Based on review of the facility reported incident (FRI) and family and staff interviews, the facility failed to ensure alleged violations involving neglect were reported timely to the State Agency (SA) for 1 of 1 sampled resident (Resident #1). Failure to report an elopement in a timely manner placed all residents at risk for neglect and/or elopement. Findings include: Review of the FRI identified Resident #1 eloped from the facility on 01/27/25. The facility failed to report the elopement to the SA until 04/09/25. The facility could not identify how or when the resident left the building. During an interview on 04/14/25 at 5:00 p.m., Resident #1's family member stated the facility contacted her and stated a member of the community found the resident in the town gym about one block from the facility and returned her to the facility. During an interview on 04/14/25 at 5:30 p.m., two administrative staff members (#1 and #2) stated the elopement actually occurred on 02/01/25, and confirmed the facility failed to report the elopement to the SA in a timely manner.

Based on review of the facility report incident (FRI), record review, and family and staff interview, the facility failed to thoroughly investigate an elopement for 1 of 1 sampled resident (Resident #1). Failure to thoroughly investigate an elopement to determine causative factors may limit the facility's ability to put appropriate interventions in place to prevent further elopement episodes. Findings include: Review of the FRI, received by the SA on 04/09/25, indicated Resident #1 eloped from the facility on 01/27/25. Review of Resident #'1's medical record occurred on 04/14/25. A nurses' note dated 02/01/25 at 2:55 p.m., stated the following: * Res. [resident] confusion regarding leaving elm crest and applying a code alert for her safety. Code alert applied to right ankle. The facility could not identify when the resident left the building but stated the elopement occurred on 02/01/25, not 01/27/25, but the medical record showed to staff charting charting between 1:40 p.m. and 2:44 p.m. (over 1 hour). During an interview on 04/14/25 at 5:00 p.m., Resident #1's family member stated the facility contacted her and told her a member of the community found the resident in the town gym about one block away from the facility and returned her to the facility. The facility failed to thoroughly investigate/determine the causative factors of Resident #1's elopement which placed Resident #1 at risk for elopements and limited the facility's ability to put interventions in place.

Based on record review, review of facility policy, review of facility investigation report, and staff interview, the facility failed to report an incident of potential abuse/neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #7) who experienced a fall from the mechanical lift. Failure to report an event of potential abuse/neglect to the SSA places all residents at risk of potential abuse/neglect. Findings include: Review of the facility policy Abuse Policy occurred on 01/07/25. This policy, dated 06/10/20, stated, The resident has the right to be free from . negligence . Investigations must be documented and all findings including the initial report of allegation reported in writing to the administrator as soon as possible but no later than 24 hours following the incident. The Administrator or Designee will notify the State Department of Health of the reported incident. Review of Resident #7's medical record occurred on all days of survey. A fall report, dated 09/20/24, indicated Resident #7 fell from the mechanical lift. Review of the Final Abuse Investigation Report stated, . On Friday September 20th at 0520 [5:20 a.m.] resident stretched her arms over her head and whole body stiffened during a hoyer [full-body mechanical lift] transfer. This movement caused the resident's body to slide out of the sling on the side. Assessment revealed a small open area to L [left] upper thigh and redness above the right eye. The record lacked evidence the facility reported the above incident to the SSA as possible abuse/neglect. During an interview on 01/08/25 at 10:05 a.m., an administrative nurse (#1) confirmed the facility failed to report the above incident to the SSA.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#3) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 01/06/25 at 11: 55 a.m., the dietary supervisor (#3) stated she is enrolled in the Certified Dietary Manager (CDM) course, but has not competed the training. During an interview on 01/07/25 at 10:40 a.m., an administrative staff member (#2) confirmed the dietary supervisor (#3) lacked the required training for the position. The facility failed to ensure the dietary manager (#3) completed the education for a certified dietary manager, certified food service manager, or national certification for food service management and safety from a national certifying body.

Based on record review and review of the facility reported incident investigation, the facility failed to provide food textures according to the resident's prescribed diet for 1 of 1 sampled resident (Resident #1) who had a choking incident. Failure to ensure Resident #1's diet is followed while serving snacks resulted in a hospital emergency room transfer and treatment for choking. This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 06/14/24. The facility implemented corrective action and education on 06/14/24. Review of the facility policy titled Therapeutic Diet Order Policy occurred on 06/25/24. This policy, dated, 02/24/24, stated, . Therapeutic Diet is a diet ordered by a physician or delegated registered dietician, a part of treatment for a disease or clinical condition . dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form as prescribed . NDD1 Level 1 (National Dysphagia Diet) Level 1 . Dysphagia Pureed diet . this diet consists of pureed food . food should be 'pudding-like'. meats . recommended . pureed meats . breads . recommended facility prepared pureed bread . Review of Resident #1's medical record occurred on 06/25/24 and included diagnoses of dementia. Physician orders showed a regular NDD1 Level 1 diet, also known as a Dysphagia-pureed diet with small portions. The resident's current care plan stated, Resident to receive ordered diet NDD1- pureed diet . small portions . Resident #1's progress notes, dated 06/14/24 at 6:44 a.m., stated, Late entry . Resident began choking and unable to breathe . O2 Sats [oxygen saturation rate] was 87-88% . asked if the certified nurse aide [CNA] had done any Heimlich maneuver [abdominal thrusts] . she had and said some of the obstruction came out . resident stated had something in her throat and that it hurt . call to on call provider . said she should be looked at . ambulance called . ER [emergency room] given report of incident . resident's daughter informed . resident is on a pureed diet . she had snacks that did not meet her diet requirement . Review of physician notes, dated 06/14/24 at 2:53 p.m., . resident was seen today following an emergency room visit for a choking episode . she is currently on a regular diet with pureed consistency . she was given a granola bar and a piece of beef jerky and choked on them . recommend to continue a pureed diet and do not offer foods that are difficult for her to chew or swallow . The facility's investigation report, dated 06/14/24, stated, . resident was given a snack . resident started to cough and was struggling with her airway . asked resident if there was something in her throat . she shook her head yes . was given a couple of back blows . called on call doctor and received orders to send to ER . resident was given a beef jerky stick, milk and a granola bar . the staff member stated they did not look at the resident's diet as they did not think about it at that time . Based on the following information, noncompliance at F684 is considered past noncompliance. The facility implemented corrective actions on 06/14/24 to ensure the deficient practice does not recur by: * The facility completed an investigation with interviews of staff that determined the cause of the incident. Resident #1's morning snack on 06/14/24 consisted of a granola bar and beef jerky. Staff failed to follow the pureed diet order. * The facility provided immediate staff education to the CNA and nurse present during the incident. * The facility provided education to nursing staff through the communication book. * The facility placed binders noting all resident diets in the resident's coffee/snack area and the nurses' station. * On-going education with all staff will continue to occur.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 19 sampled residents (Resident #23, #28, and #33). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled RESIDENT CARE PLANNING occurred on 11/21/23. This policy, dated 12/19/20, stated, . Each resident has a resident care plan (RCP) that is current, individualized, and consistent with the medical regimen. Implementation: Times and actions are stated so that caregivers new to the resident can carry out care with complete continuity. - Review of Resident #23's medical record occurred on all days of survey and identified the resident experienced a fall which resulted in a fracture on 08/01/23. Resident #23's care plan failed to identify a risk for falls and lacked specific interventions and measurable goals for falls. - Review of Resident #28's medical record occurred on all days of survey. The Minimum Data Sets (MDSs), dated 05/27/23 and 08/26/23, identified weight loss. Resident #28's care plan failed to identify weight loss. During an interview on 11/21/23 at 1:54 p.m., an administrative nurse (#1) agreed the care plans should include falls and weight loss. - Observation on 11/19/23 at 2:59 p.m. showed Resident #33 wore a continuous glucose monitor (CGM). A physician's order, dated 08/27/23, stated [FreeStyle Libre 2 Sensor] Continuous Blood Gluc [glucose] Sensor . Resident #33's care plan lacked information related to use of a CGM.

Based on observation and facility policy, the facility failed to assure safe and secure storage of narcotic medications for 2 of 2 medication carts. Failure to store all medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Drugs occurred on 11/21/23. This policy, dated 03/04/20, stated, . Strict control of narcotics is maintained always. Procedures: . All controlled medications are kept under double-lock and in a separate drawer (also known as the narcotic drawer) from other medications. Observation on 11/20/23 at 2:30 p.m. with two nurses (#2 and #3) showed schedule II-V narcotics/controlled medications ordered as needed (PRN) stored in the bottom drawer of two medication carts with non-controlled medications and not double locked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to prevent skin breakdown and pressure ulcers for 1 of 1 sampled resident (Resident #14) reviewed for pressure ulcers. Failure to turn/reposition residents may result in worsening of existing pressure ulcers and additional skin breakdown/pressure ulcers. Findings include: Review of the facility policy titled Terminal Care occurred on 11/03/22. This policy, dated January 2021, stated, Purpose: To assure residents receive appropriate care through the last stage of life. If resident is immobile, change their position every two to three hours . Review of Resident #14's medical record occurred on all days of survey. Physician's orders stated, . 10/21/2022 SKIN TREATMENT mepilex [absorbent foam adhesive dressing] to coccyx Change 2 x wk [twice a week] . 10/29/22 SKIN TREATMENT: Apply Protective dressing to mid back change 2 x wk . A significant change Minimum Data Set (MDS), dated [DATE], identified three Stage 2 (partial thickness loss of skin which presents as an abrasion or blister) unhealed pressure ulcers. Resident #14's care plan, stated, . Stage 2 [pressure ulcer] Mid Spine 10/05/22 . Stage 2 coccyx 09/30/22 . 10/14/2022 Potential for End of Life. Disease progression. On Comfort Cares. Resident #14's pressure ulcer risk assessment, dated 10/14/22, stated, . MOBILITY: Very limited-Makes occ. [occasional] slight changes in body/extremity position-can't make freq/signif [frequent/significant] changes alone . ADDITIONAL RISK FACTORS: . history of pressure areas . SCORE:14 . moderate risk for skin breakdown. Observations showed Resident #14 laid in bed in the same position as follows: * On 10/31/22, from 1:19 p.m. to 4:43 p.m. (approximately 3.5 hours), right side. * On 11/01/22, from 12:19 p.m. to 3:43 p.m. (approximately 3.5 hours), left side. * On 11/02/22, from 8:59 a.m. to 2:31 p.m. (approximately 5.5 hours), on back. During an interview on 11/02/22 at 2:35 p.m., an administrative nurse (#1) stated she expected facility staff to reposition Resident #14 every two to three hours.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure proper respiratory care for 1 of 1 sampled resident (Resident #1) with orders for continuous oxygen therapy. Failure to provide oxygen as ordered may complicate the resident's respiratory status. Findings include: Review of the facility policy titled OXYGEN THERAPY-MASK AND NASAL CANNULA occurred on 11/03/22. This policy, dated December 2020, stated, . portable liquid tanks or e-cylinders are used for transportation of resident throughout facility . turn oxygen source to the prescribed flow . place cannula in resident's nose . check liter flow . to assure flow is correct and bottle is filled appropriately. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included shortness of breath and a recent history of COVID-19. Physician's orders stated, . Administer oxygen 3.0 liter/min [minute] (per nasal cannula) continuous. Observation on 10/31/22 at 2:42 p.m. showed two certified nurse assistants (CNAs) (#2 and #3) transferred Resident #1 into a wheelchair. The CNA (#3) placed a nasal cannula attached to a portable oxygen tank on the back of the resident's wheelchair and proceeded to push Resident #1 to an activity. Assessment of the the oxygen tank showed it empty. Observation on 11/01/22 at 11:55 a.m. showed Resident #1 seated in the dining room, wearing a nasal cannula attached to a portable oxygen tank on the back of her wheelchair. Assessment of the portable oxygen tank showed the tank empty. The CNA (#4) stated, It [portable oxygen tank] should have been filled before she was brought out to the dining room. During an interview on 11/02/22 at 2:35 p.m., an administrative nurse (#1) stated she expected facility staff to ensure portable oxygen tanks are full prior to resident use.

Based on observation and review of professional literature, facility staff failed to follow standards infection control standards for 1 of 6 sampled residents (Resident #3) and 1 supplemental resident (Resident #41) observed during transfers using a mechanical sit-to-stand lift. Failure to follow infection control standards related to disinfecting patient care equipment has the potential to transmit infections to other residents, staff, and visitors. Findings include: Review of guidelines found at https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf, updated May 2019, page 86, stated, . Ensure that, at a minimum, noncritical patient-care devices are disinfected . after use on each patient . Observations on 10/31/22 showed the following: * 2:39 p.m., Two certified nurse assistants (CNAs) (#2 and #3) transferred Resident #3 to the bathroom and then to a wheelchair using a mechanical sit-to-stand lift. After completion of the transfer, the CNAs failed to sanitize the lift prior to placing it in the hallway. * 2:56 p.m., Two CNAs (#2 and #3) transferred Resident #41 to the bathroom and then into a wheelchair using the same mechanical sit-to-stand lift used for Resident #3. After completion of the transfer, the CNAs again failed to sanitize the lift prior to placing it in the hallway.

Based on observation, review of professional literature, and staff interview, facility staff failed to prepare and serve foods under sanitary conditions in 1 of 1 kitchen. Failure to serve food in a sanitary manner may result in forborne illness to residents, staff, and visitors. Findings include: The Food Code, U.S. Public Health Service, Food and Drug Administration, U.S. Department of Health and Human Services, 2017, page 78, stated, . SINGLE-USE gloves shall be used for only one task . used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Observations during the 11/01/22 and 11/02/22 noon meals showed a dietary staff member (#5) touched multiple surfaces (cupboard, drawer, and microwave handles and dietary meal cards) with gloved hands. With the same gloves, the staff member placed bread into and out of a toaster, and placed sandwiches onto the resident's meal plates. During an interview on 11/03/22 at 4:16 p.m., a dietary manager (#6) stated she expected the dietary staff member (#5) to use a utensil to serve the sandwiches for both meals.