Every finding on record at Adamsville Healthcare and Rehabilitation Center

Based on observation and interview, the facility failed to ensure kitchen sanitation when a black slimy substance was found inside 1 of 3 (500-hall ice machine) ice machines observed. There were 8 residents on the 500-hall who had the potential to be affected. The findings include: Observation of the 500-hall ice machine on 7/29/2025 at 3:05 PM, revealed a black slimy substance noted on the right and left inside walls of the ice machine and along the length of the ice tray. Observation and interview of the 500-hall ice machine on 7/29/2025 at 3:30 PM, the Dietary Manager (DM) confirmed the black slimy substance was there and stated, .I see what you are talking about. That should not be there. During an interview on 7/30/2025 at 8:09 AM, the Administrator stated, . We don't have a policy or procedure for cleaning the ice machine. During an interview on 7/30/2025 at 10:19 AM, the Maintenance Supervisor was asked who is responsible for cleaning and maintaining the ice machines. The Maintenance Supervisor stated, .A company named [named company] comes every 3 months to clean and service the ice machines.Once a week either myself or the Maintenance Assistant will wipe them down and dump the ice. The Maintenance Supervisor was asked about the black slimy substance found in the 500-hall ice machine on 7/29/2025. The Maintenance Supervisor stated, .We just hadn't gotten to cleaning it this week. During an interview on 7/30/2025 at 10:41 AM, the DM stated, .ice is food, and it [500-hall ice machine] should have been clean. During an interview on 7/30/2025 at 11:55 AM, the Maintenance Supervisor was asked if there is a check off or sign off sheet that shows when maintenance staff cleans the ice machines. The Maintenance Supervisor stated, No, not yet. It's not a scheduled task in [Named program to schedule tasks and work orders] so we don't sign it off.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders and to monitor the oxygen flow rate for 2 of 2 (Resident #11 and #27) sampled residents reviewed for respiratory therapy. The findings include: 1. Review of the undated facility policy titled, Providers Orders, revealed .This facility shall use uniformed guidelines for the ordering of medication.Medication should be administered only upon the signed order of a person lawfully authorized to prescribe.Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Review of the undated facility policy titled, Oxygen Administration, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice.Oxygen is administered under order of a physician .Equipment setting for the prescribed flow rates. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Pneumonia, and Chronic Respiratory Failure. Review of the Significant Change Minimal Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident # 11 was moderately cognitively impaired. Resident #11 was assessed for shortness of breath (SOB) or trouble breathing when lying flat and required oxygen therapy. Review of the Physician's Orders dated 6/24/2025, revealed .O2 [oxygen] @ [at] 2L/min [liter per minute] via [by] N/C [nasal canula] to keep O2 sats [saturations] > [greater than] 90% [percent] If < [less than] 90%, encourage resident to cough & take a deep breath, then recheck O2 Sat & [and] Notify MD [Medical Doctor] If O2 sat is checked with oxygen on chart Y [yes] , if checked on room air chart N [no] every shift.2 LITERS BY NASAL CANNULA every 1 hours as needed for SHORTNESS OF BREATH.HOB [head of bed] is elevated to prevent of SOB [shortness of breath] while lying flat r/t [related to] chronic lung disease (bed or pillows) every shift for COPD/ Emphysema/ Asthma. Observations in the Resident room on 7/28/2025 at 10:06 AM, 12:15 PM, and 2:10 PM, and 7/29/2025 at 4:50 PM, revealed Resident #11 was wearing oxygen at 3 Liters (L) binasal cannula (BNC). During an interview on 7/29/2025 at 4:53 PM, Licensed Practical Nurse (LPN) C confirmed Resident #11's oxygen flow rate was set to 3 L BNC, when the order was for 2L BNC. LPN C then changed the oxygen flow rate to 2 L BNC. Resident #11 was not receiving the correct flow rate of oxygen as ordered by the physician. 3. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease (COPD), Acute Pulmonary Edema, and Tobacco Use. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #27 was moderately cognitively impaired. Resident #27 received oxygen therapy. Review of the Physician's Orders for July 2025 revealed no orders for oxygen therapy. Review of the Medication Administration Record and the Treatment Administration Record for July 2025, revealed no administrations of oxygen therapy. Review of the Progress Note on 7/11/2025, revealed .Res [Resident] on 02 @ 3L BNC. Review of the Progress Note on 7/19/2025, revealed .02 sats 95% 0n 02 @3 liters. Review of the Progress Note on 7/22/2025, revealed .Remains noncompliant with continuous O2 removes it frequently, will let staff assist in reapplying. Observations in the Resident's room on 7/28/2025 at 12:27 PM and 3:30 PM, revealed Resident #27 with oxygen at 2 l/min BNC. During an interview on 7/29/2025 at 2:30 PM, LPN B confirmed there was not a physician order for oxygen for Resident #27. During an interview on 7/30/2025 at 10:00 AM, the Director of Nursing confirmed that Resident #27 should have an order prior to receiving oxygen.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 5 nurses (Licensed Practical Nurse (LPN) A) failed to disinfect reusable resident equipment for 1 of 5 (Resident #61) residents observed during medication administration. The findings include: 1. Review of the facility's undated policy titled, Cleaning and Disinfection of Resident- Care Equipment, revealed Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection. Cleaning is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process of eliminating microorganisms, except spores, from inanimate objects, usually by chemical means.Direct care staff who use the semi-critical items will be educated on the system for verifying clean/disinfected equipment and proper handling of used/dirty equipment. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment.Multiple-resident use equipment shall be cleaned and disinfected after each use.Use only EPA [Environmental Protection Agency]-registered disinfectants with kill claims for the common organisms found in the facility. 2. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, and Anxiety. Review of the Medication Administration Record (MAR) dated July 2025, revealed .Inhaler [inhaled medication used for asthma and COPD] 160-4.5 MCG/ACT [Microgram/per actuation] (Budesonide-Formoterol Fumarate Dihydrate) [an inhaled medication for breathing] use 1 puff inhale orally two times a day for COPD. Review of the Medication Administration Record (MAR) dated July 2025, revealed Verapamil.[Medication used to treat high blood pressure] ER [Extended Release] .240 MG [Milligrams] Give 1 tablet by mouth one time a day for HTN [hypertension]. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #61 had a Brief Interview for Mental Health (BIMS) score of 15, which indicated the Resident was cognitively intact. Observation in Resident #61's room on 7/30/2025 at 8:55 AM, revealed after LPN A used the blood pressure machine to obtain Resident #61's vital signs and used a stethoscope to listen to the Resident's lung fields. LPN A took the dirty blood pressure machine into the hallway and left it. LPN A failed to disinfect the stethoscope or the blood pressure machine before or after use. LPN A administered the inhaler for Resident #61 then returned the inhaler to the medication cart and stated, I need to clean off the mouthpiece of the inhaler. LPN A took a clean piece of wax paper from the cart and used that to wipe off the mouthpiece of the inhaler. During an interview on 7/30/2025 at 12:45 PM, the Assistant Director of Nursing (ADON) confirmed the process for the nurses after using resident reusable equipment such as blood pressure cuff, inhaler, eyedrops .The ADON stated, They should wipe them down after use, with purple top sani cloth wipes [disposable disinfectant wipe] and should be able to tell you the kill time [time required for the disinfectant to kill the organism].

Based on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when 1 of 6 nurses (Licensed Practical Nurse (LPN) #1) failed provide a substantial snack or meal within 15 minutes of insulin administration for Resident #60. The failure to provide a substantial snack or meal within 15 minutes of insulin administration resulted in a significant medication error. The findings included: The GERIATRIC MEDICATION HANDBOOK, 13TH edition, provided by the American Society of Consultant Pharmacists, page 41 and 43, revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Insulin [MEDICATION(S)] .Rapid-Acting Insulin Analog .Onset .15 min [minutes] .ADMINISTRATION/COMMENTS . 15 minutes prior to meals .NovoLog .Insulin [MEDICATION(S)] .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes before meals . Review of the medical record, revealed Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .inject as per sliding scale .if .301- 350 = [equal] 6 units .subcutaneously before meals for DM [Diabetes] . Observation in the resident's room on 8/3/2021 at 11:36 AM, revealed LPN #1 administered 6 units of Novolog to Resident #60 for a blood glucose level of 330. No meal or substantial snack was offered until LPN #1 delivered a meal tray to Resident #60 at 12:00 PM, 24 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolog resulted in a significant medication error. During an interview on 8/4/2021 at 10:52 AM, the Director of Nursing (DON) stated, .we do not have a policy on rapid onset insulin administration .we follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON would not confirm that the residents should receive a meals or snack within 15 minutes of a Rapid onset insulin.

Based on observation and interview, the facility failed to ensure opened medications were properly labeled and dated, external and internal medications were not stored together, and medications were not stored past their expiration date in 4 of 11 medication storage areas (100/200 Hall Medication Cart, 200/500 Hall Medication Cart, 400 Hall Medication Cart, and 400 Hall Treatment Cart). The findings include: Observation of the 400 Hall Medication Cart on 8/2/2021 at 12:01 PM, revealed the following: a. 2 open undated [MEDICATION(S)] vials b. 1 open Ultratuss bottle (a medication taken by mouth) in the same drawer as Theraworx Relief cream (a topical medication) Observation of the 200/500 Hall Medication Cart on 8/2/2021 at 4:53 PM, revealed the following: a. 1 open undated [MEDICATION(S)] Insulin b. 1 open undated [MEDICATION(S)] N Insulin vial During an interview on 8/2/2021 at 4:53, Licensed Practical Nurse (LPN) #3 confirmed when insulins are opened, the staff should record open dates on the insulin. Observation of the 100/200 Hall Medication Cart on 8/3/2021 at 4:11 PM, revealed the following: a. 1 open undated [MEDICATION(S)] inhaler b. 1 open undated [MEDICATION(S)] inhaler During an interview on 8/3/2021 at 4:11 PM, LPN #5 confirmed when inhalers are opened, the staff should record open dates on the medications. Observation of the 400 Hall Treatment Cart on 8/4/2021 at 2:01 PM, revealed the following: a. 1 hemorrhoid cream with an expiration date of 12/2020 b. 1 bucket of Micro-Kill One germicidal alcohol wipes with an expiration date 6/2021 During an interview on 8/4/2021 at 2:01 PM, LPN #6 confirmed that expired medications should not be on the cart. During an interview on 8/4/2021 at 3:10 PM, the Director of Nursing (DON) confirmed that medications should have open dates and internal and external medications should not be stored together.

Based on policy review, observation, and interview, the facility failed to ensure food was distributed and served in a sanitary manner when 1 of 11 staff members (Certified Nursing Assistant (CNA) #2 ) did not perform hand hygiene between serving residents and after touching contaminated surfaces, and placed dirty meal trays in a clean meal cart with other residents' meal trays. The findings include: Review of the facility's undated policy titled, Hand-hygiene technique, revealed .if hands are not visibly soiled, use an alcohol-based hand rub for .after contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the resident; and/or after removing gloves . Review of the facility's Inservice Education form dated 6/10/2021, revealed .Hand hygiene before & [and] after EVERY res [resident] room during meal tray pass .Hand hygiene (soap and water or alcohol gel) must be performed before passing ice or serving meal trays and in between each tray . Observation of the facility's 500 Hall new admission isolation hall during dining, revealed the following: a. On 8/2/2021 at 12:17 PM, CNA #2 entered Resident #74's room with a meal tray, set the tray down on the bedside table, removed the Styrofoam tray and containers from the plastic tray, picked up a dirty cup from the bedside table and placed the cup in the refrigerator, then removed the plastic tray from the room and placed it in the clean meal cart with other residents' trays. CNA #2 did not perform hand hygiene. CNA #2 then returned to the resident's room, put on gloves and assisted Resident #74 with tray set up, removed the gloves, and exited the room without performing hand hygiene. b. On 8/2/2021 at 12:23 PM, CNA #2 removed a meal tray from the cart and delivered it to Resident #330's room, set the tray down on the bedside table, removed the Styrofoam contents from the tray, then removed the plastic tray from the room and placed it in the clean meal cart with other residents' trays. CNA #2 did not perform hand hygiene. c. On 8/2/2021 at 12:28 PM, CNA #2 delivered a meal tray to Resident #326's room, set the tray on the bedside table, removed the contents from the tray, then removed the plastic tray from the room and placed it in the clean meal cart with other residents' trays. CNA #2 did not perform hand hygiene. d. On 8/2/2021 at 12:35 PM, CNA #2 delivered a meal tray to Resident #327's room, set the tray down on the bedside table, removed the contents from the tray, then removed the plastic tray from the room and placed it in the clean meal cart with other residents' trays. CNA #2 did not perform hand hygiene. CNA #2 donned a glove on her right hand, removed butter from the meal cart, and delivered the butter to Resident #327, then removed the glove from her right hand, and exited the room without performing hand hygiene. e. On 8/2/2021 at 12:40 PM, CNA #2 delivered a meal tray to Resident #328's room, set the tray down on the bedside table, removed the contents from the tray, then removed the plastic tray from the room and placed it in the clean meal cart with other residents' trays. CNA #2 did not perform hand hygiene. CNA #2 reentered Resident #328's room, donned gloves and assisted the resident with meal set up, removed the gloves and exited the room without performing perform hand hygiene. During an interview on 8/4/2021 at 12:56 PM, the Director of Nursing (DON) confirmed that staff should perform hand hygiene before and after each resident at meal pass and dirty meal trays should not be placed in the meal tray cart with other residents' trays.

Based on policy review, observation, and interview, the facility failed to provide and maintain a sanitary and comfortable environment as evidenced by strong malodorous odors on 1 of 5 halls (200 Hall). The findings include: Review of the facility's undated policy titled, Housekeeping and Maintenance Department Responsibilities, revealed .It is important to maintain a clean, safe, and sanitary environment for our residents .Areas of the building will need to be cleaned at a moment's notice .If body fluids are found on floor, furniture .they will need to be cleaned immediately . Review of the facility's policy titled, Resident Rights, dated 12/2017, revealed .It is our belief that you as a resident have the right to expect certain standards of care and considerations while at our facility. You have the right to .Considerate and respectful care . Observation of 200 Hall on 8/2/2021 at 9:12 AM, 10:25 AM, 3:44 PM and 4:40 PM, revealed a strong malodorous odor present. Observation of 200 Hall on 8/3/2021 at 7:12 AM, 8:22 AM and 3:34 PM, revealed a strong malodorous odor present. Observation of 200 Hall on 8/4/2021 at 8:11 AM and 9:45 AM, revealed a strong malodorous odor present. The malodorous odor permeated the 200 Hall into many of the resident rooms. During an interview on 8/3/2021 at 8:30 AM, Certified Nursing Assistant (CNA) #1 was asked what the smell was on 200 Hall. CNA #1 stated, smells like urine .smells this way about every day . During an interview on 8/4/2021 at 3:50 PM, the Director of Nursing (DON) confirmed the facility's 200 Hall should not smell like urine.

Based on observation and interview, the facility failed to provide privacy during 1 of 1 meeting with active Resident Council members. The findings include: Observations in the Sunroom on 10/15/19 at 10:00 AM, revealed the Resident Council Meeting location was not completely private. A bi-fold screen was used to block the entrance from hall 500 to the Sunroom but was accessible to anyone on the 500 Hall. During the meeting there were three interruptions: a. A resident on the 500 Hall folded the bi-fold screen, wheeled through the Sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. b. A Certified Nursing Assistant (CNA) from the 500 Hall folded the bi-fold screen, wheeled a resident through the sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. c. The Activity Director entered the room during the meeting and assisted one of the residents to leave the room. Interview with Activity Assistant #2 on 10/17/19 at 9:36 AM in the 400 Hall, Activity Assistant #2 stated, The Resident Council Meeting should never be interrupted.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by a dirty hand-washing sink in the Kitchen, dishwashing racks stored on the floor in the Kitchen, opened, unlabeled and undated foods stored in the Kitchen and in 1 of 3 (,[DATE] Hall Nourishment Room) nourishment rooms, wet towel on the floor in the Kitchen, a dirty steam table in the Kitchen, raw chicken and frozen foods left sitting at room temperature in the Kitchen, and foods on the floor in the Kitchen. The facility had a census of 98 residents, with 91 of those residents receiving a meal tray from the kitchen. The findings include: 1. The facility's FOOD STORAGE policy with a revision date of [DATE], documented, .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded .Use use-by-dates on all food stored in refrigerators .Remember to cover, label and date .Chicken should be stored on ice to maintain an optimal temperature .Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture .milk .should be stored .in refrigeration at 41 (degrees) F (Fahrenheit) or less .All foods should be stored .off the floor .Internal thermometers are to be in the warmest area of the refrigerator or freezer .Record temperatures from the internal thermometers .Employee food and resident food should not be stored together . 2. Observations in the Kitchen on [DATE] beginning at 8:45 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. Two dish racks on the floor in the dishware washer area. The Dietary Manager (DM) confirmed they were on the floor, and picked them up. c. A milk cooler filled with milk and no thermometer inside. The DM confirmed there were no thermometers in the milk cooler. The DM stated, Milk delivery was today .thermometers may have been taken out in the empty crates . d. Milk cooler with undated, unlabeled plastic container with orange-peach colored substance. The DM stated, It looks like a pureed dessert. e. A thawing single serve container of ice cream. The DM removed the ice cream. f. A wet towel on the floor beside the ice machine. The DM removed the wet towel from the floor and stated, We have been having problems with it .waiting on a part for it. g. A portable steam table empty with stained sides and all wells with crusty black dirty substance in the bottom of the wells. The DM stated, .Thermostat went out on the steam table .using this mobile one until the part for the other one comes in .supposed to be here the 25th ([DATE]) . h. Two large shallow baking pans containing uncovered raw chicken breasts. No dietary staff member was working with the foods. The DM stated, .preparing for lunch today . i. A reach-in cooler with 5 uncovered/unlabeled containers of mandarin oranges and 2 uncovered/unlabeled containers of blueberry crumble dessert. The DM stated, It looks like blueberry crumble leftover from Saturday ([DATE]). j. A reach-in cooler with 2 containers of parfait from the local grocery store dated ,[DATE]. The DM removed the parfaits. k. The main milk cooler full of milk with no thermometer. 3. Observations in the Kitchen on [DATE] at 9:56 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. A reach-in cooler with an opened bag containing 3 lettuce heads, with lettuce spilling out of the bag The DM removed the bag of lettuce. c. Twelve bags of frozen hushpuppies and 1 bag of frozen french fries beside the 3-compartment sink. No dietary staff member was working with the foods. The DM stated, They are making corn nuggets from those. d. An empty portable steam table with stained sides and all wells with crusty black dirty substance in the bottom of the wells. 4. Observations in the ,[DATE] Hall Nourishment Room on [DATE] at 5:35 PM, revealed the following: a. An unlabeled and undated large Styrofoam cup with a straw in it from a local restaurant half-filled with liquid in the resident refrigerator. The Regional Registered Nurse stated, I'm just going to toss it . b. A sandwich wrapped in a local restaurant paper wrapper on top of the microwave. The Regional Registered Nurse threw it in the trash. c. An uncovered/unlabeled/undated cup half full of ice and clear liquid and an unlabeled half-full bottle of water on the counter beside the microwave. The Regional Registered Nurse threw it in the trash. 5. Observations in the Kitchen on [DATE] at 12:00 PM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. A case of crushed pineapple and a case of brown sugar on the floor. The Registered Dietician stated, .We just got a shipment. 6. During the Resident Council Group meeting, which consisted of 12 alert and oriented residents, the Resident Council Group expressed concerns the ice cream was not served cold. 7. Interview with the DM on [DATE] at 8:20 AM, in the Conference Room, the DM was asked how foods should be stored in the refrigerator. The DM stated, Produce needs to be stored in refrigerator usually in the box or we unpack them into or a plastic box with a lid, covered, and dated when they come in .Produce is good for 1 week .leftovers, we cool it down and store it for 3 days in the cooler in plastic bins with lids, labels, and dates. The DM was asked if any foods should be stored uncovered, unlabeled, or undated. The DM stated, No. Everything should be labeled. The DM was asked if foods should be stored in boxes on the floor. The DM stated, No .He brings it in on a dolly .until we get it unpacked and put away, it is going to be on the floor. The DM was asked if the nourishment room refrigerators were managed by the kitchen staff. The DM confirmed they did, and confirmed anything that does not belong to the residents, and anything that was not labeled and dated was not acceptable. The DM was asked how often the steam table and the hand-washing sink were cleaned or wiped down. The DM stated, As often as possible between tasks. The DM confirmed there was no set schedule for cleaning the hand-washing sink or the steam table. The DM was asked if there should always be thermometers in the refrigerators and freezers. The DM stated, Yes. The DM was asked about the 2 pans of raw chicken on the stove top. The DM stated, It was marinating in herbs .She had just filled one of the sheet pans . The DM was asked if it should have been covered. The DM stated, I would say yes.

Based on policy review, medical record review, observation, and interview, 1 of 2 nurses (Licensed Practical Nurse (LPN) # 4) failed to follow facility policy for administration of medications through a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach for nutrition and medication) when medications were pushed through the enteral tube and not allowed to flow per gravity. The findings included: The facilities Administering Medications through an Enteral Tube policy revised (MONTH) (YEAR) documented, .Administer medication by gravity flow . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Thera liquid give 10 ml (milliliter) .peg .once a day .[MEDICATION NAME] formula capsule .once daily . The physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg tablet per peg . The physician's orders [REDACTED].[MEDICATION NAME] 125 mg (milligram)/5 ml susp (suspension) give 7 ml .PEG 2 TIMES DAILY @ (at) 6 AM & (and) 6 pm . Observations in Resident #35's room on 10/15/19 at 5:09 PM, revealed LPN #4 poured 60 ml of water into Resident #35's PEG and pushed the water through the tube with the plunger. LPN #4 then administered the medications with water and pushed each medication through the tube with the plunger. LPN #4 poured 60 mL of water into the PEG tube and pushed the water through the tube with the plunger. LPN #4 did not allow the medications to flow by gravity, in accordance with the facility's policy. Interview with the Director of Nursing (DON) on 10/17/19 at 7:15 PM, in the Conference Room, the DON was asked should medications be pushed through a PEG tube. The DON stated, .no .should be by gravity .

Based on policy review, observation, and interview, the facility failed to ensure the survey results were readily accessible for all residents residing in the facility. The facility had a census of 98 residents. The findings include: 1. The facility's undated Resident Rights policy documented, .results of the most recent survey of the Center conducted by Federal or State surveyors and any plan of correction in effect to the Center. The Center must make the results available for examination in a place readily accessible to residents . 2. Observations in the Lobby on 10/14/19 at 9:05 AM and 10/15/19 at 11:42 AM, revealed a white binder labeled .Survey Results The results from surveys on 6/10/19, 7/2/19, and 8/30/19 were not available for the residents to review. Interview with the Administrator on 10/16/19 at 4:46 PM, in the Lobby, the Administrator was asked if the survey results were in the survey book from the surveys conducted (June, July, and Sept of 2019). The Administrator stated, .no they are not in there . The Administrator was asked if the survey results should be in the book available for residents to review. The Administrator stated, .yes .

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 23 (Certified Nursing Assistant (CNA) #1, #4, #6, #7, and #9) facility staff members referred to clothing protectors as bibs, did not use courtesy titles to address residents, used a personal cell phone while assisting a resident with a meal, stood over a resident to assist with a meal, and failed to knock before entering a resident's room. The findings included: 1. The facility's Assisting with Meals policy documented, .Residents shall receive assistance with meals in a manner that meets the individual needs .not standing over residents while assisting them with meals .avoiding the use of labels .bibs . The facility's Quality of Life-Dignity policy revised (MONTH) 2009 documented, .shall be treated with dignity and respect at all times .staff shall knock and request permission before entering residents' room .Staff shall speak respectfully to residents at all times .addressing the resident by his or her name of choice and not 'labeling' .demeaning practices and standards of care that compromise dignity are prohibited .promote dignity . 2. Observations in the 400 Hall Dining Room on 10/14/19 at 12:10 PM, revealed CNA #7 stated to Resident #57, .the bib is cold, isn't it . Observations in the 400 Hall Dining Room on 10/14/19 at 12:17 PM, revealed CNA #6 stated to Resident #57, .that's your food, baby . Observations in Resident #63's room on 10/15/19 at 5:15 PM, revealed CNA #4 looked at her cell phone while she assisted Resident #63 with her meal. Observations in the 200 Hall on 10/15/19 at 5:40 PM, revealed CNA #1 entered Resident #16's room to deliver his meal tray without knocking. Observations in the 200 Hall on 10/15/19 at 5:44 PM, revealed CNA #1 entered Resident #64's room to deliver his meal tray without knocking. CNA #1 then left the room, returned at 5:50 PM, and entered again without knocking. Observations in Resident #243's room on 10/16/19 at 12:40 PM, revealed CNA #9 stood to assist Resident #243 with her meal. Interview with Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked should staff stand to assist a resident with a meal. The DON stated .no . The DON was asked should clothing protectors be referred to as bibs. The DON stated, .I wouldn't think so . Interview with the Director of Nursing (DON) on 10/17/19 at 3:45 PM, in the Conference Room, the DON was asked if he expected staff to knock before entering residents' rooms. The DON stated, Yes.

Based on medical record review, review of the facility staffing schedules and interview, it was determined the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had a census of 98 residents. The findings include: 1. Review of the quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #31 on 10/14/19 at 3:07 PM, in Resident #31's room, Resident #31 was asked about staffing at the facility. Resident #31 stated, Not at night time especially. They say it's just 1 or 2 (staff members) at night. Resident #31 was asked if he had to wait a long time for someone to help him if he called for help. Resident #31 stated, .takes an hour or 2 and sometimes 3 or 4, takes a long time . Even sometimes in the daytime they don't come as quick as they should. 2. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #29 on 10/14/19 at 3:58 PM, in Resident #29's room, Resident #29 was asked about staffing at the facility. Resident #29 stated, Sometimes at night it's pretty bad, especially at bedtime .have to wait at least 30 minutes before they can go to bed .sometimes at night it's way more than 30 minutes . 3. Review of the admission MDS dated [DATE] revealed Resident #143 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #143 on 10/15/19 at 8:09 AM, in Resident #143's room, Resident #143 was asked about staffing at the facility. Resident #143 stated, A lot of times at night we only have 1 aide for 30-something patients .they (call lights) might go off 30 minutes to an hour before they're answered. 4. During the Resident Council Group meeting, which consisted of 12 alert and oriented residents, the Resident Council Group expressed staffing concerns, which included not enough help at night or on weekends, and 1 staff member works with 30 beds/residents. 5. Review of the Certified Nursing Aide (CNA) schedule revealed there were 3 CNAs scheduled for the night shift (6:45 PM - 7:00 AM) on Sunday 10/13/19. The facility had a census of 99 residents as of midnight 10/14/19. Review of the CNA schedule revealed there was 1 CNA scheduled for 6:45 PM - 11:00 PM, and 3 CNAs scheduled for 6:45 PM - 7:00 AM for the night shift on Monday, 10/14/19. The facility had a census of 99 residents. Review of the CNA schedule revealed there were 4 CNAs scheduled for 6:45 PM - 7:00 AM for the night shift on Tuesday, 10/16/19. The facility had a census of 96. 6. Interview with CNA #2 on 10/15/19 at 8:55 PM, in the Sunroom, CNA #2 was asked if she felt the facility had enough staff for her to get all of her assignments completed. CNA #2 stated, .not enough time to complete everything .way too many residents to care for . CNA #2 was asked how many residents she was assigned tonight. CNA #2 stated, Twenty-five .responsible for 32 at most . Interview with CNA #5 on 10/15/19 at 8:18 PM, in the Secured Unit Lobby, CNA #5 was asked if she felt there was enough staff. CNA #5 stated, No. CNA #5 was asked how many residents she was assigned. CNA #5 stated, .last night .I had 27 on my own .I need to spend more time with the residents . Interview with Licensed Practical Nurse (LPN) #4 on 10/16/19 at 10:55 AM, in the 100 Hall, LPN #4 was asked if she was off after today. LPN #4 stated, No I have to work 12 hour shifts until Saturday (10/19/19) .a nurse walked out .

Based on review of the PHYSICIANS' DESK REFERENCE 69th EDITION, medical record review, observation, and interview, the facility failed to ensure medications administered were appropriately monitored for adverse effects for 1 of 6 (Resident #16) sampled residents reviewed for unnecessary medications. The findings include: 1. The PHYSICIANS' DESK REFERENCE 69th EDITION (YEAR) documented, .[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication) .INDICATIONS AND USAGE .[MEDICAL CONDITION] .Pituitary TSH ([MEDICAL CONDITION] Stimulating Hormone) Suppression .PRECAUTIONS .has a narrow therapeutic index .Regardless of the indication for use, careful dosage titration is necessary to avoid the consequence of over- or under-treatment .These consequences include .effects on .cardiovascular function, bone metabolism .cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism .The adequacy of therapy is determined by periodic assessment of appropriate labortory tests .frequency of TSH monitoring during [MEDICATION NAME] dose titration .is generally recommended at 6-8 week intervals until normalization .When the optimum replacement dose has been attained .It is recommended .a serum TSH measurement be performed at least annually . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Unspecified Sequelae of Other [MEDICAL CONDITION] Disease. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 had severe cognitive impairment and required supervision for all activities of daily living. A hospital discharge summary report dated 3/21/18 documented, .TSH ([MEDICAL CONDITION] Stimulating Hormone) .2/28/2018 .Result .6.44 .H (High) .Reference Range .0.45 - 5.0 .ulU/ml (micro-international units per milliliter) . The physician's orders [REDACTED].Start Date .6/30/18 .[MEDICATION NAME] 0.025 MG (milligrams) TABLET by mouth @ (at) 6am (6:00 AM) daily . The facility was unable to provide documentation that any laboratory testing for [MEDICAL CONDITION] function had been done since the abnormal result was obtained 2/28/18. Observations in Resident #16's room on 10/15/19 at 5:06 PM and 8:45 PM, 10/16/19 at 10:25 AM and 12:11 PM, and on 10/17/19 at 2:32 PM and 6:39 PM, revealed Resident #16 lying in bed with his eyes closed. Interview with the Director of Nursing (DON) on 10/17/19 at 9:01 PM, in the Conference Room, the DON was asked if TSH levels should be monitored for residents taking [MEDICATION NAME]. The DON confirmed these levels should be monitored.

Based on policy review, review of the JoVE Science Education Database Nursing Skills. Preparing and Administering Intramuscular Injections, medical record review, observation, and interview, the facility failed to ensure 2 of 8 (Licensed Practical Nurse (LPN) #2 and #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings included: 1. The JoVE Science Education Database. Nursing Skills Preparing and Administering Intramuscular Injections documented, .The deltoid site (upper arm) .immunizations .maximum volume should never exceed 2 mL (milliliters) . The facilty's Administering Medications policy revised (MONTH) 2019 documented, .Medications are administered in a safe and timely manner, and as prescribed .The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions .Medications are administered in accordance with prescriber orders . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 120 mg (milligram) IM (intramuscular) q (every) 12 hrs (hours) x (for) 14 days . Observations in Resident #18's room on 10/16/19 at 9:15 AM, revealed LPN #2 injected 3 ml of [MEDICATION NAME] into Resident #18's left upper arm (deltoid site). Interview with the Director of Nursing (DON) on 10/17/19 at 8:23 PM, in the Conference Room, the DON was asked is it acceptable to give 3 ml of medication Intramuscular (IM) in the upper arm. The DON stated, .no . Failure of LPN #2 to administer an IM injection of [MEDICATION NAME] of less than 2 ml into the deltoid site resulted in medication error #1. 3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .152-200=3 units . Observations in Resident #34's room on 10/16/19 at 4:08 PM, revealed LPN #3 performed a blood glucose level check with a result of 153. Interview with LPN #3 on 10/16/19 at 4:10 PM, at the 400 Hall Nurses' Station, LPN # 3 stated, .doesn't get any insulin . Interview with the DON on 10/16/19 at 8:23 PM, in the Conference Room, the DON was asked how much insulin should Resident #34 receive for a blood glucose of 153. The DON stated, .3 units . The DON confirmed insulin should be administered as ordered. Interview with the Medical Director on 10/17/19 at 3:52 PM, in the Conference Room, the Medical Director was asked if he expected his medication orders to be followed. The Medical Director stated, .Yes ma'am, I expect all my orders to get carried out, they're not just suggestions . Failure of LPN #3 to administer insulin as prescribed resulted in medication error #2.

Based on review of the (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information, policy review, medical record review, and interview, the facility failed to ensure medications were administered free from significant medication errors for 1 of 24 (Resident #70) sampled residents. The findings include: 1. The (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information documented, .Take [MEDICATION NAME] once a day . 2. The facility's Medication and Treatment Orders policy with a revision date of 7/2016, documented, .Orders for medications must include .Dosage and frequency of administration .Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders . 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 2/25/19 documented, .insulin dependent diabetic .at risk for hypo/[MEDICAL CONDITION] and complications of the disease .Intervention .Medications .as directed per MD (Medical Doctor) .orders . The Physician admission orders [REDACTED].[MEDICATION NAME]-5mg (milligrams)-take 1 tab (tablet) po (by mouth) before meals . The Telephone physician's orders [REDACTED].Order Clarification .[MEDICATION NAME] 5mg po (by mouth) QD (every day) . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 Monthly Consultant Pharmacist Report documented, .Please note the following medication(s) are dosed above the usual geriatric dosage .[MEDICATION NAME] 5mg tid (three times daily) .Recommendation .[MEDICATION NAME] 5mg daily . Telephone interview with the Pharmacist on 10/17/19 at 8:52 AM, the Pharmacist was asked if there had been a problem with Resident #70's diabetic medication, [MEDICATION NAME]. The Pharmacist stated, Yes .There's no way they are supposed to be given three times a day .it was supposed to be given once a day. It was some kind of mistake .She actually went without her meds a few days .It was 9/14 (9/14/19) by the time we got it straightened out . The Pharmacist confirmed Resident #70 ran out of [MEDICATION NAME] before it could be refilled again because it was administered three times daily instead of once daily. Interview with Licensed Practical Nurse (LPN) #5 on 10/17/19 at 9:33 AM, at the Hall 5 Nurses' Desk, LPN #5 was asked if there had been a problem with Resident #70 getting her [MEDICATION NAME] refilled. LPN #5 stated, Yes .it was scheduled for three times a day .insurance would only pay for one time a day. It was ordered .with meals, so the order was put in for 3 times a day. When she ran out, the insurance wouldn't pay for it to be refilled. LPN #5 was asked if it should have been ordered for only once a day instead of 3. LPN #5 stated, Yes. LPN #5 was asked if there was any documentation of the medication order error. LPN #5 provided a physician's telephone order dated 9/27/19 that documented, .Order Clarification .[MEDICATION NAME] 5mg po QD . Interview with the Director of Nursing (DON) on 10/17/19 at 1:00 PM, in the Conference Room, the DON was asked the facility's process for transcribing orders. The DON stated, We just take the hospital orders they sent to us and write them on a physician's orders [REDACTED]. The DON stated, We would clarify the order. The DON confirmed physician medication orders should include how many times a day the medication was to be administered.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 9 (500 Lower Hall Medication Cart) medication storage areas was unlocked and unattended. The findings included: The facility's Storage of Medications policy revised (MONTH) 2019 documented .drugs and biologicals .are stored in locked compartments .unlocked medication carts are not left unattended . Observations in the 500 Hall on 10/15/19 at 8:16 PM, the 500 Lower Hall Medication Cart was left unlocked and unattended. Interview with the Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked if medication carts are to be left unlocked. The DON stated, .no .

Based on the Resident Assessment Instrument (RAI) Manual, policy review, medical record review, observation, and interview, the facility failed to ensure accurate documentation related to pressure ulcers for 1 of 4 (Resident #31) sampled residents reviewed for pressure ulcers and medication administration related to insulin and intravenous (IV) antibiotics for 2 of 6 (Resident #59 and #61) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the RAI Manual, (YEAR) Minimum Data Set (MDS) 3.0 Updates, revealed that when a resident who is admitted to the nursing home without a pressure ulcer develops a pressure ulcer in the nursing home, is admitted to the hospital for acute condition changes and then readmitted to the nursing home with the same pressure ulcer, that pressure ulcer is not considered present on admission but is a facility acquired pressure ulcer. Medical record review revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A weekly Wound Assessment Report dated 3/27/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date Wound Identified .8/29/2017 .Present upon admission .No .Stage 4 . A weekly Wound Assessment Report dated 4/2/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date wound identified .4/2/19 .Present upon admission .Yes .Assessment Occasion .Re-assessment .Resident out of the facility From Date .3/28/2019 .Thru Date .4/2/2019 . All weekly Wound Assessment Reports from 4/2/19 through 10/15/19 documented, .Date wound identified .4/2/2019 .Present upon admission .Yes . Observations in Resident #31's room on 10/16/19 at 10:08 AM, revealed wound care was performed on Resident #31's Stage 4 coccyx pressure ulcer. Interview with Licensed Practical Nurse (LPN) #1 on 10/16/19 at 3:10 PM, in the 400 Hall Dining Area, LPN #1 was asked if Resident #31 had a stage 4 coccyx pressure ulcer when he went out to the hospital on [DATE]. LPN #1 stated, He had it when he went out .was a Stage 4 .it is the same wound .it's the only wound he's had on his bottom . Interview with the Regional Director of Clinical Services on 10/16/19 at 6:02 PM, in the Front Lobby, the Regional Director of Clinical Services was asked should Resident #31's weekly wound assessment document that his pressure ulcer was present on admission when it was a facility acquired pressure ulcer. The Regional Director of Clinical Services stated, .Coming back from the hospital, if it was a facility acquired wound, the record should always reflect that it is a facility acquired wound . 2. Review of the facility's Administering Medications policy revised (MONTH) 2019 documented .medications are administered in accordance with prescriber orders, including any required time frame . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#59 had scheduled accuchecks before meals and at bedtime with the following Humalog Sliding Scale Insulin: HUMALOG 100 UNIT/(per) ML (milliliters) .SLIDING SCALE .0-199=0U (units); 200-250=2U; 251-300=4U; 301-350=6U; 351-400=8U; 401 >=10U AND RECHECK IN 30 MINUTES . Review of the Medication Administration Record [REDACTED] a. 8/19/19 at 6:30 AM the blood glucose was 110 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. b. 8/19/19 at 5:30 PM the blood glucose was 127 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. c. 8/22/19 at 6:30 AM the blood glucose was 119 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. d. 8/27/19 at 6:30 AM the blood glucose was 113 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. e. 9/1/19 at 6:30 AM the blood glucose was 114 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. f. 9/5/19 at 6:30 AM the blood glucose was 118 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. g. 9/14/19 at 6:30 AM the blood glucose was 142 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. Review of the (MONTH) 2019 Medication Regimen Review by the Pharmacist for Resident #59 revealed the resident .appears to have been given a dose of SSI (sliding scale insulin) (1 unit) at 6:30 on (MONTH) 1st, 5th, and 14th. Blood sugars were 114, 118, and 142, respectively. Per the active order, the use of SSI starts at a blood sugar of 200 (2 units). Erroneous administration of SSI could lead to severe [DIAGNOSES REDACTED]. Please ensure that the nurses double check sliding scale instructions prior to administration . Interview with LPN #5 on 10/17/19 at 9:20 AM, in the 500 Hall, LPN #5 confirmed Resident #59's blood glucose level was never high enough to receive insulin. LPN #5 reviewed Resident #59's blood glucose record for (MONTH) and (MONTH) 2019 and confirmed Resident #59 did receive insulin three times each month. She also confirmed Resident #59 should never have received insulin for the blood glucose level documented. Interview with the Director of Nursing (DON) on 10/17/19 at 2:25 PM, in the Conference Room, the DON confirmed no insulin should have been administered with the blood glucose levels documented. Interview with the Medical Director on 10/17/19 at 3:44 PM, in the Conference Room, the Medical Director stated, I do not understand why this happened according to the sliding scale orders. Interview with the DON on 10/17/19 at 5:25 PM, in the Conference Room, the DON stated that both nurses responsible for the inaccurate documentation were new graduate nurses and it was a computer medication education issue. 3. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician's admission orders [REDACTED].[MEDICATION NAME] .80mg (milligrams) / (per) 2ml (milliliters) .420mg/NS (Normal Saline) .100ml .220ml/HR (hour) .q (every) 24 (hours) .D/C (discontinue) 10-19-19 . The (MONTH) 2019 Medication Administration Record [REDACTED]. [MEDICATION NAME] .was not administered .Resident not available . The NURSE notes dated 10/14/19 documented, .IV (Intravenous) antibiotics given at 1015 (10:15 AM) . Observations in Resident #61's room on 10/14/19 at 10:56 AM, revealed Resident #61 sitting in a wheelchair at bedside. [MEDICATION NAME] was infusing IV per pump at 220 ml/hr. Interview with the DON on 10/17/19 at 5:26 PM, in the Conference Room, the DON was asked about the documentation on the MAR indicated [REDACTED]. The DON stated, I think the problem with the documentation might be the LPNs are signing it off, and the RNs (Registered Nurses) are actually the ones giving it .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when isolation precautions were not followed for 1 of 2 (Resident #49) sampled residents reviewed and facility staff failed to protect resident's personal clothing from environmental contamination. The findings include: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) (YEAR) revealed .when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC (The Centers for Disease Control) (CDC) precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Pt (patient) to be in contact isolation r/t (related to)[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in wound . Observations in the 500 Hall on 10/14/19 at 8:30 AM, revealed no isolation signs on Resident #49's door. Resident #49 had a roommate who was not in isolation. Observations in the 500 Hall on 10/14/19 at 9:00 AM, revealed Licensed Practical Nurse (LPN) #7 donned gloves to enter Resident #49's room. LPN #7 confirmed that she wore gloves only because his wounds were contained and he was not contagious. Observations on 10/15/19 in the 500 hall revealed the following: a. Certified Nursing Assistant (CNA) #3 entered Resident #49's room at 8:00 AM to deliver the breakfast tray. CNA #3 did not wear gloves or any Personal Protective Equipment (PPE) when she entered the room. b. CNA #4 entered Resident #49's room at 5:45 PM to deliver the supper tray. CNA #4 did not wear gloves or any PPE when she entered the room. Interview with CNA #3 and CNA #4 on 10/15/19 at 6:30 PM, in the 500 Hall, CNA #3 and CNA #4 stated the wounds were contained and PPE was not required. Interview with LPN #1 on 10/17/19 at 9:30 AM, LPN #1 confirmed staff should don gowns, gloves, and foot covers before entering Resident #49's room. LPN #1 was asked should Resident #49 and Resident #62 share a room. LPN #1 stated it was safe for Resident #49 and #62 to be in the same room because Resident #49 had a [MEDICAL CONDITION] and a suprapubic catheter and they did not share a bathroom. LPN #1 confirmed that Resident #49's [MEDICAL CONDITION] and catheter bags were emptied into the commode that Resident #62 used. 2. Review of the facility's Laundry and Linen policy revised (MONTH) 2014 documented, .The purpose of this procedure is to provide a process for the safe and aseptic handling .of linen .clean linen will remain hygienically clean (free of pathogens (germs)) . Interview with Laundry Assistant #1 on 10/17/19 at 9:00 AM, in the 500 Hall, Laundry Assistant #1 revealed three of four dryers were not working on Tuesday 10/15/19 so wet laundry was taken to the community laundromat to dry the resident clothes. Laundry Assistant #1 confirmed she did not disinfect the dryers prior to placing the resident's personal clothing in the dryers.

Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for wound care treatments for 1 of 4 (Resident #70) sampled residents reviewed for wound care. The findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #70 required staff assistance for all activities of daily living, and had Moisture Associated Skin Damage (MASD). The care plan dated 2/25/19 documented, .at risk for skin breakdown r/t (related to) decreased mobility, incontinence .Intervention .Treatments as directed . The Physician's Orders dated 10/7/19 documented, .Start Date .10/03/19 .RLE (Right Lower Extremity) AND LLE (Left Lower Extremity) EXCORIATION .CLEAN C (with) NS (Normal Saline), APPLY SSD (Silver [MEDICATION NAME])/[MEDICATION NAME]/[MEDICATION NAME]/ZINC TRIPLE CREAM EQUAL MIXTURE TO AFFECTED AREAS DAILY ET (and) PRN (as needed) X (times) 14 DAYS, THEN RE-EVALUATE . The Wound Assessment Report dated 10/15/19 documented, .MASD .apt (appointment) (with) .wound clinic on 10/15/19 .N.O. (new order) Cont (Continue) to apply SSD/[MEDICATION NAME]/[MEDICATION NAME]/zinc combined triple cream equal parts to affected areas daily . Observations in Resident #70's room on 10/16/19 at 10:55 AM, revealed Licensed Practical Nurse (LPN) #1 performed wound care to raised reddened areas to Resident #70's bilateral posterior upper thighs. LPN #1 wiped the wound with Aloe disposable wipes, and then applied SSD 1 percent (%) cream to the area. Interview with LPN #1 on 10/17/19 at 6:51 PM, in the 500 Hall, LPN #1 confirmed she applied SSD 1% cream to Resident #70's MASD wounds. LPN #1 was asked if the treatment was administered as ordered. LPN #1 stated, .This is what they sent from (Named Pharmacy) . Interview with the Director of Nursing (DON) on 10/17/19 at 6:54 PM, in the 500 Hall, the DON was asked if the SSD 1% cream was the treatment that was ordered. The DON stated, No.

Based on policy review, closed medical record review, and interview the facility failed to ensure care plans were revised for 1 of 4 (Resident #1) sampled residents reviewed to include new interventions for wandering, exit seeking behaviors, and elopement after Resident #1 a cognitively impaired and vulnerable resident with vision impairment eloped from the Secure Unit. The facility's failure to update Resident #1's care plan with new interventions to address Resident #1's exit-seeking behavior resulted in Resident #1 leaving the facility and being found 0.7 miles away at a grocery store. This failure placed Resident #1 in Immediate Jeopardy. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-657 was cited at a scope and severity of J. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's undated Care Plans-Comprehensive policy documented, .individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .develops and maintains a comprehensive care plan for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed quarterly .care plan goals and objectives are defined .goals and objectives are reviewed and/or revised .significant change in the resident's condition .when the desired outcome has not been achieved .resident has been readmitted to the facility from a hospital/rehabilitation stay .nurse supervisor uses the care plan to complete the CNA's (Certified Nursing Assistant) daily work assignment sheets .CNA's are responsible for reporting to the nurse supervisor any changes in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved .changes in the resident's condition must be reported to the MDS (Minimum Data Set) Assessment Coordinator so that a review of the resident's assessment and care plan can be made .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans .when the resident has been readmitted to the facility from a hospital stay . 2. The facility's undated Care Planning-Interdisciplinary Team policy documented, .development of an individualized comprehensive care plan for each resident .Prior to attending the care planning conference, each discipline will be responsible for developing a problem identification list .any area of difficulty or concern that prevents the resident from reaching his/her fullest potential. Problems must be stated .short-term goals must be resident oriented, behaviorally stated, measurable. Approach-The specific action (s) or intervention (s) that the staff will take to assist the resident in meeting/achieving the short-term goals . 3. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Closed medical record review of the MDS dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status score of 7 which indicated Resident #1 was severely impaired cognitively. Closed medical record review of Resident #1's comprehensive care plan created on 3/12/19 documented, .3/12/19 .Has wandering tendencies and exit seeking behaviors at times d/t (due to) Dementia .Place resident in area where frequent observation is possible .Provide diversional activities .Redirect when wandering into other resident's rooms .Instruct visitors to inform staff when they are leaving the designated area with the resident .Implement facility protocol for locating an eloped resident .If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them . There were no new interventions implemented until 6/28/19. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at facility, anxiety, and noted instability. Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator's Office, the Administrator was asked had Resident #1 ever left the facility before. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked about when Resident #1 had exited the Secure Unit without awareness of the staff. LPN #1 stated, .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM). I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .I know I wrote a nurse's note about him leaving the unit but it's gone .I'll go talk to (Named Clinical Manager #1) she was the nurse that brought him to the unit .she will know the date . LPN #1 returned a few moments later and stated, .I asked (Named Clinical Manager #1), she said it was (MONTH) 20th (5/20/19) . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report .just a head to toe assessment to be sure he was ok .and a nurses note which is gone . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked about when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM - 7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station .I immediately escorted him back to the unit . Closed medical record review of the comprehensive care plan reviewed on 6/20/19 revealed there were no new interventions for the exit seeking behaviors that occurred on 5/20/19 when he was readmitted on [DATE]. Closed medical review of a Nurses' Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave and attempting to call on nurse station phone w/o (without) permission . Closed medical review of a Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . Interview with MDS Coordinator #1 on 7/12/19 at 4:55 PM, in the Conference Room, MDS Coordinator #1 was asked who updated and initiated the care plans. MDS Coordinator #1 stated, .sometimes I do care planning but (Named MDS Coordinator #2) does most of it . MDS Coordinator #1 was asked if she attended the morning meetings. MDS Coordinator #1 stated, .yes .we go over the 24 hour nurse report book, go over incidents and orders that are written . MDS Coordinator #1 was then asked if Resident #1 had ever left the Secure Unit or the building. MDS Coordinator #1 stated, .I have no knowledge of him leaving the unit or the building . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked about the care plan process and who was involved. MDS Coordinator #2 stated, .we cover incident reports in the daily clinical meeting and update the care plans .the DON, the Administrator, Risk Management, (Named Clinical Manager #1) .the meetings are not held on the weekend. If it happens on the weekend it will be discussed Monday . MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) (2019). MDS Coordinator #2 stated, .no .I don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were any interventions related to Resident #1 exiting the Secure Unit in (MONTH) (2019). MDS Coordinator #2 stated, .No . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put into place after this exit seeking behavior. The facility failed to ensure that the care plan was revised to include new interventions to prevent elopement for a cognitively impaired resident with known exit seeking behaviors and a history of elopement. Refer to F600 and F689 The surveyor verified the A[NAME] by: 1. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 2. Director of Nursing and/or Designee will educate all licensed and registered nurses on how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. Noncompliance of F-657 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on policy review, closed medical record review, and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 of 4 (Resident #1) cognitively impaired, vulnerable, visually impaired residents who had wandering/exit seeking behaviors resulting in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer wandering outside of a grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-689 was cited at a scope and severity of J. F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's Accident-Incident-Elopement-Wandering Resident undated policy documented, .every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .should a wandering/elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the resident's medical record and review by the interdisciplinary team .responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse . 2. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was admitted to the facility on [DATE]. Closed medical record review of the Care Plan dated 3/12/19 and revised 6/28/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. The interventions included if wandering away from unit, instruct staff to stay with the resident, converse and gently persuade to walk back to designated area, place resident in an area where frequent observation is possible, provide diversional activities as needed, implement facility protocol for locating an eloped resident, designate staff to account for residents whereabouts throughout the day, alert staff to wandering behaviors, and approach wandering resident in a positive, calm, and accepting manner. Closed medical record review of the quarterly Minimum data Set (MDS) with an assessment reference date (ARD) of 6/12/19 revealed Resident #1 was assessed to have a BIMS of 7, which indicated severe cognitive impairment. The resident was visually impaired, had hallucinations and other behavioral symptoms not directed toward others which occurred 1 to 3 days of the assessment period. Resident #1 had wandering behaviors which occurred 1 to 3 days of the assessment period, needed limited assistance with walking, and required no assistive devices. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at the facility, anxiety, and noted anxiety. The Psychiatric Evaluation dated 5/22/19 from this hospital stay documented, .Justification for hospitalization - Inpatient Failure or treatment at a lower level of care, hallucinations, delusions, agitation, anxiety, depression, resulting in a significant loss of functioning. Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care. Failure of social or occupational functioning, Inability to meet basic life and health needs . Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator Office, the Administrator was asked if Resident #1 ever left the facility prior to 6/28/19. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises . The Administrator was asked when this occurred and what interventions were implemented to address it. The Administrator stated, .about 3 months ago .I'll have to check .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked when Resident #1 exited the Secure Unit without awareness of the staff. LPN #1 stated, yes .I was the nurse the day he stepped out of the unit .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM) because I had went to the 300 hall to give medications. I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .was (MONTH) 20th . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report just a head to toe assessment to be sure he was ok . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM-7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station I immediately escorted him back to the unit . Review of Resident #1's medical record revealed there was no documentation of the incident on 5/20/19. There were no new interventions for the exit seeking behavior when the resident returned from the hospital on [DATE]. There was no investigation of the incident to determine how the resident left the Secured Unit. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was readmitted to the facility on [DATE] from the hospital. Closed medical record review revealed documentation that Resident #1 displayed impaired cognitive status and exit seeking behaviors: a. A Nurse's Note dated 6/6/19 at 6:48 PM documented, .repetitive confusion noted with place. Periods of anxiety . b. Review of an Admission/Readmission Note dated 6/6/19 revealed Resident #1 had Chronic Repetitive Disruptive Behavior that could potentially cause harm to himself or other, Chronic Wandering Behavior and Hallucinations. c. A Nurse's Note dated 6/9/19 at 7:28 PM documented, .resident pulled fire alarm in dining room . d. A Nurse's Note dated 6/10/19 at 4:13 PM documented, .continues to ask where his (he is) at and who comes to see him . e. Review of a Long Term Care Observation nurses' note dated 6/14/19 revealed Resident #1 was anxious, agitated, had chronic repetitive behavior, and wandering that included wandering at night and hallucinations. Resident #1's current level of mental status was documented as severe impairment that affected all areas of judgment. f. Review of a Long Term Care Observation nurses' note dated 6/21/19 revealed Resident #1 had chronic repetitive behavior, short term memory loss, and was currently disorientated and confused. g. A Nurse's Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission . h. A Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . i. A Nurse's Note dated 6/29/19 documented, .start of shift (7:00 AM 6/29/19), resident watched one on one . Based on the National Weather Service records, the recorded high temperature for the facility area on 6/28/19 (the day of the elopement from the facility) was 86 degrees Fahrenheit. The facility is located near an abandoned factory, a public park, and a community center with public parking. Closed medical record review revealed Resident #1 was transferred to the psychiatric hospital on [DATE], after this elopement episode. Closed medical record review of the (Named Hospital) ADMISSION NURSING assessment dated [DATE] documented, .Reason for admission .per facility pt. (patient) having danger issues and has been combative and tries to elope .Has the patient been violent to others in the past 6 months? (Yes checked) . Behaviors .Other (checked) exit seeking .Potential for elopement (checked) . The History and Physical from this hospital stay dated 6/30/19 documented, .anger, agitated threatens to shoot people high elopement risk . 3. Interview with LPN #2 on 7/12/19 at 8:52 AM, in the Conference Room, LPN #2 was asked if Resident #1 had exited the building on 6/28/19. LPN #2 stated, .I work the 400 hall day shift .I worked day shift 7 AM-7 PM (7:00 AM-7:00 PM) .when he formulates a plan, he will execute it if he wants to get out .standing by the door, when someone was going out the door, he would try to talk to them, and try to go out behind them .he had left here and went to another facility but they couldn't handle his exit seeking, he got out of that facility while he was there .I talked to him the night he eloped about 6:20 PM .that was the last time I saw him that night .changed shift and went home . Interview with Certified nursing Assistant (CNA) #1 on 7/12/19 at 9:40 AM, in the Conference Room, CNA #1 stated, .(Resident #1) always watching the door, seemed to be more focused on who was coming in and out of door .that day in particular (6/28/19) he was waving at me out the window .I saw him about 6:40 PM leaned against the corner of the 400 hall near the exit door (to outside) . Interview with Activity Assistant #1 on 7/12/19 at 9:55 AM in the Conference Room, Activity Assistant #1 stated .(Resident #1) always exit seeking .seemed more agitated that day (6/28/19) . Interview with the police officer on 7/12/19 at 1:05 PM, at the (Named City) Police Department, the police officer was asked about the incident on 6/28/19. The police officer stated, .there is not a police report .just the 911 dispatch information .according to it (dispatch log) the call came in at 19:11 (7:11 PM) suspicious person .the person was confused and doesn't know where he is .sitting on bench out front .the officer arrived at 7:15 PM at the grocery store. I arrived at 19:26 (7:26 PM) .he was confused and seemed scared .I asked his name and where he was from .he told me his name and that he was from (Named city) .I asked some more questions about his family and I recognized his daughter's name. We have a mutual friend so I got on (Named social media website) to find the more information, contacted a friend and got in touch with his daughter .I took him back to the facility around 8:00 PM .(staff) didn't know a resident was missing from the nursing home . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were new interventions related to the resident exiting the Secure Unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .it was reviewed 6/20/19 . Telephone interview with the grocery store employee on 7/13/19 at 2:00 PM, the employee was asked what happened on 6/28/19. The employee stated, .it was later in the day .a regular customer came in the store and said there was a gentleman wandering around outside at the front of the store. The customer said you might want to call 911, so I did. We asked him his name and he told us, but we didn't know anyone to call. The police came and the officers asked who his children were .the officer got in touch with someone that knew the man's daughter the police put him in vehicle and left . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put in place after the exit seeking behavior on 5/20/19. The surveyor verified the A[NAME] by: 1. Door Code was immediately reset by the Maintenance Director on 6/28/19. 2. Signage was posted on the back exit door on the unit not to utilize door except in an emergency. Signage was posted on all other exit and corridor doors reminding visitors to be aware of others potentially exiting with them on 6/28/19. The signage was viewed by the surveyor on 7/16/19. 3. Maintenance Director checked all the windows on the Secure Unit to ensure that [MEDICATION NAME] were in place that limit the windows opening more than 4 inches on 6/28/19. This was confirmed by the surveyor through observations and interview on 7/16/19. 4. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 5. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 6. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary and how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 7. The DON and designee re-assessed all residents in the building to determine any residents with exit seeking behaviors on 6/28/19 and 6/29/19. Results were no new residents identified as an elopement risk or added to the list. The assessments were reviewed by the surveyor. 8. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 9. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 10. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 11. Beginning 6/28/19 Maintenance Director or Designee checked all windows in resident rooms and will continue on a monthly basis to ensure that [MEDICATION NAME] are in place to limit opening to 4-6 inches on an ongoing basis. This began on 6/28/19. 12. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 13. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 14. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 15. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. 16. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on the Administrator's Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and training of staff to prevent a cognitively impaired, vulnerable resident from eloping from the Secure Unit of the facility. The resident walked 0.7 miles to a local grocery store. The Administrator's failure to provide resident safety placed Resident #1 in Immediate Jeopardy when staff did not complete assessments related to elopement risks, investigate an incident when Resident #1 exited a Secure Unit of the facility to an unsecured area, failed to ensure Resident #1 was free from neglect, and failed to ensure a safe environment for Resident #1. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of J. F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented. .lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .oversee regular rounds to monitor delivery of nursing care .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator was asked about the incident when Resident #1 eloped. The Administrator stated, .I was here that day (6/28/19) .I was leaving to go home .I walked outside and saw 2 police officers standing outside talking. I waved at them and went to my car. It was between 7 (7:00 PM) and 8 (8:00 PM) that night .I called into the facility and they said the police had just brought (Resident #1) back to the facility from (named grocery store) .the only thing we can figure out is he walked out of the exit door on Secure Unit with a family member .we are unable to determine which route he took to the grocery store .I treated this like a jeopardy .my first question was how did they (staff) not know he was gone . The Administrator was asked if Resident #1 had ever eloped before. The Administrator stated, .he left the Secure Unit 1 time and he was found on the 100 hall .we didn't investigate it as an incident because he didn't leave the facility .no incident report . Administration failed to update Resident #1's Care Plan with new interventions for his exit seeking behavior. Refer to F657 Administration failed to ensure supervision of residents with wandering/exit seeking behaviors. Administration neglected to ensure staff were knowledgeable of the location of the residents with wandering/exit seeking behaviors when a resident exited the Secure Unit and was not identified as missing until the police returned the resident to the facility. Refer to F600 and F689. The surveyor verified the A[NAME] by: 1. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 2. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 3. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 4. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 5. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 6. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 7. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-835 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to prevent neglect for 1 of 4 (Resident #1) sampled residents reviewed with wandering/exit seeking behaviors which resulted in Immediate jeopardy (IJ) when Resident #1 exited the facility, crossed 2 side streets, and walked to a local grocery store, 0.7 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility neglected to ensure a safe environment for Resident #1 which placed Resident #1 in Immediate Jeopardy (IJ), The facility neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors. Resident #1 had a history of [REDACTED]. The resident exited the facility on 6/28/19 and was located 0.7 miles from the facility at a local grocery store. The facility had no knowledge the resident was missing until the resident was returned to the facility by the police. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600 was cited at a scope and severity of J. F-600 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: Review of the facility's Abuse Prevention Policy & Procedure revised 1/23/17 documented, .the right to be free from .neglect .Neglect: The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] from a Geriatric Psychiatric Unit with [DIAGNOSES REDACTED]. Resident #1 resided on the Secure Unit in the facility. Closed medical record review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/8/19 revealed Resident #1 was assessed with [REDACTED]. The MDS documented Resident #1 had disorganized thinking, inattention, delusions, verbal behaviors, physical behavior symptoms 1-3 days during the assessment period, impaired vision, and wore corrective lens. These behaviors placed the resident at significant risk for physical injury or illness. The resident was unsteady when ambulating. There were no Nursing Risk Assessments completed after the resident was admitted on [DATE] and readmitted on [DATE] to alert staff that Resident #1 was an elopement risk. Closed medical record review of the quarterly MDS with an ARD of 6/12/19 revealed Resident #1 was assessed to have a BIMS score of 7 which indicated the resident was severely impaired for decision making, had hallucinations, other behavioral symptoms, and the wandering behavior occurred 1 to 3 days. The resident did not require any assistive devices and needed limited assistance with walking. Closed medical record review of Resident #1's comprehensive care plan dated 3/12/19 and reviewed 6/20/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. Interventions to address this behavior included placing the resident in an area where frequent observation was possible, to implement facility protocol for locating an eloped resident, designate staff to account for resident's location throughout the day, and alert staff to the wandering behaviors. Interview with the Administrator on 7/11/19 at 7:30 PM in the Administrator's Office, the Administrator was asked if Resident #1 had exited the facility unattended prior to 6/28/19 and the Administrator stated, .I believe he got out .but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM in the Conference Room, LPN#1 confirmed Resident #1 had exited the Secure Unit without staff being aware on 5/20/19. Review of a nurses' note dated 6/28/19 at 6:00 PM documented .continued exit-seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission. Will monitor behaviors . Review of the Resident Incident Report provided by the facility dated 6/28/19 revealed Resident #1 was confused and disoriented. The (named grocery store) employee notified the police department at 7:11 PM that the resident was in the store parking lot. The police returned the resident to the facility at 8:00 PM. Review of a nurses' note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .stated 'I just followed some man out' . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator stated, .I was here that day (6/28/19) .I was leaving to go home .I walked outside and saw 2 police officers standing outside talking. I waved at them and went to my car. It was between 7 (7:00 PM) and 8 (8:00 PM) that night .I called into the facility and they said the police had just brought (Resident #1) back to the facility from (named grocery store) .the only thing we can figure out is he walked out of the exit door on secure unit with a family member .we are unable to determine which route he took to the grocery store .I treated this like a jeopardy .my first question was how did they (staff) not know he was gone . Interview with the DON on 7/11/19 at 5:40 PM in the Conference Room, the DON was asked about Resident #1. The DON stated, .wandering .saw him at the door .around shift change stand by the door (on 6/28/19) . Interviews on 7/12/19 throughout the day with LPN #2, CNA #1, CNA #2, and Activity Assistant #1, all confirmed that on 6/28/19 Resident #1 exhibited exit seeking behavior, seemed more focused on exiting the facility, and seemed more agitated. Telephone interview with LPN #3 on 7/12/19 at 5:03 PM, LPN #3 revealed Resident #1 was .very aggressive at times .watches the doors .push on doors .watch people coming in and out through the doors .hadn't been back long from geri (geriatric)-psych (psychiatric) . LPN #3 was asked about the evening of 6/28/19 when he exited the facility. LPN #3 stated, .he wasn't in the lobby when I came on shift. He sometimes goes to bed after supper so I thought he was in bed .day shift had reported he was exit seeking that day .I had started med (medication) pass .around 8:00 PM. The 100 hall nurse (LPN # 4) brought Resident #1 in through the door (of the Secure Unit). The police had just returned him to the facility. His daughter was with him .he (Resident #1) stated, 'I went for a walk and had to find someone to bring me back' . LPN # 3 further stated .He was very, very determined .very sneaky .watching us go in and out of door . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM in the Conference Room, the DON was asked how sending Resident #1 to a geri-psych facility addressed his exit seeking behavior and the DON stated, .adjusting his medications adding or decreasing and giving us other interventions that might help . The DON was asked if the staff should have been aware if a resident was missing from the facility for over an hour. The DON stated, .he wasn't gone that long . The Administrator was asked if the nurse responsible for the care of Resident #1 the evening of 6/28/19 was unaware the resident was missing from the facility prior to the police returning the resident to the facility at 8:00 PM. The Administrator stated, .yes that's true . The Administrator was asked if the employee at (Named grocery store) had not called 911 what could have happened to Resident #1. The Administrator stated, .I don't know .don't want to think about it . Interview with the Administrator, Regional Consultant for Clinical Services, and DON on 7/14/19 at 12:08 PM in the Conference Room, the Regional Consultant for Clinical Services stated, .the care plan was reviewed and updated .medications were changed .he was sent to geri-psych hospital. That is an intervention on his care plan and the activity was updated on 6/20/19 I don't think this meets criteria for an IJ . Interview with LPN #4 on 7/14/19 at 6:15 PM in the Conference Room, LPN #4 was asked about the night Resident #1 exited the facility and was located at a local grocery store, LPN #4 stated, .it was around 8:00 PM. The police walked down the 100 hall with Resident #1 and I assisted Resident #1 back to the Secure Unit . LPN #4 was asked if she was aware a resident was missing from the facility, LPN #4 stated, .no . Interview with the Regional Consultant for Clinical Services on 7/15/19 at 5:05 PM in the Conference Room, the Regional Consultant for Clinical Services was asked if the occurrence when Resident #1 exited the Secure Unit on 5/20/19 was documented on the 24 hour nurse report, the Regional Consultant for Clinical Services stated, .he did not actually leave so we did not consider that an incident .it's documented highly exit seeking behaviors noted . Interview with the DON on 7/16/19 at 5:23 PM in the Conference Room, the DON was asked if a resident should leave the Secure Unit unattended. The DON stated, .no The DON was asked if the staff should be unaware a resident was missing from the facility until the police returned the resident to the facility. The DON stated, .no . The facility's failure to supervise Resident #1, failure to respond to Resident #1's exit seeking behavior, and failure to know where Resident #1 was for 1 hour and 20 minutes resulted in neglect when Resident #1 eloped from the facility on 6/28/19 with a recorded high temperature of 86 degrees, crossed 2 side streets, and walked 0.7 miles to a local grocery store which was located 247 feet from a major 4 lane highway. Refer to F 689 The surveyor verified the A[NAME] by: 1. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 2. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 4. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audits. 5. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audits. 6. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 7. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 8. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. Noncompliance of F-600 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.

Based on review of the Administrator job description, review of the Director of Nursing (DON) job description, Quality Assurance (QA) Coordinator job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to exit seeking behavior assessments, completion of incident investigations, completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility implemented and/or provided new interventions related to active exit seeking, and that staff ensured a safe environment for residents placed 1 of 4 (Resident #1) sampled residents in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer when Resident #1 was wandering outside of a local grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of J. F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented. .lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Review of the QA Coordinator job description revised 6/2008 documented, .reports to Director of Nursing .supports successful implementation and maintenance of clinical and quality initiatives and protocols for use at the facility .to assure the facility is following .regulations .Identify deficit(s) related to policy/procedures and develop draft policy for review .identify weakness .of clinical initiatives to provide/promote resident well-being .new clinical initiatives to correct weaknesses .develop a detailed report on findings to report to QA Committee. Report any high risk areas immediately .staff .to provide accurate information and correct negative trends .Identifies Safety and Risk Management issues and communicates areas of weakness to Administrator .conduct meaningful weekly Quality Assurance meetings .weekly Quality Services department meetings .Protect residents from neglect . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, Clinical Manager #1 was asked if she attended Interdisciplinary Team (IDT) Meetings. Clinical Manager #1 stated, .yes I attend the meetings . Clinical Manager #1 was asked if exit seeking behaviors were discussed in the meetings. Clinical Manager #1 stated, .I don't recall discussing exit seeking behavior or (discussing) him (Resident #1) leaving the Secure Unit in (MONTH) (2019) . Clinical Manager #1 was the staff member who saw Resident #1 leave the Secure Unit on (MONTH) 20, 2019. Interview with the QA Coordinator on 7/15/19 at 3:04 PM, in the Conference Room, the QA Coordinator was asked if any concerns related to behaviors and exit seeking behaviors had been identified. The QA Coordinator stated, .no . Interview with the QA Coordinator on 7/16/19 at 5:15 PM, in the Conference Room, the QA Coordinator was asked if the QA committee was effective. The QA Coordinator stated, .no .the things we put in place (indicating the A[NAME]) will help it to be better . 1. The facility's QA committee failed to identify areas of improvement related to active exit seeking behaviors. Refer to F600, F657, F689, F835 2. The facility's QA committee failed to identify an incident of elopement, failed to investigate the incident to determine the root cause of the incident, failed to identify appropriate plans of action, and failed to ensure new interventions related to the incident of elopement were added to the resident's care plan. Refer to F 600, F657, F689, F835 3. The facility's QA committee failed to identify that elopement risk assessments were not current and updated for residents of the facility's Secure Unit. Refer to F 600, F657, F689, F835 The surveyor verified the A[NAME] by: 1. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 2. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 3. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 4. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 5. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 6. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 7. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-865 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.