when he attempted to clean the rack. The DM stated he did not know when the rack was last cleaned. The DM stated the plate covers did not come in direct contact with residents' food, so he was unsure of how the unsanitary storage of the covers would affect the resident's food. <BR/>In an interview and record review on 01/10/23 at 4:29 p.m., the Admin stated [NAME] A told her about the unsanitary condition of the rack used to store the plate covers. The Admin stated she believed the rack was scheduled to be cleaned monthly. The Admin stated the rack was supposed to be power washed but had not been washed yet. The Admin stated she expected all dietary equipment to be cleaned and sanitized on a regular basis. The Admin stated she believed the rack was on the monthly cleaning schedule and she was unsure of when it was last cleaned. While the Admin reviewed the cleaning tasks binder with the State Surveyor, the Admin stated she provided the binder to the DM to use and she was not aware staff were not completing the checklists. The Admin stated storing clean dishes on a dirty rack could be harmful to the residents and could lead to foodborne illness. The Admin stated to prevent this failure from happening again, kitchen staff would be in-serviced on kitchen sanitation and monitor the cleaning schedule to ensure all dietary equipment was cleaned and sanitized on a regular basis. <BR/>Record review of the Kitchen Cleaning Tasks binder revealed partially completed Daily Kitchen Cleaning Schedule checklists from August and September of 2022. The binder also housed blank checklists for weekly, monthly, quarterly and after use cleaning schedules, including to scrub the shelves, frame, handles, underside of shelves wheels and bumpers of tiered tray carts on a weekly basis. <BR/>Record review of the facility's policy entitled Sanitation, revised October 2008, reflected the following:<BR/>Policy statement: The food service area shall be maintained in a clean and sanitary manner. <BR/>Policy Interpretation and Implementation . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 16 of 30 days reviewed for RN coverage.<BR/>The facility failed to ensure they had an RN on duty on. 02/05/24 (Monday); 02/06/24 (Tuesday); 02/07/24 (Wednesday); 02/08/24 (Thursday); 02/09/24 (Friday); 02/12/24 (Monday); 02/13/24; (Tuesday); 02/15/24 (Wednesday); 02/16/24 (Thursday); 02/17/24 (FR); and 03/07/24 (Thursday)<BR/>This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.<BR/>Findings included:<BR/>Review of the RN staffing hours for February and March 2024 reflected zero hours worked by an RN on 02/05/24 (Monday); 02/06/24 (Tuesday); 02/07/24 (Wednesday); 02/08/24 (Thursday); 02/09/24 (Friday); 02/12/24 (Monday); 02/13/24; (Tuesday); 02/15/24 (Wednesday); 02/16/24 (Thursday); 02/17/24 (Friday); and 03/07/24 (Thursday).<BR/>During an interview on 03/07/24 at 4:14 PM, the ADM stated the facility did not have a DON for around a month.The ADM explained it had been approximately the facility two weeks, including 03/07/24, that the facility has had RN 8 hours a day 7 days a week. The DON was not here today(03/07/24) and we were not able to get the PRN Nurse to come in. When asked how this could affect the facility the ADM explained it could affect assessments, and possibly care for residents. <BR/>During an interview on 03/07/24 at 6:17 PM the DON stated that RN coverage was not there (at the facility) for the middle two weeks of February and 3/7/24 of course as I was not there today. Not having a RN could affect assessments for residents and possibly care, there is a reason that you must have a RN there.<BR/>Record review of the facility policy dated August 2006 reflected the following, Policy Statement: <BR/>The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. <BR/>Policy Interpretation and Implementation: <BR/>1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. <BR/>2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. <BR/>3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN), and are duly licensed by the state.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 16 of 30 days reviewed for RN coverage.<BR/>The facility failed to ensure they had an RN on duty on. 02/05/24 (Monday); 02/06/24 (Tuesday); 02/07/24 (Wednesday); 02/08/24 (Thursday); 02/09/24 (Friday); 02/12/24 (Monday); 02/13/24; (Tuesday); 02/15/24 (Wednesday); 02/16/24 (Thursday); 02/17/24 (FR); and 03/07/24 (Thursday)<BR/>This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.<BR/>Findings included:<BR/>Review of the RN staffing hours for February and March 2024 reflected zero hours worked by an RN on 02/05/24 (Monday); 02/06/24 (Tuesday); 02/07/24 (Wednesday); 02/08/24 (Thursday); 02/09/24 (Friday); 02/12/24 (Monday); 02/13/24; (Tuesday); 02/15/24 (Wednesday); 02/16/24 (Thursday); 02/17/24 (Friday); and 03/07/24 (Thursday).<BR/>During an interview on 03/07/24 at 4:14 PM, the ADM stated the facility did not have a DON for around a month.The ADM explained it had been approximately the facility two weeks, including 03/07/24, that the facility has had RN 8 hours a day 7 days a week. The DON was not here today(03/07/24) and we were not able to get the PRN Nurse to come in. When asked how this could affect the facility the ADM explained it could affect assessments, and possibly care for residents. <BR/>During an interview on 03/07/24 at 6:17 PM the DON stated that RN coverage was not there (at the facility) for the middle two weeks of February and 3/7/24 of course as I was not there today. Not having a RN could affect assessments for residents and possibly care, there is a reason that you must have a RN there.<BR/>Record review of the facility policy dated August 2006 reflected the following, Policy Statement: <BR/>The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. <BR/>Policy Interpretation and Implementation: <BR/>1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. <BR/>2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. <BR/>3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN), and are duly licensed by the state.