Every finding on record at Accura Healthcare of Stanton

Based on clinical record review, policy review, family interview and staff interviews the facility failed to provide adequate nursing supervision for 1 of 3 residents reviewed with a high risk for elopement (Resident #2). The facility reported a census of 40.Findings include:1. The Minimum Data Set (MDS) for Resident #2, dated 8/10/25 did not document a Brief Interview for Mental Status (BIMS). Review of Progress Notes dated 8/10/25 revealed a BIMS evaluation with a BIMS of 7 indicating moderate cognitive impairment documented. The MDS also documented diagnosis of unspecified dementia. Review of Risk Assessment: Elopement dated 6/10/25 documented Resident #2 was at high risk for elopement. Risk Assessment further documented Resident #2 was considered an elopement risk at that time, wore a wander guard and had a history of exiting the building. Review of document titled, Self Report for Resident #2 had documented on 7/3/25 at approximately 2:00 pm the Director of Nursing (DON) became aware that Resident #2 was not present at an outdoor supervised activity. At approximately 2:40 pm on 7/3/25 the Executive Director was notified by the DON of the incident. Resident #2 had been returned to the facility and had not sustained any injuries. On 7/3/25 at approximately 4:45 pm the state was notified via an online portal by the Executive Director.The last time Resident #2 was seen by staff before the incident was at approximately 1:45-1:50 pm when he pushed his wife out to the front patio for the activity. At approximately 2:00 pm a female resident notified the DON that Resident #2 was no longer present at the outdoor supervised activity. Staff immediately initiated a head count and started missing resident procedures. The DON notified Resident #2's Power of Attorney (POA) at 2:05 pm. On 7/3/25 at 2:06 pm Resident #2's son called the facility to report Resident #2 walked to the family home and they were returning with Resident #2. Head to toe assessment done on Resident #2 on 7/3/25 at 2:30 pm by the DON with no problems noted at this time, vitals assessed and WNL. Resident #2 had last eaten at approximately 11:30 am on 7/3/25. All staff (DON, BOM, Activities, nurse manager, dietary manager, and multiple CNA's in and out) present during the incident were interviewed and it was concluded that the resident was outside attending a supervised group activity. Staff were passing ice cream, providing entertainment, and assisting other residents when the DON was alerted by another resident of Resident #2's walking away from the group activity. Staff immediately initiated a head count and started missing resident procedures and resident was returned to the facility by family approximately 6 minutes after the notification to staff. The resident walked to his family home near the facility, returned without incident and no injuries observed.Resident #2's Care Plan at the time of the incident stated Independent for transfers/ambulation and the resident is an elopement risk/wanderer. The following interventions were listed on the plan of care: call family to see if they can take him to the farm as this usually calms him down for a period of time; distract resident 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; serve me whiskey daily in the evening as ordered by my Dr as I have a history of attempts to elope to go home to get m whiskey/alcohol; the resident's triggers for wandering/eloping are wanting to go home and behavior is de-escalated by 1:1 or calling the family to come visit the resident. These interventions were being followed as stated in his care plan at the time of the incident.Review of Resident #2's Orders documented a physician's order with a start date of 10/24/23 for wander guard 24/7 and to check placement / function every shift for elopement risk.Review of Resident #2's Treatment Administration Record (TAR) for 7/25 documented a physician's order with a start date of 10/24/23 for wander guard 24/7 and to check placement / function every shift for elopement risk.Review of Resident #2's Care Plan related to elopement risk intervention with start date of 1/8/24 and revision on 6/30/25 documented to distract residents from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. Also an intervention with a start date of 1/8/24 and revision date of 1/8/24 Resident #2's triggers for wandering / eloping are wanting to go home.On 10/6/26 at 11:28 Resident #2's Son stated the facility did not call him and he did not call the facility. Resident #2's Son stated he was headed to the family house because he helped with yard work at the house. Resident #2's Son stated he went into the house because doors were left open and apparently Resident #2 had just gotten there. Resident #2's Son stated he asked Resident #2 if the facility knew he was gone. Resident #2's Son stated once he pulled out of the driveway the facility staff were within a block of the house. Resident #2's Son stated he did not know how long Resident #2 had been away from the facility. Resident #2's Son stated the family house was about 3 blocks from the facility. Resident #2's Son stated Resident #2 was not injured. Resident #2's Son stated the facility knew Resident #2 was at risk for leaving the facility. Resident #2's Son stated Resident #2 wore a wander guard. Resident #2's Son stated Resident #2 had left the facility before.On 10/6/25 at 2:58 PM Resident #2's POA / Daughter acknowledged the staff at the facility called her. Resident #2's POA / Daughter stated the staff were concerned because Resident #2 had left the facility. Resident #2's POA / Daughter stated everyone knew that Resident #2 was headed up to the family house. Resident #2's POA / Daughter stated he was wearing a wander guard at that time. Resident #2's POA / Daughter stated Resident #2 had one on his shoe and one on his wrist. Resident #2's POA / Daughter explained Resident #2 was always wearing a wander guard. Resident #2's POA / Daughter stated her brother happened to be in town and saw the house open. Resident #2's POA / Daughter stated her brother seen the garage door go up and then found Resident #2 inside. Resident #2's POA / Daughter stated her brother then took Resident #2 back to the facility. Resident #2's POA / Daughter stated some of the CNA's from the facility were already on their way up the hill. Resident #2's POA / Daughter stated Resident #2 was not injured from the event. On 10/6/25 at 1:28 PM Staff A, Registered Nurse (RN) stated she was familiar with Resident #2. Staff A stated Resident #2 did not exit seek in a traditional sense. Staff A stated Resident #2 would get upset and pack his things and say he is going to leave. Staff A stated Resident #2 had left the facility in the past. Staff A stated there was an incident where Resident #2 left the facility without staff when there was an activity going on outside. Staff A stated Resident #2 left when the staff were not looking. Staff A stated Resident #2 had a house that was not far from the facility and when he left that was where he went. Staff A acknowledged she was working that day. Staff A stated she was not outside with Resident #2 that day. Staff A stated it was the same situation when Resident #2 went to his house to get a bottle of whiskey. Staff A stated staff started to head up the hill towards Resident #2's house. Staff A stated one of Resident #2's family called the facility and told them Resident #2 was up at the house. Staff A stated the family member brought Resident #2 back to the facility. On 10/7/25 at 8:37 AM Staff B, Activities Director acknowledged she was working on 7/3/25 during the day. Staff B acknowledged she was lighting fireworks off for the residents around 1:45 PM. Staff B stated staff started bringing residents outside around 1:30 PM that day. Staff B stated residents were sitting in front of the facility under the covered porch. Staff B stated she was to the right of the facility lighting off fireworks. Staff B stated she was lighting fireworks when #2 left. Staff B stated the CNA working on Resident #2's hall brought him outside. Staff B stated Resident #2 pushed his wife outside that day but a CNA had to help because Resident #2 wore a wander guard. Staff B stated she did not know who assisted Resident #2 outside because she was getting water buckets at that time. Staff B stated the DON was outside. Staff B stated she was unaware if there was any staff assigned to supervise residents outside that day. Staff B stated she was unaware of any residents in particular that wore wander guards that were outside that day. Staff B stated when she took a resident with a wander guard to the patio she told the staff who was going outside and where they were going. Staff B stated if she personally took a resident with a wander guard outside she always stayed with them. Staff B stated she does not take multiple residents with wander guards outside at once because she does not think she could help them appropriately if a resident fell outside. Staff B stated Resident #2 never tried to leave when she had him outside. Staff B stated Resident #2 stated that he hated it at the facility all the time. Staff B stated Resident #2 tried to leave when he first arrived at the facility a while ago. Staff B stated in the beginning he had a window alarm on the window. Staff B stated he talks about leaving the facility a lot especially now because of the fact it was harvest season. Staff B stated Resident #2 left towards the east side of the building because that was the fastest way to his old house. On 10/7/25 at 9:07 AM Staff C, Certified Nursing Assistant (CNA) acknowledged working 6:00 AM - 2:00 PM on 7/4/25. Staff C stated she was assigned to the North hall that day. Staff C stated on 7/4/25 around 1:30 PM the residents were being assisted outside to watch a fireworks display put on by the facility. Staff C stated she assisted a couple of residents to go outside but did not remember which residents. Staff C stated she did not assist Resident #2 outside that day. Staff C stated there were staff members already set up outside to receive the residents as they got outside. Staff C stated she did witness Resident #2 push his wife outside. Staff C stated the door was open and there were staff that lined the hallway assisting residents out the door and staff outside to receive the residents. Staff C stated she did not put the code in the wander guard door alarm to shut it off. Staff C stated she could not remember which staff was standing at the door holding the door open and put the code in. Staff C stated she was not aware of any change in supervision for any residents with wander guards when outside. Staff C stated she thought there had to at least be a staff member present outside with the residents with wander guards. Staff C stated after every resident was helped outside there was a lot of management and staff outside. Staff C stated it was a shift change and she was giving a report to the oncoming staff. Stated Staff D, CNA was sitting outside. Staff C stated Staff D was her partner that day. Staff C stated Staff D was outside with the residents. Staff C stated she checked all the residents to determine who was missing. Staff C acknowledged Resident #2 was the resident that had eloped. Staff C stated she was inside and did not know how the elopement occurred so she did not know how Resident #2 had left. Staff C stated she heard Resident #2 was around the building but when she went out back Resident #2 was not there. Staff C stated she climbed up the hill. Staff C acknowledged Resident #2 had a history of leaving the facility to go home so she started walking towards Resident #2's previous address. Staff C stated Resident #2 had a wander guard on that day. Staff C explained she got to the top of the hill and Resident #2 was sitting in a truck that might have been a family member of Resident #2. Staff C explained that person transported Resident #2 back to the facility. Staff C stated Resident #2 did not appear injured. On 10/7/25 at 9:31 AM Staff D, CNA acknowledged she was working at the facility 7/3/25. Staff D stated she came in at 2pm as the situation was happening. Staff D stated the only staff that she knew that was outside was Staff B. Staff D stated when she came in to work that day there were no CNA's that she had seen outside with the residents. Staff D stated when residents with wander guards are outside there is usually CNA's outside to monitor the residents but she knew for sure there were no CNA's outside that day. Staff D stated she arrived before anyone noticed Resident #2 had eloped. Staff D stated she heard over the walkie that Resident #2 had wandered off. Staff D stated the administration was upset that Resident #2 had eloped because there was no staff outside supervising the residents as they had thought. Staff D stated when she came inside she received a report from the AM shift CNAs. Stated Staff E, Staff C, Staff F and Staff G were the am shift CNA's the day of the incident. Staff D stated she was assigned the hall that Resident #2 was on that day. Staff D stated she was working with Staff H, Licensed Practical Nurse (LPN) currently CNA at the time of the incident. Staff D acknowledged that Staff H was inside getting a report with her as well at the time of the incident. Staff D stated it was reported over the walkie that Resident #2 was on the move so she thought he was wandering around at that time. Staff D stated she headed towards the gas station. Staff D stated Resident #2's son was getting ready to bring Resident #2 back from his previous residence when eyes were put on Resident #2. Staff D stated the Activities Director was shooting off 4th of July fireworks and was told Resident #2 was one of the first residents brought outside that day. Staff D stated residents were sitting under the covered porch and Resident #2 left towards the east around the side of the building towards his house. Staff D stated there is a sidewalk on the side that he went on. Staff D stated she assumes that he walked up the street but did not witness him leave the building. Staff D stated there was usually staff outside with the residents with a wander guard. Staff D stated staff should be present to supervise residents when they are outside with a wander guard. Staff D stated she did not know why there wasn't that day. Staff D stated Resident #2 was fine when he returned. Staff D stated she knew that Resident #2 had eloped before this incident and went back to his house then as well. On 10/7/25 at 11:32 AM Staff I, LPN acknowledged she was working 7/3/25. Staff I stated a call came over the radio that Resident #2 was missing from the facility. Staff I stated she remember thinking to herself that she had not seen Resident #2 walk past the window. Staff I stated about 1:00 PM the staff started assisting residents outside for the fireworks. Staff I stated she was part of the process of residents being assisted outside. Staff I stated she was the staff that was turning the wander guard door alarm off when the residents went outside. Staff I stated she observed Resident #2 pushing his wife in the wheelchair outside. Staff I stated it was around 1:15 PM or 1:20 PM when she made that observation. Staff I stated the incident occurred around 1:45 pm - 2:00 PM. Staff I acknowledged the incident happened right about shift change. Staff I stated there were several members of management outside the DON, the Administrator and Staff E was outside. On 10/7/25 at 11:42 AM Staff G, Business Office Manager stated she was working at the facility on 7/3/25. Staff G stated residents were assisted outside by staff. Staff G stated she seen Resident #2 leaving the building with his wife. Staff G stated she was holding the door at the time. Staff G stated once he passed by her she did not have eyes on him. Staff G explained she did not hold the door the entire time. Staff G stated there was other staff outside with the residents during the fireworks. Staff G stated she could not remember who was outside at the time because it was her and Staff B that were setting off the fireworks. Staff G stated it was not the expectation of the facility that Staff G or Staff B supervised the residents while they were outside. Staff G stated the residents with wander guards typically the resident with wander guards had 1:1 supervision while outside. Staff G stated since the elopement it was really drilled in that staff will be 1:1 with all residents with wander guards. On 10/7/25 at 12:01 PM Staff F, CNA acknowledged she was working 7/3/25 from 6:00 am - 2:00 pm. Staff F stated she did not assist any residents outside. Staff F stated she was working the South hall and was toileting residents. Staff F stated she heard that Resident #2 had eloped. Staff F stated she was not outside the incident. Staff F stated she felt there were CNA's outside but could not remember which ones. Staff F stated the CNA's were just starting their shift report at that time. Staff F explained she was giving a report at that time. Staff F stated Staff E and Staff C were working on North hall that morning. Staff F stated Staff J, Infection Preventionist came though the building and said Resident #2 was missing. Staff F stated Staff E, her and Staff C left. Staff F stated all the CNA's were giving shift reports when the elopement happened. Staff F stated Resident #2 was found. Staff F explained it came across the walkie that Resident #2 was found. Staff F stated Resident #2 was always supposed to be with someone when outside. Staff F stated the DON, Staff B, Staff J and Staff G, were outside at the time of the elopement.On 10/7/25 at 12:09 PM Staff E, CNA acknowledged she was working 6:00 am - 2:00 pm on 7/3/25. Staff E acknowledged she was working the hall that Resident #2's room was on that day. Staff E stated she was taking out the trash when the incident happened. Staff E stated management was taking residents out around 1:30 PM. Staff E stated she did not know the residents were going out at 1:30 PM. Staff E stated she was working with Staff C and was taking out the trash at the time. Staff E stated she turned off her walkie and put it in her locker. Staff E stated she heard a commotion that someone had got away. Staff E stated saw the DON walking from north of the building and asked if she could take her car to look for Resident #2. Staff E stated she left out the back end of the building and went towards the railroad tracks. Staff E stated the rest of the staff were checking at his house. Staff E stated she got back to the facility and the staff had found Resident #2. Staff E stated she did not know if there were any CNA's outside with the residents. Staff E stated management was actively getting all the residents outside prior to the elopement. Staff E stated the CNA's were not quite done with their duties. Staff E stated management did not tell the CNA's they were required to be outside with the residents. Staff E stated she did not go out front with residents at all on 7/3/25. Staff E stated she took 1 or 2 residents outside but was never outside to supervise residents. Staff E stated she had not finished her work duties inside and that was what she was doing at the time. Staff E stated Staff C was also working with her and not present outside to supervise residents. Staff E stated when a resident with a wander guard goes outside there would be eyes on all the residents that were elopement risks. Staff E stated Resident #2 searched frequently for exits but was usually easily redirected. Stated it was her understanding that management was outside and the CNA's were supposed to be finishing the work inside. On 10/7/25 at 12:26 PM Staff J RN, IP acknowledged she was working 7/3/25 during the morning shift. Staff J acknowledged she was present during the incident where Resident #2 eloped from the facility. Staff J stated residents were being assisted outside between 1pm and 1:30 PM. Staff J stated she was inside the building bringing residents outside. Staff J stated Staff G, Staff B and the DON were outside the building with the residents. Staff J stated she could not remember a CNA present outside the building to supervise the residents. Staff J stated Staff B and Staff G were doing fireworks and the DON were outside supervising the residents. Stated Staff I was inside at the time of the incident. Staff J stated Resident #2's wife stated her husband was missing to the DON and it was broadcasted over the walkie that Resident #2 was missing. Staff J stated that was when the elopement process was started. Staff J stated Resident #2 was found. Staff J stated Resident #2 had walked up the hill to his previous residence and staff walked straight up to his house. Staff J explained Resident #2's son was at the house and Resident #2 was with his son. Staff J stated Resident #2 stated were you looking for somebody when staff found him. Staff J stated some residents with wander guards are 1:1 but supervision is expected at some level for all residents with a wander guard when outside. Staff J stated he was supervision when outside at that time. On 10/7/25 at 2:03 PM Staff H, stated she was working 7/3/25 and was familiar with Resident #2. Staff H stated she had just arrived at the facility when the incident occurred. Staff H stated she was getting residents up and getting report from day shift CNA's and was told Resident #2 was heading away from the facility. Staff H stated she was told to search for Resident #2. Staff H stated she headed to Resident #2's previous residence. Staff H stated she was headed that way and when Resident #2 was found. Staff H stated she was not outside supervising residents at that time. On 10/7/25 at 12:53 PM the DON acknowledged she was working 7/3/25 during the am shift during the time of Resident #2's elopement. The DON stated one of the pictures that Staff G that day pictured her looking were Resident #2 should have been and did not realize that he was not. The DON stated Staff G and Staff B were outside. The DON stated Staff J was outside and was the first to notice that Resident #2 was not present. The DON stated CNA's were coming, going and completing tasks inside at the time. The DON stated it was nursing's responsibility for supervision outside. The DON stated one of the nursing department staff should have stayed outside with the residents. The DON explained during her investigation nobody acknowledged they let Resident #2 outside. The DON stated she could not determine that there was any staff present outside at the time of the incident supervising the residents. The DON explained she did not know why she did not realized that Resident #2 was missing. The DON stated one of the residents said to her that Resident #2 had gone around the corner a while ago and he never came back. The DON stated immediately they knew Resident #2 was headed to his previous residence and that was where they found Resident #2 with his son. The DON stated Resident #2 requested for his son to take him back to the nursing home. The DON acknowledged there was a lack of supervision during the fireworks activity for Resident #2 that led to his elopement. The DON stated Resident #2 was not injured. The DON stated an assessment was completed upon return. The DON stated Resident #2's physician and family were notified of the incident. The DON stated Resident #2 is currently 1:1 when outside. The DON stated at the time she did not know that there was a lot of thought that went into the level of supervision for any residents with a risk for elopement when outside for a group activity. Review of policy updated 10/29/24 titled, Missing Resident / Elopement Process documented an elopement risk assessment would be completed upon admission, readmission, quarterly, annually and with any significant change MDS. The Care plan would be modified as needed based on risk assessment. Residents identified at risk for elopement with moderate or high risk would have an alarm bracelet placed on to audibly alert the staff of attempts by the resident to exit the facility, the resident's care plan shall address behaviors using resident specific goals and / or approaches as assessed by the IDT, and Staff will encourage activities which the resident enjoys in order to occupy / distract the resident.

Based on clinical record review, PASRR document review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #35) reviewed for PASRR requirements. The facility reported a census of 38 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #35 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of Resident #35's Electronic Health Record (EHR) titled, Diagnosis revealed diagnoses of anorexia on 5/2/25 and unspecified psychosis on 10/2/25. Review of Resident #35's EHR titled, Notice of PASRR level 1 Screen Outcome dated October 1, 2024 documented under mental health diagnoses major depression and anxiety disorder. Document did not include the diagnosis of anorexia or psychosis. On 6/18/25 at 8:57 AM the Director Of Nursing (DON) stated October was the time when the previous MDS Coordinator went on maternity leave and Staff D, Licensed Practical Nurse (LPN) took over doing MDS and that was when the facility realized the previous MDS Coordinator was not completing what should have been completed. The DON stated she had not thought of anorexia as something that should be resubmitted to PASRR. The DON acknowledged that the diagnosis of psychosis was a diagnosis that should have been sent to PASRR for another evaluation. The DON stated as soon as the facility received the order for anorexia and psychosis the PASRR should have been updated. The DON acknowledged that she dropped the ball on that. The DON stated she was the staff that was in charge of completing the PASRR submissions at that time. Review of undated document titled, Status Change PASRR documented a resident required a new PASRR referral when an additional diagnosis of a mental health disorder was identified. On 6/19/25 the Administrator stated the facility did not have a policy for PASRR submissions. The Administrator stated the facility follow requirements for change in status per PASRR.

Based on clinical record review, hospital record review, and staff interviews, the facility failed to provide adequate and timely assessment and intervention for 1 of 13 residents (Resident #38) reviewed. Resident #38 experienced nausea with vomiting for 4 days and the chart lacked vital signs or bowel assessments throughout that time period. The resident was sent to the hospital and was found to have a bowel obstruction with perforation. The facility reported a census of 38 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required partial assistance with hygiene, dressing and toileting. He was occasionally incontinent of urine and bowel and had occasional constipation. Diagnoses for Resident #38 included anemia, atrial fibrillation, heart failure, Benign Prostatic Hyperplasia (BPH) and urgency incontinence. The Care Plan initiated on 4/16/25, showed that Resident #38 had the potential for bowel and bladder incontinence related to BPH, a history of malignant neoplasm of the prostate and constipation. Staff were to assess bowel sounds and abdomen and to report abnormalities to the primary care physician. Staff were to follow bowel protocols and to give as needed medication for constipation. The following was found in the Nursing Progress Notes: a. On 5/7/25 at 9:18 AM, Resident #38 complained of nausea/vomiting and refused food and medications. A fax was sent to the provider. b. On 5/7/25 at 11:34 AM, the resident requested to see the doctor related to vomiting and back pain. An appointment was made to see the doctor at 2:00 PM that day c. On 5/7/25 at 7:08 PM, the resident came back from clinic. The doctor suspected complicated urinary tract infection. He was given an antibiotic in the clinic and a follow up prescription for Zofran for nausea. The resident was added to the hot list. The Doctor Clinic Note dated 5/7/25, indicated that Resident #38 presented with left sided back pain and vomiting and was uncomfortable going to the bathroom. The doctor noted that the resident had some trouble with his prostate in the past, and his overall functional status had declined since he was admitted to the nursing home. His bowel sounds were not assessed in the clinic and a urine culture was initiated. The resident was given a gram of antibiotic; Rocephin and Toradol for pain. Continued Nursing Progress Notes: d. On 5/8/25 at 8:08 AM, Zofran was given for nausea after vomiting 3 times. e. On 5/8/25 at 11:17 AM, unable to keep pills down this morning. f. On 5/8/25 at 11:38 AM, Cefdinir 300 mg antibiotic prescribed for UTI g. On 5/8/25 at 6:11 PM, the resident was still nauseous, given Zofran. h. On 5/9/25 at 8:48 AM, Zofran given for nausea i. On 5/10/25 at 7:19 AM Zofran needed for nausea j. On 5/10/25 at 9:25 AM, came out for breakfast but didn't eat much k. On 5/10/25 at 12:46 PM, the resident stated he vomited after breakfast. The housekeeper reported dark colored vomit. Contacted Director of Nursing (DON) and asked if he should be sent to the ED l. On 5/10/25 at 1:10 PM, call received from doctor and order was received to send to the Emergency Department (ED) due to possible dehydration. m. On 5/10/25 at 6:01 PM, the resident was being transferred to a different hospital for a small bowel obstruction, acute kidney injury, pneumoperitoneal. A review of the Vitals and Progress Notes showed that from 5/8 through 5/10/25, the chart lacked completed vital signs or bowel assessments. The ED report dated 5/10/25 at 1:42 PM, showed that Resident #38 presented with abdominal pain, nausea, vomiting, a heart rate of 105 Beats Per Minute (BPM), and Blood Pressure (BP) of 95/56. The abdomen was soft, mildly distended, tenderness to palpation with significant tenderness in right lower extremity, positive guarding, no rebound tenderness. Vital signs show that he was tachycardic and hypotensive. Fluids and pain medication started. After fluids the BP was 86/63. Radiology findings were suggestive of a small bowel obstruction with possible transition point in the right hemiabdomen, suggestive of perforation. The patent and family agreed to have him transferred for possible surgical intervention. The hospital report dated 5/10/25 at 7:51 PM, showed that the admitting diagnosis was septic shock. The BP was 76/53, HR 121 BPM, respiration 50 breaths per minute. The active problems included; septic shock, bowel perforation and congestive heart failure. On 5/10/25 at 10:43 PM, the postoperative diagnosis included perforated small bowel, small bowel obstruction internal hernia causing small bowel volvulus (twisting of intestine cutting off blood.) Nursing Progress Notes showed: a. On 5/16/25 at 2:17 PM, the resident was admitted back to facility b. On 6/1/25 at 2:25 AM, the resident passed away. On 6/18/25 at 9:56 AM Staff C Licensed Practical Nurse (LPN) remember calling the doctor on 5/10/25 to get an appointment in the clinic that day. She said that she found out the next day, that he still had stomach issues and pain in his back. She did not remember having listened to his bowel sounds or taking any vitals. The resident had been on antibiotics for a couple days, he was lethargic, didn't want to come out of his room. She called the doctor on 5/10 because he was not getting any better and he looked septic. Staff C said he was pail, lethargic, isolating, and just laying there in bed. Staff C acknowledged the symptoms of sepsis included a high temperature, low BP, and high pulse. On 6/18/25 at 10:29 AM Staff E, Certified Nurse Aide (CNA) stated that Resident #38 was very nauseous, and was up half the night vomiting. She got him to try some broth, and crackers, but he ended up getting sick and much weaker. When he was first admitted he was able to get himself to the bathroom but then he became weaker and had several falls because he was trying to take himself to the bathroom. On 6/18/25 at 10:39 AM, Staff B, Registered Nurse (RN) worked with him one day before he was hospitalized . He had been complaining of stomach hurting, and it was passed on in report that he had a UTI. That morning he threw up the pills that she had given him so she contacted the doctor to see if he wanted her to re-administer the antibiotic. She gave him some Zofran, he said he felt better, and tried to eat a little breakfast and she gave him another dose of antibiotic. He had vomited in the trash can, she said it was a watery orange, and it looked like bile. Staff B said that they complete hot charting when a resident was on an antibiotic. What they were expected to do was to check a temperature and any adverse effect of antibiotic. She thought that she had assessed his bowel sounds and they were quiet, but he didn't have pain in the abdomen, it was more generalized back pain. She said that he didn't complain of burning with urination. On 6/18/25 at 7:14 AM, the Director of Nursing (DON) said that if a resident was on hot charting that meant that they would keep a running list at the nurse's station of the residents that were on an antibiotic and they were expected to chart on that resident daily. When asked if that meant to include vital signs, she said that it depends on the situation. On 6/18/25 at 1:18 PM, the DON said that that nurses should have put something in the notes about pain, should have done daily vitals as the Resident #38 was not getting better. On 6/19/25 at 7:08 AM, the DON said that they did not have a policy on resident change in status, and they would follow standard of care. The facility did not provide the resource for the standard of care for resident assessments that they teach the staff.

Based on observations, staff interviews and clinical record review the facility failed to ensure that a resident was provided supplemental oxygen for 1 of 1 resident reviewed. In two separate observations in the dining room, it was discovered that the oxygen tank for Resident #89 was empty. The facility reported a census of 38 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #89 had a Brief Interview for Mental Status (BIMS) of 15 (intact cognitive ability). She required minimal assistance with hygiene, dressing, personal hygiene and was on continuous oxygen therapy. Her diagnoses included atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, presence of cardiac pacemaker. The Care Plan dated 6/12/25, showed that the resident had the potential for actual respiratory abnormalities related to Congestive Heart Failure (CHF), shortness of breath and the use of supplemental oxygen. Staff were to assist with the tank/concentrator as needed. The Orders tab in the electronic charts showed an order dated 6/5/25 at 3:49 PM, for continuous oxygen, 3 liters, via nasal cannula. On 6/16/25 at 11:57 AM, Resident #89 was sitting at the lunch table in her Wheel Chair (WC) with an oxygen tank on the back of the WC. The gauge on the top of the tank showed the needle in the red zone that indicated it was empty. The Nasal Cannula (NC) was hanging on the tank and attached to the resident's nostrils. At 12:36 PM, the resident propelled herself back to her room and the oxygen tank was still on empty. On 6/17/25 at 11:43 AM, Resident #89 was at the lunch table in her WC with an oxygen tank on the back. The needle was in the red zone. The Director of Nursing (DON) then went over to the resident and checked the tank. She told the resident that the tank was making a ticking sound and wheeled her out of the dining room area. They came back a short time later with a different oxygen tank and the needle showed there was oxygen in that tank. On 6/17/25 at 12:03 PM, Staff D Licensed Practical Nurse (LPN) said that she had pushed Resident #89 out to the dining room but she hadn't looked at the oxygen tank. She said that they keep the tank on the back when the WC was in the resident's room. Staff D said that some of the tanks will have a ticking sound if/when it was getting low or empty. She said that the Certified Nurse Aides (CNA) will usually will tell them if/when the oxygen tank was empty. On 6/19/25 at 7:05 AM, the DON said that at 3 liters, the tank would get empty pretty quickly. She acknowledged that the staff should have been checking it more closely. The DON said that they did not have a policy for supplemental oxygen use but to follow the standards of care. The facility did not provide the resource used to educate staff on the standards of care for oxygen use.

Based on clinical record review and staff interviews, the facility failed to fully develop and personalize comprehensive care plans for 6 of 14 residents reviewed. (Residents #3, #6, #25, #29, #32 & #40). The facility reported a census of 42 residents. Findings include: 1. The Medication Administration Record (MAR) of Resident #6 for July 2024 documented the resident to have an order for Eliquis, an anticoagulant medication (a medication, also called a blood thinner, used to prevent and treat blood clots), twice day due to chronic atrial fibrillation (a type of an irregular heartbeat). The Care Plan revealed a Focus Area of anticoagulant therapy, dated 5/6/24. The only intervention on the focus area stated Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. The Care Plan failed to reveal a reason why the resident takes the medication. The Care Plan failed to reveal what side effects to monitor for or how to monitor for effectiveness. 2. The MAR of Resident #25 for July, 2024 documented the resident to have an order for Quetiapine Fumarate, an antipsychotic medication, daily for bipolar disorder. The Care Plan of Resident #25 revealed a Focus Area of antipsychotic medications. In parenthesis it stated to specify the medication and then stated related to which was left blank. The Focus area was dated 3/5/24. The only intervention on the focus area stated Administer antipsychotic medications as ordered by physician. Monitor for side effects and effectiveness every shift. The Care Plan failed to reveal the name of the medication/medications Resident #25 was being administered. The Care Plan failed to reveal a diagnosis related to the order. The Care Plan failed to reveal any personalized information for the resident as to what behaviors have been exhibited correlated to the use of the medication. The Care Plan failed to reveal what side effects to monitor for how or where to monitor the effectiveness. 3. The Census Line of the Electronic Health Record of Resident #40 revealed she had been admitted to the facility under hospice care on 2/19/24. The Care Plan of Resident #40 revealed a Focus Area of Hospice Services dated 2/19/24. The interventions listed the name of the hospice company. The second intervention stated to notify hospice of any changes in condition. The Care Plan failed to be personalized to the resident to include any other interventions such as pain management, emotional support, end of life education, what goods or services hospice was providing in the facility, or the facility staff working cohesively with the hospice team. On 7/19/24 at 12:19 pm, the Director of Nursing (DON) stated she expects care plans to be personalized. She stated, for instance, for psychotropic medications, specific behaviors should be included on the care plan. She stated when a resident begins a new medication, the nurses do hot charting through progress notes to include behaviors or side effects and those should be carried to the care plan. 50471 4. The MDS of Resident #29 dated 6/25/24 identified a BIMS score of 4 which indicated severe cognitive impairment. The MDS recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless on 2 to 6 days and little interest or pleasure in doing things on 12 to 14 days of the previous 2-week look back period. The MDS did not reveal any wandering or exit seeking behavior. The MDS revealed the resident independent with bed mobility, personal care, transfers, toileting, eating, and dressing. The MDS documented diagnoses that included: type 2 diabetes mellitus, coronary artery disease, hypertension, renal insufficiency, non-Alzheimer's dementia, adjustment disorder with depressed mood, and pancytopenia (low levels of red blood cells, white blood cells, and platelets). The MDS documented the resident received insulin injections on 7 out of 7 days of the assessment reference period and Antidepressant. The Care Plan revised 10/12/23 identified the resident having anxiety related to dementia. The care plan informed the staff a calendar in his room for orientation and the resident is currently seeing telepsych. The care plan identified the resident having depression related to adjustment disorder. The care plan informed the staff continue therapy, encourage engagement in facility activities, provide 1:1 as needed, and Telehealth for med review and medication changes. The care plan did not reveal any personalized interventions related to dementia, wandering, and anxiety. 5. The MDS assessment of Resident #3 dated 4/7/24 identified a BIMS score of 1 which indicated severe cognitive impairment. The MDS revealed no behaviors. The MDS revealed the resident is dependent with bed mobility, personal care, transfers, toileting, and dressing. The MDS revealed the resident frequently incontinent of urine and bowel. The MDS documented diagnoses that included: Parkinson's Disease, coronary artery disease, hypertension, renal insufficiency, non-Alzheimer's dementia, anxiety, depression, atrial fibrillation, and other personality & behavior disorders due to know physiological condition. The MDS revealed the Doctor prescribed the following classification of medications for the resident: antipsychotic, antidepressant, opioid, and antiplatelet. The Care Plan revised 7/9/24 identified the resident with altered thought process/cognition related to dementia. The care plan informed the staff assess resident upon admission, quarterly or with significant changes to identify decline/further decline in cognitive status, education family or responsible party regarding changes, and reassure resident to decrease frustration. The care plan identified the resident receiving hospice services due to vascular dementia without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety. The care plan informed the staff with Hospice services and notify hospice of changes in my condition. The care plan did not reveal any targeted behavior related to dementia, other personality and behavior disorder, no personalized interventions for hospice care, no focus on depression, anxiety, and Parkinson's Disease. 6. The MDS assessment of Resident #32 dated 6/4/24 identified the resident is rarely or never understood. The MDS revealed no behaviors. The MDS revealed the resident is totally dependent upon 2 person physical assistance for toilet use, bed mobility, and transfers. The MDS revealed the resident frequently incontinent of urine and bowel. The MDS documented diagnoses that included: Alzheimer's Disease, hypertension, cerebrovascular accident, anxiety, depression, chronic obstructive pulmonary disease, unspecified mood disorder, and atrial fibrillation. The MDS revealed the Doctor prescribed the following classification of medications for the resident: antipsychotic, antidepressant, and antiplatelet. The Care Plan revised 6/10/24 identified the resident potential for behavior/altered coping (actual or history) related to: becoming tearful. The care plan informed the staff move resident to a quiet area to deescalate behavior, provide 1:1 activities as needed, and provide the mechanical cat for resident to help self soothe. The care plan revealed resident with altered thought process/cognition related to dementia, TIA. The care plan informed the staff assess resident upon admission, quarterly or with significant changes to identify decline/ further decline in cognitive status. The care plan revealed potential for depression related to recurrent major depressive episodes, mild (disorder). The care plan informed the staff administer medications as ordered, assess for signs and symptoms of depression and report abnormal's, encourage visits from family members and friends, provide reassurances as needed. The care plan did not reveal any targeted behavior and personalized interventions related to Alzheimer's Disease, cerebrovascular accident, anxiety, and depression. On 7/19/24 at 8:05 am, the MDS Coordinator, RN revealed she is still learning the process of completing and updated Care Plans for the residents. Stated the residents targeted behaviors should be on their care plan and personal interventions should also be on the care plan. Certified Nurses Aides are educated to complete behavioral tracking for residents having behavior and Nurses are educated to document a progress note for any behaviors that occur. MDS Coordinator stated she reviews the documentation to complete her Minimum Data Sheets Assessment. On 7/19/24 at 12:57 pm the DON stated the facility does not have policies for Care Plan and MDS initiating or revising. She stated the facility follows the regulations.

Based on document review and staff interview, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility reported a census of 42 residents. Findings include: On 7/17/24 at 11:30 AM, the Dietary Manager (DM) stated she passed the certification test but hadn't purchased the license. On 7/18/24 at 1:15 PM, a course completion certificate revealed she was not certified as an approved nutrition and food service manager. On 7/18/24 at 1:19 PM, the DM stated she did not have a national certification. A policy titled Personnel - General dated 2021 indicated the food and nutrition services department will be staffed to assure that sufficient, competent, supportive personnel carry out the functions of the department. On 7/22/24 at 8:35 AM, the Administrator stated the Dietary Manager was expected to have the correct dietary management certification.

Based on observation, menu review, and staff interview, the facility failed to properly prepare pureed diets for 2 of 2 residents (Resident #27 & #20) reviewed. The facility also failed to serve the appropriate portions for 11 residents who received regular diets and 3 residents who received carbohydrate-controlled (4 CHO) diets (Resident #17, #22, and #29). The facility reported a census of 42. Findings include: The facility's Menu for lunch for 7/18/24 identified the following items to be served as part of the planned pureed textured diet: #12 scoop (2 2/3 oz) of pureed ribs #8 scoop (4 oz) of pureed macaroni & cheese #12 scoop (2 2/3 oz) of pureed green beans, no bacon #20 scoop (1 5/8 oz) of pureed bread & margarine #12 scoop (4 oz) of pureed gooey butter cake 8 fluid oz milk The facility's Menu also identified a 2-oz serving for 4 CHO diets. Record review of the Diet Orders for Residents #20 and #27 revealed both had an order for regular diet, puree texture and Residents #17, #22, and #29 had an order for 4 CHO (carbohydrate controlled) diet. Continuous observation of lunch preparation and service began on 7/18/24 at 10:50 pm. On 7/18/24 at 10:50 AM, Staff A, Cook, used a basting spoon to place four (4) unmeasured servings of carrots into the blender. He added an unmeasured amount of 2% milk. He blended the mixture and divided the total amount into two (2) small bowls. He covered the bowls with cellophane and placed them in the microwave. No measurement of volume was done. At 11:07 AM, Staff A placed one (1) slice of bread, two (2) pork ribs, and an unmeasured amount of milk into the blender. He blended the items and added more unmeasured milk to the blender. He divided the total volume into two (2) separate bowls and placed them in a pan on the steam table. No measurement of volume was done. At 11:25 AM, Staff A placed an unknown amount of macaroni into the blender with a basting spoon. He added an unmeasured amount of milk and blended it. He divided the mixture into two (2) bowls and placed them in a pan on the steam table. He took the carrots from the microwave and placed them in a pan on the steam table. No measurement of volume was done. At 12:00 PM, Staff A began preparing residents' lunch plates. The first 11 plates were prepared with partially full 4-oz servings of macaroni & cheese, green beans, and mixed vegetables. Throughout lunch service, a 4-oz serving scoop was used for every resident plate prepared with macaroni & cheese. On 7/19/24 at 5:15 PM, the Dietary Manager stated the facility did not have a policy specifically for the puree process but staff should follow the designated ([NAME] Brothers) puree process. An undated document titled Puree Process directed staff to measure the total volume of food after it has been pureed and divide the total volume of the pureed food by the original number of portions using the Puree Scoop Chart. A policy titled Accuracy and Quality of Tray Line Service dated 2021 indicated the meal will be checked against the therapeutic diet spreadsheet to assure that foods are served as listed on the menu and each meal will be checked for proper portion sizes. On 7/22/24 at 8:47 AM, the Dietary Manager stated staff should follow the diet spreadsheet.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food. The facility reported a census of 42 residents. Findings include: On 7/16/24 at 8:25 AM, an initial kitchen observation identified the following findings: An Arctic Air refrigerator contained: 1) An unlabeled, undated clear container with sliced orange items. 2) An undated, previously opened bottle of tomato juice. 3) An unlabeled pouch of round, yellow items. An American Panel refrigerator contained: 1) An unlabeled, clear package of chopped meat. 2) An undated, partially closed, clear storage bag of sliced Swiss and American cheese. 3) An undated, previously opened jar of minced garlic. 4) An undated, previously opened bottle of Sweet and Smokey BBQ sauce. An American Panel freezer contained: 1) A box of packaged breaded chicken chunks stored on the floor. 2) An open box of exposed beef patties. The dry goods storage contained: 1) An opened box of packaged hot dog buns stored on the floor. 2) A shelf of seasonings with an opened container of black pepper and garlic powder. On 7/16/24 at 8:25 AM, Staff A, Cook, propped his left, gloved hand on the garbage can rim with his fingers touching the inside. He walked over to the serving steam table, repositioned the lids of two pans of food, grabbed a rag, and wiped the food serving table area. He did not change gloves nor perform hand hygiene throughout the process. On 7/16/24 at 8:45 AM, Staff A laid a pair of gloves on the steam table platform where resident meal plates were previously prepared. He donned the gloves, staged two styrofoam plates in the same area on the platform, and put a serving of oatmeal on each plate. He grabbed a black marker, wrote something on the styrofoam plate used as a plate cover, and put the black marker on the steam table platform. He grabbed another plate, sliced a banana, put the slices on the plate, and gave it to the food service aide to served it to a resident. He did not change gloves nor perform hand hygiene throughout the process. On 7/16/24 at 12:00 PM, a large baking sheet with serving bowls of sherbet was observed on a wooden table with a baking sheet of sherbet bowls lying directly on top of the lower bowls. On 7/17/24 at 8:40 AM, Staff C, Registered Nurse (RN) took uncovered styrofoam cups of coffee and breakfast trays on a cart to room [ROOM NUMBER]. On 7/17/24 at 8:55 AM, Staff D, Certified Medicine Aide (CMA) took an uncovered bowl of cereal to a resident in the rear lobby. She was observed feeding the resident a piece of toast with her bare hands. On 7/17/24 at 10:35 AM, a follow-up kitchen observation revealed the following findings: An Arctic Air refrigerator contained: 1) An opened, unlabeled, and undated package with a disc-shaped item. 2) An opened, unlabeled storage bag of square, thinly sliced, orange items. 3) An unlabeled baking sheet of meat. An American Panel refrigerator contained: 1) An undated, unlabeled, clear bag of chopped meat. 2) An undated, clear storage bag of sliced Swiss and American cheese. 3) An undated, previously opened jar of minced garlic. 4) An undated, previously opened bottle of Sweet and Smokey BBQ sauce. 5) An undated, unlabeled sealed package of round meat. 6) An unlabeled, previously opened white bag. 7) Two unlabeled pitchers of brown liquid. An American Panel freezer contained: 1) An unlabeled baking sheet of tube-shaped meat. 2) An unlabeled, undated previously opened white bag. The dry goods storage contained: 1) An undated, unlabeled previously opened, opaque bag of small, doughnut shaped item. 2) An unlabeled, clear storage On 7/17/24 at 11:40 AM, Staff E, Dietary Aide (DA) performed a sanitizer test on two (2) buckets of solution used to clean the food preparation area. She got a piece of Hydrion Chlorine test strip and submerged it in the first bucket, held in the solution for 10 seconds, removed it and stated it should be documented at 10 parts per million (ppm). She repeated the process for the second bucket and yielded the same results of 10 ppm. The manufacturer's quaternary sanitizer solution recommendations indicate levels below 50 ppm should be discarded. At 12:42 PM, Staff F, Environmental Services (EVS) entered the kitchen area, walked to the coffee maker, grabbed the pot of coffee and took it out of the kitchen area. No hand hygiene was performed throughout the process. The Dietary Manager confirmed the coffee maker was within the kitchen area and stated staff should wash their hands upon entering the kitchen. On 7/18/24 at 10:40 AM, a kitchen observation revealed a portable fan on the serving counter blowing air into a cut out section in the ceiling directly above the food serving area. Staff B, Dietary Aide (DA) was sweeping pieces of ceiling insulation from beneath the serving steam table. At 10:55 AM, the Maintenance Director laid a piece of sheet metal on the food preparation counter to use for repairing the ceiling. At 11:00 AM, Staff A, Cook, placed a strainer in the sink designated for washing dirty dishes, poured cooked macaroni into the strainer, placed the strained macaroni back into the pot, and returned the pot back on the stove. At 11:07 AM, he used tongs to place pork ribs into a blender and laid the tongs on the sheet metal lying on the food preparation counter. He used milk with a best buy date of 7/17/24 to prepare two (2) pureed diets. At 11:30 AM, Staff A placed several small paper plates on the food preparation counter. His thumb touched the center food area side of every plate. A policy titled Food Storage dated 2021 indicated food should be dated as it is placed on the shelves if required by state regulation. It also indicated all foods should be stored off the floor. A policy titled General Food Preparation and Handling dated 2021 indicated food items will be prepared to conserve maximum nutritive value, develop, and enhance flavor and keep free of harmful organisms and substances. It also indicated disposable gloves should be discarded after each use and food should be prepared and served with clean utensils. On 7/22/24 at 8:51 AM, the Dietary Manager stated staff should follow the facility's policies regarding food storage, hand hygiene, and prevention of cross-contamination.

Based on observations, staff interviews, record reviews, and policy review, the facility failed to implement the Infection Prevention and Control Program (IPCP) by staff not discarding Personal Protective Equipment (PPE) immediately after use nor appropriately performing hand hygiene. The facility also failed to identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility reported a census of 42 residents. Findings include: On 7/16/24 at 12:45 PM, a covered, yellow isolation container in the northeast hall had PPE (isolation gowns) hanging out of it. On 7/17/24 at 8:20 AM, Staff G, Certified Nurse Aide (CNA) picked up a resident's meal ticket off of the floor in front of the service window, put it on the counter, then grabbed 2 packs of plastic utensils wrapped in paper towel and took it to the residents in room [ROOM NUMBER]. No hand hygiene was observed. On 7/17/24 at 8:23 AM, an observation revealed a covered isolation bin near room [ROOM NUMBER] had PPE gown straps hanging out of the top. A PPE gown was observed hanging on the outside of room [ROOM NUMBER]'s door. On 7/17/24 at 9:50 AM, the Infection Preventionist (IP) stated the bin for used PPE should be covered and PPE should not be hanging out of it. On 7/17/24 at 2:20 PM, a document titled General Information Prevention and Control - Nursing Standards updated 5/06/24 revealed single-use disposable equipment or devices labeled by the manufacturer for single-use are not to be reused. The IP stated interpreted the policy to indicate the gowns should not be reused. On 7/18/24 at 2:15 PM, the Maintenance Director stated he was not familiar with the facility's water flow diagram and was not able to verbalize the water flow system. A visual observation of the maintenance department utility room revealed a water heater with a set-point of 118 degrees Fahrenheit and two (2) tanks labeled water storage tanks with a set-point of 112 degrees F. The facility also had a water softener. On 7/18/24 at 3:04 PM, the Maintenance Director stated the facility did not have a water management plan, a water flow diagram, nor measures to assess the risk of or prevent the growth of Legionella or other waterborne pathogens. He stated his water temperature checks in resident rooms is what he used for high risk area checks. On 7/18/24 at 3:44 PM, the Maintenance Director provided blank templates dated 8/23 for water system flow and Legionella risk areas and stated he didn't have completed versions. On 7/18/24 at 4:43 PM, Staff H, CNA exited room [ROOM NUMBER] in PPE (gown, mask, and gloves) and walked to the other end of the unit hall, removed it, and placed it in a trash bin. He donned new PPE and walked back down the hall to room [ROOM NUMBER]. On 7/19/24 at 11:42 AM, the Maintenance Director provided completed water system flow and a Legionella Risk Area documents dated for 7/18/24. A policy titled Transmission-Based Precautions updated 4/01/24 directed staff to use contact precautions on those residents who are known or show are suspected to be infected or colonized with epidemiological organisms. It also directed staff to remove gown and gloves prior to leaving a room. A policy titled Legionella dated 10/24/23 indicated sound engineering, preventative maintenance and housekeeping practices will be utilized to minimize the risk of exposing residents and team members to the legionella bacteria. On 7/22/24 at 8:35 AM, the Administrator stated the Legionella assessment and prevention policy and procedure should be followed and the checks should be completed.

Based on clinical record review and staff interview, and instructions of CMS form 10123-NOMNC, the facility failed to provide notice within the required 2 calendar days of Medicare Non Coverage for 2 of 3 (Resident #43 and #44) residents reviewed. The facility reported a census of 42. Findings include: The census portion of the Electronic Health Record (EHR) of Resident #43 revealed the Resident began receiving skilled care under Medicare A payer source on 5/2/24 and Medicare continued to pay for her stay through 5/20/24. The facility provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) which was signed by the resident representative on 5/17/24. The facility was unable to produce a signed Notice of Medicare Non Coverage (NOMNC) form. The NOMNC form given was the typed name of the resident representative noted as t/o (telephone order) and the date of 5/17/24. The census portion of the Electronic Health Record (EHR) of Resident #44 revealed the Resident began receiving skilled care under Medicare A payer source on 11/1/23 and Medicare continued to pay for her stay through 1/4/24. The facility provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) which was signed by the resident representative on 12/21/23. The facility was unable to produce a signed Notice of Medicare Non Coverage (NOMNC) form. The NOMNC form given was the typed name of the resident representative noted as t/o (telephone order) and the date of 12/21/23. On 7/19/24 at 12:58 pm the Social Services Director stated she took over the position of Social Services in March of 2023. She said she had been trained that there was only one form, the SNF ABN form. She found out later about the NOMNC. She said when she found out about the NOMNC she called the residents or resident representative after they had all discharged home and told them about the form but dated it the same date as the ABN had been signed. The residents who were discharged during this time frame were not given information of filing an appeal to continue their skilled stay through Medicare.

Based on employee file review, staff interview, and facility policy review the facility failed to ensure 2 of 5 staff members reviewed (Staff L & Staff M) completed the two hour Dependent Adult Abuse training within 6 months of their hire date. The facility reported a census of 42 residents. Findings include: 1. Review of the employee file of Staff L, conducted on 7/19/24, revealed a hire date of 12/8/23. The employee file lacked documentation of Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse Mandatory Reporter training having been completed. 2. Review of the employee file of Staff M, conducted on 7/19/24, revealed a hire date of 1/4/24. The employee file lacked documentation of Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse Mandatory Reporter training having been completed. On 7/19/24 at 2:38 pm the Business Office Manager stated she would search to see if the certificates could be located. On 7/19/24 at 5:00 pm, no certificates had been located. The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated 1/10/22, documented the following: - Within six months of hire each employee shall be required to complete an initial 2-hour training course provided by the Iowa Department of Human Services relating to the identification and reporting of dependent adult abuse. Each employee will take a 1-hour recertification training within 3 years of the initial training and every three years thereafter.

Based on clinical record review, facility document review, and staff interview, the facility failed to report timely an allegation of possible abuse or injury of unknown origin for 1 of 1 resident (#21). The facility reported a census of 42 residents. Findings include: A facility self-report dated 7/05/24 revealed a resident sustained an injury of unknown origin and accused a staff member of making her fall on 6/26/24. The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of cancer, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and thoracogenic scoliosis (spinal curvature caused by disease or surgery). It revealed the resident was dependent with toileting hygiene and putting on and removing footwear, required supervision with eating and maximum assistance with all other activities of daily living (ADLs). The Electronic Health Record (EHR) included a progress note indicating the resident had an X-Ray in response to a left elbow injury. Facility Investigation notes dated 6/26/24 indicated the facility investigated the accused staff member and terminated her on 7/01/24 for other reasons. The investigation notes indicated the Director of Nursing (DON) contacted the facility's corporate office on 7/01/24 regarding reporting of the incident to the proper State Agency. The notes revealed the State Agency reporting process began on 7/03/24. On 7/19/24 at 5:35 PM, the DON stated she initially thought to report the incident to the state agency but was informed by her corporate administration that it was not a reportable event. She stated she later received direction to report the event to the state agency. On 7/22/24 at 8:35 AM, the Administrator stated the facility should follow the reporting requirements set by the State Agency.

Based on clinical record review, observations, and staff interviews, the facility failed to assure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 3 of 14 residents reviewed (Resident #25, Resident #33 and Resident #37). The facility reported a census of 42 residents. Findings include: 1. The MDS assessment of Resident #25 documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated cognition intact. The MDS recorded the resident experienced no mood symptoms of feeling down, depressed or hopeless. The MDS documented the resident exhibited no physical or verbal behaviors. The MDS documented diagnoses that included Alzheimer's disease, anxiety disorder, depression and bipolar disorder. The MDS documented the resident took antipsychotic and antidepressant medications during the lookback period. The MDS documented no gradual dose reduction (GDR) of psychotropic medications had been attempted and the physician had not documented a GDR as clinically contraindicated. The MDS documented bed rails were used daily as a restraint. On 7/16/24 at 1.53 pm Resident #25 was observed lying in bed. She had 2 mobility rails in place on her bed. The Side Rail Assessment of Resident #25 dated 2/19/24 documented Side rails are indicated and serve as an enabler to promote independence. The Medication Administration Record (MAR) for Resident #25 for May of 2024 failed to reveal any documentation of the resident taking any antidepressant medications. The Psychotropic Utilization Detail of Resident #25 for May, 2024 documented GDR's had been declined in August 2023 and October 2023 per the psychiatric progress notes. The encounter Psyche Progress Notes of Resident #25 documented Dose reductions of the psychotropic medications are not clinically indicated due to the patient's psychiatric symptoms as detailed in this progress note. Tapering of the medication would not achieve the desired therapeutic effects and the current dose is necessary to maintain or improve the resident's function, well-being, safety and quality of life. 2. The MDS assessment of Resident #33 dated 5/14/24 documented bed rails were used daily as a restraint. On 7/16/24 11:54 am Resident #33 was observed lying in bed with 2 mobility rails up. The Side Rail Assessment of Resident #33 dated 5/10/24 documented Side rails are indicated and serve as an enabler to promote independence. On 7/17/24 at 2:02 pm, the MDS Coordinator stated side rails being documented on an MDS is an error. She stated the facility is restraint free. She said rails are needed for bed mobility and to promote independence. She stated she would look at the MDS and make modifications. On 7/19/23 at 8:00 am, the MDS Coordinator stated the person who had been in her position prior to her had no tracking system in place for GDR's. She stated the Director of Nursing (DON) is now keeping a book to track them. She stated she had no way of knowing if GDR's had been contraindicated due to no tracking system so she marked no on the MDS form. On 7/19/24 at 12:19 pm, the DON stated MDS should be completed accurately. She stated there is a corporate person who oversees the MDS but she is not aware if each one is checked over as the MDS Coordinator is still in training. 50471 #3 The MDS assessment of Resident #37 dated 7/2/24 identified a BIMS score of 7 which indicated severe cognitive impairment. The MDS revealed the resident independent with bed mobility, personal care, transfers, toileting, eating, and dressing. The MDS revealed the resident occasionally incontinent of urine and always continent of bowel. The MDS documented diagnoses that included: unspecified dementia without behavioral, cancer, atrial fibrillation (irregular and often very rapid heart rhythm), hypertension, renal insufficiency, arthritis, anxiety disorder, spinal stenosis lumbar region without neurogenic [NAME] (chronic condition-spinal canal narrows, compressing the spinal cord and nerve roots), and cervicalgia (neck pain). The MDS revealed the resident was not at risk for developing pressure ulcers/injuries and the resident does not have one or more unhealed pressure ulcers/injuries. The Care Plan updated 7/11/24 revealed no documentation of the resident's unstageable pressure ulcer on right lateral foot. The Resident Matrix dated 7/16/24 revealed the resident has an unstageable pressure ulcer. The Physician Order for treatment dated 7/4/24 revealed Promegran Prisma to area on right outer foot. Cover with Mepilex. Change on bath days and as needed until healed. Noted Nursing staff completed treatment as ordered. On 7/19/24 at 8:05 am the MDS Coordinator, RN revealed she is still learning the process of completing and updated Care Plans for the residents. The MDS Coordinator is still learning the process of each section of MDS. On 7/19/24 at 12:57 pm the DON stated the facility does not have policies for Care Plan and MDS initiating or revising. She stated they follow the regulations.

Based on clinical record review, observation, staff interview, the facility failed to revise and update the care plan for 2 of 14 residents reviewed for care plan revision (Resident # 37, #16). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Sheet (MDS) assessment of Resident #37, dated 7/2/24, identified a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The MDS revealed the resident independent with bed mobility, personal care, transfers, toileting, eating, and dressing. The MDS revealed the resident occasionally incontinent of urine and always continent of bowel. The MDS documented diagnoses that included: unspecified dementia without behavioral, cancer, atrial fibrillation (irregular and often very rapid heart rhythm), hypertension, renal insufficiency, arthritis, anxiety disorder, spinal stenosis lumbar region without neurogenic [NAME] (chronic condition-spinal canal narrows, compressing the spinal cord and nerve roots), and cervicalgia (neck pain). The MDS revealed the resident was not at risk for developing pressure ulcers/injuries and the resident does not have one or more unhealed pressure ulcers/injuries. The Care Plan, updated 7/11/24 revealed no documentation of the resident's unstageable pressure ulcer on right lateral foot. The Resident Matrix dated 7/16/24 revealed the resident has an unstageable pressure ulcer. The Physician Order for treatment dated 7/4/24 revealed Promegran Prisma to area on right outer foot. Cover with Mepilex. Change on bath days and as needed until healed. Noted Nursing staff completed treatment as ordered. On 7/18/24 at 4:49 PM Staff N, RN reviewed Doctor's order for right lateral foot. The staff gathered supplies, knocked and entered the whirlpool room, set supplies on barrier, hand-washed, gloved, assessed area. Area was closed. The staff stated will talk with Director of Nursing, area appears healed, treatment is to be discontinued if healed. On 7/19/24 at 8:05 am, the MDS Coordinator, RN revealed she is still learning the process of completing and updated Care Plans for the residents. The MDS Coordinator is still learning the process of each section of MDS. 46873 2. On 7/16/24 at 10:52 am, Resident #16 stated she had taken a fall which resulted in a broken tailbone prior to moving to the facility. She stated she still had a lot of pain and although the facility administered pain medication, it was not effective enough. She stated that at that moment, she could hardly stand to sit in the chair due to pain. The MDS of Resident #16 dated 5/21/24 identified a BIMS score of 13 which indicated cognition intact. The Care Plan of Resident #16 documented a Focus Area of Pain initiated 12/11/23. The Care Plan directed staff to administer as needed pain medication as directed by physician and notify the nurse of any signs of pain. The fax written to the physician on 4/21/24 indicated staff noted the resident complaining of pain and refusing meals. On 4/22/24 the physician ordered scheduled pain medication three times a day. The Medication Administration Record (MAR) for Resident #16 for July of 2024 indicated Acetaminophen, extended release, 650 mg had been given three times a day scheduled since 4/22/24. The Care Plan was not updated to reflect the resident had been ordered scheduled pain medications. On 7/19/24 at 12:57 pm, the Director of Nursing (DON) stated the facility does not have a policy regarding care plans. She stated the facility follows the regulations and standards of care.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to provide restorative activities for 1 of 2 sampled residents in order to maintain a functional range of motion and prevent a decline in activities of daily living (Resident #22). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 to be dependent on staff for bathing, dressing, bed mobility, transferring and toileting. The MDS revealed the resident to have a functional limitation in range of motion on 1 upper extremity and 1 lower extremity. The MDS documented the resident to have diagnoses of hypertension (high blood pressure), diabetes, hemiplegia (paralysis of one side of the body) and a prior stroke. The MDS failed to reveal the resident had received any Speech, Occupational or Physical Therapies or any Restorative Nursing Programs during the lookback period. The Care Plan revealed a Focus Area of CVA/Stroke, revision date of 3/26/24 which directed staff to perform range of motion exercises several times a day. The Care Plan revealed a Focus Area of Self Care Deficit related to right side hemiparesis which directed staff of the resident needing staff assistance for bathing, bed mobility, dressing, toileting and transfers. The Care Plan also directed staff the resident had a Restorative Nursing Program, revised 5/11/21. On 7/16/24 at 1:32 pm, the resident was observed sitting in his wheelchair in his room resting. His right wrist was noted to be contracted. On 7/18/24 at 11:19 am, the Social Services director stated Resident #22 is non verbal. She stated he is picky about what staff members work with him and his wrist contracture has been there for a long time. She stated she was unaware of the resident having a Restorative Program. She said the MDS Coordinator also acts as the Restorative Nurse. On 7/18/24 at 3:16 pm, the Rehabilitation Director stated Resident #22 would be screened that day to see if he is appropriate to receive Medicare Part B therapy services. She stated typically a resident is screened by therapy each quarter during his or her MDS period. She stated she had been the therapy director for a year and Resident #22 had never been screened for therapy during her time as director. On 7/18/24 at 4:07 pm, the Rehabilitation Director stated she had screened Resident #22 and he had displayed no change in status from when he last received therapy in 2021. She stated he would be able to be picked up for therapy for the purpose of writing a restorative program. On 7/19/24 at 8:00 am, the MDS Coordinator stated she does not know why Resident #22 does not have a restorative program. She stated there is no reason she is aware of and that he would be appropriate for an Activities of Daily Living (ADL) and/or Dressing program. On 7/19/24 at 12:19 pm, the Director of Nursing (DON) stated any residents who are fully independent do not have a restorative program. She said all other residents should have a program but some may be removed if a resident repeatedly refuses. The facility policy Restorative Program Process, dated 11/1/19 documented the following: 1. Upon admission, quarterly and with significant change the resident's level of function will be assessed by the licensed nurse or in collaboration with therapy. 2. Based on the results of the assessment the licensed nurse will develop a care plan showing the resident's individual problems, determine approaches/interventions and set goals. 3. The licensed nurse will develop a restorative nursing program with individualized interventions and goals which may include recommendations for strategy and adaptive equipment from therapy. 4. The licensed nurse will educate all direct care staff assigned to the resident(s) on their restorative nursing program. 5. The licensed nurse will monitor staff and resident(s) to ensure compliance with the restorative nurse program. 6. The licensed nurse will monitor the daily restorative nursing program documentation in POC and follow-up with staff as needed. 7. The licensed nurse will write a monthly restorative nursing summary to track the resident(s) progress. 8. The licensed nurse will update the care plan and the restorative nursing program to reflect the resident(s) specific goals and interventions as needed. 9. The licensed nurse will make referrals to therapy as needed. 10. The licensed nurse will develop a discharge plan for the resident(s) who no longer need a restorative nursing program.

Based on clinical record review, facility document review, staff interviews, family interview, and facility policy review, the facility failed to supervise and provide a secure environment for 1 of 1 residents reviewed for elopement (Resident #29). The facility reported a census of 42 residents. Finding include: The Minimum Data Sheet (MDS) assessment of Resident #29, dated 10/5/23, identified a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The MDS recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless on 12 to 14 days of the previous 2-week look back period. The MDS did not reveal any wandering or exit seeking behavior. The MDS revealed the resident independent with bed mobility, personal care, transfers, toileting, eating, and dressing. The MDS documented diagnoses that included: type 2 diabetes mellitus, coronary artery disease, hypertension, renal insufficiency, and pancytopenia (low levels of red blood cells, white blood cells, and platelets). The MDS documented the resident received insulin injections on 7 out of 7 days of the assessment reference period. The Care Plan revised 10/3/23 identified the resident as an elopement risk. The care plan informed the staff to check the wander guard every shift, the resident's wander guard on shoelaces, history of removing wander guard, the resident will ask to leave the facility and walk around, and behaviors stating his is not in prison. The Wander Guard monitoring for the resident #29 revealed the Staff documented 10/24/23 to 7/17/24, current. The facility initiated, monitor the wander guard device every shift every day, started on 9/28/23. The staff did not complete documentation from 10/24/23 to 7/17/24, current. The Communication with Physician Progress Note dated 10/11/23 revealed Doctor started Donepezil 5 mg daily for dementia. New diagnosis of unspecified dementia, updated in the residents chart on 10/12/23. The Nurse Progress Note (PN) dated 10/20/23 revealed the resident left the building for unknown time, stated the resident exited the building between 4:30 PM and 5:00 PM. The staff unaware of the resident absence until the resident returned, approximately 5:45 PM. The resident brought to the facility whiskey and sandals. The PN revealed the resident wanted to drive the car to the facility, the resident unable to find the keys. Staff I, LPN stated she asked wife at dinner where the husband was, wife stated she did not know, she forgot. The resident revealed to Staff I that he attempted two other times, staff intervened, the resident waited and succeeded the last attempt. Staff I notified the Administrator, instructions placed wander guard on left ankle, 15 minute visual observations, head to toe assessment, and BIMS assessment. The sign in and sign out paper on 10/20/23 revealed the resident's daughter took the resident out of the facility at 3:15 PM and returned at 4:10 PM. The 15 minute visual observations for the resident #29 started 10/20/23 after the incident occurred, to 7/17/24, current. The facility did not provide documentation from 10/20/23 to 11/4/23. The staff did not provide any documentation for 12/1/23 to 12/31/23 and 5/1/24 to 5/31/24. The staff did not complete documentation from 1/1/24 to 4/30/24. The staff documented 6/1/24 to 7/17/24, current. The Elopement Drills are completed monthly. The staff provided documentation for every month with exception from 10/1/23 to 2/29/24, the staff was unable to provide documentation. The Elopement education is provided for staff at orientation and periodically at staff meetings. Observation on 7/18/24 revealed the resident's house is two and a half blocks north of the facility up a hill. Noted multiple houses, structures, and trees, unable to see the resident's house. South of the facility up the hill about half of a block is a active train track, south of the facility parking lot is an active walking trail. On 7/17/24 at 3:02 PM the Director of Nursing (DON) stated she was informed from the Regional [NAME] President of Operations via email about the elopement. The facility did a compliant review on the incident that occurred on 10/20/23 at 5:45 PM. Regional [NAME] President of Operations stated the resident #29 had higher BIMS upon return from the facility. The resident was educated about signing in & signing out when he wanted to leave the facility. Staff denied education about the code to the door, stated resident already knew the code. DON stated she does not know when staff stopped him from independently leaving at his will and when the wander guard was removed. On 7/18/24 at 8:06 AM Daughter and POA of the resident #29 recalled the elopement. Staff I updated her about the resident arriving back to facility about 5:45 PM. Staff I informed her the resident left and walked to his house, gathered sandals and whiskey, and walked back. He wanted to drive the car but could not find the keys. Daughter stated the resident is memory impaired, unable to make proper judgement decisions, resulted in placement at the facility. Daughter stated if the resident was able to find the keys to the car, he would have drove it back to the facility, the resident's wife resides at the facility. Stated earlier that day the Social Worker informed her that the resident was anxious, the resident stated to the staff he did not want to be there, his condition was better than others that live here. The daughter and social worker made arrangements for the daughter to come and take the resident(s) out for a walk. The daughter stated she took her parents out for a walk on the nearby trail after 3:00 PM and returned after 4:00 PM, stated she completed the sign in and sign out sheet, that would have the exact time. The daughter stated she arrived back to the facility checked parents back in, walked to the front entrance, the resident liked to walk her to the door, she punched the code in and said bye. The daughter stated he watched her punch in the code and he must have used that to get out. The resident stayed at door while she left. Stated she thought he was not anxious anymore and appeared to be okay. She thought he stole scissors or nail clippers to get the wander guard off. The resident was trying to prove a point, he wanted to show us that he can still do things on his own, that he does not need a nursing home. The daughter stated the resident is being monitored and treated by the telepsych Doctor, is involved in 1:1 activity, brother takes the resident to the farm with his dog, and on medications to help with his anxiety, he has been so much better. The daughter stated he has lived in [NAME] his entire life and knows the town and the way home. She feels like he was safe the day he got out. On 7/18/24 at 2:52 PM Staff J, CNA stated she worked the 2:00 pm to 10:00ppm shift on 10/20/23, she assisted another resident at the time of elopement. Staff J, seen the resident walking from the south nurses station to the north nurse station carrying a black garbage bag, as she was walking from the east wing to the west wing. Staff J denied hearing any alarms that shift. Staff J stated she was informed by other staff working that shift that the resident eloped that evening. Staff J denied hearing any pages for lost residents that shift. Staff J stated the resident will be sneaky when attempting to leave the facility, one attempt he wore a coat and sunglasses. Staff stated the education she received, frequent visual checks and redirect the resident when showing signs of increase exit seeking. Staff stated she is pretty sure, the resident is to always be supervised when outside. On 7/18/24 at 2:59 PM Staff K, CNA stated she worked the 2:00 pm to 10:00ppm shift on 10/20/23, Staff K aware the resident was out of the facility with his wife and daughter, unaware of the return time. Staff K denied any alarms sounding that shift and denied any pages for lost residents. Staff K updated about the elopement late that shift. Revealed she seen the Nurse laughing about it, shocked that the Nurse did not appeared to be taking the incident serious. The education that was provided redirect the resident when exit seeking, notify the nurse, and supervise the resident when outside. On 7/18/24 at 3:15 PM Staff I, LPN confirmed she was the nurse supervising the resident on 10/20/23 during the elopement. Staff I stated lots of visitors coming in and going out of the facility that evening. Staff I informed that the resident having increase anxiety, Social Worker spoke with daughter, daughter took wife and the resident out of facility in attempt to decrease anxiety. Staff I stated she seen them arrive back, and seen the daughter, the resident, and a third person walk to the front door (south entrance), she did not stand there to see them walk out the door. Staff I assumed the resident left with daughter. Staff I stated the daughter does not always tell the staff when she is taking the resident out of the building. Staff I denied reviewing the sign in and sign out sheet or calling the daughter to verify. Staff I revealed continued doing her tasks. Staff I stated when she assisted the wife at supper she asked the whereabouts of the resident, the wife stated she forgot. Staff I continued to assume the resident was out with the daughter. Staff I was informed by the south nurse that the resident walked back into building holding a sack of items. Staff I asked the resident where he came from, the resident replied I left and went home to take care of a few things. The resident had whiskey and sandals. Staff I stated the resident was approximately gone from 4:30 PM to 5:45 PM. The resident is to have a wander guard on, the resident had different shoes on therefore the wander guard alarm did not sound. The resident revealed to staff I that he waited until he got the chance and then followed someone out. Other residents and their families outside of the facility. The resident ignored the questions asked by the families and kept walking to his house. Staff I stated you can see his house from the window in his room. Staff I revealed the resident wore a long sleeve flannel plaid shirt and jeans. Staff I stated resident appeared to be proud of himself. Staff I reported she called the administrator, the daughter, and the primary care physician. Staff I was instructed to start 15 minute checks, head to toe assessment, and BIMS. Staff I stated the resident recently admitted and did not have a routine yet, nor showed a certain time of day to be more anxious. The facility policy titled Missing Resident/Elopement Process updated 7/12/21 directed staff: Care Plan will be modified as needed based on risk assessment. An alarm bracelet may be placed on the resident to audibly alert the staff of attempts by the resident to exit the facility. The resident's care plan shall address behaviors using resident specific goals and/or approaches as assessed by the IDT. Staff will encourage activities which the resident enjoys in order to occupy/distract the resident.

Based on clinical record review, resident interview, family interview and staff interviews, the facility failed to provide appropriate pain management for 2 of 2 residents reviewed (Res #16 and Res #21). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #16 dated 5/21/24 identified a Brief Interview of Mental Status (BIMS) score of 13 which indicated cognition intact. The Care Plan of Resident #16 documented a Focus Area of Pain initiated 12/11/23. The Care Plan directed staff to administer as needed pain medication as directed by physician and notify the nurse of any signs of pain. On 7/16/24 at 10:52 am, Resident #16 stated she had taken a fall which resulted in a broken tailbone prior to moving to the facility. She stated she still had a lot of pain and although the facility administered pain medication, it was not effective enough. She stated that at that moment, she could hardly stand to sit in the chair due to pain. The Treatment Administration Record (TAR) of Resident #16 for the months of May, June and July of 2024 were reviewed. The TAR revealed the resident had an order for a lidocaine patch, 4% for lower back pain. It was not signed off as being utilized at all for the months reviewed. The Medication Administration Record (MAR) for Resident #16 for July of 2024 indicated Acetaminophen, extended release, 650 mg had been given three times a day scheduled since 4/22/24. Neither the MAR or the TAR for any of the months reviewed revealed any staff had documented a pain level for the resident at any time. The Weights & Vitals portion of the Electronic Health Record revealed a numerical pain assessment had last been documented on 4/7/24. The Progress Notes indicated the following: 5/20/24: Pain: Indicators of Pain: None 5/25/24: Resident denies shoulder pain and no bruising noted to left deltoid from B12 injection. No other progress notes were found indicating a pain assessment since 5/25/24. On 7/18/24 at 10:24 am, Staff O, Certified Nurse Aide (CNA) stated the resident complained of back pain earlier that morning during cares. She stated the resident complains of pain every day, sometimes more than once a day. She stated she notifies the nurse to see if the resident has anything available for pain. On 7/18/24 at 10:26 am, Staff P, Registered Nurse (RN) stated Resident #16 has chronic pain. She said her pain level ranges day to day anywhere from stating her pain is 0 as high as a 7 or 8 on a 1-10 pain scale. She explained pain should be monitored three times a day with the scheduled acetaminophen and she would update the order to add pain monitoring into the MAR. She stated she knows the resident has increased pain when she is in her chair. She said the family is looking at hospice care and she hoped the resident could obtain better pain management once she enrolled in hospice care. She also stated some days the resident refuses to get out of bed due to her pain being so high. She said she is not aware if the physician had ever been notified of the resident's pain not being appropriately managed. On 7/18/24 at 10:37 am the Director of Nursing (DON) stated pain management documentation is individualized for the resident. She stated if a resident who generally does not have pain and has no scheduled pain medication, it should be monitored at minimum once a month along with monthly vital signs. She stated for any resident who is on any scheduled pain medication, it should be documented with each administration of the medication. All residents receive a quarterly pain assessment as part of the MDS as well. On 7/19/24 at 12:19 pm, the DON stated if staff is noting a resident to have increased pain, especially to the point of not being able to get out of bed, she would expect the nurse to notify the physician so the pain medication regimen could be evaluated by the physician. 47079 2. On 7/16/24 at 1:20 PM, Resident #21's relative confirmed the resident was under hospice care and had not had her morning pain medication. The Pain Interview dated 6/15/24 revealed the resident reported she had almost constant pain within the preceding five (5) days. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of cancer, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and thoracogenic scoliosis (spinal curvature caused by disease or surgery). It revealed the resident was dependent with toileting hygiene and putting on and removing footwear, required supervision with eating and maximum assistance with all other Activities of Daily Living (ADLs). The Electronic Health Record (EHR) included a physician order dated 6/13/24 and reordered on 6/26/24 for Hydrocodone-Acetaminophen Oral tablet 10-325 mg and directed staff to give 2 tablets by mouth three times a day for pain and give 1 tablet by mouth every 24 hours as needed for pain. The Medication Administration Record (MAR) indicated the resident's Hydrocodone-Acetaminophen order was to be administered at breakfast, mid AM, and at bedtime. The Medication Administration Audit Report revealed the resident's Hydrocodone-Acetaminophen was administered late 41 times out of 105 doses when following the standard administration schedule or 19 times out of 105 doses when following the custom administration schedule (3-hour time range for each ordered dose). A Pain Scale rating review indicated the resident had an average pain rating of 4.8 out of 10. The Care Plan dated 6/13/24 included pain due to arthritis and scoliosis and directed staff to administer pain medication as directed by the physician. On 7/19/24 at 12:57 PM, the Director of Nursing stated the facility did not have a policy directly addressing pain management. She stated the facility followed regulations.

Based on document review and staff interview, the facility failed to complete and post nurse staffing information at the beginning of each shift. The facility reported a census of 42 residents. Findings include: On 7/19/24 at 12:45 PM, the posted staffing sheet revealed incomplete day and evening shift staffing data. On 7/19/24 at 2:30 PM, a nurse staffing information binder review revealed 17 out of 17 staffing sheets for July 2024 were incomplete. There was no staffing sheet for July 17, 2024. On 7/19/24 at 3:15 PM, the Director of Nursing (DON) stated the staffing information sheet is initiated during night shift and the nurse for each shift was expected to complete and post the staffing information. On 7/22/24 at 8:35 AM, the DON stated the facility did not have a policy regarding posting of staffing data.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 42. Findings include: On 7/19/24 at 11:50 AM, Staff A, Cook, prepared pork ribs, carrots, and macaroni & cheese for two (2) pureed lunch menus. He divided each menu item into separate bowls, heated the pureed carrots, and placed all six (6) bowls in a pan on the steam table. The temperatures were not checked for any of the pureed items before being placed in the steam table pan. At 12:22 PM, Staff A put one (1) of each item on a plate for Staff B, Dietary Aide (DA) to deliver to the resident. Both Staff A and Staff B indicated the lunch plate was being delivered to the resident. A temperature check of each item was performed with the following results. a) Pureed pork ribs were 129.4 Fahrenheit (F). b) Pureed macaroni & cheese was 80.1 F. Staff A gave Staff B the plate and she took it to the resident. A policy titled Food Temperatures dated 2021indicated all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. On 7/22/24 at 8:47 AM, the Dietary Manager stated staff should follow the safe food temperature ranges.

Based on observations, clinical record review, facility record review and staff interviews the facility failed to provide appropriate hand hygiene while assisting with dining, during perineal care and during grooming for 6 of 12 residents reviewed (Resident #8, Resident #12, Resident #20, Resident #22, Resident #25 and Resident #30). The facility reported a census of 37 residents. Findings include: 1. On 5/15/23 from 12:00 PM - 1:00 PM the dining observation revealed the following: A. Staff M, Certified Nursing Assistant (CNA), assisted Resident #8 with eating then moved to the table on the right and assisted Resident #30 with eating. Staff M then moved to the table on the right and assisted Resident #22 with eating and walked back to Resident #8 and assisted him with eating. This pattern was completed throughout lunch without any hand hygiene between residents. B. Staff N, CNA, entered the dining room at 12:05 PM and applied gloves. Staff N assisted Resident #8 with eating then moved to the table on the left and assisted Resident #12 with eating. This pattern was completed throughout lunch without any hand hygiene between residents. C. Staff C, CNA, assisted Resident #25 with eating then moved to the table on the right and assisted Resident #22 with eating. This pattern was completed throughout lunch without any hand hygiene between residents. On 5/15/23 at 12:40 PM Staff C stated she did not know the policy, procedure, or facility expectation for hand hygiene between residents during meal time when assisting with dining. Staff C stated she decided herself she would complete hand hygiene after every other resident. On 5/15/23 at 12:43 PM Staff M stated she doesn't know the policy, procedure, or facility expectation but could ask management. On 5/15/23 at 12:52 PM Staff N stated that she usually completes hand hygiene between every resident every time but knows that she did not complete hand hygiene during lunch 5/15/23. Staff N stated she doesn't know the policy, procedure, or facility expectation for hand hygiene between residents. The facility policy titled Standard Precautions dated 10/19/22, provided by Staff L revealed: a. handwashing: wash hands after touching blood, body fluids, secretions, and contaminated items, whether or not gloves are worn, after gloves are removed, between resident contacts and any other time necessary, such as between tasks or procedures on the same resident. The facility policy titled Hand Hygiene dated 10/19/22, provided by the Director of Nursing (DON) revealed: a. alcohol based hand sanitizer should be utilized after contact with blood, body fluids, or contaminated surfaces. On 5/15/23 at 12:30 PM Staff L stated the facility's expectation is for hand hygiene to be completed between every resident every time when assisting with meal service. On 5/15/23 at 1:00 PM the DON stated the facility's expectation is at least hand sanitizer if not soap and water is utilized for hand hygiene between every resident every time. The DON stated hand hygiene should also be completed before and after assistance with eating meals. 40905 2. The MDS assessment for Resident #20, dated 5/3/23, included diagnoses of non-Alzheimer's dementia, anxiety disorder, muscle wasting, and difficulty in walking. The MDS identified the resident needed extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and the resident was frequently incontinent of urine and bowel. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 possible points, indicating severe cognitive impairment. During an observation on 5/17/23 at 7:57 AM, Staff C, CNA entered Resident #20's room and washed her hands in the sink. Staff C placed shoes on the resident, assisted resident to stand and walked the resident to the bathroom. Staff C applied gloves, removed the resident's wet brief and with the same gloves proceeded to gather clean clothes. Staff C applied hand sanitizer to the same gloves, and applied clean socks, pullup, and pants. Staff C placed a washcloth in the sink, ran water onto the wash cloth, and proceeded to wipe the resident's face with the cloth that sat in the sink. Staff C removed the gloves, sanitized hands, gloved, assisted resident to stand, and provided perineal care. Staff C removed gloves, sanitized hands, adjusted resident's clothing and walked resident out to room holding resident's hand. Staff C confirmed the brief was wet. During an interview on 5/17/23 at 2:00 PM, the DON stated it was an expectation to remove gloves and use hand hygiene after removing a brief and before touching clean items.

Based on observations, clinical record review, facility policy review, and staff interview the facility failed to provide an adequate door alarm system to mitigate a resident's risk for elopement (leaving the facility without staff knowledge or permission) for 1 of 3 residents reviewed (Resident #1). The facility had replaced a broken alarm with an alarm that automatically shut off after sounding briefly and/or failed to be loud enough to be heard by the staff for prompt response. On 11/6/21, Resident #1 exited the southwest door of the facility, and proceeded to walk approximately 0.41 miles uphill and crossed a busy street. The resident was gone approximately 10 minutes without staff awareness until the nurse observed the light on at the alarm panel at the nurses' station that signaled the SW door had been opened. A community member found the resident and they called the facility to report they had located Resident #1 by the local school on [NAME] St. These findings constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 42 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 10/29/21, Resident #1 had diagnoses that included hypertension, Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression. The MDS documented the resident scored 4 of 15 possible points on the Brief Interview for Mental Status (BIMS), which indicated the resident displayed severely impaired cognitive abilities. The MDS documented the resident exhibited wandering behavior 4 to 6 days during the 7 day look back period and also identified the wandering had gotten worse compared to the prior assessment and placed the resident at significant risk of getting to a potentially dangerous place (outside of the facility). The MDS documented the resident as independent with bed mobility, transfers, ambulation (walking), and locomotion on and off the unit. The MDS identified the resident did not use an assistive device with ambulation and was not steady with ambulation or turning around, but could stabilize without staff assistance. The Care Plan initiated 11/17/20, identified the resident's potential for behavior/altered coping related to history of elopement, wandering, and dementia. Interventions for staff included: check function and placement of wander guard as ordered (11/9/21), increased supervision as needed (11/7/20), provide one to one activities as needed (11/17/20), re-direction as needed (11/17/20), check the resident every 15 minutes for 72 hours (11/6/21 initiated and resolved), visual checks 32 times per shift for 72 hours (11/6/21), applied wander guard bracelet (11/17/20). The Care Plan initiated 1/11/21, identified the resident as at risk for injury related to fall risk. Interventions for staff included: assess quarterly for fall risk and as needed (10/18/21), occupational therapy to evaluate and treat (10/14/21), primary care provider (PCP) to review medications (2/4/21), notify telehealth, review of medication related to increase wandering and anxiety (6/24/21). The Care Plan initiated 11/17/20, identified the resident's potential for self-care deficit related to dementia. Interventions for staff included: transfers and ambulates independently (11/17/20). The Elopement Risk assessment dated [DATE], identified the resident as at high risk for wandering with a score of 6, due to: a diagnosis of Alzheimer's disease and ambulates independently with a history of wandering. The form documented episodes of disorientation/confusion and non-acceptance of placement, and talking about leaving the facility. The assessment documented the resident as at risk for elopement and the care plan current to the resident's elopement risk. Comments included: the resident had dementia and exit seeks often with wander guard in place. The Fall Risk assessment dated [DATE], identified the resident as at high risk for falls with a score of 16, due to: history of multiple falls in the last 6 months, medications which included narcotics and [CONDITION(S)], difficulty with memory and recall ability, occasional incontinence, daily agitated behavior, and strayed off the straight path of walking with gait analysis. The document titled POC (point of care) response history printed 11/16/21, identified behaviors in the last 30 days that included: a. 10/18/21 at 10:40 AM - wandering b. 10/19/21 at 12:07 PM - wandering c. 10/20/21 at 12:04 PM and 6:23 PM - wandering d. 10/21/21 at 1:10 PM - wandering e. 10/22/21 at 12:21 PM - frequent crying and at 6:54 PM displayed repetitive movements f. 10/25/21 at 1:42 PM and 6:49 PM - wandering g. 10/26/21 at 12:02 PM - wandering h. 10/28/21 at 8:58 PM - wandering i. 10/29/21 at 7:47 PM - wandering j. 11/1/21 at 7:58 PM - wandering k. 11/6/21 at 11:40 AM and 9:02 PM - wandering l. 11/8/21 at 12:12 PM and 7:28 PM - wandering The progress notes contained the following entries: a. On 11/6/21 at 1:28 PM, a behavior note documented the resident pacing and exit seeking, looking for folks, no care for Rusty (the resident's stuffed dog) and difficult to redirect. b. On 11/6/21 at 10:26 PM, health status note - at 5:00 PM, a fell ow nurse reported the Southwest (SW) exit door alarm light on without the alarm sounding. A resident head count initiated without locating this resident. Staff last saw the resident ambulating in the dining room at 4:50 PM. Staff searched inside the facility and then expanded to the outdoor area surrounding the facility and to the outlying areas to include: the trail, neighboring yards, roadway, and the park. At 5:10 PM, a local citizen called and reported the resident seen near [NAME] Village apartments and the local school. A CNA located the resident and they returned to the facility at 5:20 PM. Staff completed a physical status assessment upon the resident's return and identified no injuries. c. On 11/7/21 at 2:23 AM, behavior note - the resident asleep in bed at this time, will continue to monitor. The document titled Elopement dated 11/6/21 at 5:20 PM, identified the incident location as outside. Incident description: Nursing: at 5:05 PM, fell ow nurse noted the SW exit alarm panel light on but alarm not sounding. Staff completed a resident head count which resulted in the inability to locate Resident #1, so they sent two staff members to check the perimeter (outside areas surrounding the facility including the courtyard), and then expanded the search to the outer areas including the trail, neighboring yards, roadways, and the local park. The other staff continued to check all rooms, bathrooms, common areas, and locked room within the facility. Staff interviewed and they last saw Resident #1 mined the resident last seen ambulating in the dining room at 4:55 PM toward the south nurse's station and her room. The resident reported she needed to use the restroom and staff believe the resident went to the bathroom at 4:55 PM. Resident #1 wore a turquoise outfit: turquoise stretch pants, turquoise light weight jacket similar to a sweatshirt, turquoise top with light tank top underneath, ted hose (compression stockings), white shoes, turquoise purse, and glasses. The Administrator and the nurse on-call notified. At 5:10 PM, the facility received a call from a local citizen that reported the resident was seen at a house across the street from the [NAME] village apartments. The local citizen stayed with the resident until the facility staff arrived and returned the resident to the facility at 5:20 PM. Resident: the resident unable to give description. Immediate action taken: a. Description: the resident assessed head to toe upon return to the facility. All clothing removed and clothing did not contain blood, dirt, or grass stains and staff determined the resident had no new skin issues other than ones followed on weekly skin log. Vital signs and range of motion within normal limits for the resident. The resident denied any pain or discomfort and reported they were tired, although the resident demonstrated a pleasant and cooperative mood, and to supper once assessment completed. After supper the resident sat in the south hallway with the facility staff watching the exits until approximately 10:45 PM when the resident assisted to bed. The Administrator, PCP, POA (power of attorney), and the on call nurse notified. Extra alarms placed on the SW and SE doors at 9:55 PM on 11/6/21. The resident placed on 32 checks per shift and vital signs every shift x 72 hours. b. Resident taken to hospital: No injuries observed at time of the incident: Level of Pain: no pain, alert, and ambulatory without assistance. Mental Status: orientated to person Notes: the resident had memory/cognitive issues and varying levels of awareness with a bruise noted today below the trochanter (hip), on the right upper back thigh which was dark in color on the one edge and green/yellow on the other edge, tender to touch. All appropriate parties notified: PCP, Director of Nursing (DON), Administrator, POA, and the skin nurse. Strongly suspect new skin area from the elopement Saturday afternoon. Injuries reported post incident: bruise left trochanter (hip) Predisposing Environmental Factors: the environmental factor contributed Predisposing Physiological Factors: confused, impaired memory, physiological factors contributed, and contributing diagnosis listed below Predisposing Situation Factors: active exit seeker, wanderer, the predisposing factors contributed to the fall, ambulating without assist Other Information: adjustment disorder with mixed anxiety and depressed mood, recurrent major depression disorder, early onset Alzheimer's disease, dementia, and mental disorder due to unknown physiological condition. Witness: no witness found. The undated document titled Self Report documented the following: Timeline of incident: On 11/6/21, at approximately 5:10 PM, the Administrator notified Resident #1 eloped from the facility and found. The Administrator and Business office manager arrived at the facility at 6:00 PM to monitor the SE & SW exit doors until further alarms placed. Resident #1 observed at the supper table at 4:45 PM, and then observed by Staff C, ambulating down the south hall and the resident stated needed to go to the restroom. At approximately 5:05 PM, Staff I observed the SW alarm light on and not sounding. Called for head count, checked the perimeter of the facility. At approximately 5:15 PM, community member called the facility to report Resident #1 located across from the school. Staff G picked the resident up in private vehicle and returned to the facility at 5:20 PM. Staff J completed head to toe assessment upon the return of Resident #1 with no injuries found. Resident #1 was in a good mood, ate supper and observed by staff in the hallway until approximately 10:45 PM, when they went to bed. The document titled Exit Security Monitoring dated November 2021 directed: test each exit daily by visually inspecting, opening the door and monitoring to ensure that the alarm is functioning by signaling on the panel. Check exits that have a resident elopement monitoring system on a daily basis to ensure proper function, i.e. code alert or wander guard system. Initial when specified door checked and functioning properly. Identify each exit door below: North, Northeast (NE), Northwest (NW), Hall, Patio, South, Southeast (SE), South wander guard, and North wander guard. The facility failed to check the door alarms on 11/6/21 as the documentation area was blank. The facility document titled Missing Resident/Elopement process updated 7/12/21 documented Assessment and identification of wandering residents: a. Staff to complete an elopement risk assessment upon admission, readmission, quarterly, annually, and with any significant change MDS b. Staff to modify care plan as needed on the risk assessment c. Complete a missing resident identification form - activities will be in charge of having a missing resident identification form completed for each resident on admission and annually Residents identified at risk for elopement: a. Staff may place an alarm bracelet may be placed on the resident to audibly alert the staff of the attempts by the resident to exit the facility b. The resident's care plan shall address behaviors using the resident specific goals &/or approaches as assessed by the IDT (Interdisciplinary team) c. A current picture of the resident will be maintained in the facility d. Facility staff will ensure that all exit alarms are responded to immediately e. Staff will encourage activities which the resident enjoys in order to occupy/distract the resident When the door alarm sounds the facility staff shall: a. Check the alarm panel to determine which door opened. Do not assume someone else already did this. b. Check the exit door for any existing resident by means of visual check. Visual check means observing the area around the exit and may require leaving the building. c. If a resident discovered outside the facility inappropriately, staff assist them back into the facility d. Reset the door alarm after it determined by visual check that no resident exited the facility inappropriately or returned to the facility e. If for any reason, door alarms are turned off, the staff will continually visually monitor the door/doors f. If an alarm is discovered de-activated, staff will perform an immediate head count to ensure all residents are accounted for Elopement Process (missing resident): a. When staff determine a resident is missing the following will occur: i. Alert the nurse in charge and all shift personnel to search the facility. If the resident is not located a grounds search will begin. ii. If the resident is unaccounted for after a thorough grounds search of the building and grounds, immediately notify: Executive Director/DON, family &/or legal representative, attending physician, and police. b. A complete description of the resident will be given to the police along with a current photo of the resident. Provide law enforcement the Missing Resident Identification form. When the resident is located, the following procedure will be followed: a. Head to toe assessment of the resident will be completed to determine if medical attention is required. Document in the nurses notes the head to toe assessment completed and findings. b. After the assessment is completed, the attending physician will be notified and the results of the assessment reported. The physician's plan of care will be documented in the resident's record. c. The resident's family/legal representative shall be notified of the resident's condition d. The resident's condition will be monitored every shift x 72 hours e. A detailed incident report will be completed f. An Elopement/Missing Resident Investigation form will be completed by the DON &/or designee g. The Incident Report will be reviewed at the Monthly Safety Committee meeting and each quarter with the QA (quality assurance) Committee Education and Training: a. All staff will be educated on proper identification, assessment, and treatment of the resident's identified as an exit seeking risk. This education will occur during orientation and annually thereafter. b. Missing Resident Drill will be completed on all shifts quarterly In an observation of the light panel at the North Nurse's station with the Director of Nursing (DON) on 11/9/21 at 11:20 AM, the DON stated the light panel contained corresponding lights that would light up and alarm when the North, NE, NW, SW, SE, Patio, and Hall doors opened. The DON stated when the alarm sounded, staff responded by going to the panel to note the door opened, and proceeded to check the corresponding door. The DON stated the alarm is not reset until staff determined why the alarm sounded, and then they must turn off the alarm and reset it. The DON stated housekeeping checked the door alarms daily and staff also checked the wander guard bracelets the residents wore every shift for placement and functioning. Observation on 11/9/21 at 3:27 PM, revealed Resident #1 had ambulated over 4 blocks with a gradual incline, and crossed a busy street, before being found by a private citizen in a residential driveway. Additional observation revealed the resident traveled an estimated distance 0.41 miles from the facility depending on the route taken. It would have taken approximately 9.5 minutes if the resident had ambulated continuously without any stops. Observation on 11/9/21 at 4:55 PM accompanied by the Administrator showed the exit doors and alarms contained a magnetic type alarm and a small white box alarm placed on the SW & SE exit doors. Upon opening the SW door, the magnetic type alarm sounded and did not shut off until the magnet reattached. The small white box alarm shut off automatically once the door closed. The staff located at the light panel at the North Nurse's station reported on the radio that the light turned on, however, no alarm sounded for the SW door. Upon opening the SE door, the magnetic type alarm sounded and did not shut off until the magnet reattached. The small white box alarm shut off automatically once the door closed. The staff located at the light panel at the North Nurse's station reported on the radio that the light turned on and the alarm sounded for the SE door. The Administrator reported the facility placed the small white box alarms on the SE & SW doors when they determined the door alarms were not consistently sounding at the panel when the light activated during checks. During an interview on 11/9/21 at 11:50 AM, the Administrator stated when the door alarm sounds, a corresponding activates at the North Nurse's station panel - all staff should respond. The Administrator stated the facility provided re-education to all staff on Saturday 11/6/21 related to the alarm response and potential head count if they could not determine why alarm sounded. The Administrator stated all staff are educated upon hire regarding the door alarms and the panel at the North Nurse's station. The Administrator stated door alarms are checked and logged daily by the housekeeping staff. The Administrator reported the nursing staff check the function and placement of the wander guard device worn by the resident at least daily and document it on the resident treatment administration record (TAR). The Administrator stated Resident #1 had eloped through the SW hall door at suppertime on Saturday 11/6/21, however, no alarm sounded. Staff did observe the light at the panel at the North Nurse's station had activated, The Administrator stated staff had been outside searching for Resident #1 when a member of the community found the resident across the street from the local school. The Administrator stated they had determined the resident was gone approximately 25 minutes because staff had observed the resident in the dining room at 4:45 PM, identified the light at the panel at 5:05/5:10 PM, and took the call from the community member at 5:15 PM. The Administrator stated Resident #1 had history of exit seeking behavior and a diagnosis of dementia. The Administrator reported the resident had days of increased restlessness and believed that occurred on 11/6/21. On Saturday 11/6/21, housekeeping staff had not checked the door alarms, but on Friday 11/5, they checked them and determined they were working to be working properly. The Administrator stated the facility placed the magnet type alarm on the SE & SW exit doors on Saturday 11/6/21, after the resident had eloped. The Administrator stated they placed the small white box alarms on the SE & SW exit doors approximately 3 months ago, because the door alarms were not sounding consistently when the doors opened. The Administrator confirmed the small white boxes would sound when the door opened, however, they automatically shut off when the door closed. The Administrator stated the facility received a bid from an alarm system company to replace the alarms on the front door, SE, & SW doors, in September, however, the company was not able to complete the job due to staffing. The Administrator stated they were aware the alarms were not working properly. In an interview on 11/9/21 at 1:10 PM, the Director of Nursing (DON) stated she had been out of town on Saturday 11/6/21, and not involved with the elopement of Resident #1. The DON stated the facility failed due to the staff not hearing the exit door alarm when the resident eloped from the facility at suppertime. The facility staff were in the dining room and did not hear the alarm from the SW door. The DON reported they were unaware the door alarms were not functioning properly at the time Resident #1 had eloped. The DON stated door alarms were checked daily and she had never heard they had not worked properly. The DON reported she knew the small white boxes were placed on the SE & SW exit doors, but did not know why. The DON stated Resident #1 had a history of elopement and would repeatedly state they were leaving the facility; the resident was at risk for elopement and had a wander guard in place. The DON stated the resident went outside for activities and outings with family, however, they had never made it outside of the facility undetected. On 11/9/21 at 1:38 PM, Staff A Licensed Practical Nurse (LPN) confirmed working on 11/6/21. Staff A stated Resident #1 appeared under duress on the day of 11/6/21, and did not want anything to do with Rusty, the stuffed dog that had previously been good distraction tool. Staff A stated Resident #1 had not slept the previous night, displayed elevated anxiety, and wandered during the day on 11/6/21. Staff A stated the resident had asked about going outside, however, had made no attempt leave through the doors. Staff A stated they were always aware of Resident #1's location, and knew when the resident had a bad day. Staff A stated the Certified Nursing Assistants (CNAs) were aware of the resident's behaviors and kept/keep an eye on the resident. Staff A reported being aware of issues with the SE door, such as when the door would catch and had to be pulled all the way shut. Staff A reported being unaware of any alarm malfunctions related to the other exit doors, and was also unaware of any additional alarms placed. In an interview on 11/9/21 at 2:31 PM, Staff B Certified Medication Aide (CMA) confirmed working on the 2-10 PM shift on 11/6/21. Staff B stated she started each shift by checking residents in her assigned hallway. Staff B stated she observed Resident #1 in Room #28, going through a fell ow residents' drawers at approximately 2:30/2:45 PM. Staff B stated she assisted Resident #1 to leave the room, but the resident then attempted to go in other rooms. Staff B stated Resident #1 eventually went to her room and sat in the recliner. Staff B stated room #28 was located at the end of the SW hall by the exit door, but the resident did not usually go that direction. Staff B stated the last time she had observed Resident #1 she had come out of the bathroom around 3:20/3:30 PM to sit in a recliner in the room. Staff B stated at 4:45/4:50 PM, she reminded residents it was time for supper and asked fell ow a CNA if they had seen Resident #1, and they replied not in the room, but in the dining room. Staff B stated around 5:00 PM, she heard on the walkie talkie that the red light was on at the panel for the SW exit door. Staff B stated she did not hear an exit door alarm sound at that time and reported they completed a head count, checked rooms, and went to the nurse's station to check if the resident had been found. Staff B stated she went out the front door and checked both sides of the building and down to the creek. Staff B stated supper time was a busy time and she did not hear an alarm sound. Staff B stated she was informed the alarms were broken and she had been unaware of that. Staff B added the exit door alarms used to sound until they were shut off and added Resident #1 had a history of wandering and going to the exit doors. Staff B commented the resident returned to the facility that night smiling. In an interview on 11/9/21 at 2:42 PM, Staff C CMA confirmed she worked a double shift on the North Hall on 11/6/21, 6 AM - 10 PM. Staff C stated Resident #1 displayed increased behaviors throughout the facility on Saturday 11/6/21. Staff C stated she questioned if it was possibly due to the weather change and/or the time change. Staff C stated she had observed Resident #1 in the main dining room around supper time, which was a little before 5 PM. Staff C stated at times, Resident #1 required assistance to locate their seat in the dining room, and on 11/6/21, she assisted her with locating her table. However, Resident #1 then reported needing use the restroom and said they would return shortly. Staff C stated she did not observe Resident #1 return to the dining room. Staff C stated Resident #1 had history of exit seeking behaviors to find their family. Staff C reported she did not know if Resident #1 exited the facility prior to 11/6/21 without staff knowledge. Staff C stated she did not hear the door alarm sound when the resident exited the facility on 11/6/21; she had been in another resident's room when staff were over the walkie talkie to complete a head count of all the residents. Staff C stated she went outside through the NW exit door and completed a perimeter check and returned to the facility. Staff C said she had not been unaware of the exit door alarms not working properly. Interview on 11/9/21 at 2:53 PM, Staff D CNA confirmed she worked 6 AM-2 PM on 11/6/21. Staff D stated Resident #1 seemed agitated when she arrived at work that morning with increased confusion; the resident repeatedly stated had not slept, had not stayed at the facility, and was unaware of whose belongings were on the bed in room. Staff D stated Resident #1 was usually not agitated in the mornings, as that usually occurred in the afternoon and evenings. Staff D reported she did not know if Resident #1 attempted to exit the facility prior, but said that she wandered and was easily re-directed. Staff D stated the exit door alarms sound when opened and when the door shut, the alarm would shut off. Staff D stated was unaware how long the SW & SE exit door alarms did not regularly sound when opened. On 11/9/21 at 3:11 PM, the State climatologist reported the temperature on 11/6/21 between 4:30-5:00 PM, 57 degrees with wind out of the south at 6 miles per hour (mph). In an interview on 11/9/21 at 3:27 PM, Staff G CNA confirmed working on 11/6/21 when Resident #1 eloped from the facility. Staff G reported working the North hall, however, observed Resident #1 wandering throughout the halls of the facility. Staff G reported observing the resident around 4:45 PM, ambulating in the South hall. Staff G did not hear the alarm sound and had been unaware alarm the system was not functioning properly. Staff G said after staff saw the light on for the SW door, they completed head a count, checked the halls and the rooms prior to proceeding out the SW exit door to check for the resident. Staff G looked behind the building and down the trail prior to returning inside the facility. Staff G stated a community member called the facility to report they found the resident stayed with the resident until she had arrived. Staff G stated she arrived to pick up Resident #1, across from the school in a residential drive way, and Resident #1 appeared content and no injuries observed. In an interview on 11/9/21 at 4:21 PM, Staff E Housekeeper confirmed working on Saturday 11/6/21, 8 AM-3:50 PM, but left prior to Resident #1 eloping from the facility. Staff E stated exit door alarms checked daily by the housekeeping staff. Staff E stated the light at the panel located at the North nurses station will light up, however, they cannot consistently hear the alarm for the exit doors. Staff E stated she had worked at the facility for 2-3 weeks and had only check the door alarms a couple of times and had been in trained how to check the exit door alarms. Staff E stated she failed to check the exit door alarms on 11/6/21, when Resident #1 had eloped. Staff E stated when they check the exit door alarms, 1 housekeeper stands at the nurse's station light panel to reset the alarm, and the 2nd one opens the exit door to sound the alarm. Staff E stated the light would turn on, but not sound. Staff E stated a magnet alarm was placed after the incident on 11/6, and alarms have to be checked daily at 9 AM. An interview on 11/10/21 at 8:52 AM, Staff F Laundry/Housekeeping Supervisor confirmed working 8 AM-4:30 PM on 11/6/21. Staff F stated they were to check exit door alarms daily, however, staff had asked her to take labs to the hospital and she forgot to check the door alarms on 11/6/21. Staff F stated exit door alarms did not function properly. Staff F stated the SE & SW exit doors did not sound consistently when opened, so the facility placed small white boxes on the SE & SW doors. Staff F reported they did not know exactly when the facility installed the small white box alarms, but it had been months. Staff F stated when they check the exit doors. Staff initial that an alarm sounded and light turned on when tested . On 11/10/21 at 9:03 AM, Staff H CNA confirmed they worked the day shift on 11/6/21. Staff H stated Resident #1 ambulated throughout the facility and looked out the exit doors, but did not try to leave the facility. Staff H stated Resident #1 was easily re-directed and in a pleasant mood on 11/6/21. Staff H said Resident #1 had a history of exit seeking behavior, but the CNA was unaware of a previous elopement. Staff H denied difficulty hearing the door alarms when they sounded and didn't know there were any problems with any of the alarms. Interview on 11/10/21 at 9:08 AM, Staff I Registered Nurse (RN) stated worked 6 AM-6 PM on the North hall 11/6/21. Staff I stated Resident #1 restless on 11/6/21, and had asked if the alarms go off. Staff I stated the resident unaware lived at the facility and re-directed to room. Staff I stated the resident did not attempt to leave the facility prior to 11/6/21. Staff I stated observed Resident #1 approximately 4:30 PM, not anxious or exit seeking at that time. Staff I stated passed supper medications for the residents on the NE hall and checked the light panel prior to leaving the nurses station at 4:40 PM, and no lights on. Staff I stated returned to the nurse's station at 5:05 PM, and observed the light on for the SW door. Staff I stated instructed the facility staff to complete head count of residents, check rooms, and sent staff outside to check the perimeter of the building. Staff I stated called the Administrator and received call from a community member at that time that Resident #1 observed in the community. Staff I stated Resident #1 returned to the facility without behaviors. Staff I stated observed the light on at the panel, however, never heard an alarm sound. Staff I stated unaware of the exit door alarms not functioning properly. Interview on 11/10/21 at 9:27 AM, Staff J LPN confirmed worked 2-10 PM on 11/6/21. Staff J stated Resident #1 restless upon arrival to work, looked around and appeared lost. Staff J stated Resident #1 behavior on 11/6/21, worse than baseline. Staff J stated received in report the resident not exit seeking, looked for grandparents and how to get upstairs & downstairs. Staff J stated observed Resident #1 carry bag of clothes and left in a fell ow resident's room end of the SW hall. Staff J stated observed the resident up and down the halls, however, did not attempt to open the doors. Staff J stated passed supper medication in the main dining room, medication cart located in the hallway by the DON office. Staff J stated did not hear an alarm sound, heard Staff I RN announce the SW light on at the panel. Staff J stated head count completed, concentrated on the residents that wander, and did not locate Resident #1. Staff J stated checked the rooms and the bathrooms prior to sending the staff outside to check the perimeter of the building. Staff J stated received a call from a community member observed Resident #1 by the school. Staff J stat[TRUNCATED]

Based on record review and staff interviews, the facility failed to adequately supervise Resident #7 and ensure the resident ' s care plan directed staff appropriate interventions (application of sit to stand alarm) for staff to follow to prevent further falls from occurring. The sample consisted of 8 residents and the facility identified a census of 39 residents. Findings include: 1. Resident #7 had an MDS (Minimum Data Set) assessment with a reference date of 5/28/12 which included [DIAGNOSES REDACTED]. The MDS documented a BIMS (Brief Interview of Mental Status) at 13 which identified intact cognitive function. The MDS documented Resident #7 required extensive assist of 2 persons for transfers and toilet use. Resident #7 required limited assist of 1 person for bed mobility and dressing. The MDS identified Resident #7 as not steady and only able to stabilize with staff assistance when moving from a seated to standing position, moving on or off the toilet, and for surface to surface transfers. The MDS documented Resident #7 had a fall in the last 2-6 month period prior to admission or reentry and the resident had a fracture related to a fall in the 6 months prior to admission or readmission. The resident Care Plan dated 5/22/12, identified the resident had a problem with a history and a potential for falls. The interventions directed staff to remind the resident to use the call light, Physical Therapy to screen quarterly and PRN (as needed), give resident verbal reminders not to transfer or ambulate without assistance, use assistive/supportive device, maintain environment free of clutter and safety hazards. Review of a document titled Unusual Occurrence Report dated 6/23/12 at 11:05 PM documented Resident #7 had been observed on the floor. The report identified areas of injury as head, c/o (complaints of) neck pain, c/o back pain, c/o left arm pain, left elbow, right eye hematoma, and c/o left rib pain. The report documented injury type as abrasion, hematoma, skin tear, and swelling. The report documented interventions at the time to be a low bed and a pressure reduction mattress. The report documented no alarms in use at the time of the fall. The IPN (Interdisciplinary Progress) notes on 6/23/2012 indicated the staff transferred the resident to the hospital at 12:02 a.m. via ambulance. The IPN notes at 3:00 a.m. revealed the hospice nurse provided information that the resident was transported to another hospital due to a cervical spine fracture (C-1) and also possible brain bleed on the right side. The History and Physical report with an admission date of [DATE] documented the resident had been transferred from an outside facility where the CT (Computerized Tomography) of the neck and head revealed a longitudinal fracture of the C1 lateral mass on the right side involving both the superior and inferior cortexes of this lateral mass. The IDP Notes dated 6/22/12 at 12:30 PM documented Resident #7 had been found in his/her room in AM attempting to get out of bed without assistance, and the resident's feet and bottom (buttocks) hung off the bed. Staff C, RN documented a sit-to-stand alarm had been placed on the resident. Review of the IDP Notes dated 6/22/12 at 5:25 PM written by Staff B, RN documented alarm in place. Review of the IDP Notes for 6/23/12 at 1:50 AM and 6/23/12 at 8:00 PM did not document the use of a sit-to-stand alarm. The IDP Notes dated 6/23/12 at 11:05 PM documented Resident #7 found on floor, described the injuries, and method of getting the resident off the floor. The IDP Note did not identify that a sit-to stand alarm had been in place. Review of a document titled Communication Form dated 6/22/12 signed by Staff C which notified staff that Resident #7 had a sit-to-stand alarm in place. Review of the 24 Hour Nursing Report dated 6/22/12 documented Resident #7 had a sit-to-stand alarm. Review of the Major Injury Determination Form dated 6/24/12, and signed by physician, documented the injury to be considered a major injury. On 6/27/12 at 9:20 AM, Staff C (Licensed Practical Nurse) revealed that she had placed a sit-to-stand alarm on Resident #7 herself after she had found the resident attempting to get out of bed without assistance. During another interview with Staff C on 6/27/12 at 1:50 PM revealed that Staff R, CNA had approached her prior to shift change stating that the sit-to-stand alarm did not work. Staff C directed Staff R to find Staff Q to get new batteries for the sit-to-stand alarm. On 6/27/12 at 4:00 PM, Staff R (Certified Nursing Assistant) was interviewed and stated when she assisted Resident #7 to the bathroom and back to the recliner on 6/22/12 the sit-to-stand alarm did not sound. Staff R took the alarm to the charge nurse, Staff C and Staff C then instructed Staff R to find Staff Q whom had the batteries for the alarms. Staff R attempted to find Staff Q but unsuccessful. Staff R then stated after she could not find Staff Q, she told the North side nurses, Staff B and Staff E that the alarm belonged to Resident #7 and did not work. Staff R also stated that she had told the second shift aides that Resident #7's alarm did not work. Staff R laid the alarm down on the nurse's station and left for the day On 6/27/12 at 2:46 PM, Staff E (Licensed Practical Nurse) was interviewed and revealed she thought Resident #7 had an alarm but could not be 100% sure. On 6/26/12 at 9:38 PM, Staff H (Certified Nursing Assistant) was interviewed and revealed on 6/22/12 it had been passed down (communicated) that Resident #7 had a sit-to-stand alarm but that it needed new batteries. The alarm had been on the nurse's station but disappeared. Staff B had been assigned to charge nurse duties and Staff E passed (administered) medications. On 6/27/2012 at 2:25 p.m. Staff O, (Certified Nursing Assistant) was interviewed and stated he had worked the night of 6/22/12 and assisted Resident #7 to bed and he/she did not have an alarm on. Staff O also said he worked the evening shift on 6/23/12 and the resident did not have a sit-to-stand alarm that night either. On 6/2612 at 11:33 PM, Staff F (Licensed Practical Nurse) was interviewed and revealed she had read on the communication sheet that Resident #7 needed a sit-to-stand alarm. On both evenings of 6/22/12 and 6/23/12, she did not observe an alarm on the resident. On 6/26/11 at 3:50 PM, Staff U (Licensed Practical Nurse) spoke with the resident ' s daughter regarding the alarm. The daughter stated on Friday evening on 6/22/12, she had visited Resident #7 and did not see an alarm. The daughter also reported her sister from Kansas had been at the nursing home with Resident #7 all day and her brother had spent the evening with Resident #7 and none of the family members saw an alarm attached to Resident #7.