**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #50) reviewed for falls, the facility failed to ensure the Resident Care Plan was comprehensive to include interventions that the facility had implemented for fall prevention. The findings include: Resident #50 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, dementia, repeated falls and ataxia. A physician's order dated 10/18/23 directed Resident #50 required assistance with transfers and ambulation of 1 and a rolling walker. An admission MDS assessment dated [DATE] identified Resident #50 was moderately cognitively impaired and required supervision touching assistance with bed to chair to bed transfers without limitation in range of motion. Additionally, the MDS identified Resident #50 was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS further identified Resident #50 had a falls prior to admission. The RCP dated 11/6/23 identified a problem with being at risk for falls, weakness from hospitalization, poor safety, and psychoactive medication use. Interventions included orthostatic blood pressure every shift for 3 days and encourage to participate in therapy if ordered. Nursing notes from 11/6/23 through 1/22/24 identified Resident #50 sustained 12 falls including a hip fracture from a fall on 12/15/23. On 2/5/24 at 10:15 AM, Resident #50 was observed in his/her room, seated in a wheelchair watching television. Fall mats were observed folded up at the bedside, auto locking brakes were observed on his/her wheelchair and a low bed was noted to be against the wall with 1 enabler on the bed. On 2/5/24 at 1:35 PM interview, RCP review and observation of Resident #50's room with RN #3 (MDS Coordinator) identified although interventions of fall mats, auto locking brakes, low bed and 1 enabler were utilized, the RCP failed to include those interventions. Additionally, RN #3 identified that nurses or herself were responsible to update the RCP when new interventions were implemented. RN #3 also identified that in January 2024, the RCP was updated and was unsure of the reason the interventions were not documented in the RCP, although implemented. Facility policy regarding care planning identified that the resident care plan is written, workable individualized record indicating needs and care of the resident. Identification of problems and needs including potential problems, establishing goals and limiting solutions within a time frame and implementation or approach to problems and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, staff interviews and facility policy for 1 of 5 residents(Resident #18) reviewed for psychotropic medications, for 1 of 2 residents (Resident #39) reviewed for pressure ulcers and for 1 of 1 sampled resident (Resident #50) reviewed for elopement, the facility failed to revise the resident care plan. The findings include: 1. Resident #18 was admitted to the facility on [DATE] with a diagnosis including dementia, anxiety, and irregular heart rhythm. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was moderately cognitively impaired and required partial or moderate assistance to roll left and right on the bed and substantial or maximal assistance to transfer from the bed to a chair. The MDS also identified Resident #18 did not exhibit physical or verbal behaviors directed towards others or self and that Resident #18 had not received any antianxiety or antidepressant medication. A physicians order dated 3/29/23 directed to administer Trazodone (a medication for depression) 25 milligrams (mg) every 6 hours as needed for anxiety for 14 days. The Resident Care Plan dated 6/5/23 identified Resident #18 was receiving a psychotropic medication (Tramadol) related to pain management. Interventions included to consult with pharmacy and provider to consider dosage reduction when clinically appropriate. A physicians order dated 12/6/23 directed to administer 25 mg of Trazodone twice a day and 50 mg in the afternoon. The Medication Administration Record (MAR) identified Resident #18 received 25 mg of Trazodone at 9:00 AM and 1:00 PM and 50 mg of Trazodone at 5:00 PM from 1/1/24 to 1/23/24. A physicians order dated 1/24/24 directed to administer 50 mg of Trazodone once in the day and once in the evening. The MAR identified Resident #18 received 50 mg of Trazodone at 5:00 PM and 9:00 PM from 1/24/24 to 1/30/24. On 1/31/24 at 11:30 AM, Resident #18 was observed to be sleeping in a wheelchair and did not arouse to surveyor speaking during the screening process. On 2/5/24 at 10:24 AM, Resident #18 was observed sleeping in bed and aroused to surveyor speaking. Resident #18 was able to answer that they had eaten breakfast and then fell back asleep during the conversation. On 2/5/24 at 10:30 AM, an interview with the Nursing Supervisor (RN #1) indicated that new medications such as antidepressant and other psychotropics would be included in the care plan, but was unable to locate a care plan for the use of Trazodone. She further identified that all team members were responsible for updating the care plan. RN #1 also indicated that the MDS Coordinator (RN #3) also gets updated on resident changes through the facility morning report and that RN #3 would also update the RCP. On 2/5/24 at 1:30 PM an interview and clinical record review with RN #3 indicated that sometimes a care plan for antidepressant medication use would be combined with other psychotropic medication use. The clinical record identified that there was a care plan present for the psychotropic medication Tramadol (a medication for pain) but not for Trazodone ( a medication for depression). RN #3 indicated that medication orders would sometimes contain information on symptom or side effect monitoring and interventions. Subsequent to surveyor inquiry, the RCP was updated on 2/5/24 to include the use of an antidepressant, however, the updated RCP incorrectly identified Tramadol as the antidepressant instead of Trazodone. 2. Resident #39 was admitted on [DATE] with a diagnoses including dementia, generalized muscle weakness, and muscle contracture of the left leg. The Resident Care Plan dated 8/11/23 identified Resident #39 had a potential to have altered skin related to decreased mobility and incontinence. Interventions included providing a pressure relieving mattress and other devices, keeping skin clean and dry, and assisting to reposition as needed. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #39 had short term and long term memory problems. Resident #39 was dependent for toileting, dressing, putting on and taking off footwear, and transferring from bed to a chair. The MDS also indicated that Resident #39 was at risk for developing pressure injuries but did not have any unhealed pressure ulcers. Nursing notes dated 9/25/23 indicated that an open area to Resident #39's coccyx measuring 0.2 centimeters (cm) by 0.2 cm by 0.1 cm was noted during care and that the wound bed had yellow slough. The nursing note also indicated that an Algicell Silver dressing and protein liquid were ordered. The September 2023 Treatment Administration Record (TAR) identified Resident #39 received an Algicell Silver dressing on 9/25/23 and 9/28/23. A wound physician initial evaluation dated 10/9/23 indicated that Resident #39 had a Stage 2 pressure ulcer to the sacrum. The recommended treatment plan included placing an Alginate Calcium dressing and changing it daily. A wound physician's follow up evaluation dated 11/6/23 indicated that the Stage 2 pressure ulcer to Resident #39's sacrum resolved on 11/6/23. A wound physician evaluation dated 1/5/24 indicated that Resident #39 had an unstageable deep tissue injury to the left heel. The recommended treatment was application of a daily skin protectant. A wound physician evaluation dated 1/15/24 identified that Resident #39 continued to have an unstageable pressure ulcer to the left heel and recommended the addition of an Alginate Calcium dressing with silver daily. The January 2024 TAR indicated that Resident #39 received daily skin protectant from 1/1/24 to 1/30/24 and an Alginate Calcium dressing with silver on 1/18/24 and 1/21/24. An interview and RCP review on 2/2/24 at 1:38 PM with RN #3 identified that the last time the RCP was reviewed was on 8/11/23 and 12/8/23 and the RCP was not revised to include the development of pressure ulcers on 9/25/23 or 10/9/23. RN #3 also indicated that the RCP was expected to be updated with any changes or additions when a resident experiences changes including in diet, diagnosis, mood, and skin. RN #3 indicated that the nurse that found a new pressure ulcer would also update the RCP and that it may have been an oversight. On 2/5/24 at 10:30 AM an interview with the Nursing Supervisor (RN #1) indicated that new wounds would be included in the resident's care plan. RN #1 also indicated that all team members were responsible for updating the care plan but that there are a lot of new nurses who may not know they need to update the care plan or might not get to it during the work day. Subsequent to surveyor inquiry, the care plan was updated on 2/2/24 and identified that Resident #39 had an actual impairment to their skin related to a deep tissue injury to the left heel. Interventions included keeping a foam heel protector in place at all times and follow facility protocols for treatment of injury. 3. Resident #50 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, repeated falls and ataxia. The Resident Care Plan (RCP) dated 10/17/23 identified a problem with elopement as evidenced by wandering, exit seeking and impaired judgement. Interventions included Redirect exit seeking behavior, wander guard left ankle, check daily at night for functioning and every shift for placement. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was moderately cognitively impaired and required supervision touching assistance with bed to chair to bed transfers without limitation in range of motion. The MDS further identified Resident #50 had falls prior to admission, had wandering behavior and utilized a wander guard/elopement alarm daily. Treatment Administration Record (TAR) dated 12/1/23 to 12/31/23 indicated wander guard to the left ankle to check functioning of the wander guard every night check placement every shift for exit seeking with discontinued dated 12/16/23. On 2/4/24 at 10:15 AM review of the NA care card with NA #6 identified Resident #50 utilized a wander guard to the left ankle. Observation of Resident #50 with NA #6 at that time identified Resident #50 did not have a wander guard in place to the left ankle or any other extremity. On 2/5/24 at 1:35 PM interview and RCP review with RN #3 (MDS Coordinator) identified the wander guard was in place until 12/16/23 when Resident #50 was admitted to the hospital status post facility fall with hip fracture. Additionally, RN #3 identified Resident #50 was immobile and the wander guard was not reordered upon return from the hospital on [DATE]. Furthermore RN #3 identified she should have removed the use of the wander guard from the RCP and the NA care card. Subsequent to surveyor inquiry on 2/5/24 at 1:45 PM, RN #1 revised the care plan to reflect the discontinuation of the wander guard Facility policy regarding care planning directed, that the resident care plan is written, workable individualized record indicating needs and care of the resident. Identification of problems and needs including potential problems, establishing goals and limiting solutions within a time frame and implementation or approach to problems and needs. Additionally, the policy identified that care plans are reviewed every 90 days and that the resident care coordinator shall be responsible for conducting spot check reviews of written care plans to correct any deficiencies in documentation or lack of updating by any discipline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview for 1 of 1 sampled resident (Resident #36) reviewed for Activities of Daily Living (ADLs), the facility failed to provide personal hygiene for nails and removal of facial hair. The findings include: Resident #36's diagnosis included peripheral vascular disease, dementia, and arthritis. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #36 was severely cognitively impaired, required extensive supervision and assist of 1 for dressing, eating, and personal hygiene, extensive assist of 2 for bed mobility, and toileting, dependent with assist of 2 for transfers. The Resident Care Plan dated 1/27/24 identified Resident #36 required assistance/was dependent for activities of daily living in personal hygiene with interventions that included to supervise ADLs, assist Resident #36 with bathing, hygiene and dressing. Observation on 1/31/24 at 12:00 PM and 2/1/24 at 8:51 AM identified Resident #36's fingernails were long, soiled beneath the nails and had chipped nail polish. Additionally, Resident #36 had a substantial amount of facial hair growth. Interview and observation of Resident #36 with Licensed Practical Nurse (LPN) #1 on 2/2/24 at 10:35 AM identified that Resident #36 nails needed to be cut and his/her facial hair needed to be trimmed. Interview with Nurse Aide (NA) #1 on 2/2/24 at 11:05 AM identified that she did not have the resources to trim Resident #36's fingernails (which she identified resources to mean nail clippers) and was not aware of the facility policy for trimming resident's nails. Registered Nurse (RN) #1 who was present at the end of the interview with NA #1 identified that the policy was for the residents to be well groomed and that nail clippers were available at the nurse's station. Observation with RN #1 identified 10 pairs of nail clippers were located at the nurse's station. Facility policy regarding AM care indicated shaving was essential part of daily AM care for males. Shave the ladies when indicated Facility policy regarding AM care directed to notice if the nails were in need of grooming. Nails should be included in the regular bath day. If they haven't been, take the initiative and soak those nails. On 2/5/24, subsequent to surveyor inquiry, Resident #36 was noted to have a shaved face and clean, trimmed nails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interview for the only sampled resident, (Resident #50), reviewed for bladder and bowel incontinence, the facility failed to correctly code bladder continence and failed to complete a bowel assessment on readmission following a hospitalization. The findings include: Resident #50's diagnoses included a right hip fracture, repeated falls, and dementia. Review of the Nursing admission assessment dated [DATE] identified Resident #50 had multiple daily episodes of urinary incontinence with little to no control, and a bowel evaluation that identified the resident was occasionally incontinent of bowel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was moderately cognitively impaired, required assistance with activities of daily living, and was frequently incontinent of urine and occasionally incontinent of bowel. The Resident Care Plan dated 10/25/23 identified Resident #50 was at risk for bowel and bladder incontinence. Interventions included to be alert for continence changes, signs and symptoms of infection, stress incontinence, and to notify the physician as indicated. Review of Nurse Aid (NA) daily urinary flow sheets for October 2023, November 2023, and through December 15, 2023, indicated that Resident #50 was mostly continent of bladder during the day in October and November and mostly incontinent of bladder at night. Additionally, Resident #50 was noted to be mostly continent of bowel in November and mostly incontinent of bowel through December 15, 2023. A physician's order dated 12/15/23 directed Resident #50 to be sent to the hospital. Review of the Nursing readmission assessment dated [DATE] identified a bladder assessment indicating Resident #50 was completely continent of urine (a significant improvement), and the bowel assessment was left blank. Review of the quarterly MDS assessment dated [DATE] identified Resident #50 was severely cognitively impaired, required assistance with activities of daily living, and was always incontinent of both bowel and bladder. The Resident Care Plan dated 1/1/24 failed to identify changes from the care plan dated 10/25/23. An interview with the Director of Nursing (DNS) on 2/6/24 at 10:16 AM identified that the facility policy for bladder and bowel assessments indicated an assessment should be conducted on admission, readmission, and quarterly. The DNS was unsure why the resident was coded as fully continent of urine on the readmission nursing assessment and was unable to locate that a bowel assessment had been conducted following readmission on [DATE]. Review of the facility Bladder Assessment policy directed, in part, that a comprehensive bladder assessment will be done upon admission, annually, upon readmission with a significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility documentation, facility policy, and interviews for 3 of 3 residents, (Resident #7, Resident #27, and Resident #253) reviewed for oxygen therapy, the facility failed to appropriately label nasal cannula oxygen tubing (Resident #7), and failed to follow a physician's order related to oxygen administration (Resident #27 and Resident #253). The findings include: 1. Resident #7's diagnoses included respiratory failure with hypoxia, sleep apnea, and Chronic Obstructive Pulmonary Disease (COPD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was cognitively intact and required moderate assistance for bed mobility and transfers, and required maximum assistance for personal hygiene. Additionally, the MDS identified Resident #7 utilized oxygen therapy. The Resident Care Plan dated 12/26/23 identified Resident #7 had COPD and asthma and required supplemental oxygen. Interventions included oxygen administration as ordered by the physician, monitoring for signs and symptoms of respiratory distress, and reporting to the physician. The physician's orders dated 1/6/24 through 2/6/24 directed oxygen administration via nasal cannula at 2 L/min (liters per minute) as needed for shortness of breath, and to change and date the oxygen tubing every Sunday on the 11:00 PM to 7:00 AM shift. Observations on 1/31/24 at 11:55 AM, on 2/1/24 at 10:55 AM, and on 2/2/24 at 11:49 AM identified Resident #7 utilizing oxygen at 2.0 L/min via a nasal cannula, the nasal cannula was not labeled or dated. Interview with LPN #2 on 2/2/24 at 12:12 PM identified that the oxygen tubing was changed and labeled with the date and nurses initials every Sunday on the 11:00 PM to 7:00 AM shift, per the facility policy. She identified that Resident #7's oxygen tubing was not labeled, and she was unsure of the reason, but if a NA's (Nurses Aid) changed the tubing due to soiling, the nurse should have been alerted. Subsequent to surveyor inquiry, LPN #2 indicated she would replace the nasal cannula oxygen tubing, ensuring it was labeled and dated appropriately. Review of the Cleaning, Maintaining and Changing of 02/Nebulizer Equipment policy dated 12/2018 directed, in part, that once a week 02 equipment (cannulas, hand-held nebulizers, humidifier bottles, masks and extension tubing) will be changed and labeled with the date and initials by the 11:00 PM to 7:00 AM nurse. 2. Resident #27's diagnoses included respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and dependence on supplemental oxygen. The admission MDS assessment dated [DATE] identified Resident #27 was cognitively intact and had impaired lower extremity function. Additionally, the MDS identified Resident #27 required set up assistance with eating, required maximum assistance with toileting, required partial assistance with upper body dressing and personal hygiene. The MDS further identified Resident #27 utilized oxygen therapy. The Resident Care Plan dated 1/19/24 identified Resident #27 had pneumonia. Interventions included oxygen therapy as ordered, medications administered as ordered and monitor/document for side effects and effectiveness, and to monitor vital signs as ordered. A physician's order dated 1/19/24 directed oxygen administration via nasal cannula at 2 L/min (liters per minute) continuously. A nurse's note dated 2/1/24 at 12:59 AM indicated that oxygen via nasal cannula was held on Resident #27 and not in place due to the oxygen saturation (the amount of oxygen in the blood) reading of 94% (despite a physician's order for continuous oxygen at 2L/min). Observation on 2/1/24 at 10:46 AM identified Resident #27 in bed with his/her eyes closed. The oxygen nasal cannula was not in place and was in a bag on the concentrator to the right of the bed, not within reach of Resident #27 (despite a physician's order for continuous oxygen at 2L/min). Observation on 2/1/24 at 1:36 PM identified Resident #27 in his/her wheelchair with no nasal cannula on, and the oxygen concentrator was no longer in the room. Interview and review of the clinical record with RN #1 and LPN #2 on 2/2/24 at 12:16 PM indicated that per the physician's order, Resident #27 should have been receiving oxygen at 2 L/min continuously via nasal cannula. Neither nurse was aware of the reason Resident #27 was not wearing the ordered oxygen, but if he/she refused, there should have been a nursing note and the APRN and/or physician should have been notified. LPN #2 reviewed the clinical record and failed to locate a nursing note indicating that Resident #27 had refused oxygen or a physician's order to titrate (increased or decreased) oxygen. Although RN #1 and LPN #2 were unsure of the reason for the lack of oxygen they felt it could have been a mistake in admission orders on readmission from the hospital. Interview with MD #1 on 2/2/24 at 1:36 PM indicated that he would expect the nursing staff to notify him if a resident was not utilizing an active order or refusing an ordered treatment or medication. He would then re-evaluate the order as needed based on the facility report, clinical data, and/or assessment. Subsequent to surveyor interview, a new physician's order was obtained on 2/2/24 at 12:30 PM directing oxygen at 2 L/min via nasal cannula as needed for Shortness of Breath (SOB). 3. Resident # 253's diagnoses included respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and sleep apnea. A physician's order dated 1/25/24 directed oxygen administration via nasal cannula at 2 L/min (liters per minute) continuously. The admission MDS assessment dated [DATE] identified Resident #253 was cognitively intact, had no upper/lower extremity limitations, and required partial assistance with personal hygiene, dressing, toileting, and oral hygiene. Additionally, the MDS identified Resident #253 utilized oxygen therapy. Observation on 2/1/24 at 10:56 AM identified Resident #253 in the Rehab gym exercising with weights without the benefit of oxygen (despite a physician's order directing oxygen at 2 L/min continuously). Interview with Resident #253 on 2/1/24 at 12:06 PM identified that staff was attempting to wean him/her off of oxygen prior to his/her discharge home, and that the removal of the oxygen by therapy was planned. Resident #253 reported that he/she was short of breath without oxygen, but that he/she was starting to feel better once the oxygen was reapplied after therapy. A physician's order dated 2/1/24 at 8:00 PM (after surveyor's observation) directed that staff may titrate oxygen via nasal cannula to maintain oxygen saturation greater than 95% twice daily. The Resident Care Plan dated 2/4/24 identified Resident #253 had COPD. Interventions included oxygen therapy as ordered by the physician, the head of the bed to be elevated during episodes of difficulty breathing, and monitoring for signs and symptoms of acute respiratory failure. Subsequent to surveyor inquiry, the physician's order dated 1/25/24 directing that Resident #253 remain on oxygen via nasal cannula at 2 L/min continuously, was discontinued on 2/5/24 at 10:10 AM. Interview with PT #1 on 2/5/24 at 10:13 AM identified that therapy had attempted an oxygen titration but had not yet documented their assessment in the progress notes because Resident #253's Managed Care (insurance) policy does not require notes until 2/7/24. She reported they had completed PT/OT evaluations, but that would not identify any oxygen therapy except for what the resident was admitted with. She indicated they would not initiate any oxygen changes in therapy unless nursing first obtained a physician's order, but reported they had a different charting system because they are an outside vendor, and she did not know how to use the facility's electronic charting system. She reported therapy gives a verbal hand off to nursing after each visit, and nursing documents as needed. Review of the Physical Therapy notes dated 1/26/24 and Occupational Therapy notes dated 1/30/24 provided by the outside vendor failed to document oxygen trials or titration with Resident #253. Interview with RN #3 on 2/5/24 at 10:17 AM identified that she was not able to locate any notes in the facility record related to oxygen or the titration of the oxygen. She indicated that nursing should be documenting their observations and the therapy reports, and was unsure of the reason there was no documentation. Further, she identified that there were two active oxygen orders in place, one for continuous oxygen and one for oxygen titration. Interview with the DNS on 2/5/24 at 11:02 AM identified that a physician's order for oxygen titration should be entered prior to staff removing the oxygen or attempting the titration. She did not know the reason there were two orders for both continuous oxygen and a titration, but indicated she would investigate it. At 11:51 AM, the DNS identified that the nurse who entered the oxygen titration order was new to the facility, and that she would educate her on updating orders for the future. Review of the Use of Oxygen policy dated 12/1998 directed, in part, that oxygen is used only on the order of a physician. Although requested, an oxygen titration policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident reviewed for environment, the facility failed to ensure Resident #20's call bell was within reach. The findings include: Resident #20's diagnoses included dementia, extrapyramidal movement disorder and history of falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 was moderately cognitively impaired and required a moderate amount of assistance for all transfers, and substantial amount of assistance for toileting and personal hygiene. The Resident Care Plan dated 12/28/23 identified Resident #20 was a fall risk due to unawareness of safety needs. Interventions included ensuring the call bell was within reach and encouraging the resident to use the call bell. Additional interventions included ensuring a working and reachable call light. A physician's order dated 1/6/24 directed to use a rolling walker and assistance of 2 for all transfers. Observation on 2/1/24 at 10:32 AM identified Resident #20 was sitting in a wheelchair next to his/her bed facing the television. The tray table was at the front of the bed. The electronic call bell was on a chair by the head of the bed behind the resident and not within his/her reach. A manual bell was on the nightstand at the head of the bed, behind the resident and not within his/her reach. Upon request, Resident #20 was unable to turn around or remove the brakes of his/her wheelchair to turn the wheelchair around to access the call bells. Interview with Licensed Practical Nurse (LPN) #3 on 2/1/24 at 10:32 AM identified Resident #20 would not be able to reach his/her call bell as he/she couldn't get up. Additionally, LPN #2 noted they usually put the tray table in front of him/her and the call bell on the tray table. Interview with Nurse Aide (NA) #7 on 2/2/24 at 10:30 AM indicated that after Resident #20 was transferred into his/her wheelchair he/she was usually transported to an activity or a meal. NA #7 was unsure of the reason the call bell wasn't placed within Resident #20's reach, other than he/she was going to be transported to an activity or a meal. Although staff indicated Resident #20 was going to be taken to an activity or a meal, he/she was observed alone in his/her room for 15 minutes after being transferred into his/her wheelchair without the call bell within reach. Facility policy regarding Call Bells dated 10/20 directed when caring for a resident, be sure to position the call bell conveniently, telling/showing resident where the call light is located.

Based on the tour of the Dietary Department, staff interview, facility documentation and policy, the facility failed to ensure the Dietary department consistently labeled canned food to reflect their age or shelf life, failed to discard dented cans and failed to ensure proper hair covering for a beard. The findings included: Tour of the Dietary Department on 1/31/24 at 10:37 AM during the initial walk through of the kitchen with the [NAME] Supervisor identified the following: a. The dry storage room had the following food items with no expiration dates: 2 cans of dark red kidney beans (104 oz per can ), 4 cans of white beans (104 oz per can), 2 cans of white beans (14 oz per can), 8 cans of diced tomatoes (104 oz per can ), 15 cans of beets (104 oz per can), 4 cans of baked beans(104 oz per can), 6 cans of corn (104 oz per can), 9 cans of roasted red peppers (22 oz per can), 8 cans of corned beef Hash (104 oz per can), and one opened bag of cornbread stuffing. b. The following cans were dented and were on the shelf within the usable stock: 1 can mandarin oranges(4 oz), 1 can of jellied cranberry sauce (5 oz), 2 cans of corned beef hash (104 oz per can) and 1 can of new england style beaked beans (4 oz). c. The walk-in freezer was noted to contain a homemade Chocolate Crème Pie (#6) and a Boston Crème Pie (#7) and with no expiration date. e. The walk-in refrigerator was observed to contain blueberries, strawberries, and grapes that were observed in open cartons with no open date or expiration date. f. Observation on 1/31/24 at 11:39 AM identified [NAME] #1 was stirring macaroni salad, had a beard without the benefit of a beard covering. Interview on 1/31/24 at 11:39 AM with the [NAME] Supervisor indicated [NAME] #1's beard was not appropriately covered. g. Observation on 2/2/24 at 9:50 AM identified of [NAME] #1 with his bread uncovered while preparing food. Interview with [NAME] Supervisor at that time identified that [NAME] #1 had trimmed his beard since 1/31/24 and he thought it was short enough to not warrant a beard covering. Interview on 1/31/24 at 11:20 AM with the [NAME] Supervisor indicated that she and staff were responsible for dating the products after removing them from the original package and opening them. She additionally stated the kitchen supervisor was responsible for checking the dented cans at least once per week and staff was responsible for notifying the supervisor if they drop and dent a can. Subsequent to surveyors' inquiry, the [NAME] supervisor provided expiration dates for the canned items listed in exhibit A. Facility policy indicated Dietary employees are required to wear hair restraints to cover any loose hair. Policy additionally indicated beards longer than 1 inch requires a guard or net. The facility was unable to provide a policy regarding labeling and dating of foods, however, the facility policy indicated that Dietary would monitor for expiration dates upon restocking. Facility policy additionally indicated that deeply dented cans should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, interviews review of facility documentation and review of policy for one of two residents reviewed for Mood or Behavior for (Resident #54), the facility failed to ensure notification to the physician/practitioner following a threat of serious physical harm to Resident # 21. The findings include: 1 a. Resident #21's diagnoses included depressive episodes, anxiety disorder and intellectual disabilities. Resident #21's quarterly MDS assessment dated [DATE] identified the resident had no cognitive impairment, no problems with mood or behaviors and was independent in transfers and ambulation in the room and corridor. Resident #21's care plan dated 6/22/21 identified the resident was at risk to be a victim of abuse or mistreatment, had been aggressive toward others, and had pushed another resident down onto the floor on 6/20/21. Interventions included: Intervene as necessary to ensure my safety, monitor mood and behavior and provide early interventions on any changes, provide emotional support as needed, and psychiatric consult as ordered. Resident #21's physician's orders dated 8/4/21 directed behavior monitoring for aggression toward another resident/pushing, and sexually inappropriate statements. Resident #21's nurse's note dated 8/15/21 identified: Resident had a verbal altercation at 12:15 PM with another resident regarding use of shared bathroom. Resident walked into the other resident's room to unlock his/her side of the door and the other resident became upset to see someone walk in his/her room and both residents began to exchange words. Resident # 21 became very angry and agitated. Emotional support was provided. Psychiatric Advanced Practice Registered Nurse (APRN #1) and the responsible party were updated. A new order was obtained for Ativan (Anti-anxiety) 0.5 Milligrams (MG) once daily x 14 days as needed for agitation, and every 15-minute checks until seen by psychiatric. b. Resident #54's diagnoses included recurrent depressive disorder and dementia with behavioral disturbance. Resident #54's quarterly MDS assessment dated [DATE] identified the resident had moderate cognitive impairment, no mood problems, no behaviors exhibited and indicated the resident was independent in all Activities of Daily Living (ADL) with supervision, except for requiring limited assistance of one staff for personal hygiene. The care plan dated 7/29/21 identified the resident was at risk for being a victim of abuse, neglect, or mistreatment, and further identified, in part, risk was related to congregate living, and displays behavioral symptoms that have the potential to annoy others and was vulnerable due to cognitive deficits. The care plan further identified the resident had on the following dates: 9/7/19 Pushed another resident; 10/8/19 Struck a resident in the arm; 1/10/20 Allegation that the resident had punched a roommate in the face; 1/12/20 Struck another resident with a walker; and on 5/25/21 Held another resident by both hands up against the wall. Interventions included: Intervene as necessary to ensure my safety, monitor mood and behavior and provide early interventions on any changes, provide emotional support as needed, and psychiatric consult as ordered. The physician's orders dated 8/1/21 directed behavior monitoring every shift for grabbing others, hitting and making paranoid statements. The nurse's note dated 8/15/21, written by Registered Nurse (RN #4), identified: The resident had a verbal altercation with another resident regarding use of a shared bathroom. The resident became upset when Resident # 21 walked in his/her room to unlock the door on the other side. Words were exchanged and this writer separated both residents. Emotional support was provided. Resident # 54 was calm and cooperative. Psychiatric APRN was updated, new order was provided which included: Every 15-minute checks until seen by Psychiatric APRN. The nurse's note written by Licensed Practical Nurse (LPN #1) dated 8/17/21, identified: The resident was alert and confused, frequently reporting to nurse about other residents that he/she believes are doing or saying things that interrupt his/her living space; reported one resident that he/she believed is trying to fight with him/her again, (had previous altercation with said resident), and stated another resident was saying inappropriate things and threatening me; when asked whom the said resident was he/she couldn't point out nor describe other than stating, he/she walks. The resident re-approached this writer to state that people are telling him/her that he/she doesn't belong here, and he/she can't walk around in the halls. The resident also stated he/she needs someone to deal with his/her neighbor before he/she puts a hole in his/her head. This writer has offered emotional support and encouraged him/her to voice his/her concerns, as well as redirection, all with positive outcomes. Staff will continue every 15-minute checks until seen by psychiatry, as well as another referral was placed in the psychiatric consults book. The resident's safety is maintained, supervisor aware. No further nurse ' s notes were documented on 8/17/21 reflecting notification to the physician /practitioner. Interview with the Director of Nursing Services (DNS) on 11/22/21 at 10:05 AM identified the physician/practitioner should be notified when a resident threatens harm to self or others. Interview with Registered Nurse (RN #2) on 11/22/21 at 10:50 AM identified he/she had not been informed of the statement of potential violence made by Resident #54 but had been informed by LPN #1 that Resident #54 was upset and LPN #1 was able to calm Resident #54. RN #2 identified he/she would have notified the physician and psychiatric APRN if RN #2 was made aware. Interview and record review with LPN #1 on 11/22/21 at 11:06 AM identified that he/she did tell RN #2 specifically Resident 54 's statement that someone needed to deal with his/her neighbor before he/she puts a hole in his/her head. LPN #1 further identified that he/she would expect the psychiatric APRN or physician to be notified, because that is their policy, and this was the responsibility of the RN. Interview with APRN #1 on 11/22/21 at 1:07 PM identified APRN#1 would expect to be called when a resident indicated thoughts or threats of harm, but was not called, the APRN became aware of the statement when he/she came into the facility and read the consult book prior to seeing residents. APRN #1 further identified that he/she would expect the facility to have initiated 1:1 staffing following any threat of potential violence. APRN #1 further identified if he/she had been notified, APRN #1 would have ensured the resident was seen by a psychiatric provider as soon as possible and would have directed 1:1 staffing until the resident could be seen. The facility policy for Suicide Attempt or Threats/Homicidal Ideation identified in part: Staff are to take all allegations seriously. Ensure the resident's immediate safety. Have the RN Supervisor assess the need for 1:1. The Supervisor or charge nurse will notify nursing administration and physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, policies, and interviews for one resident (Resident # 15) reviewed for abuse, the facility failed to protect the residents from abuse from (Resident # 21). The findings include: 1a. Resident #15 's diagnosis included Alzheimer's disease, dementia with behavioral disturbances, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #15 was severely cognitively impaired and required limited assistance for ambulation and toileting. The care plan dated 6/7/21 identified Resident #15 was at risk to be a victim of abuse, neglect, or mistreatment and lacks self-protection skills and vulnerable due to cognitive deficits and will not be abused or victimized by others during the review period. The care plan revised on 6/20/21 identified Resident #15 was pushed down by another resident. Interventions included the resident who pushed Resident #15 was moved to another room on a different unit to avoid interaction. b. Resident #21 has a diagnosis that include anxiety disorder, dorsalgia, and unspecified intellectual disabilities. The quarterly MDS assessment dated [DATE] identified Resident #21 had no cognitive impairment and required limited assistance with ambulation. A care plan dated 6/20/21 identified that Resident #21 was being aggressive toward others, vulnerable due to cognitive deficits. Interventions included to advise resident to seek out staff for assistance if having difficulty with others, monitor mood and behavior and provide early interventions on any changes, and every 15-minute checks until seen by psychiatry. A social service note dated 6/21/21 at 11:37 A.M. identified Resident #21 was very apologetic about the incident. A review of the psychiatry note dated 6/23/21 identified Resident #21 was very apologetic with no intent to harm or interact with Resident #15 and not currently a threat to self or others. A review of the Reportable Event Investigation on 11/17/21 at 2:00 P.M. identified on 6/20/21 at 1:30 A.M. Nurse Aide (NA#1) was in the hallway and heard a bang. Upon entering the bathroom between rooms [ROOM NUMBERS], he observed Resident #15 sitting on the floor with his/her back against the wall. Resident #15 reported he/she hit me. Resident #21 reported that while he/she was in the bathroom Resident #15 entered. Resident #21 reported that he/she was fed up with Resident #15 wandering into his/her room and he/she got pissed off and pushed him/her. Both residents were separated immediately and assessed by RN #3. Resident #15 complained of pain inside, but no observable injury was noted. Police were notified and provided a case number. Interview with NA #1 on 11/18/21 at 6:15 A.M. identified that after he heard a noise coming from Resident #21's room, in the shared bathroom, and found Resident #15 on the floor. Resident #21 told me that he/she pushed Resident #15 and stated that I am tired of Resident #15 coming in my room. Interview with RN #3 on 11/22/21 at 8:30 A.M. identified that Resident #21 was frustrated with Resident #15 constantly being in everything and admitted that he/she pushed him/her out of frustration. Interview with Resident #21 on 11/22/21 at 9:00 A.M. identified that s/he told Resident #15 to get out of his/her room and that Resident #15 put his/her fists up like s/he wanted to fight and I pushed Resident #15 but didn't mean for Resident #15 to fall to the ground. Resident #21 stated he/she felt very badly after the incident. Although the previous DNS did not state in the Reportable Event Summary that the allegation of abuse was substantiated, an interview with the current DNS on 11/22/21 at 10:15 A.M. stated upon review of the Reportable Event and Investigation that the allegation of abuse is substantiated. A review of the Policy and Procedures identified that each resident has the right to be free from abuse, neglect, and misappropriation of resident property and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for 1 of 1 sampled resident reviewed for dignity (Resident #212), the facility failed to ensure that Resident #212 was treated in a dignified manner. The findings include: Resident #212 was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis, type 2 diabetes mellitus, anxiety disorder, depressive disorder, morbid (severe) obesity due to excess calories. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #212 was without cognitive impairment and required limited assistance with personal hygiene. The Reportable Event (RE) form dated 8/13/18 on the 3:00 PM to 11:00 PM shift identified Resident #212 indicated Licensed Practical Nurse (LPN) #2 allegedly stated to his/her famile member/Person #1 do you know what I caught this assho__ doing last night? and also stated that Resident #212 would lose more toes, because Resident #212 ordered pizza. The Advanced Practice Registered Nurse (APRN) was notified at 4:45 PM and the facility initiated an investigation. Psychiatric and Social Services provided support. The Department of Public Health was notified on 8/14/18 at 4:46 PM. The care plan dated 8/14/18 identified Resident #212 was at risk to be a victim of abuse, neglect, or mistreatment. Interventions directed to intervene as necessary to ensure safety. Monitor mood, behavior and provide early interventions on any change. Provide emotional support as needed. Psychiatric consult as ordered and Social Services support. An interview conducted by the facility with Resident #212 dated 8/14/18 at 4:30 PM identified Resident #212 indicated on Sunday (8/12/18) on the 3:00 PM to 11:00 PM shift he/she ordered a pizza. Resident #212 indicated he/she opened the window when the delivery man came and made the transaction through the window. Resident #212 indicated he/she heard LPN #2 say to him/her that he/she would end up with more of his/her toes cut off if he/she kept eating that way. LPN #2 was outside smoking while this was taking place. On Monday evening (8/13/18) on the 3:00 PM to 11:00 PM shift, Resident #212 was with a family member (Person #1) in his/her room. LPN #2 was outside smoking and opened Resident #212's bedroom window from the outside and poked her head in and stated to Person #1 do you know what I caught this assho doing last night? Resident #212 was not sure if LPN #2 was joking but feels no one should call him/her that. Resident #212 indicated he/she does not feel LPN #2 was trying to be abusive to him/her. The disciplinary action report dated 8/14/18 identified LPN #2 was notified via telephone on 8/14/18 at 5:00 PM that she was suspended pending an investigation. The nurse's note dated 8/14/18 at 5:11 PM identified Resident #212 reported an allegation of verbal abuse. Emotional reassurance provided. Referred to Social Services and Psych. APRN updated. Resident #212 is responsible for self. The Social Service progress note dated 8/15/18 at 9:47 AM indicated meeting with Resident #212 regarding the allegation of verbal abuse. Emotional support provided. Resident #212 indicated he/she was fine and feels safe. Social service will continue to monitor. The APRN progress note dated 8/15/18 identified Resident #212 had an uneventful stay at the facility. The Psychiatry APRN note dated 8/15/18 identified medication and mood evaluation. Status post allegation of verbal abuse by staff of Resident #212. Per Resident #212 no residual negative feelings or ill-will regarding incident. Resident #212 verbalized disappointment of verbal abuse to him was witnessed by his/her family. An interview with Person #1 conducted by the facility and dated 8/16/18 identified Resident #212 ordered a pizza and it was delivered through the bedroom window. LPN #2 saw this and went around telling everyone like Resident #212 did something wrong. Person #1 indicated he/she was in the room on Monday 8/13/18. Person #1 indicated he/she heard a knock at the window and LPN #2 lifted the window up, poked her head in and said you hear what this assho did yesterday?. Person #1 identified LPN #2 was trying to joke with them. An interview with LPN #2 conducted by the facility on 8/16/18 at 11:30 AM via telephone identified on Sunday (8/12/18) she was sitting outside and saw a delivery man deliver pizza and soda through Resident #212 bedroom window between 9:30 PM and 10:00 PM. LPN #2 indicated on Monday she asked Person #1 did Resident #212 tell you what happened? what a piece of work he/she is. LPN #2 identified she educated Resident #212 regarding noncompliance with diet. LPN #2 indicated he/she told Resident #212 this keeps happening and you wonder why you keep coming back. LPN #2 indicated Resident #212 replied my blood sugar has been good. An interview with Resident #212 on 6/19/19 at 11:02 AM indicated he/she ordered a pizza on Sunday (8/12/18). Resident #212 identified he/she knew the code to the side door by his/her room and usually let the delivery person in if there was no staff available. Resident #212 identified on Sunday he/she asked the delivery person to come to his/her bedroom window for the delivery. Resident #212 indicated he/she told the delivery person that the nurse gives him/her a hard time when he/she orders out. Resident #212 indicated the delivery person stated its too late there is a nurse standing out here smoking. Resident #212 indicated LPN #2 stated to the delivery person that is why he/she keeps getting his/her toes cut off. Resident #212 indicated the next day Person #1 was visiting in his/her room. LPN #2 was outside smoking. LPN #2 opened his/her bedroom window from the outside and stuck her head in and said to Person #1 you know what I caught this assho . doing last night. Resident #212 indicated he/she and Person #1 did not say anything at that moment. Resident #212 indicated LPN #2 explained to Person #1 that he/she was sneaking pizza through the window. Resident #212 indicated he/she felt that LPN #2 was joking and it was inappropriate for LPN #2 to talk that way to Person #1 and opening his/her window from the outside. Interview and clinical record review with DNS on 6/19/19 at 11:24 AM identified that LPN #2 was disciplined for opening Resident #212 bedroom window without Resident #212 permission and for joking with a resident and/or resident family member in an unprofessional manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, interviews and review of facility documentation for 1 sampled resident reviewed for podiatry visits (Resident #36), the facility failed to ensure Resident #36 received podiatry services in a timely manner. The findings include: Resident #36 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (PVD), acquired absence of left leg below knee and diabetes. A care plan dated 9/12/18 identified a problem with being a new admission with interventions to follow up with the podiatrist. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #36 was cognitively intact and required extensive assistance of two for bed mobility, transfers, dressing and toilet use. The MDS further identified Resident #36 required extensive assistance of one for personal hygiene. The care plan dated 10/8/18 identified a diagnosis of a history of bacteremia, left foot ulcer, cellulitis, with interventions that included to follow up with podiatrist, and to assist with arranging and scheduling of recommended follow up appointments and tests. Physician's order dated 11/28/18 directed podiatry consults as needed. A podiatry consultation form for request of service was signed by Resident #36 on 5/14/19. A Grievance form dated 6/14/19 identified a concern that Resident #36 had not been seen by a podiatrist since admission with a resolution that Resident #36 was signed up for podiatry services. Interview and record review with the DNS on 6/18/19 at 2:54 PM identified that May 2019 and June 2019 foot check observations on the Treatment Administration Record (TAR) did not identify the long toenails. Interview with the Medical Scheduler on 6/19/19 at 10:40 AM identified that the podiatrist is at the facility every other month and Resident #36 would be seen on 7/8/19. On 6/19/19 at 11:07 AM, interview and observation of Resident #36 with the DNS identified Resident #36's right great toenail was long, approximately ¼ inch in length extending over the edge of the right great toe. The DNS further identified that the long toenail should have been identified on the TAR's, the supervisor should have been notified to obtain a podiatry consult. Additionally, the DNS identified that toe nail care for a resident with Peripheral Vascular Disease and Diabetes should be completed by a podiatrist and not by the facility staff.Additionally, the DNS identified Resident #36's does need to be seen by the podiatrist related to long toenails. On 6/19/19 at 11:37 AM, an interview with the Advanced Practice Registered Nurse identified that she saw Resident #36's foot on 6/19/19, there were no signs of any ingrown toenail, the nails were clean, intact, smooth, no redness, the only issue was that that the great toenail was too long. Review of the clinical record failed to identify Resident #36 was seen or had podiatry services from admission on [DATE] through 6/19/19 despite having a diagnoses of Diabetes Mellitus, PVD and a recent left leg below the knee amputation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for 1 of 2 sampled residents reviewed for an elopement (Resident #56), the facility failed to conduct an immediate search and/or failed to contact a law enforcement agency in a timely manner for assistance in locating a missing resident. The findings included: Resident #56's diagnoses included depressive disorder, repeated falls, diabetes mellitus II and dementia with behavioral disturbance. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 was severely impaired for cognitive status, no presence of wandering behaviors, required supervision from staff for most activities of daily living, unstable with ambulation and utilized a cane for mobility. The Resident Care Plan dated 8/25/18 identified a problem with elopement and/or risk for wandering. Interventions included to distract Resident #56 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; every 15 minutes visual checks resident self-removed wander guard. Review of the clinical record identified Resident #56 was assessed for wandering during the month of May 2018 on 5/25/18 and 5/29/18; Elopement assessments were also completed on 6/6/18 and Resident #56 was not an elopement risk, on 6/8/18 Resident #56 verbalized a desire to leave the facility without permission, was considered an elopement risk and placed on every 15 minute checks. On 6/15/18 the elopement risk assessment identified Resident #56 was not an elopement risk. An elopement assessment was completed on 8/2/18 which identified Resident #56 was non-compliant with the facility policy regarding restricted areas but was not considered an elopement risk, and a quarterly elopement risk was completed on 8/22/18 and 11/20/18 that identified Resident #56 was not considered an elopement risk. On 6/21/19 at 12:46 PM an interview and review of the clinical record and facility documentation with the DNS indicated Resident #56 initially had a wander guard which was placed on his/her right ankle after being assessed at risk for wandering on 5/29/18 following statements made by Resident #56 in regards to looking for his/her car and on 6/1/18, Resident #56 self-removed his/her wander guard and was placed on every 15 minute checks for 48 hours without any issues or concerns during and after the 15 minute checks were discontinued. The DNS further indicated that when Resident #56 made statements related to packing his/her clothes and/or looking for his/her car and/or would make attempts to take the stairwell instead of taking the elevator to the lower level of the facility to the main dining room, Resident #56 would be placed on every 15 minute checks following an assessment for wandering and/or elopement. The DNS further noted that by the end of August 2018 and up until November 2018, Resident #56 became adjusted to the facility, received education on safety and was allowed to walk in the front area of the facility to collect rocks as a recreation activity and to go on leaves of absence (LOA) with a responsible party. A review of a Reportable Event (RE) dated 12/20/18 at 7:10 PM identified Resident #56 could not be found anywhere in the building. Search initiated (via Dr. Hunt), but unable to find Resident #56. A time line and/or sequence of events on 12/20/18 per the facility investigation noted Resident #56 was seen by staff around dinner time 5:15 PM, headed towards the exit door in the lower level of the facility (near the main dining room) and was observed by the bus driver standing at the entrance of the front door looking out. By 5:22 PM, Resident #56 was observed on video recording during the investigation as walking out the front door. At 5:30 PM staff calls to the nurse's station to report Resident #56 was not in the main dining room. At 6:00 PM or 6:30 PM Dr. Hunt search was initiated. At 7:21 PM, the DNS was notified Resident #56 was missing and instructed Registered Nurse (RN) #4 to call the local police. Resident #56 was subsequently found by the police at a bar and returned to the facility on [DATE] at 11:30 PM (6 hours after leaving the facility). Upon further review of Resident #56's clinical record and the facility's investigation, it was noted that although the facility was consistently assessing and/or monitoring Resident #56 as an elopement risk and had mechanisms in place to help minimize the risk for Resident #56 to leave the facility unauthorized; RN#4 failed to implement the elopement policy in a timely manner in calling for the search (Dr. Hunt) and/or in contacting the local police department for assistance with locating Resident #56. RN #4 initiated the Dr. Hunt search 30 minutes to 1 hour after it was noted Resident #56 was missing and further waited 1 hour and 51 minutes before contacting the local law enforcement agency for assistance when it was determined the resident had eloped. On 6/21/18 at 2:30 PM, an interview and review of the RE and the facility's elopement policy with the DNS indicated RN #4 was to have followed the facility's elopement policy as to when to initiate the search (Dr. Hunt) and/or when to contact the police to assist with locating the resident. RN#4 was disciplined for his/her non-compliance with the previously noted areas of the elopement policy and subsequently resigned from his/her position voluntarily. According to the facility elopement policy identified in part, when a staff member suspects a resident elopement will immediately notify the nursing supervisor. The nursing supervisor will immediately make the overhead page Dr. Hunt is looking for (announce the resident's name three times). The nurse supervisor will contact the police department if the resident is not located within 10 minutes.

Based on observations, review of facility documentation, review of facility policy, and interviews, the facility failed to wear protective hair coverage while distributing and serving food in accordance with professional standards for food service safety. The findings include: Observations of the afternoon meal from the steam table on 6/17/19 and 6/18/19 at 12:44 PM and 12:30 PM identified the following: a. The Food Service Supervisor was observed with approximately 2 inches in length of hair on his/her chin and approximately ½ - 1 inch in length of hair on his/her face without the benefit of wearing a beard restraint while plating food for the residents. b. Dietary Aide (DA) #1 was noted with his/her hair in a semi-bun fashion with the front area of hair down approximately 6 inches in length or greater noted to be on his/her forehead. The hairnet was covering the area of hair in the semi-bun while the front portion of the hair on his/her forehead did not have the benefit of a hairnet. An interview and review of facility documentation on 6/17/19 at 12:55 PM with the Director of Dietary indicated although the facility did not have a policy on facial hairnets, the expectation was the facility would follow the Food and Drug Administration's (FDA) 2013 Food Code policy. Review of the FDA's 2013 Food Code indicated that food employees are required to wear hats, hair coverings or nets, beard restraints, and clothing that covers body hair at work. A subsequent interview and observation 6/24/19 at 10:35 AM with the Director of Dietary indicated that he/she would expect that 6 inches of hair hanging on the forehead would be contained within a hairnet. At that time, DA #1 was again noted to have his/her hair hanging on his/her forehead. The Director of Dietary acknowledged that DA #1 should have the hair on his/her forehead contained within the hairnet. Review of facility policy of dietary department guidelines identified dietary employees will wear clean uniforms, rubber-soled shoes and hair restraints (for long hair a hairnet is to be worn, for short hair, a cap). The facility failed to provide documentation of a policy that would dictate the requirement for the use of beard nets, including length of facial hair that would trigger a beard net policy.