Every finding on record at Antioch TN Opco, LLC

Based on facility policy review, employee file review, National Weather Service statistics review, Grievance Log review, Hospital documentation review, medical record review, police report review, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 of 5 (Resident #3) sampled residents reviewed. Resident #3, a severely cognitively impaired resident with known exit seeking behaviors, who was incontinent and dependent for toileting hygiene and supervision for eating, left the facility through a window in his room. The facility was unaware Resident #3 was missing, alone and unattended from the facility for an undetermined length of time. The last known time Resident #3 was seen in the facility was approximately 10:30 PM on 3/29/2024, 18 hours before being located at approximately 4:00 PM on 3/30/2024, 5.1 miles away from the facility beside a busy 5 lane, high traffic street which resulted in Immediate Jeopardy for Resident #3. 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, serious impairment, or death to a resident. The Administrator, Director of Nursing (DON), [NAME] President of Clinical Services (VPCS), and Regional Regulatory Compliance Officer (RRCO) were notified of the Immediate Jeopardy at F-689 during the complaint investigation on 10/3/2023 at 2:43 PM in the Administrators office. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is substandard quality of care. The Immediate Jeopardy began on 3/30/2024 through 10/8/2025 and was removed on 10/9/2025. An acceptable Removal Plan which removed the immediacy of the Jeopardy was received on 10/7/2025 and was validated onsite by the surveyor on 10/7/2025 through 10/8/2025 by medical record reviews, observations, review of education records, and staff interviews. A partial extended survey was conducted on 10/3/2025 through 10/9/2025. Noncompliance at F-689 continues at the scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Elopement/Wandering, Unsafe Resident, dated 3/30/2024, revealed .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.staff will identify residents who are at risk for harm because of unsafe wandering.staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering.resident's care plan will indicate the resident is at risk for elopement.Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document.wandering, by a resident.Staff will institute a detailed monitoring plan. 2. Review of the employee file for Certified Nursing Technician (CNT) X revealed multiple disciplinary progressive action forms and statements of verbal warnings to include failure to provide care and services to residents during the 10:30 PM to 6:30 AM shift. CNT X's progressive discipline notes included failure to provide assigned showers, sitting in a resident's room talking on the cell phone, failure to turn and reposition a resident until 4:00 AM during the 10:30 PM to 6:30 AM shift, and failure to answer call lights. 3. Review of the National Weather Service statistics revealed the recorded low temperature during the night of 3/29/2024 through the morning of 3/30/2024, the time of the elopement, was 54 degrees Fahrenheit. The high temperature on 3/30/2024 was 79 degrees Fahrenheit. 4. Review of the facility's Grievance Logs dated 5/2024 through 7/2025, revealed 22 complaints within 15 months related to staff not coming into resident rooms to provide care during the 10:30 PM to 6:30 AM shift, incontinent residents waiting hours for call lights to be answered, and staff turning off the call lights without providing care. Resolutions for these complaints was education provided to staff. 5. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included Metabolic Encephalopathy, History of Falling, Cocaine Abuse, Dementia, Viral Hepatitis B and C, Alcohol Abuse, Altered Mental Status, Restlessness and Agitation, and Needs Assistance with Personal Care. Review of a Progress Notes dated 1/23/2024, revealed .[Family Member-FM BB].stated that [Named Resident #3] had a Wander Guard [sensor that alarms when resident nears an exit to prevent elopement] on at [Named Facility #2] and he would need one here.She said when the weather is better, he will really want to go outside and enjoy the sunshine. A Wander Guard was placed on R [Right].Ankle. Review of the Wandering/Elopement Risk assessment dated [DATE], revealed Resident #3 ambulated independently, was cognitively impaired, expressed the desire to leave the facility, wandered aimlessly and sat next to exit doors. Resident #3 scored as high risk with 10 or more risk factors for an elopement from the facility. Review of the comprehensive care plan dated 1/23/2024, revealed .Focus.(WANDERING) The resident is at risk for Elopement or Wandering r/t [related to].Disoriented to place.Impaired safety awareness.Resident wanders aimlessly, requires wander guard.Interventions/Tasks.Distract resident from wandering by offering pleasant diversion.Functional Wanderguard [Wander Guard] attached to resident's right ankle.Make sure all staff are aware of elopement risk. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Resident #3 was dependent on staff for toileting hygiene, lower body dressing, putting on and taking off footwear, required supervision or touching assistance from staff for eating, and required substantial/maximal assistance from staff with sit to stand and toilet transfers. Resident #3 was incontinent of bowel and bladder, had a fall prior to admission, experienced shortness of breath (SOB) with exertion and sitting at rest. Mobility devices used in the last 7 days were a walker and wheelchair. Review of the Progress Note dated 2/17/2024, revealed . [Resident #3] has been walking all over the building all night. He need [needs] continue monitor [monitoring]. Review of the Progress Note dated 3/8/2024, revealed .[Resident #3] had to be redirected a few times because he was trying to exit the back door said he needed to go see someone. Resident #3's care plan was not revised for actual exit seeking behaviors noted on 3/8/2024. Review of the Progress Note dated 3/14/2024, revealed .[Resident #3] removed his battery/disk off his Wander Guard, he left the bracelet on. A new Wander [NAME] [Guard] was placed on his right ankle. Review of the comprehensive care plan dated 3/14/2024, revealed .Resident [#3] with non-compliant behavior and resistive to care.Removes Wander Guard/Wanders.Continue to check wander guard placement every shift, check to see if he has pulled off square alarm device and left the bracelet. Replace wander guard (new ones located in med room).Redirect resident when he wanders. Review of the Progress Note dated 3/17/2024, revealed .[Resident #3] has been wandering into 600 halls [Hall]. He had verbally aggressive behavior with nurse. Review of the Progress Note dated 3/21/2024, revealed .[Resident #3] would not allow this nurse to check his wander guard. He has a history of removing it. His nurse was notified of this refusal of care. Review of the Progress Note dated 3/21/2024 at 8:24 PM, revealed .[Resident #3] refused this nurse to check his wanderguard [wander guard] placement and active status. Will pass on to following nurse to attempt over night [overnight]. Review of the Progress Note dated 3/24/2024 at 3:56 AM, revealed .[Resident #3] was awake most of the night. All attempts to redirect him was futile. Resident went to be [bed] at 0320 [3:20 AM]. Review of the Progress Note dated 3/24/2024 at 3:59 AM, revealed .[Resident #3] is up again, roaming around. Review of the Progress Note dated 3/30/2024 at 6:20 AM, revealed .[Resident #3] was noted missing from his room by [CNT X] assigned to his hallway. [CNT X] alerted this writer and a search was donein [done in] all the rooms and bathrooms on this hallway. Also noted was an open window in his room and what appears to be a footprint on the windowframe [window frame]. Code gray [code elopement] was activated without success.this [success. This] writer went outside of [Named room number] and noted the fence had been broken in 3 places. 911 was called.More [called. More] search was done by staff around the facility and other staff drove around the neighborhood with no success.Adminisrator [success. Administrator], family was made aware. Review of a written statement dated 3/30/2024, revealed .0600 [6:00 AM] Came into work thru [through] front door for work shift. As I came onto the front desk (nursing station) verbally was told [Resident #3] was gone - absent from building cannot locate. The statement was signed by Registered Nurse (RN) Y. 6. Review of the Metropolitan Police Department's Missing Person, Runaway, Escapee, Kidnapping Report, dated 3/30/2024, revealed police were dispatched to Facility #1 on 3/30/2024 at 8:18 AM, approximately 2-3 hours after staff discovered Resident #3 was missing from his room. The report indicated staff reported Resident #3 was last seen between 4:00 AM - 5:00 AM on 3/30/2024 (Per interview, video footage indicated no one had seen Resident #3 since approximately 10:30 PM on 3/29/2024). The report indicated Facility #1's staff reported Resident #3 had verbalized plans to go to a location where he grew up. Staff reported Resident #3 had opened his window and climbed a fence to leave the facility grounds. Facility #1's staff reported Resident #3 left the facility with his clothes on and no shoes. The report noted Family Member (FM) BB confirmed Resident #3 had Dementia and could not understand where he is going or how to navigate successfully. The report stated Resident #3 might be attracted to gas stations, liquor stores, and fast-food businesses. Police received a tip from the Tennessee Bureau of Investigations (TBI) Silver Alert System indicating Resident #3 had been located 5.1 miles from the facility on the side of a 5-lane street with heavy traffic. 7. Review of Hospital #3's Emergency Department Clinical Notes for Resident #3 dated 3/30/2024, revealed Resident #3 was transferred to the emergency room for evaluation following an elopement from Facility #1. During a telephone interview on 9/25/2025 at 1:30 PM, the Ombudsman stated she had received multiple complaints related to care needs not being met, particularly on the 10:30 PM to 6:30 AM shift. During an interview on 9/30/2025 at 11:36 PM, the Maintenance Assistant (MA) stated he received a phone call from the facility requesting him to come in due to the elopement on 3/30/2024 around 6:30 AM. The MA stated he came to the facility immediately and went to Resident #3's room. The MA concluded the window was open all the way and the screen was pushed out. The MA was asked if the window had a mechanism to prevent opening past a certain point. The MA stated, .The stop [small metal part used to prevent window from opening past a specified point] was not in place.I did not see the stop or screws to secure it [the stop] anywhere in the room. The MA stated he wasn't sure if the window had a stop or when the stop had been removed. The MA concluded at that time the staff checked the doors routinely and did not check the windows. The MA was asked if a window monitoring requirement was put in place after the elopement. The MA replied, .We did check the windows daily for 1 month, then 1 time a month for 4 or 5 months, then we stopped. The MA confirmed the facility recently started checking the windows again. During an interview on 9/30/2025 at 2:59 PM, the Business Office Manager (BOM) stated she viewed the video footage starting at approximately 10:30 PM on 3/29/2024 and ending approximately 7:00 AM on 3/30/2025. The BOM stated the video did not show anyone enter Resident #3's room after 10:30 PM on 3/29/2024 until approximately 5:30 AM on 3/30/2024 when CNT X looked into Resident #3's room then walked down the hall and came back with the nurse to the room. The BOM confirmed the video footage revealed Resident #3's door was closed all night, and no one went in or came out of the room during the hours of 10:30 PM to around 5:30 AM. During an interview on 9/30/2025 at 3:12 PM, the Activities Assistant (AA) stated Resident #3 did not participate in all activities. The AA stated Resident #3 would often come to activities, sit for a few minutes and then get up and walk away. The AA confirmed she had not been asked to monitor Resident #3 or to provide extra activities due to wandering behaviors. During a telephone interview on 10/1/2025 at 6:40 PM, FM BB stated she was not aware Resident #3 had been taking off his wander guard bracelet and refusing to allow staff to put it back on him. FM BB stated, .[Named Facility #1] called me and said he [Resident #3] had left the building and they thought it might have been dark when he left but they were not sure what time he had actually left the property.the nurse said he had his clothes on but left his shoes.When the police brought him back, he looked exhausted and he was hungry. During an interview on 10/2/2025 at 11:09 AM, the Medical Director (MD) stated she expected staff to monitor residents with exit seeking behavior closely, including making rounds during the 10:30 PM to 6:30 AM regardless of whether incontinent care was required. During an interview on 10/7/2025 at 3:45 PM, the Nurse Supervisor (NS) acknowledged Resident #3 frequently made statements about needing to go home because family needed his help and that increased his risk of elopement. The NS stated, .I'm not sure how he [Resident #3] was able to get out of the window in his room.We did not determine when he actually left. The NS was asked if Resident #3 was likely to encounter unsafe conditions outside of the facility. The NS replied, .He [Resident #3] was unsteady when getting up or walking.He was confused.He traveled quite a way [5.1 miles from the facility] most likely through suspicious [high crime] neighborhoods, crossing streets, major intersections.I'd say the chances were pretty high for him to get hurt.He came back and wasn't hurt thankfully. The NS was asked if the facility had addressed the cause of Resident #3's elopement. The NS concluded prior to this survey, staff did not address checking the window stops. The NS was asked if video footage confirmed staff had not been in Resident #3's room after 10:30 PM on 3/29/2024 and if lack of care or monitoring for an exit seeking resident had been addressed. The NS responded, .I didn't view the video footage for that time [3/29/2024-3/30/2024] so I can't answer that question. The NS was asked if residents had complained about staff not coming into rooms at night to check on them. The NS replied, .Not answering call lights is always a problem . During an interview on 10/7/2025 at 5:15 PM, CNT X stated on 3/29/2024 she worked two shifts, the 2:30 PM to 10:30 PM shift and the 10:30 PM to 6:30 AM shift. CNT X stated during the 10:30 PM to 6:30 AM shift her assignment included Resident #3. CNT X stated she wasn't sure how many times she went into Resident #3's room during the shift. CNT X was asked how often she makes rounds during the 10:30 PM to 6:30 AM shift. CNT X stated, .If they wet themselves, I go in every two hours.CNT X was asked if Resident #3 was in bed when she made her rounds to check. CNT X responded, .Yes.the tech [CNT] on prior shift got him undressed and ready for bed. (photographs provided by the facility revealed Resident #3 was dressed with his shoes on when he returned the afternoon of 3/30/2024. Resident #3's MDS assessment indicates he was dependent on staff for lower body dressing and putting on shoes. Photographs taken the morning of 3/30/2024 also revealed Resident #3's bed undisturbed.) CNT X confirmed some time that morning (3/30/2024) she entered Resident #3's room and found the window open with the screen out, a blanket laying on the ground outside of the window and the resident was gone. CNT X stated she cannot recall seeing a window stop in place on the window in Resident #3's room. During an interview on 10/8/2025 at 3:37 PM, the Director of Nursing (DON) stated she was aware of the complaints from residents about long wait times for call lights to be answered. The DON stated nurse managers had conducted call light audits and provided education to staff regarding answering call lights timely. The DON was asked if audits were conducted during the 10:30 PM to 6:30 AM shift. The DON replied, .Yes, [Named NS] and [Named SDC] come in early at times.5 or 6 [5:00 AM to 6:00 AM] . The DON was asked if nurse management had been in the facility during the 10:30 PM to 6:30 AM shift to investigate concerns voiced by residents related to care not being provided during the shift. The DON replied, .Not before 5 or 6 [5:00 or 6:00 AM] when [Named SDC] comes in early. The DON was asked for documentation of call light audits for the 10:30 PM to 6:30 AM and was unable to provide documentation of audits occurring before 5:00 AM. The DON stated staff had received in-services on answering call lights timely and confirmed she did not know of anyone counseled individually for not providing care overnight. During a telephone interview on 10/9/2025 at 11:34 AM, Licensed Practical Nurse (LPN) U stated Resident #3 frequently wandered in the facility and made statements about being ready to go home. LPN U confirmed Resident #3 wore a Wander Guard bracelet and often took it off, refusing to allow staff to put the device back on him. LPN U stated she did not recall increased monitoring of Resident #3 after he returned to the facility on 3/30/2025. During a telephone interview on 10/9/2025 at 11:40 AM, LPN T confirmed she was the nurse assigned to Resident #3 on 3/29/2024. LPN T stated, .I remember he [Resident #3] disappeared out the window.I am not sure when or how often the tech [CNT X] checked on him.I know he was gone and the window was open when she checked on him the next morning. LPN T stated she did not remember seeing a window stop on Resident #3's window. LPN T was asked if she had been required to check resident's windows before Resident #3's elopement on 3/29/2024-3/30/2024. LPN T replied, No. LPN T was asked if she was required to increase monitoring for Resident #3 once he returned to the facility. LPN T stated, .I am not sure about being told to increase monitoring, I do not recall documenting on monitoring.but I am sure we did. During a telephone interview on 10/9/2025 at 12:27 PM, Former DON V stated Resident #3 wandered in the building and frequently made comments about needing to leave and get home. Former DON V stated Resident #3 had to be redirected when found pushing on the door to exit a few days before he eloped from the building. Former DON V stated she had viewed the video footage for 3/29/2025 to 3/30/2025, which confirmed no one entered or left Resident #3's room after approximately 10:30 PM until approximately 5:30 AM. Former DON V was asked what was done about CNT X not providing care and monitoring for Resident #3. Former DON V replied she wasn't sure if there had been a consequence for the staff. During an interview on 10/9/2025 at 1:45 PM, the Administrator was asked if Resident #3 had been monitored during the 10:30 PM to 6:30 AM shift on 3/29/2024-3/30/2024. The Administrator replied, .Yes, there was always staff present on that hall . When asked if Resident #3's door should have been closed during the night and if staff had checked on Resident #3 during the shift. The Administrator was asked if the video footage on 3/29/2024 to 3/30/2024 revealed no one had entered or left Resident #3's room during the 10:30 PM to 6:30 AM shift on 3/29/2024-3/30/2024. The Administrator stated the video footage showed LPN T in the room before 10:30 PM on 3/29/2024 and then CNT X at approximately 5:00 AM on 3/30/2024. An acceptable Removal Plan which removed the immediacy of the Jeopardy was received on 10/7/2025 and was validated onsite by the surveyor on 10/7/2025 through 10/8/2025 by medical record reviews, observations, review of education records, and staff interviews. A. Immediate action to address the residents affected or likely to be affected: Staff who were not available during the training will be trained before being allowed to work. In addition, the staff should attain a 100% score and be retrained by the DON, VP of Clinical Services, SDC (staff development coordinator) or Unit Manager if the score is less than 100%. On 10/06/25, the DON, VP of Clinical Services, SDC (staff development coordinator)/ Unit Manager provided staff with education/re-education related to frequency of monitoring of residents, especially with wandering and exit seeking behaviors. The training includes notifying the DON/Administrator if a resident is noted with new or worsening behavior of wandering and/or exit seeking, notifying and obtaining order from the physician to implement enhance supervision which includes one-to-one supervision, every 15-minute, every 30-minute, or hourly supervision. The training also includes having an IDT (interdisciplinary team) when implemented interventions fail to work, to discuss additional, new intervention if necessary to protect the resident. To alert staff about a resident who have been identified as high risk for elopement, the DON/Administrator will ensure that the resident is added to Elopement Binder and is also discussed in the staff huddle meetings. The high risk for elopement residents are being monitored by nurses and nursing assistants. To ensure interventions are being implemented, the DON and other clinical managers (MDS Nurse, SDC, Unit Managers), SSD (social service director), Administrator will conduct unit rounds daily (Mondays - Fridays). In the weekends, the Nurse Supervisor and/or MOD (manager on duty) will also conduct the unit rounds to ensure compliance with the interventions. The residents who are at high risk for elopements will also be reviewed during clinical meetings daily which is attended by the DON and other clinical managers (MDS Nurse, SDC, Unit Managers), SSD (social service director). During the weekends, the MOD/Nurse Supervisor will also conduct a clinical meeting to discuss the residents who are at high risk for elopements. 1. Resident #3 no longer resides in the facility. The resident was discharged to another facility on 4/5/24. 2. Elopement risk reassessments were completed for all residents. This was completed by the DON - director of nursing, unit manager, MDS - minimum data set Nurse) and [NAME] President of Clinical Services (VPCS) on 10/03/2025. 3. The care plans of the residents who were identified as high risk for elopement were also reviewed and updated by the DON - director of nursing, unit manager, MDS - minimum data set Nurse) and [NAME] President of Clinical Services (VPCS) on 10/03/25. B. Immediate Actions to Prevent Occurrence/Recurrence: 1. Ad-Hoc QAPI Meeting: Ad-Hoc QAPI meeting was completed on 9/25/25 which were participated by the leadership team which includes the Administrator, Director of Nursing (DON), Unit Manager (UM), RD (registered dietician), Social services Director (SSD), Minimum Data Set (MDS) Coordinators, Business office Manager (BOM), Medical Records, Rehabilitation Manager, and Nursing Scheduler. This was also participated by the VP of Clinical Services, Chief of Operations and Regional Regulatory Compliance Officer. The QAPI team discussed the incident which happened on 3/30/24 and facility actions as specified in the plans of removal which includes but is not limited to: a) Elopement drills b) Signs asking visitors not to assist residents outside the door c) Window and door checks d) Staff education e) Review of policies f) Care plan review g) Review of elopement risks h) Unit observation for new or worsening exit seeking/wandering behavior during weekdays and weekends i) Assessment for risk for elopement of new admissions and re- admissions j) Review of elopement binders k) Review of 24-hour reports and nurses' notes daily to identify new and/or worsening wandering and/or exit seeking behaviors l) Employee elopement post tests m) Ad-Hoc QAPI meetings weekly to review results of observations and monitoring activities n) Monthly QAPI meetings o) Governing body facility oversight The medical director was unable to attend the Ad-Hoc QAPI meeting but was notified by the DON about the 9/25/25 QAPI meeting minutes on 9/26/25. The medical director did not have additional recommendations at that time. 2. Elopement Binders: The elopement binders were reviewed by the DON and VP of Clinical Services (VPCS) on 10/3/25. The elopement binders are up to date. The DON checks the elopement binders weekly to ensure that the information in the binder is up to date. The elopement binders are located in all nursing stations, and another binder is in the receptionist area, laundry and kitchen. The staff will utilize the elopement binder in the following areas/situations: a) It serves as the notification tool to provide information to the staff of the residents who are at risk for elopement b) It is used during orientation of new staff in the facility c) It is used to orient new staff in the unit d) It is used during elopement drills e) It is used to provide information to the staff about the residents who are at risk for elopement 3. Elopement Drill: The Elopement drills were conducted on 9/24/25, 9/29/25, 10/2/25 and 10/3/25. The elopement drills were facilitated by the Staff Development Coordinator (SDC), Maintenance Director/Maintenance staff and/or Administrator. The drills will be performed on different shifts and weekends by the Maintenance Director/Maintenance staff, MOD, SDC (staff development coordinator), DON or the Administrator. Elopement drills being conducted will ensure that staff are following the Missing Resident guidelines, actions to take when door alarms sound, which include, responding to active door alarms, walking outside perimeter by the alarming door to ensure no resident is observed outside of resident care area unattended. Reporting to charge nurse and initiating headcount is included in the drill. To ensure compliance, elopement drills will be completed daily for seven (7) days, then weekly for three (3) months, then start completing monthly thereafter. The elopement drills will be conducted monthly, by the Administrator, DON or Maintenance Director. 4. Elopement Prevention Posting: Signs were posted on the lobby doors on yellow paper asking visitors to not assist residents outside the door on 9/25/25. This was completed by the Administrator. 5. Door and window checks: All doors in the facility were checked by the Maintenance Director/ Maintenance Staff/ Administrator on 9/26/25 to ensure all doors were locked and secure and that delayed egress was functioning properly. There are no concerns identified. All windows in the facility were checked by the Maintenance Director/ Maintenance staff/ Administrator on 9/24/25 to ensure all windows were secured. There are no concerns identified. All exit stopper door alarms which were in place were functioning properly. If the checks reveal a problem, the Maintenance Director/ Maintenance Staff will notify the Administrator/DON, and a staff member will be assigned to monitor the door/window until the problem is fixed. To ensure that this is being completed, the administrator does a spot check (of doing door checks) and is also reviewing and signing the monitoring tool after review. Maintenance Director/ Maintenance staff/ Administrator/ MOD (manager on duty)/ Charge Nurse will perform daily checks of doors and windows for daily for three (3) months, including weekends. After three (3) months, the QAPI team will review the results of the door and window checks to determine if additional checks are necessary or frequency of checks can be downgraded. 6. Review of policies: The Administrator, DON, VP of Clinical Services and Regional Regulatory Compliance Officer reviewed the policies which include but are not limited to: a) exit-seeking behaviors, b) elopement and wandering care plan, c) missing resident, responding to alarms and resident safety and supervision on 9/25/25. There was no revision needed. 7. Staff education and Posttests: The DON/ SDC/ Administrator/ Unit Manager provided the staff with training on items which includes but not limited to: a) exit-seeking behaviors, b) elopement and wandering care plan, c) missing resident, d) redirecting residents, especially residents with cognitive deficit e) responding to alarms and f) resident safety and supervision The training was completed on 9/25/25. For any staff members who were on vacation, or were not available at that time, training will be completed upon return to work. The training included posttests, and the acceptable score is 100%. Any staff who did not achieve 100% test results was provided with additional retraining from a trained department head, DON, Unit Manager, SDC or Administrator. The facility is not using agency staff. If agency staff are used in the future, the facility will utilize the same process of providing the education to ensure that they (agency staff) will receive the same training as the facility staff. 8. Monitoring for new and/or worsening behavior: The DON, SDC, Unit Manager will monitor nursing documentation during daily clinical (Mondays to Fridays) meetings and conduct unit observation rounds to identify new or worsening exit seeking/wandering behaviors of residents and to ensure care plans are followed. The documentation which are being reviewed includes but is not limited to: a) Nurses Notes b) Incidents c) New physician orders d) Events/Incidents in the electronic health records e) Review of new admissions for elopement risk assessments and ensure appropriate care plan interventions have been implemented and the elopement books have been updated as applicable. f) Nurses' notes for the previous 24 hours to ensure if any new/worsening exit seeking behaviors was noted and if so, the behaviors are care planned, and interventions are implemented as applicable During unit observation rounds, the DON/ SDC/ Unit Manager/ Administrator will also observe for any new or worsening exit seeking/wandering behaviors and to ensure care plans interventions are being followed. This will be completed during the week (Mondays - Fridays). During the weekends, the nurse supervisor and/or MOD (manager on duty) will complete the review of the above-mentioned documents and will also conduct unit observations to observe for any new or worsening exit seeking/wandering behaviors and to ensure care plans interventions are being followed. Any concern identified will be addressed immediately. The DON or Administrator will also be notified of the concern. Additional interventions will be implemented, if necessary, by the direction of the DON or the Administrator. 9. Review of new admissions & re-admissions: New admissions will be reviewed by the SSD/ DON/ Unit Manager, SDC (staff development coordinator) or MDS Nurse for elopement risk. Any new admission/ re-admission who are identified as being at risk fo

Based on facility policy review, medical record review, facility incident report review, staffing agency timeslip review, Metropolitan Police Department Public Record Request Response review, and interviews, the facility failed to conduct a thorough investigation for allegations of sexual abuse for 1 of 4 (Resident #4) sampled residents reviewed for abuse. On 3/6/2024, Resident #4 reported she was sexually assaulted by a man fitting the description of an agency employee working in the facility. Resident #4 reported the male entered her room, pulled his penis out, turned her over and stuck his penis in her rectum. The facility's failure to thoroughly investigate allegations of sexual abuse to determine if necessary actions were needed to ensure the protection of all residents from abuse resulted in Immediate Jeopardy (IJ) for Resident #4. 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 Administrator, the Director of Nursing (DON), the [NAME] President of Clinical Services (VPCS), and the Regional Regulatory Compliance Officer (RRCO), were notified of the Immediate Jeopardy (IJ) at F-610 during the complaint investigation on 10/3/2023 at 2:42 PM. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from 10/3/2025 through 10/9/2025. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-610 was received on 10/7/2025. The Removal Plan was validated onsite by the surveyor on 10/7/2025-10/8/2025 through medical record review, observation, review of education records, and staff interviews. The IJ began on 3/6/2024 - 10/8/2025 and was removed on 10/9/2025. Noncompliance at F-610 continues at the scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.The findings include: Review of the undated facility policy titled, Abuse, Neglect and Exploitation, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.Sexual Abuse is non-consensual sexual contact of any type with a resident .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident.visitors or others but has not yet been investigated.mental faculty; requiring medical intervention as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse.Criminal sexual abuse is serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conduct described.relating to aggravated sexual abuse.The facility will follow the State and federal guidelines for investigating and reporting.An immediate investigation is warranted when suspicion of abuse, neglect.or reports of abuse, neglect.occur.Identifying staff responsible for the investigation.Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.Focusing the investigation on determining if abuse, neglect.mistreatment has occurred, the extent, and cause.Providing complete and thorough documentation of the investigation.The facility will make efforts to ensure all residents are protected from physical and psychosocial harm.Responding immediately to protect the alleged victim and integrity of the investigation.Taking all necessary actions as a result if the investigation, which may include.Analyzing the occurrence(s) to determine why abuse, neglect.of resident.and what changes are needed to prevent further occurrences.Training of staff on changes made, and demonstration of staff competency after training is implemented .Identification of staff responsible for implementation of corrective actions.The expected date for implementation.Identification of staff responsible for monitoring the implementation of the plan.The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses which included Peripheral Vascular Disease, Anxiety Disorder, Acquired Absence of Right Leg Above Knee, and Acquired Absence of Left Leg Above Knee. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Resident #4 was dependent on staff for toileting hygiene, lower body dressing, and transfers, and was incontinent of bowel and bladder. Review of the Temporary Staffing Agency's signed time slips provided by the facility revealed Certified Nursing Technician (CNT) Z worked in the facility assigned to the 200 Hall where Resident #4 resided. On 3/4/2024, CNT Z was assigned to the 200 Hall during the 6:30 AM to 2:30 PM and the 2:30 PM to 10:30 PM shift. On 3/5/2024 CNT Z was assigned to the 200 Hall during the 6:30 AM to 2:30 PM shift. On 3/6/2024, CNT Z was assigned to the 200 Hall during the 6:30 AM to 2:30 PM shift. Review of the Facility's Incident/Accident Report dated 3/6/2024, revealed .Date of incident/accident 3/5/24 [2024].Time of incident/accident 1:05 PM.[Named Resident #4] reported she was sexually assaulted on Tues. [Tuesday] 3/5/24 during the night.could not recall the time.stated a black man dressed in blue top + [and] bottom with a bald head. Review of the Progress Note dated 3/6/2024, revealed, .[Named Resident #4] reported that she was sexually assaulted on Tuesday March 5, 2024 doing [during] the night, she could not recall the time of the incident.stated that a black man dressed in Blue top and bottom with a bald head enter [entered] her room pulled his private out and turned her over in bed and stuck his private part in her rectum, she told him to stop he was hurting her, he would not stop. Review of the Incident Reporting System (IRS) report dated 3/6/2024, revealed the Facility reported Sexual abuse allegations made by Resident #4 to the State Agency (SA). The report revealed Resident #4 alleged on 3/5/2024, a black man with a bald head and wearing blue scrubs came into her room and put his private part in her behind (anus) and hurt her. The report revealed the facility alleges Resident #4 reported a white man came into her room and licked her from behind to her front to ambulance employees. The Facility reported no serious bodily injury or abuse occurred. The report revealed the Facility concluded .The reason why no investigation is because resident had changed her story from a Black man to a [NAME] Man. Review of a Metropolitan Police Department Public Record Request Response Form dated 9/30/2025, regarding the surveyor's request for the police report related to Resident #4's allegations of sexual assault revealed, .request is denied.the following state, federal, or other applicable law prohibits disclosure of the requested records: This is still an open investigation, and is not releasable at this time. The facility failed to provide an investigation for Resident #4's allegation of sexual assault. During an interview on 9/30/2025 at 4:41 PM, the Business Office Manager (BOM) stated she turned in the report related to Resident #4's allegations of sexual assault on the IRS system on 3/6/2024. The BOM stated she viewed the video footage dated 3/5/2024 and confirmed CNT Z went into Resident #4's room approximately 3 times on 3/5/2024. The BOM stated CNT Z did not stay in the room long. The BOM was asked to describe CNT Z. The BOM stated, .[Named CNT Z] was a black man with a bald head, a salt and pepper [black and white] beard wearing blue scrubs.Just like [Resident #4] described. The BOM concluded, .I think he [CNT Z] worked a double [6:30 AM to 2:30 PM and 2:30 PM to 10:30 PM] shift that day [3/5/2024].I don't think he [CNT Z] worked again after the day [3/6/2024] she [Resident #4] reported the incident. During an interview on 10/2/2025 at 10:45 AM, the Administrator stated he had not been back to the facility as Administrator very long when Resident #4 made the allegations of sexual abuse. The Administrator concluded the Interim Administrator had received the allegations from staff on 3/6/2024 and had determined the alleged perpetrator was not in the building at the time Resident #4 alleged the assault occurred on 3/5/2024. The Administrator was asked if the facility conducted a thorough investigation to determine whether sexual abuse occurred, which included assessment of other residents residing in the facility. The Administrator stated, .We notified the police and her [Resident #4] conservator.she [Resident #4] changed her story about the color [race] of the staff member, once she said he was black and then she said he was white.There were 2 males working in the building, I don't think they went into the room without a witness.No other investigation was completed after [Resident #4] was transferred to the hospital. The Administrator was asked if other residents should have been assessed to rule out additional victims of sexual abuse. The Administrator stated, .The Interim Administrator did not feel the need to question anyone else.I know now we should have done more investigating. During an interview on 10/2/2025 at 11:09 AM, the Medical Director (MD) stated she had attended a Quality Assurance Performance Improvement (QAPI) meeting and discussed Resident #4's allegation of sexual assault. The MD was asked if the committee had determined whether there had been abuse and if interventions had been put in place. The MD stated the facility couldn't complete an investigation due to Resident #4 not returning to the facility. The MD was asked if the facility had completed an investigation, including interviewing residents to ensure there were no other residents sexually abused. The MD replied, No, I don't believe so. During an interview on 10/2/2025 at 4:33 PM, a Staffing Coordinator (SC) with the Temporary Staffing Agency confirmed CNT Z worked on assignment in Facility from 3/1/2024 through 3/6/2024. The SC concluded there had been no communication from Facility #related to any type of incidents or allegations. During an interview on 10/8/2025 at 4:16 PM, the Social Services Director (SSD) stated the Former Activity Director reported allegations of sexual abuse voiced by Resident #4. The SSD stated she reported the allegation immediately to [Named Interim Administrator]. The SSD stated she usually participates in abuse investigations by interviewing residents with a high BIMS score and confirmed she was not asked to interview other residents regarding sexual abuse allegations made by Resident #4. The SSD stated CNT Z's appearance was consistent with the description of the perpetrator provided by Resident #4 and was told not to return to the facility to work. The SSD confirmed she was not aware of any investigation conducted in the facility after Resident #4 was sent out to the hospital on 3/6/2024. Multiple attempts to contact the Interim Administrator and CNT Z for interview were made during the investigation without success. During a telephone interview on 10/9/2025 at 10:11 AM, Resident #2's Conservator stated the facility had reported the alleged perpetrator was not in the building at the time of the alleged sexual assault. The Conservator stated the Tennessee Bureau of Investigations (TBI) said they were not going to pursue the investigation due to Resident #4's cognitive level and the knowledge of the perpetrator not working during the night of 3/5/2024. Resident #2's Conservator stated he felt that it was too risky to allow Resident #2 to return to the facility. Resident #2's Conservator stated she passed away 9 months after the incident. During a telephone interview on 10/9/2025 at 11:34 AM, Licensed Practical Nurse (LPN) U stated she was not aware of an investigation related to Resident #4's allegations of sexual assault on 3/6/2024. During a telephone interview on 10/9/2027 at 12:20 PM, Former Director of Nursing (DON) V was asked if she had assisted with an investigation related to allegations of sexual assault made by Resident #4 on 3/6/2024. Former DON V stated, .I do not recall an investigation related to [Resident #4]'s allegation of sexual assault by a staff member. During a telephone call on 10/14/2025 at 3:53 PM, the Administrator stated he had found a binder with an investigation related to Resident #4's allegations of sexual assault, 5 days after the survey exit on 10/9/2025. An acceptable Removal Plan which removed the immediacy of the Jeopardy for F-610 was received on 10/7/2025, and the Removal Plan was validated on-site by the surveyor on 10/7/2025-10/8/2025 by medical record review, observation, review of education records, and staff interviews. A. Immediate action to address the residents affected or likely to be affected: Staff who were not available during the training will be trained before being allowed to work. In addition, the staff should attain a 100% score and be retrained by the DON, VP of Clinical Services, SDC (staff development coordinator) or Unit Manager if the score is less than 100%. On 10/06/25, the DON, VP of Clinical Services, SDC (staff development coordinator)/ Unit Manager provided staff with education/re-education & competency verification on sexual abuse and evidence protection. Staff who were not available during the training will receive the training & competency verification prior to being allowed to work. Besides documenting staff interviews, any concern which are identified during the interviews will be addressed by the DON/Administrator. Facility actions include but are not limited to: a) providing additional training, b) conducting additional interviews as part of the investigation, c) conducting root cause analysis of any concern identified, and d) reporting to QAPI committee any patterns and trends identified. The QAPI team developed an abuse/neglect quality assurance tool which will be used to review all incidents and allegations of abuse/neglect daily. Daily, the QAPI team will review all allegations and incidents to ensure the following action items are completed, a) the incident/ allegation of abuse/Neglect or injury of unknown origin are investigated thoroughly, b) the alleged perpetrator is removed from resident contact immediately, c) the incident/ allegation is reported to the Administrator and state agency promptly, d) to ensure that law enforcement is notified of suspicion of a crime, e) the policy of the facility's abuse/ neglect protocol is followed, and f) intervention(s) implemented to ensure protection of the resident(s). The QAPI team will discuss patterns/trends identified during Ad-Hoc QAPI meetings and scheduled monthly QAPI meetings. The QAPI team will also include members of the governing body and executive management team when investigating any allegation of abuse/neglect. 1. Resident 4 no longer resides in the facility. The resident was discharged to another facility on 3/6/24. 2. To identify other residents who may be affected by the alleged deficiency, the DON (director of nursing), UM (unit manager), SSD (social services director), and SDC (staff development coordinator) conducted resident abuse interviews or skin assessments. The residents who are able to participate were interviewed to ensure that they feel safe in the facility. The results of the interviews will be documented in the Resident Abuse Interview. The residents who are unable to participate in interviews due to cognitive deficit were assessed by the nurses to identify signs of abuse/neglect. These action items were completed on 10/05/25. B. Immediate Actions to Prevent Occurrence/Recurrence: 1. Ad-Hoc QAPI Meeting: An Ad-Hoc QAPI meeting was completed on 10/03/25 which were participated by the leadership team which includes the Administrator, Director of Nursing (DON), Unit Manager (UM), Social services Director (SSD), Minimum Data Set (MDS) Coordinator, SDC (staff development coordinator), VPCS (Vice President of Clinical Services), and RRCO (Regional Regulatory Compliance Officer). During the Ad-Hoc QAPI meeting, the leadership team discussed the alleged deficiency related to failure to thoroughly investigate a sexual allegation and the corrective actions which are described in this plan of removal. 2. Review of policies: The policies and procedures related to investigation of allegations of abuse/neglect were reviewed by the DON, Administrator, VP of Clinical Services and VP of Regulatory Compliance and QAPI on 10/03/25. There was no revision needed. 3. Investigation process & leadership training: To identify and investigate future allegations of abuse/neglect that has the potential or likelihood to cause serious injury, harm, impairment, or death, the leadership team which includes the Administrator, Director of Nursing (DON), Unit Manager (UM), Social services Director (SSD), Minimum Data Set (MDS) Coordinator, SDC (staff development coordinator) were provided with training by the Regional Regulatory Compliance Officer on 10/03/25: a) After receiving the initial notification from the staff about any allegation of abuse or neglect, the NHA (Administrator)/DON will initiate the investigation. b) While investigation is in progress, the NHA/DON will ensure residents are protected from potential abuse. c) The NHA/DON will complete the investigation of all allegations of abuse/neglect. d) The VP of Operations/VP of Operations will monitor compliance related to investigation of all allegations of abuse/neglect. A Significant Event Call or SEC call will be conducted to review the allegation of abuse/neglect. The SEC call is participated by the facility's Administrator and DON, a member of the governing body and other members of the executive management (which includes COO - chief of operations, CRCO - chief of regulatory compliance officer, [NAME] President of Behavior Management and Resident Quality of Life). During these calls, the leadership team will be provided with recommendations to ensure residents are protected during investigation of the allegations of abuse/neglect. 4. Staff education: Staff will be provided with training about their responsibility to participate/ cooperate with the administration when conducting an investigation of abuse/neglect, policy on abuse, and the responsibility of all staff to prevent resident abuse/neglect. The training was completed on 10/3/25 by the DON/SDC/ unit manager. For any staff members who were on vacation, or were not available at that time, training will be completed upon return to work. The training included posttests, and the acceptable score is 100%. Any staff who did not achieve 100% test results was provided with additional retraining from a trained department head, DON, Unit Manager, SDC or Administrator. The facility is not using agency staff at this time. If agency staff are used in the future, the facility will utilize the same process of providing the education to ensure that they (agency staff) will receive the same training as the facility staff. 5. Clinical Meetings: The DON/NHA and other members of the IDT (interdisciplinary team) which includes but not limited to activity director, MDS (minimum data set) nurse, and unit manager, will conduct clinical meetings daily (Mondays - Fridays). During the clinical meeting, the above-mentioned team members will discuss residents who have new or worsening behavior or cognition to ensure that a care plan was developed to address the behavior and worsening cognitive function. Any concern will be addressed immediately to prevent abuse and to ensure any potential abuse is reported timely and investigation is initiated immediately. During the weekends, the DON/NHA/Charge nurse/MOD (manager on duty) will review residents who have worsening behavior and cognition to ensure that a care plan was developed to address the behavior and worsening cognition. Any concern will be addressed immediately to prevent future abuse and to ensure any potential abuse is reported timely and investigation is initiated immediately. 6. Review of all allegations and incidents: The DON/ Administrator will review/audit all incidents/potential abuse daily to ensure compliance with investigation of allegations of abuse. This action item will be initiated on 10/4/25. 7. Weekly Ad-Hoc QAPI meetings: An Ad-Hoc QAPI meeting will be held weekly to review results of observations and other monitoring activities related to prevention of elopement. The meeting will be attended by the QAPI team members which includes but are not limited to the Facility Medical Director, Administrator, DON, ADON, UM (unit manager), Social Services Director, MDS Nurse, Maintenance Director, Dietary Manager, Infection Control/SDC, Activities Director, Rehab Manager, RD (registered dietician) and Business office Manager. During the Ad-Hoc QAPI meetings, the QAPI will report any concern identified from observations, interviews, record reviews, and monitoring activities. If any concern is identified, the QAPI team will determine additional items to be implemented to achieve compliance and ensure resident safety. The QAPI team will continue to review results of audits, observation, and record reviews during Ad-Hoc QAPI weekly meetings for a minimum of three (3) months. 8. Monthly QAPI meetings: Monthly QAPI will also be held. The meeting will be attended by the QAPI team members which includes but are not limited to the Facility Medical Director, Administrator, DON, ADON, UM (unit manager), Social Services Director, MDS Nurse, Maintenance Director, Dietary Manager, Infection Control/SDC, Activities Director, Rehab Manager, RD (registered dietician) and Business office Manager. The QAPI team will meet monthly and discuss facility actions related to investigation of abuse or neglect which has the likelihood to cause serious injury, serious harm, serious impairment or death. During QAPI meetings, the QAPI team will determine the need for additional interventions or corrective actions, based on the results of observation, and other monitoring activities. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 10/06/25

Based on facility policy review, behavioral hospital record review, medical record review, hospital record review, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 4 (Resident #2) sampled residents reviewed. The facility failed to provide the necessary structure and processes to meet the care needs of Resident #2 when staff failed to effectively supervise and monitor for potential accident hazards, and provide a safe environment, which resulted in bodily injury. Resident #2 was admitted to the facility on [DATE] from a Behavioral Health Hospital where she had exhibited behaviors of eating non-food items which included items large enough to pose suffocation hazards. The facility had documentation which identified Resident #2's unusual behaviors of eating non-food items and failed to develop a person-centered plan of care which addressed and monitored the resident for continuing behaviors. According to documentation in the medical record on 6/25/2024, Resident #2 began to complain of difficulty swallowing with pain in her throat and chest (symptoms of adverse conditions caused from ingesting non-food items) and was not transferred to the hospital until 7/2/2024, 8 days later. Resident #2 was admitted to the hospital with multiple non-food items identified in her stomach and damage to her digestive tract and died on 7/9/2024. The facility's failure to provide the structure and processes to meet the care needs of Resident #2 resulted in an Immediate Jeopardy. Immediate Jeopardy (IJ), 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, serious impairment, or death to a resident. The Administrator, Director of Nursing (DON), [NAME] President of Clinical Services (VPCS), and Regional Regulatory Compliance Officer (RRCO) were notified of the Immediate Jeopardy at F-600 during the complaint investigation on 10/3/2023 at 2:40 PM. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is substandard quality of care. The Immediate Jeopardy began on 1/12/2024 through 10/8/2025 and was removed on 10/9/2025. An acceptable Removal Plan which removed the immediacy of the Jeopardy was received on 10/7/2025 and was validated onsite by the surveyor on 10/7/2025 through 10/8/2025 by medical record reviews, observations, review of education records, and staff interviews. A partial extended survey was conducted on 10/3/2025 through 10/9/2025. Noncompliance at F-600 continues at the scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled, Abuse, Neglect and Exploitation, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.assure that staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.Addressing features of the physical environment that may make abuse, neglect.of a resident.more likely to occur.Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. 2. Review of the medical record revealed Resident #4 was admitted to the Behavioral Health hospital on [DATE] for further evaluation related to being a danger to herself. Review of the Behavioral Health Hospital's Progress Note dated 11/22/2023, revealed .No foreign body identified in stomach (she [Resident #2] apparently had reported to nursing that she had swallowed a fork) . Review of the Behavioral Health Hospital's Progress Note dated 11/24/2023, revealed .Patient [Resident #2] was placed on one-to-one level of observation last night due to attempting to choke herself with a toothpaste tube. Review of the Behavioral Health Hospital's Progress Note dated 11/25/2023, revealed .pt [Resident #2] attempted to put crackers up her nose and gauze in her mouth. Review of the Behavioral Health Hospital's Progress Note dated 11/28/2023, revealed .Patient [Resident #2] exhibits ongoing behaviors and attempted to put sugar in her ears this morning.she requires frequent re-direction to maintain her safety. Review of the Behavioral Health Hospital's Progress Note dated 11/30/2023, revealed . [Resident #2] attempts to place items in her ears and mouth.insight and judgement are poor. Review of the Behavioral Health Hospital's Progress Note dated 12/1/2023, revealed .Staff noted she [Resident #2] was attempting to drink water from the toilet. Review of the Behavioral Health Hospital's Progress Note dated 12/11/2023, revealed . [Resident #2] reportedly drank her own urine out of a cup last night. Review of the Behavioral Health Hospital's Progress Note dated 12/20/2023, revealed .Nursing staff reports patient [Resident #2] ate her own feces this morning.[Resident #2] denies attempting to eat it [feces] and cannot explain how feces got into her mouth.repeated pattern of eating non-food items. Review of the Client Uploaded Files revealed the Behavioral Health Hospital Progress Notes were uploaded to Resident #2's electronic health record on 1/12/2024. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Deficiency of Other Vitamins, Dementia, Schizoaffective Disorder, and Anxiety Disorder. Review of the Weights and Vitals Summary revealed Resident #2's weight was 181.7 pounds (lbs) on 1/12/2024. Review of the Care Plan Report dated 1/12/2024 through 9/29/2025 revealed there was no implemented focus with interventions for behavior related to eating non-food items. Review of Order Summary Report revealed, .Ipratropium-Albuterol Inhalation Solution [inhalation therapy used to treat difficult breathing, wheezing and shortness of breath] 0.5-2.3 (3) MG [milligram]/3 ML [milliliters].1 inhalation inhale orally every 6 hours as needed for 1 treatment QID [4 times per day].Order Date 01/14/2024. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of the CT (Computed Tomography) Chest w (with) Contrast dated 1/26/2024, revealed .Evaluation of the upper abdomen demonstrates multiple indeterminate [unknown or uncertain] foreign bodies within the lumen [interior space of the stomach] of the stomach. There is a centrally lucent [an area that appears dark] longitudinal [elongated or lengthwise] structures seen within the gastric fundus [upper, rounded portion of the stomach]. An additional longitudinal metallic structure also seen within the gastric body with additional structures noted in the gastric [NAME] [lower part of the stomach] .Impression.Indeterminate radiolucent [appear dark] and metallic foreign bodies within the gastric body and fundus. At least 2 [of] the structures were not present on the prior study [12/7/2023]. Review of a CT scan report transcribed on 1/29/2024, revealed .Evaluation of the upper abdomen demonstrates multiple indeterminate foreign bodies within the lumen of the stomach. The CT scan results were uploaded to Resident #2's electronic health record on 1/29/2024. Review of the Weights and Vitals Summary revealed Resident #2's weight was 169.3 lbs. on 4/3/2024. Resident #2 lost 12.4 lbs., (6.85%) in 3 months. Review of a Progress Note dated 6/12/2024, revealed .Follow up with [Medical Doctor- MD #2] regarding results of CT of chest done on 01/26/2024 noting a Left posterior lung lesion and resident's recent complaint of pain. Per [MD #2] there was no follow up needed regarding CT of chest results. The note was entered by the Nursing Supervisor (NS). Review of a Progress Note dated 6/25/2024, revealed .[Resident #2] continue asking to go to the hospital, calling for husband and telling him to come and taking [take] her to the hospital.She also complained of unable to swallow whole pills, medication crushed, and she is able to take it without difficulty. Will continue to monitor. Review of a Progress Note dated 6/26/2024, revealed .[Resident#2] continue complains [complaints] of SOB [shortness of breath] and want to go to the hospital due to the SOB and sore throat.She complains of swallowing problems during med pass and ask [asked] her medication to be crushed, crush medication with pudding without difficulties. Review of a Progress Note dated 6/27/2024, revealed .[Resident#2] continues to complains [complain] of swallowing issues. Review of a Progress Note dated 6/28/2024 at 3:05 PM, revealed . [Resident #2] continued to complaint [complain] with swallowing issues. Review of a Progress Note dated 6/28/2024 at 11:14 PM, revealed . [Resident #2] continues to complaint [complain] with swallowing issues. Review of a Progress Note dated 6/29/2024 at 11:48 AM, revealed .[Resident#2] continues to complain with swallowing issues. Review of the Speech Therapy Evaluation (Speech Language Pathology (SLP) & (and) Plan of Treatment note revealed, .6/30/2024.Pt [Resident #2] exhibiting difficulty with A-P [anterior posterior-throat to stomach] movement of meals [moving food through the digestive track from the throat to the stomach] and excessive difficulty swallowing with mech [mechanical - foods easy to chew and swallow] soft and regular texture. Pt describes what sounds as if a stricture and coughing gagging on viscous [thick] foods.Severe . Clinical S/S [signs and symptoms] Dysphagia: per nsg [nursing], pt has had swallow downgraded to grounded and crush meds.Risk Factors.the patient is at risk for anxiety and malnutrition. Review of the Progress Note dated 7/1/2024 at 11:15 AM, revealed . [Resident #2] continues to complain with swallowing issues. Review of the Progress Note dated 7/1/2024 at 11:30 PM, revealed . [Resident #2] continue [to] complains [complain] of swallowing issues. Review of the Progress Note dated 7/2/2024 at 11:19 AM, revealed . [Resident #2's] husband.called wanting to know why his wife was not being sent to the hospital for treatment. He stated that she reported to him she was not able to swallow and having chest pain.resident was assessed and verified what husband had stated.some SOB noted. Review of the Progress Note dated 7/2/2024 at 11:58 AM, revealed .Patient [Resident #2] was sent to ER [Emergency Room] via [by way of] 911 at husbands request r/t [related to] .her complaint of chest pain and not being able to swallow. Review of the Progress Note dated 7/2/2024 at 3:56 PM, revealed .Review of labs for 07/02/2024 with critical values of Carbon Dioxide level 41 [normal range 21.9 - 28.1].resident currently at.ED [emergency department]. Continued review of the lab work dated 7/2/2024 revealed an elevated white blood count of 12.7 (normal range of 4.9-11.1) which would be indicative of an infection. Review of the Progress Note dated 7/2/2024 at 10:01 PM, revealed . [Resident #2] in hospital per her request. Review of the Weights and Vitals Summary revealed Resident #2's weight was 157.2 lbs. on 7/3/2024 [7/2/2024]. Resident #2 lost 24.5 lbs., (13.5%) in 6 months, which was considered severe weight loss. 4. Review Hospital #2's History of Present Illness dated 7/3/2024, revealed .a transfer from [Named Hospital #1] ED [emergency department] for evaluation of foreign metallic object in esophagus as well as concern for necrotizing pneumonia [rare and severe bacterial lung infection] vs. [versus] pulmonary abscess [pus filled cavity on the lung often caused by aspiration-the accidental inhalation of foreign materials into the airway] on CT imaging. She initially present [presents].with complaint of chest pain and shortness of breath that started yesterday morning. She reportedly was experiencing dysphagia [difficulty swallowing] with a pureed [foods with pudding like consistency] diet at her care facility [Facility #1] as well.Repeat KUB [type of abdominal X-ray].this morning revealed A spoon is seen in the stomach. A [NAME] pin overlies [appears on top of] the RIGHT upper quadrant [upper part of the abdomen]. Additional radiopaque [appears white or light because it blocks the radiation for example metal, bone, glass] foreign bodies appear present adjacent [close] to.the spoon.Patient has been complaining of a sore throat and sharp pain in her chest.Does have some wheezing. Review of Upper Gastrointestinal endoscopy [procedure to examine your digestive system] report dated 7/3/2024, revealed .There is a large clam shell that is wedged just below the UES [upper esophageal sphincter-muscles that separate the throat from the esophagus-tube that connects the throat to the stomach]. There is a large ulceration with a mucosal tear [laceration in the lining] already present upon entry in the esophagus. There is a straw adjacent to the area. I attempted.to remove the clam shell but was unable to after multiple attempts. I was able to traverse [move/navigate] around the shell into the remainder of the esophagus. There is some trauma noted in the distal [lower end that connects to the stomach] esophagus from foreign body ingestion. In the stomach, there are multiple objects as outlined below. I used multiple types of equipment to remove all foreign bodies.A clam shell, two plastic straws (whole), a corrugated [with ridges and grooves] straw (whole), toothbrush, 4 [named cotton swab], a spoon, a [named hair] pin, 3 ampules [sealed plastic tube] of albuterol, an oxygen mask string, and a beaded bracelet.A couple of [named cotton swabs] were left behind in the stomach.Impression.THIS IS AN EXTENDED PROCEDURE THAT TOOK 1.5 HOURS TO COMPLETE. IT WAS VERY CHALLENGING AND TECHNICALLY DIFFICULT. Recommendation.transfer.Obtain stat [done immediately] CXR [Chest Xray] - I am uncertain if she has a perforation in the proximal esophagus [upper part of the chest behind the windpipe] . Review of Hospital #2's Discharge Summary Report revealed Resident #2 experienced a cardiac or respiratory arrest was resuscitated and experienced arrest a second time in the Intensive Care Unit and was pronounced deceased on 7/9/2024. During a telephone interview on 9/26/2025 at 3:06 PM, Licensed Practical Nurse (LPN) L stated Resident #2 complained of feeling like she had something in her throat and was having trouble swallowing. LPN L stated Resident #2 had taken her medication whole without having trouble swallowing, then started having problems swallowing and had to be given medications crushed. LPN L stated Resident #2 complained of a sore throat and began to clear her throat constantly. LPN L stated she had reported Resident #2's complaints of painful swallowing and throat clearing to the Nurse Supervisor(NS). LPN L confirmed she was not aware of Resident #2's behavior history of swallowing non-food items. During an interview on 9/30/2025 at 9:26 AM, Restorative Nursing Assistant (RNA) H stated Resident #2 was monitored during meals in the dining room with all residents. RNA H stated she recalls Resident #2 had to use plastic utensils for some reason, though she wasn't sure why. During an interview on 9/30/2025 at 4:17 PM, the Former Director of Nursing (DON) CC stated Resident #2 had complained to staff about having trouble swallowing, was constantly requesting water, and began to have repetitive behaviors of trying to clear her throat. Former DON CC concluded she spoke with Medical Doctor (MD) #2 and suggested evaluation with the Speech Therapist. The Speech Therapist recommended a swallow study (test to assess for abnormalities in swallowing function). Former DON CC stated she was not aware of Resident #2's prior behaviors related to eating non-food items and does not recall discussing her behaviors in the clinical meetings. Former DON CC alleges the only thing she recalled being told about Resident #2's mental health history was that she was stable for discharge to the facility. During a telephone interview on 9/30/2025 at 5:01 PM, the Radiologist reviewed Resident #2's CT scan dated 1/26/2024 and confirmed there were two longitudinal (lengthwise) foreign bodies, 1 metallic and 1 nonmetallic, present in Resident #2's stomach that were not present on a CT scan completed on 12/7/2023. The Radiologist stated he expected the ordering provider would order a follow-up study to be completed. The Radiologist stated the report was sent to MD #2. During an interview on 10/2/2025 at 11:09 AM, the Medical Director (MD #1) stated she could not recall the Quality Assurance Performance Improvement (QAPI) Committee meeting to discuss Resident #2's hospitalization related to eating non-food items. MD #1 stated Resident #2's medical history provided by the Behavioral Health Hospital during admission should have been considered when developing a care plan. MD #1 reviewed the Radiology report for Resident #2 dated 1/29/2025. MD #1 confirmed the report indicated the presence of two foreign bodies in Resident #2's abdomen and should have triggered evaluation and monitoring for behaviors. During a telephone interview on 10/2/2025 at 7:00 PM, MD #2 confirmed Resident #2 was his patient during her stay at the facility from 1/12/2024-7/2/2024. MD #2 was asked if he had been aware of Resident #2's history of behavior related to eating non-food items. MD #2 stated, .If it [Resident #2's behavior history] was in her chart, yes, I would have her history . MD #2 stated he had not read Resident #2's history in detail, though he knew Resident #2 had swallowed a spoon and was sent to the hospital. MD #2 stated he did not recall if the hospital had removed the spoon from Resident #2's stomach or if she had passed the spoon. MD #2 stated he was aware Resident #2 had passed away due to complications during a biopsy procedure performed on her pulmonary nodules and not during the procedure to remove items from her stomach. MD #2 was again asked if he had reviewed Resident #2's behaviors noted in her progress notes sent from the Behavioral Hospital and had he ordered monitoring for those behaviors. MD #2 concluded he was sure he had reviewed Resident #2's history and stated he obviously did not recall seeing any behaviors that impressed him. MD #2 was asked if he had concerns related to the results of the CT scan completed on 1/26/2024, which included two foreign bodies noted in Resident #2's stomach. MD #2 stated his concern was to follow up on the pulmonary nodules that had been identified prior to Resident #2's admission to the facility. MD #2 stated he had not ordered monitoring for Resident #2 ingesting non-food items, and he wasn't sure the facility would be able to provide monitoring for those behaviors. MD #2 stated Resident #2 should not have been admitted to the facility if she required that type of monitoring. MD #2 confirmed the ingestion of foreign bodies by Resident #2 could likely lead to harm or death. During an interview on 10/7/2025 at 3:14 PM, the admission Coordinator (AC) stated she retrieved the referrals from an admissions portal, and the Admissions Team reviewed the referral. The AC stated the Admissions Team consisted of the admission Coordinator, the DON, the Administrator, the Rehab Director, and the Business Office Manager. The AC confirmed the Admissions Team talked about Resident #2, and she (AC) had reservations because Resident #2 was coming from the Behavioral Hospital. The AC stated the referral indicated Resident #2 had received treatment for behaviors and was stable for discharge. The AC stated once the resident was accepted, the MD would be notified and given the resident's history with diagnoses and their list of medications. The AC was asked if there was a process for reviewing a resident's records from the discharge facility prior to admission to Facility #1. The AC replied, .No, before now, we basically just discussed the report we got from the facility with the referral. During an interview on 10/7/2025 at 3:54 PM, the NS was asked if he had reviewed the result of Resident #2's CT completed on 1/26/2024. The NS replied, .No, the results would go directly to [Named MD #2]'s office for review. The NS was asked if he had discussed the results of the CT with MD #2 when speaking with him on 6/12/2024 related to a follow-up CT scan. The NS replied, .I don't recall talking with [MD #2] about any of the results. The NS was given the progress note to review that was entered by him on 6/12/2024 related to Resident #2's CT results. The NS responded, .I just can't recall seeing any results on her CT scan. The NS was asked if he had reviewed Resident #2's admission history from the Behavioral Hospital. The NS responded, .I usually do not attend the clinical meetings because I have so many responsibilities.A resident's history and physical information would be up to the admitting nurse to obtain, and if not, we eventually find out what behaviors they have or build a history based on their behavior in the facility.I wasn't aware of any problems [Named Resident #2] was having with swallowing until the day she was sent to the hospital [7/2/2024].I do know that [Resident #2] was very manipulative and might have been using her sore throat problem to cut a deal with the nurse to go outside to smoke.she did that a lot.I think if she complained with swallowing difficulty, the nurse would have assessed her and followed up with the physician. During an interview on 10/8/2025 at 10:19 AM, the Registered Dietician (RD) stated she was aware of Resident #2's weight loss and had determined the weight loss was not significant until before she went to the hospital and most likely was caused by her COPD. The RD concluded interventions were implemented which included large portions and supplements. During an interview on 10/8/2025 at 11:19 AM, the Licensed Psychologist (LP) stated she had provided mental health visits to Resident #2 related to her diagnosis of severe mental illness and treated anxiety type behaviors. The LP confirmed she was unaware of Resident #2's history related to behaviors of eating non-food items. The LP stated she would expect to receive information provided to the facility related to the residents' mental health history with a referral for services. The LP stated she did see paperwork from the referring facility and did not recall reading anything about behaviors related to eating non-food items. The LP stated, . [Named Resident #2] could be very dramatic during interactions. During a telephone interview on 10/8/2025 at 12:14 PM, the SLP stated, .I received a referral to see [Named Resident #2] because she kept complaining about difficulty swallowing and feeling like something was stuck in her throat.she described a feeling of pressure when she would eat.The symptoms described were the same as patients describe when they have a narrowing in the esophagus and I ordered a swallow study [imaging exam that examines the swallowing process] and changed her diet to a pureed texture .I didn't know about her [Resident #2] history of eating non-food items or that would have been a huge red flag to send her out to the hospital for evaluation immediately.I didn't hear anything obvious.I can only hear something above the esophagus. During an interview on 10/8/2025 at 4:16 PM, the Social Services Director (SSD) stated Resident #2's history from Behavioral Hospital #1 had not been discussed in the care plan meetings or the Interdisciplinary Team (IDT) meetings. The SSD stated she was not aware of Resident #2's history of eating non-food items. During a telephone interview on 10/8/2025 at 5:36 PM, the Psychiatric Services Nurse Practitioner (PNP) stated she would expect to receive a referral for a resident with behaviors related to eating non-food items. The PNP stated she was not aware of Resident #2's prior history of eating non-food items. The PNP concluded there had been a problem with the facility getting accurate paperwork with a resident's history prior to them being admitted to the facility. During a telephone interview on 10/9/2025 at 11:34 AM, LPN U stated Resident #2 was anxious and often made repetitive requests to go to the hospital due to multiple symptoms and to go outside and smoke. LPN U stated she was not aware of Resident #2's history of eating non-food items. During a telephone interview on 10/9/2025 at 11:40 AM, LPN T stated Resident #2 was frequently awake and anxious during the 10:30 PM to 6:30 AM shift. LPN T stated Resident #2 would often complain of being hungry or thirsty at night and would eat snacks constantly. LPN T stated about a month before she went to the hospital (7/2/2024), Resident #2 complained of trouble swallowing and stopped eating her snacks at night. LPN T stated she reported Resident #2's complaints of trouble swallowing to a nurse manager (LPN T could not recall to whom she had reported the complaints of difficult swallowing to in June 2024). LPN T concluded if she had been aware of Resident #2's history of swallowing non-food items, she would have obtained an order to send her for evaluation in the emergency room. An acceptable Removal Plan which removed the immediacy of the Jeopardy was received on 10/7/2025 and was validated onsite by the surveyor on 10/7/2025 through 10/8/2025 by medical record reviews, observations, review of education records, and staff interviews. F 600 A. Immediate action to address the residents affected or likely to be affected: There were no additional residents identified during screening. There were no additional residents with abuse/neglect concerns identified. The skin assessments did not identify additional concerns. Staff who were not available during the training will be trained before being allowed to work. In addition, the staff should attain a 100% score and be retrained by the DON, VP of Clinical Services, SDC (staff development coordinator) or Unit Manager if the score is less than 100%. From 10/2/25 - 10/3/25, the DON, VP of Clinical Services, SDC (staff development coordinator) and Unit Manager reviewed the current residents' assessed history of pertinent/related behaviors. In addition, all potential admissions/patient referrals were also reviewed by the admission director, DON/Unit Manager/MDS (minimum data set) Nurse prior to admission to the facility. If any relevant behavior is identified, a care plan will be developed upon admission to address the behavior identified. The DON will follow-up pertinent radiology results within 24 hours. In the absence of the DON, the ADON will follow-up radiology results. The results will be relayed to the attending physician; a care plan will be developed to address the radiology results as needed. 1. Resident 2 no longer resides in the facility. The resident was discharged to another facility on 7/2/24. 2. The DON (director of nursing) conducted a huddle meeting on 9/29/25 with the nursing staff to identify any resident who may have similar behavior like Resident #2, a vulnerable, cognitively impaired resident with a behavioral history of eating non-food items including the ingestion of metal objects. 3. To identify residents who are likely to be affected by the alleged deficiency, on 10/2/25 to 10/3/25, the clinical leadership team (DON, UM - unit manager, SDC - staff development coordinator, MDS - minimum data set Nurse) SSD (social services director), VPCS (vice president of clinical services) and RRCO (regional regulatory compliance officer) completed a screening of all residents for aggressive behavior and screening for risk for abuse of all residents. 4. Identified concerns from the completed screenings were care planned on 10/2/25 to 10/3/25 by clinical leadership team (DON, UM - unit manager, SDC - staff development coordinator, MDS - minimum data set Nurse) SSD (social services director), VPCS (vice president of clinical services) and RRCO (regional regulatory compliance officer). 5. The DON (director of nursing), UM (unit manager), SSD (social services director), and SDC (staff development coordinator) also conducted resident abuse interviews or skin assessments. The residents who are able to participate were interviewed to ensure that they feel safe in the facility. The results of the interviews will be documented in the Resident Abuse Interview. The residents who are unable to participate in interviews due to cognitive deficit were assessed by the nurses to identify signs of abuse/neglect. These action items were completed on 10/05/25. B. Immediate Actions to Prevent Occurrence/Recurrence: 1. Ad-Hoc QAPI Meeting: Ad-Hoc QAPI meeting was completed on 9/29/25 which was participated by the leadership team which includes the Administrator, Director of Nursing (DON), Unit Manager (UM), RD (registered dietician), Social services Director (SSD), Minimum Data Set (MDS) Coordinators, Business office Manager (BOM), Medical Records, Rehabilitation Manager, and Nursing Scheduler. This was also participated by the VP of Clinical Services, Chief of Operations and Regional Regulatory Compliance Officer. The QAPI team discussed the reason Resident #2 was transferred to the hospital on 7/2/24 and the admission reports of foreign bodies found within her abdomen. The leadership team also discussed the facility actions and systemic changes which were implemented to prevent the recurrence of similar incidents. The facility actions as specified in the plans of removal which includes but are not limited to: a) Review of potential admissions (referrals) by the admission staff, DON or her designee prior to admissions b) Development of care plan upon admission to address any identified risk from review of documents, such as hospital records and other documents which provided information about the potential admissions medical and psychiatric history c) Care plan review of all current residents to ensure that any identified behaviors are addressed with person-centered interventions 2. Huddle Meeting: The DON (director of nursing) conducted a huddle meeting on 9/29/25 with the nursing staff to identify any resident who may have similar behavior like Resident #2, a vulnerable, cognitively impaired resident with a behavioral history of eating non-food items including the ingestion of metal objects. The DON will review the clinical huddle meeting records daily to identify any concern related to resident's behavior to ensure that the behaviors are care planned with person-centered interventions. 3. Care Plan review: The clinical leadership team (DON, UM - Unit Manager, SDC - staff development coordinator, MDS - minimum data set Nurse), SSD (social service director, VPCS (Vice President of Clinical Services), and VPBM (Vice President of Behavior Management & Resident Quality of Life) reviewed all care plans of current residents to ensure that all behaviors are care planned with person-centered interventions. This action item will be completed on or before 10/06/2

Based on facility policy review, facility document review, medical rcord review, observation, and interview, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to reassess and monitor ongoing concerns and develop an effective QAPI program that recognized concerns related to exit seeking behavior, and failed to ensure systems and processes were in place and consistently followed by staff to prevent an elopement. Failure of the QAPI Committee to identify the root cause of an elopement, develop and implement new interventions to prevent further elopements, and ensure a safe environment for residents placed 2 of 5 sampled residents (Resident #9 and Resident #174) in Immediate Jeopardy (IJ). Resident #9, a cognitively impaired resident with known wandering and exit seeking behaviors, eloped from the facility three times on 6/16/2023 (5:01 AM, 5:30 AM, and 5:56 AM) and once on 7/26/2023 (dinner time). Resident #174, a cognitively impaired resident with known wandering and exit seeking behaviors, eloped from the facility in a wheelchair on 2/10/2023 at 6:20 PM during cold and windy weather without wearing a jacket and wheeled herself to the adjacent apartments before a tenant from the apartments called the facility to alert staff that Resident #9 was outside. This resulted in an Immediate Jeopardy (IJ). 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. The Administrator was notified of the Immediate Jeopardy (IJ) on 7/31/2023 at 4:59 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-865. The facility was cited at F-865 at a scope and severity of J. The Immediate Jeopardy was effective 2/10/2023 and is ongoing. The findings include: Review of the facility's policy titled, Elopement/Wandering, Unsafe Resident, dated 2/1/2009 revealed .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .Staff will institute a detailed monitoring plan, as showed for residents who are assessed to have a high risk of elopement or other unsafe behavior . Review of the facility's policy titled, Quality Assurance & Performance Improvement (QAPI) Committee dated 11/28/2017 revealed .Systematic analysis and systemic action: a. Root Cause Analysis (RCA) process is used as a structured approach to fully understand the nature of an identified problem, its cause and the implications of making changes to improve the problem. b. A process to assist in determining the RCA of an area of interest will be done by the IDT (Interdisciplinary Team)/QAPI committee members and appropriate interventions for corrective action will be implemented . Review of the facility's investigation dated 2/10/2023 revealed an elopement occurred at 6:20 PM when Resident #174 wheeled herself in a wheelchair to the front door, stood up and pushed the exit button, and exited the facility. Resident #174 wheeled herself to the gate of an apartment complex next to the facility. A tenant of the apartment complex called the facility to inform them of Resident #174's whereabouts. Continued review revealed Resident #174 was alert with .periods of confusion . CNA #9 reported she was assigned to Resident #174 and recalled seeing Resident #174 in the dining room. CNA #9 was assisting another resident at the time of the elopement. LPN #3 who assigned to Resident #174 received the phone call from the tenant that Resident #174 was outside. Continued review revealed Resident #174's Wanderguard was not working during the elopement. Refer to F-689 Review of an undated QAPI CAP (Corrective Action Plan is a step by step plan of action to be followed to ensure below par outcomes are swiftly addressed and mitigated) revealed the facility replaced Resident #174's Wanderguard after staff discovered Resident #174's Wanderguard was not working. The facility placed Resident on 15 minute observation checks (resident safety check performed in 15 minute intervals). The facility checked the Wanderguards on all residents who were on the Wanderguard program and checked the device functioning at the door. Residents on the Wanderguard program were placed on 15 minute observation checks. The facility reviewed and updated as indicated physician orders for Wanderguard program orders and care plans for all residents in the Wanderguard program. The facility reviewed and updated as indicated all Wander assessments. The facility inserviced staff on the Code Gray process (code to alert staff that a resident has eloped). The facility's QAPI committee failed to thoroughly analyze the cause of the elopement, develop and maintain interventions to prevent further elopement, and effectively monitor and reassess interventions implemented to prevent further elopement. Resident #174 was able to exit through the front door by pushing the exit button to open the door and leave the facility. This was not addressed in the facility's documented corrective action plan. Wanderguards would only alarm at the front door. None of the other exit doors of the facility were equipped with the Wanderguard system. There was no documentation in the facility's corrective action plan that any of the other doors or exits were assessed for potential elopement risks. There was no documentation in the facility's action plan of how long Resident #174 or any of the other residents would be monitored with 15 minute observation checks or the criteria the facility would use to determine a resident no longer required these safety checks. There was no documentation provided that the facility inserviced staff on identifying exit seeking behaviors or interventions to prevent elopements (Code Gray is the code called after a resident has eloped). Review of the MONTHYLY QA MEETING .JANUARY 2023 [review data from January 2023] dated 2/23/2023 revealed two sections on the sheet: Focus Areas and Report data Provided. The Focus Areas included, Reportable Investigation & [and] Elopement unsafe program. The facility failed to provide any documentation of the minutes from the meeting, and there was no documentation the QAPI committee discussed the elopement by Resident #174, any interventions to prevent further elopements, or any monitoring of interventions or residents to determine the effectiveness of the interventions. Review of the MONTHYLY QA MEETING .FEBRUARY 2023 [review data from February 2023] dated 3/30/2023 revealed two sections on the sheet: Focus Areas and Report data Provided. The facility failed to provide any documentation of the minutes from the meeting, and there was no documentation the QAPI committee discussed the elopement by Resident #174, any interventions to prevent further elopements, or any monitoring of interventions or residents to determine the effectiveness of the interventions. The facility failed to provide the documentation of QAPI meeting minutes after multiple requests by the survey team. Review of the facility's investigation dated 6/16/2023 revealed an elopement (Resident #9 eloped 3 times on 6/16/2023: Elopement #1 occurred at 5:01 AM, Elopement #2 occurred at approximately 5:30 AM, and Elopement #3 occurred at 5:56 AM) occurred at 5:45 AM. Resident #9 exited (Elopement #2) through the dining room door at approximately 30 minutes prior to Elopement #3. Maintenance Personnel #1 saw Resident #9 walking from around the back of the facility unsupervised (Elopement #2). Resident #9 exited the building through the dining room door which led to the resident patio and smoking area and then exited through the patio gate (Elopement #3). Staff arriving at work noticed Resident #9 right outside the front gate. The facility did not include Elopement #1 (6/16/2023 at 5:01 AM) in their investigation on 6/16/2023. Refer to F-689 Review of the QAPI CAP dated 6/23/2023 revealed the facility referred Resident #9 to psychiatric services and moved Resident #9 to another room to allow for one-to-one monitoring (resident safety intervention in which the resident is in continuous proximity and sight of a staff member). The facility planned to update Resident #9's elopement risk assessment and care plan. The facility tested all exit doors and alarms and found that they were all functioning properly except for the dining room door. The alarm on the dining room door was replaced, and the new alarm functioned properly. The facility installed a new latch on the gate of the resident patio/smoking area which is easy for staff to access and open but not for residents. The facility planned on installing a new latch on the facility service road gate. The facility posted a sign on the dining room door. The facility inserviced staff on the gate latches and new alarm device with keys. The facility's QAPI committee failed to thoroughly analyze the cause of the elopement, develop and maintain interventions to prevent further elopement, and effectively monitor and reassess interventions implemented to prevent further elopement. Resident #9 eloped on 6/16/2023 at 5:01 AM (Elopement #1) when she exited the building through the dining room door and across the patio toward the fence which enclosed the patio (Resident #9 walked approximately 50-60 feet from the dining room door before a staff member came through the dining room door and called Resident #9 back inside the building). The facility did not include this elopement on their investigation. The Administrator and Director of Nursing stated in interview, they were unaware Resident #9 eloped on 6/16/2023 at 5:01 AM, but surveyor observed Resident #9 exiting the building on 6/16/2023 at 5:01 AM (Elopement #1) while reviewing the facility camera footage. Resident #9 eloped on 6/16/2023 at approximately 5:30 AM (Elopement #2) when she exited the building through the dining room door, across the patio, through the latched gate on the fence, and into the facility parking lot. Maintenance Personnel #1 was seated in his car in the parking lot and saw Resident #9 in the parking lot and escorted her back inside the facility. Maintenance Personnel #1 reported that the alarm sounded when Resident #9 entered the facility, but no staff responded to the alarm. Maintenance Personnel #1 escorted Resident #9 to the nurses' station, but there was no staff present. Maintenance Personnel #1 found a nurse on the back hall passing medication, and he notified the nurse about Resident #9's elopement. There was no documentation in the facility's corrective action plan that addressed why the staff was either not able to hear the alarm when Resident #9 re-entered the building or why the staff did not respond to the alarm. There was no documentation in the facility's corrective action plan to address why staff failed to put interventions in place after the first elopement to prevent further recurrences. Resident #9 eloped on 6/16/2023 at 5:56 AM (Elopement #3) when she exited the building through the dining room door, across the patio, through the gate on the fence, and down the paved service road. Resident #9 was seen near the front gate (which exited the grounds of the facility) by the Human Resources (HR) Director and Medical Records (MR) Director who were seated in a vehicle in the parking lot. The HR Director and MR Director escorted Resident #9 back to the facility. There was no documentation in the facility's corrective action plan which addressed how Resident #9, who had already eloped twice within the last hour and was supposed to be on 15 minute observation checks (for safety), exited through the same dining room door for the third time in less than an hour and walked from the dining room door, across the patio, through the gate, down the service road, and up the drive way to the front gate without any staff in the building recognizing that Resident #9 had left. There was no documentation that any staff was aware of Resident #9 being outside of the facility (no documentation of a Code Gray called) until the MR Director called nursing staff on the phone to inform them that Resident #9 was outside at the front gate. The facility failed to provide the documentation of any QAPI meeting minutes after multiple requests by the survey team which addressed these 3 elopements. Resident #9 eloped on 7/26/2023 at approximately dinner time (exact time unknown) (Elopement #4) when she exited the building through the exit door on the 500-hall. The door alarm sounded, and staff (CNA #14 and Unit Manager #2) went outside to assist Resident #9 back to the facility. Resident #9 crossed the concrete flooring and had stepped off to the service road when the staff stopped her and escorted her back to the facility. There was no documentation provided by the facility that the QAPI committee investigated this elopement to identify the root cause or evaluate the systems and processes in place to prevent elopements. Observations of 100-hall, 200-hall, 500-hall, 600-hall, and the main dining room exit doors on 7/25/2023 at 3:46 PM, revealed all exits had an alarm on top of the doors with a mesh stop sign in front of the doors. There was no Wanderguard system available on these exit doors to notify staff of residents attempting to exit through the doors. Observations on the back hallway adjacent to the laundry room on 7/26/2023 at 3:16 PM, revealed State Surveyor #1 opened an exterior door (the door was labeled service door and was used by staff to take trash to the dumpster), but no alarm sounded because the alarm was not set. There was no documentation in the facility's corrective action plan or any documentation in the QAPI committee meeting minutes that addressed staff turning off the door alarms During an interview on 7/25/2023 at 2:12 PM, the Director of Nursing (DON) stated if a resident eloped from the facility they were automatically placed on every 15 minute observation checks. If the exit seeking behavior continued the resident was placed on one-to-one monitoring. These interventions were ongoing until the behaviors resolved. The DON confirmed the facility did not implement different interventions if the immediate interventions of Q 15 minutes checks or one-to-one monitoring worked. The DON stated she did not use other interventions initally because she did not want to run out of interventions. During an interview on 7/26/2023 at 3:28 PM, the Laundry Department Director confirmed the exterior door (labeled service door) was supposed to alarm at all times. The Laundry Department Director acknowledged the door alarm for the exterior door was not set. The Laundry Department Director also confirmed the service door was not equipped with the Wanderguard system (door would not alarm when a resident with a Wanderguard exited through the door). During an interview on 7/26/2023 at 3:29 PM, the Administrator confirmed the alarm to the service door should be set at all times. During an interview on 7/31/2023 at 2:53 PM, the Administrator stated the QAPI committee had a meeting on July 27, 2023, and the committee discussed Resident #9's elopements. The Administrator stated the notes were not complete or available at this time. After multiple requests for the QAPI committee meeting minutes, the Administrator failed to provide any QAPI meeting minutes for a meeting on July 27, 2023 or any QAPI meeting minutes which addressed any of Resident #9's four elopements. The Administrator confirmed that the front door was the only door or exit in the facility that would alarm from the Wanderguard system. The Administrator confirmed this was a system failure because the exit alarm system was not a Wanderguard system. During an interview on 8/1/2023 at 12:41 PM, the DON stated she was not aware that Resident #9 had an elopement on 6/16/2023 at 5:01 AM. The DON stated if staff had made her aware of the elopement, she would have put Resident #9 on 15-minute or one-to-one observations. The DON stated she expected staff to call to and let her know of any elopements, falls, deaths, or a resident leaving against medical advice (AMA). The DON stated staff could have prevented the elopements if she had known about the first elopement. During a telephone interview on 8/1/2023 at 2:41 PM, the Psychiatric Nurse Practitioner (NP) stated she felt Resident #9 needed a secure unit. The Psychiatric NP stated elopements were a significant concern at the facility. The Psychiatric NP stated the DON tried to have Resident #9 placed at another facility but was unsuccessful. The NP stated Resident #9 should have been placed on one-to-one observation to prevent her elopements. There was no documentation in the facility's corrective action plan or QAPI committee meeting minutes that mentioned Resident #9 being moved to a secure unit or transferred to another facility for her safety.

Based on facility policy review, medical record review, facility investigation review, facility camera footage review, weather website review, observation, and interview, the facility failed to provide adequate supervision and ensure a safe and secure environment to prevent an incident of elopement for 2 of 5 sampled residents (Resident #9 and Resident #174). Resident #9 had three elopments on 6/16/2023: one elopement at 5:01 AM when she exited the dining room door to the smoking patio and was brought back by Certified Nursing Assistant (CNA) #10, a second elopement at approximately 5:30 AM when she was found in the facility parking lot by Maintenance Personnel #1 who escorted her back inside the facility, and a third elopement at 5:56 AM when she was found outside the front gate of the facility by the Human Resources (HR) Director and Medical Records (MR) Director after Resident #9 exited the facility and walked down a service road to the front gate. The HR Director and MR Director escorted Resident #9 back inside the facility. Resident #9 eloped a fourth time on 7/26/2023 during dinner time when she exited from the exit door on the 500 hall to the service road behind the facility and was brought back by CNA #14 and Unit Manager #2. Resident #174 eloped on 2/10/2023 at approximately 6:20 PM when she unlocked the front lobby door and wheeled herself to the gate of a set of neighboring apartments. Licensed Practical Nurse (LPN) #3 received a call from one of the tenants of the apartment complex to report Resident #174 was outside the gate of the apartments. Resident #174 was escorted back to the facility by facility staff. The failure of the facility to provide adequate supervision and ensure a safe and secure enviroment to prevent incidents of elopements for Resident #9 and #174 resulted in Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is a situation in which the provider's non compliance with one or more requirments of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator was notified of the Immediate Jeopardy for F-689 on 7/26/2023 at 3:00 PM in the Administrator's office. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 2/10/2023 and is ongoing. The findings include: Review of the facility's policy titled, Elopement/Wandering, Unsafe Resident dated 2/1/2009, revealed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .will identify residents who are at risk for harm because of unsafe wandering (including elopement) .will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering .care plan will indicate the resident is at risk for elopement or other safety issues .Interventions to try to maintain safety will be included in the resident's care plan .document circumstances related to unsafe actions, including wandering by a resident .institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behaviors .all residents admitted to the facility will have an elopement assessment done within first 24 hours .elopement assessment will then be completed every 90 days, and interventions updated as needed .staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Post Traumatic Seizures, Schizophrenia, Anoxic Brain Damage, Abnormalities of Gait and Mobility, Muscle Weakness, and Restlessness and Agitation. Review of Resident #9's Order Summary Report on 8/2/2022 revealed .Change Wanderguard [a lightweight transmitter worn on the wrist, ankle, or wheelchair to prevent elopements] device Q 3 months and PRN every day shift every 3 month (s) starting on the 2nd for 1 day (s) for safety .Wanderguard: Check battery weekly for proper functioning. (Every week on Thursday) Detector is located in DON's office .Monitor resident with Wanderguard for risk of elopement Q shift every shift for safety . Review of the Quarterly MDS assessment dated [DATE] for Resident #9 revealed, a BIMS score of 8 which indicated moderate cognitive impairment. Resident #9 required a Wanderguard. Review of a Care Plan dated 6/2/2023 revealed, .(ASSISTIVE DEVICES) Resident needs assistive devices/enabler .wanderguard .(WANDERING) [Resident #9] is at risk for Elopement or Wandering AS EVIDENCED BY exit seeking . The interventions listed on the care plan at the time of the elopements on 6/16/2023 were as follows, .Wanderguard: check battery weekly for proper functioning Q week. Functional Wander Guard attached to resident. Make sure all staff are aware of elopement risk. Monitor resident with Wanderguard for risk of elopement Q shift . Review of Resident #9's Wandering Risk assessment dated [DATE] revealed a wandering risk assessment score of 11 (High Risk to Wander) and, .E. History of Wandering .2. Has history of wandering (past hospitalization or history from resident/family . Review of the Resident #9's Progress Notes dated 6/16/2023 revealed, .Resident was found in the parking lot heading for driveway by a maintenance personnel [Elopement #2]. She was brought into the bldg. [building]. Resident stated she was going to go catch the bus to school. Asked resident to sit down in the main DR [dining room] with the other residents. Meanwhile, when starting paperwork, another employee called and asked if we were missing a resident. At the time writer [LPN #4] thought the resident was still in DR. Checked the DR and resident was not sitting where she was a few minutes prior to call. Another resident tried to let us know she went out the DR door and through the fence to the front of the bldg. to again to check the bus [Elopement #3] .Resident was put on every 15 min [minutes] [observed by facility staff every 15 minutes] . Review of the facility's investigation dated 6/16/2023 revealed an elopement occurred at 5:45 AM (Elopement #2 occurred approximately at 5:30 AM based on interview, and Elopement #3 occurred at 5:56 AM based on review of facility camera footage). Resident #9 had exited (Elopement #2) through the dining room door at approximately 30 minutes prior to Elopement #3. Maintenance Personnel #1 saw Resident #9 walking from around the back of the facility unsupervised (Elopement #2). Resident #9 exited the building through the dining room door which led to the resident patio and smoking area and then exited through the patio gate (Elopement #3). Staff arriving at work noticed Resident #9 right outside the front gate. The facility did not include Elopement #1 (6/16/2023 at 5:01 AM) in their investigation on 6/16/2023. Review of the facility camera footage for Elopement #1 dated 6/16/2023 revealed the following: At 5:01:31 AM, Resident #9 exited the dining room door, entered onto the resident patio and smoking area, and headed toward the gate which exited the smoking area. At 5:01:50 AM, CNA #10 exited out the same dining room door to go after Resident #9. At 05:01:50 AM, Resident #9 turned around and headed back toward the dining room door. At 5:01:58 AM Resident #9 entered back into the dining room with CNA #10 behind her. Review of the facility camera footage for Elopement #3 dated 6/16/2023 revealed the following: At 5:56:43 AM, Resident #9 walked down a paved service road (the service road ran adjacent to the facility) alone at a steady speed. At 5:57:32 AM, Resident #9 walked toward the entrance gate of the facility. At 5:57:43 AM, Resident #9 was outside the entrance gate of the facility. At 5:57:46 AM, Resident #9 exited out of sight of the facility camera. The entrance gate led to a road located between two apartment complexes near the facility. Review of the Wunderground website revealed the temperature outside on 6/16/2023 from 5:00 AM to 6:00 AM was approximately 66 degrees Fahrenheit with winds at approximately 3 miles per hour. Review of the Psychiatric Progress Notes dated 6/20/2023 for Resident #9 revealed, .type of visit: Regulatory .Behavior Problem: Wandering/Exit-Seeking .needs secure facility .should be considered a high risk for elopement behaviors .a transfer to a more secure facility locked memory unit is recommended due to multiple elopement attempts .wandering and elopement behaviors need to be addressed .continue 1 on 1 supervision until a transfer to more secure facility can be achieved . Review of Resident #9's Wandering Risk Assessment with score of 11 (High Risk to Wander) dated 7/25/2023, showed .E. History of Wandering .Has history of wandering (past hospitalization or history from resident/family .has wandered within the home without leaving the grounds .has wandered within the past month . During an interview on 7/25/2023 at 8:56 AM, the MR Director stated at approximately 6:00 AM (on 6/16/2023), she arrived in a personal vehicle along with the Human Resource (HR) Director and observed Resident #9 standing close to the entrance gate with a small bag and smiling (Elopement #3). The MR Director stated she stopped the car and asked the HR Director to get Resident #9 and bring her inside. She stated she called the nurse's station to inform them Resident #9 was outside the facility. During an interview on 7/25/2023 at 9:08 AM, the Administrator stated when she arrived at the facility at approximately 8:15 AM on 6/16/2023, LPN #4 explained Resident #9 had eloped from the facility through the dining room exit door that leads into the resident patio and smoking area (Elopement #2 on 6/16/2023 at approximately 5:30 AM). Resident #9 was put on every 15 minutes checks. LPN #4 assumed the responsibility to perform the first 15 minute check. Resident #9 was sitting in the dining room in the line of sight for LPN #4 at the nurse's station. LPN #4 was filling out the incident paperwork and after turning away to make some calls, LPN #4 noticed Resident #9 had exited out the dining room door. The Administrator stated the HR Director and MR Director arrived at work and observed Resident #9 at the edge of the parking lot on the other side of the gate next to the light post. During an interview on 7/25/2023 at 9:21 AM, the HR Director stated she and the MR Director entered the parking lot and saw Resident #9 in the parking lot by a light post (Elopement #3 on 6/16/2023 sometime after 5:57 AM). The HR Director stated the MR Director told her to step out of the car and get Resident #9. The HR Director stated Resident #9 told her that she (Resident #9) was looking for the bus stop. During an interview on 7/25/2023 at 10:24 AM, LPN #5 stated she checked all Wanderguards every Thursday since April 2023, but the order was in the MAR for the nurse to sign off. She stated she went to each resident, located the Wanderguard, and checked it against the monitor. If the monitor lights were red, the Wanderguard was not working. LPN #5 then stated she took each resident to the front door to make sure the Wanderguard was working properly with the door. She stated the front door was the only door that would alarm for the Wanderguards. During an interview on 7/25/2023 at 10:54 AM, Maintenance Personnel #1 stated he was outside, seated in his car at approximately 5:30 AM (6/16/2023) when he observed Resident #9 walking in front of the car (Elopement #2). Maintenance Personnel #1 stated Resident #9 told him she was going home. Maintenance Personnel #1 stated he helped Resident #9 inside the facility and noticed upon entrance the alarm was on. Maintenance Personnel #1 stated he took Resident #9 to the nurse's station, but no one was there. Maintenance Personnel #1 found a nurse at the back of the hall passing medications. During an interview on 7/25/2023 at 10:56 AM, the DON confirmed she had previously watched the footage of Resident #9 going out of the dining room exit door and walking down the service road (Elopement #2 on 6/16/2023 at approximately 5:30 AM). The facility did not provide camera footage of Elopement #2 for Resident #9. During an observation and interview outside of the facility on 7/25/2023 at 11:59 AM, Maintenance Personnel #1 showed the surveyors the side of the building Resident #9 left from to walk to the parking lot (Elopement #2 on 6/16/2023 at approximately 5:30 AM). Maintenance Personnel #1 stated he saw Resident #9 on the left side of the parking lot where the generator and trash receptacles were stationed. Maintenance Personnel #1 stated he brought Resident #9 into the building through the front door, and the Wanderguard system alarmed. Maintenance Personnel #1 stated he took Resident #9 to the nurse's station and confirmed no other staff met him at the door when he escorted Resident #9 inside. Observations of 100-hall, 200-hall, 500-hall, 600-hall, and the main dining room exit doors on 7/25/2023 at 3:46 PM, revealed all exits had an alarm on top of the doors with a mesh stop sign in front of the doors. There was no Wanderguard system available on these exit doors to notify staff of residents attempting to exit through the doors. During an interview on 7/25/2023 at 3:46 PM, the Director of Maintenance stated the door alarm sounded for the facility exit doors when a resident pushed the door to go out. The Director of Maintenance stated that if any resident hit the door, the alarm would sound. The Director of Maintenance stated the door alarm would have to be turned off manually with a key. The Director of Maintenance stated the alarm for the front door in the main lobby would activate and alarm when any resident got close to the door. The Director of Maintenance confirmed he did not log the door checks. During an interview on 7/26/2023 at 2:52 PM, LPN #4 stated on 6/16/2023 she and CNA #10 were assigned to Resident #9. LPN #4 stated CNA #10 had got Resident #9 up for the morning, but the staff was busy that morning getting up patients and giving medications. LPN #4 stated that at approximately 5:30 AM, Resident #9 went out the front lobby door, but the alarm did not go off (Elopement #2). LPN #4 stated Maintenance Personnel #1 arrived to work early and escorted Resident #9 back into the facility. LPN #4 stated staff had Resident #9 go to her room, but she would not stay there. Resident #9 was then put in front of the nurse's station. Resident #9 moved to the main dining room but was still in sight of LPN #4. LPN #4 stated she was on the phone asking the DON what to fill out for an elopement. LPN #4 stated when she finished the phone conversation with the DON, the MR Director called on the phone and asked her if she was missing a resident. LPN #4 stated she was unaware of any residents missing. LPN #4 stated she then looked in the dining room, and Resident #9 was gone. LPN #4 stated the door from the dining room to the resident patio and smoking area was not locked. During an observation on the back hallway adjacent to the laundry room on 7/26/2023 at 3:16 PM, State Surveyor #1 opened an exterior door (the door was labeled service door and was used by staff to take trash to the dumpster), but no alarm sounded because the alarm was not set. During an interview on 7/26/2023 at 3:28 PM, the Laundry Department Director confirmed the exterior door (labeled service door) was supposed to alarm at all times. The Laundry Department Director acknowledged the door alarm for the exterior door was not set. The Laundry Department Director also confirmed the service door was not equipped with the Wanderguard system (door would not alarm when a resident with a Wanderguard exited through the door). During an interview on 7/26/2023 at 3:29 PM, the Administrator confirmed the alarm to the service door should be set at all times. During an interview on 7/27/2023 at 8:24 AM, the Administrator confirmed Resident #9 eloped from the facility through the 500 hall exit door and was found on the service road (Elopement #2 on 6/16/2023 at approximately 5:30 AM). The Administrator confirmed CNA #10 was assigned to Resident #9 on 6/16/2023. The Administrator stated CNA #10 was in another room on the 500 hall assisting a resident, and another CNA working that morning was with Resident #9's roommate performing one-to-one monitoring when Resident #9 eloped at approximately 5:30 AM. Observations on the service road on 7/27/2023 at 8:25 AM, revealed a black gate which was fastened by a latch (gate was not locked). The black gate led to a paved service road which ran adjacent to the building. The service road ran from the left side to the front of the building past a trash receptacle and a generator. During an interview on 7/27/2023 at 8:37 AM, Unit Manager #1 stated that on 7/26/2023 while he was in the office, he heard the door alarm for the exit door on the 500-hall. Unit Manager #1 stated Resident #9 had eloped but by the time he reached the 500-hall door, she had already been brought back into the facility by staff. Unit Manager #1 stated staff reported Resident #9 came out of her room, went down the hallway, pushed on the door, and exited the facility (Elopement #4). During a telephone interview on 7/27/2023 at 1:57 PM, CNA #14 stated he was assigned on the 500 hall and was in room [ROOM NUMBER] assisting a resident with their dinner along with another CNA providing one on one supervision to the roommate in the room. CNA #14 confirmed he heard the door alarm sound and left the room. CNA #14 took off the mesh stop sign on the door and opened the exit door. When CNA #14 reached Resident #9, Resident #9 had stepped off the square(square concrete flooring connected to the facility exit door) to the service road (Elopement #4). CNA #14 reached out and grabbed Resident #9's arm, and Resident #9 told him, I'm leaving. CNA #14 stated that he and Unit Manager #2 was able to assist Resident #9 back inside. CNA #14 stated there was another CNA assigned to 500 hall but unsure where the other CNA was at during the elopement. During an interview on 7/31/2023 at 10:27 AM, the Administrator stated facility camera footage kept footage for 2 weeks, but then the video taped over the existing footage, and the facility did not have camera footage over 2 weeks old. The facility did not provide any camera footage for Resident #9's Elopement #2 which occurred on 6/16/2023 at approximately 5:30 AM. During a telephone interview on 8/1/2023 at 12:01 PM, CNA #10 stated she had given Resident #9 her shower first of the group of residents she had assigned to get up or give showers on 6/16/2023. CNA #10 stated she then had Resident #9 sit in the dining room while she went back to her hall to provide care to the other residents. CNA #10 stated she told LPN #4 that she could not watch Resident #9 and give showers to the residents who needed them. CNA #10 stated the nurse was supposed to help watch the residents too. CNA #10 stated that after she finished showering another resident, she saw Resident #9 outside and brought her back inside and told the nurse she needed to watch Resident #9. CNA #10 confirmed Resident #9 had gone outside on the smoking patio by herself unattended (Elopement #1 on 6/16/2023 at 5:01 AM). CNA #10 confirmed Resident #9 had eloped again a little while later on the same day and was told staff found her in the front of the building (Elopement #3 on 6/16/2023 at 5:56 AM). CNA #10 stated Resident #9 had told her that she left the building because she needed to go to the food stamp office. During an interview on 8/1/2023 at 12:41 PM, the Director of Nursing (DON) stated she was not aware Resident #9 had another elopement (Elopement #1 on 6/16/2023 at 5:01 AM) on 6/16/2023 and if staff had made her aware, she would have put Resident #9 on 15-minute or one-to-one observations. The DON stated she expected staff to call to and let her know of any elopements, falls, deaths, or a resident leaving against medical advice (AMA). The DON stated staff could have prevented the elopements if she had known about the first elopement sooner. The DON stated 15-minute observations worked for some residents, but the staff needed to do one-to-one observation for Resident #9 (Resident #9 was placed on 15-minute checks after Elopement #2 on 6/16/2023 at approximately 5:30 AM and placed on one-to-one observation after Elopement #3 on 6/16/2023 at 5:56 AM). During an interview on 8/1/2023 at 1:43 PM, LPN #4 stated she remembered Resident #9 had only two elopements on 6/16/2023 (Elopement #2 at approximately 5:30 AM and Elopement #3 at 5:56 AM). LPN #4 stated the CNAs put residents who got up early in the morning in the dining room. LPN #4 stated she was administering medications to other residents from 5 AM to 6:30 AM, and there was no staff to observe or sit with the residents in the dining room. During a telephone interview on 8/1/2023 at 2:41 PM, the Psychiatric Nurse Practitioner (NP) stated she felt Resident #9 needed a secure unit for safety. The Psychiatric NP stated elopement risk was discussed extensively as well as not accepting residents with these behaviors. The Psychiatric NP stated elopements were a significant concern at the facility. The Psychiatric NP stated the DON tried to have Resident #9 placed at another facility but was unsuccessful. The Psychiatric NP stated Resident #9 had been placed on one-to-one observation but was taken off for the COVID outbreak. The NP stated Resident #9 should have been placed back on one-to-one observation after the outbreak. Review of the medical record revealed Resident #174 was admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbances, Schizoaffective Disorder Bipolar Type, and End Stage Renal Disease. Review of Resident #174's Order Summary Report 9/21/2022 revealed .Change Wanderguard [a lightweight transmitter worn on the wrist, ankle, or wheelchair to prevent elopements] device Q [every] 3 months and PRN [as needed] every day shift every 3 month (s) starting on the 2nd for 1 day (s) for safety .Wanderguard: Check battery weekly for proper functioning. (Every week on Thursday) Detector is located in Director of Nursing [DON's] office .Monitor resident with Wanderguard for risk of elopement Q shift every shift for safety . Review of Resident #174's Wandering Risk assessment dated [DATE] revealed Resident #174 had a wandering risk assessment score of 12, which indicated a high risk for elopement. Review of Resident #174's Psychotherapy Progress Notes dated 2/8/2023 revealed, .Having a bad day thought she had a dr [doctors] appt [appointment] and reports spending a longtime waiting to go. Mild irritability is not taking it out on others. Increased restlessness . Review of Resident #174's Quarterly MDS assessment dated [DATE] revealed Resident #174 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Resident #174 required a wheelchair for ambulation and needed supervision with setup help from staff while in her room. Continued review revealed Resident #174 required limited help with one staff member while in the wheelchair at other locations in the facility. Resident #174 was not steady but able to stabilize without staff assistance for walking. Resident #174 could wheel herself in the wheelchair manually 150 feet with supervision or touch assistance. Continued review revealed Resident #174 required a wander/elopement alarm to monitor Resident #174's movement and to alert staff. Review of an undated care plan revealed Resident #174 was care planned for wandering and elopement. The interventions listed on the care plan at the time of the elopement (2/10/2023) were as follows, .Wanderguard: check battery weekly for proper functioning Q week. Change Wanderguard device Q 3 months and PRN. Monitor resident with Wanderguard for risk of elopement Q shift. Functional Wanderguard attached to resident or resident wheelchair if resident is non-compliant with wearing her Wanderguard . Review of Resident #174's Progress Notes dated 2/10/2023 revealed .This PM at 6:20 this facility got a call notifying us that one of our residents in a W/C [wheelchair] was next door at the gate of the neighboring apts [apartments]. A code GRAY [a signal which alerts staff of an elopement] was immediately called per this writer. DON was in the facility at this time. Resident was seen on the monitor located at the nurse's station. She [Resident #174] was in the parking lot .She said she traveled to the front door, stood up from her W/C pushed the exit button and rolled out the door. She said she was going to smoke . Review of Resident #174's Wandering Risk assessment dated [DATE] revealed Resident #174 had a wandering risk assessment score of 16, which indicated a high risk for elopement. Review of the facility's investigation dated 2/10/2023 revealed the elopement happened at 6:20 PM and Resident #174 wheeled herself to the front door and stood up and pushed the exit button to let herself out of the facility. Resident #174 wheeled herself to the gate of the apartments next to the facility. A tenant of the apartment called the facility to inform them of Resident #174's whereabouts. Continued review revealed Resident #174 was alert with .periods of confusion . CNA #9 reported she was assigned to Resident #174 and recalled seeing Resident #174 in the dining room. CNA #9 was assisting another resident at the time of the elopement. LPN #3 assigned to Resident #174 received the phone call from the tenant. Continued review revealed Resident #174's Wanderguard was not working during the elopement. Review of the Wunderground website revealed the temperature outside on 2/10/2023 at 6:20 PM was approximately 47 degrees Fahrenheit with winds at approximately 15 miles per hour and wind gusts up to 28 miles per hour. During an interview on 7/25/2023 at 9:28 AM, the Medical Records (MR) Director stated she worked from 11 AM to 8 PM on 2/10/2023. One of her job duties was to answer the phone and watch the camera monitors. The MR Director stated she did not see Resident #174 leave the facility on the monitor on 2/10/2023, and she was not always seated at the monitor due to filing records. The MR Director stated she received a phone call from an unknown caller saying one of the facility's residents was in a wheelchair at the apartment complex to the right of the facility. The MR Director confirmed she did not know which door Resident #174 exited because the Wanderguard system did not alarm. The MR Director confirmed the front lobby door did not automatically open to allow exit. The MR Director stated a person or resident had to push the button on the left side wall near the front lobby door to exit the facility. The MR Director confirmed she remembered it was cold outside when she received the phone call about Resident #174 being outside the facility at the neighboring apartments. The MR Director stated that when Resident #174 was brought back to the facility after the elopement, Resident #174 was wearing a sweater, pants, and shoes but did not have a jacket on. The MR Director asked Resident #174 where she was going and the resident told her she wanted to go to the store. During an interview on 7/25/2023 at 9:44 AM, CNA #8 confirmed when Resident #174 wanted to the leave the facility, it was to go out and smoke. CNA #8 confirmed Resident #174 could stand and transfer to her wheelchair. During a telephone interview on 7/25/2023 at 9:59 AM, LPN #3 stated Resident #174 was quick and often tried to get out of the building. LPN #3 stated Resident #174 often wanted to smoke before the assigned times or just sit outside and liked to go outside through the dining room by pushing the door open to the smoking patio. LPN #3 confirmed the exit button was at the front lobby door up high, but Resident #174 could reach the button and push it if she locked her wheelchair and stood up. LPN #3 confirmed the exit button was not encased. LPN #3 stated a lady called from the apartment complex, which was a family member of one of the CNAs, informed the facility Resident #174 was outside. LPN #3 confirmed Resident #174's Wanderguard was not working at the time of the incident and was unsure if anyone had checked it. During an interview on 7/25/2023 at 10:28 AM, the Quality Assurance (QA) Nurse, who was the DON at the time of the incident, confirmed she was at the facility at the time of Resident #174's elopement. The QA Nurse heard the MR Director tell LPN #3 one of the residents was at the gate in the parking lot. The QA Nurse confirmed she did not hear the Wanderguard system alarm. The QA Nurse checked Resident #174's Wanderguard device after the elopement and found it was not working. Resident #174 told the staff after she returned to the facility that she went out the front door to smoke, realized she did not have cigarettes, and then tried to go to the store to buy some. The QA Nurse stated a person who lived at the apartment complex called the facility to inform them Resident #174 was outside. During an interview on 7/25/2023 at 10:52 AM, the Social Service Director (SSD) stated she checked the Wanderguards every Thursday and told the nurses if they worked or not. The SSD stated the nurses then charted on the MAR that the Wanderguards were checked. The SSD confirmed the nurses charted the Wanderguard checks even though they did not perform the checks themselves. During an interview on 7/25/2023 at 10:56 AM, the Director of Nursing (DON) stated she worked at the facility as a consultant to train the MDS nurse at the time of the elopement. The DON confirmed she watched video footage (dated 2/10/2023) which revealed that Resident #174 came to the front lobby in a wheelchair, stood up at the front door, pressed the exit button, and exited the building in the wheelchair (the video footage was not archived and no longer available). The DON stated Resident #174 wanted to exit the building whenever she wanted to smoke. 38830

Based on facility policy, job description, record review, and interview the Infection Preventionist (IP) failed to demonstrate knowledge in implementing an effective infection control program when he failed to implement a process for surveillance of Influenza and Pneumococcal immunizations and failed to participate in monitoring of water management system. The failure of the IP to implement a process for an effective infection control program has the potential to affect all residents in the facility. The census upon entrance was 71. The findings include: Review of the policy titled Influenza, Pneumonia and COVID-19 Immunization with revision date 4/1/2023 revealed, .The intent of this policy is to minimize the risk of residents acquiring, transmitting, or experiencing complications from the influenza, pneumococcal and COVID-19 disease during their stay in this facility .All new residents shall be assessed for current vaccination status upon admission .The Infection Preventionist will maintain surveillance data on influenza, pneumonia .vaccine coverage . Review of the job description titled, Infection Control Nurse, with revision date of 6/2006 revealed, .Supervise and coordinate the multiple facets of the Infection Control Program. Assure a high quality of resident care by .eliminating infection risks to residents and personnel through surveillance of multiple activities and practices .Teaching information pertinent to infection control and isolation to all involved associates .Implementing monitoring and surveillance programs in an effort to identify and reduce infection hazards in the facility . Review of the undated facility policy titled, Legionella Water Management, revealed, .As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team .The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator . Review of the Infection Prevention and Control Program with revised date of 7/6/2023 revealed, .The facility will establish and maintain an infection prevention and control program designed to provide a safe environment .to help prevent the development and transmission of communicable diseases and infections .must included an ongoing system of surveillance .to identify possible communicable diseases or infections before they can spread to other persons in the facility .Facility leadership will ensure that all active staff are trained or re-educated in infection control policies and procedures, at least annually . Review of the facility electronic record medical system for Immunization Report dated 1/1/2021-8/31/2023 revealed documentation of Influenza vaccines for 54 residents and only 8 residents with documentation for Pneumococcal vaccinations. The census upon entrance was 71 residents. During an interview with the IP on 8/1/2023 at 10:00 AM, IP stated, I don't keep a running list for Influenza and Pneumococcal Immunizations for the residents. The nursing staff just inputs the information in the electronic computer system for each resident. During an interview on 8/2/2023 at 11:48 AM, the IP stated, I do not oversee or monitor the Water Management Program. The IP stated the Water Management Program was the Maintenance Director's responsibility and was not part of the Infection Control Program. During an interview on 8/2/2023 at 11:55 AM, the Administrator confirmed she was unable to provide training on Legionella and water management for the facility staff in the last year.

Based on facility policy review, medical record review, and interview, the facilty failed to properly store nebulizer equipment for 2 of 7 (Resident #40 and #58) residents reviewed for nebulizer treatments and facility failed to demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems. Failure to minimize the risk of Legionella and other opportunistic pathogens could potentially affect all residents residing in the facility. The census upon entrance was 71. The findings include: Review of the undated facility policy titled, Legionella Water Management, revealed, .As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team .The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator . Review of the Infection Prevention and Control Program with revised date of 7/6/2023 revealed, .The facility will establish and maintain an infection prevention and control program designed to provide a safe environment .to help prevent the development and transmission of communicable diseases and infections .must included an ongoing system of surveillance .to identify possible communicable diseases or infections before they can spread to other persons in the facility .Facility leadership will ensure that all active staff are trained or re-educated in infection control policies and procedures, at least annually . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses which included Bullous Pemphigoid, Type 2 Diabetes Mellitus, Chronic Lymphadenitis, and Dysphagia. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated no impairment in cognition. Review of the Order Summary Report for Resident #40 dated 7/27/2023, revealed, .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram)/3 ML (milliliter) (Ipratoplum-Albuterol) 1 dose inhale orally four times a day for sore throat .5/16/2023 . Observations in Resident #40's room on 07/27/23 at 8:13 AM, revealed Resident #40's nebulizer mask was laying on top of the night stand uncovered. During an interview on 7/27/2023 at 8:15 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #40's nebulizer mask should be covered and stored in a clear plastic bag. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS for Resident #58 dated 5/18/2023 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Review of the Order Summary Report dated 7/27/2023 revealed an order for, . 2/3/2023 .Ipratropium-Albuterol Inhalation Solution .1 vial inhale orally every 6 hours as needed for shortness of breath .2/9/2023 .Ipratropium-Albuterol Solution .1 vial inhale orally three times a day for shortness of breath . Observations and interview in Resident #58's room on 7/25/2023 at 8:12 AM, revealed Resident #58 was seated in a wheelchair beside her bed. There was a nebulizer machine and mask laying on top of her bed linens in her unmade bed. Resident #58 stated she was finished with her breathing treatment, and the staff would put her machine and mask up when they came in to make her bed. Continued observation on 7/25/2023 at 12:30 PM, revealed the nebulizer machine and mask were still on top on the unmade bed. During an interview on 7/27/2023 at 10:00 AM, the Director of Nursing confirmed the nebulizer masks were to be stored in a plastic bag when not in use. During an interview on 8/2/2023 at 11:48 AM, the Infection Preventionist (IP) stated, I do not oversee or monitor the Water Management Program. The IP stated the Water Management Program was the Maintenance Director's responsibility and was not part of the Infection Control Program. During an interview on 8/2/2023 at 3:13 PM, the Administrator stated she was unable to provide a detailed description and diagram of the water system in the facility and documentation of ongoing surveillance of risk factors related to the Legionella Water Management Program. The Administrator confirmed she had not been involved in oversight or monitoring of the Water Management Program.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food safety service for 69 of 71 residents who received meal trays in the facility. The findings include: During initial tour of the kitchen on [DATE] beginning at 9:55 AM, three (3) half-gallon containers of buttermilk with an expiration date of [DATE] were observed in the cooler. During an interview on [DATE] at 10:00 AM, the Dietary Supervisor confirmed the three containers of buttermilk expired on [DATE]. The surveyor requested a copy of the facility's food storage policy. Policy was not provided.

Based on policy review, job description review, observation, and interview, the facility failed to provide effective housekeeping and maintenance services to maintain a clean, safe, and homelike environment in 23 of 41 (room [ROOM NUMBER], #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #304, #305, #306, #307, #308, #309, #310, #311, #505, #510, #516) rooms reviewed. The facility's failure to provide effective housekeeping and maintenance services resulted in urine odors in rooms, rusty and dirty overbed tables and chair, desilvering of bathroom mirrors, peeling paint, holes in drywall, dried debris scattered on floors, and 2 wheelchairs with damaged arm rests. The findings include: Review of the facility's policy titled, Residents Rights, revised 10/16/2016, revealed, .Right to an environment that is safe, clean, comfortable, and home like environment . Based on review of the facility's policy titled, Infection Control/Cleaning and Disinfection of Environmental Surfaces, dated 8/1/2010 revealed, .Housekeeping surfaces (e.g. [for example], floors, tabletops, over bed table) will be cleaned on daily basis, when spills occur, and when these surfaces are visibly soiled .Environmental and Horizontal surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled . Review of an undated Housekeeping/Laundry Supervisor job description revealed, .ensure the facility is maintained in a clean, safe, and comfortable manner .Conduct daily inspections of assigned work areas to assure cleanliness and sanitary conditions are maintained . Review of an undated Physical Plant and Maintenance Manager job description revealed, .Repair doors, hinges, handles, and locks .Replace light bulbs, fuses, ballast, circuit breakers, extension cords, electric plugs, bed-call cords, pull chains, emergency-call system cords, electrical outlets, etc. [and more] .Repair beds, bedrails, wheelchairs, geri chairs, walkers, canes, crutches, hand rails, railings, grab bars, towel [NAME], soap dishes, and water/bath sprays .Paint walls, ceilings, doors .Repair, maintain, and paint closets, rods, shelves, bedside tables, drawers, and closet doors .Complete routine maintenance inspections throughout the building . Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 9:35 AM, the floor had dried brown debris on the left side of the bed, in the corners of the bathroom floor, and at the base of the toilet. A damaged area of drywall behind A bed had been filled with drywall putty and left unfinished with uneven putty and unpainted. On 7/25/2023 at 7:45 AM, the floor had dried brown debris and dried food crumbs on the left side of A bed (bed closest to the door). The bathroom floor had brown debris around the base of the toilet and in the corners of the floor at the baseboards. The bathroom mirror had desilvering in areas including the edges of the mirror. On 7/26/2023 at 1:00 PM, the base of the overbed table was rusted in multiple areas and had dried brown debris. The floor had dried brown debris in the corners of the room and in the bathroom around the base of the toilet and walls. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:55 PM, the Administrator confirmed the bathroom mirror had areas of desilvering, the drywall damage behind the bed had dried unfinished drywall putty, and the overbed table was rusted and dirty. The Administrator stated the areas of concern needed to be repaired. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:58 PM, the Environmental Supervisor (ES) confirmed the overbed table was dirty, and there was dried debris on multiple areas of the floor including in the corners of the room, around the base of the toilet, and in the corners along the bases of the bathroom walls. The ES stated the housekeeper did not clean the room well enough. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 9:42 AM, A bed had dried debris on the base of the overbed table and on top of the table. The bathroom floor had brown/black debris around the base of the toilet and along the base of the walls. The floor in the room had areas of black build-up throughout the room. There was a strong urine odor present in the bathroom. There were multiple areas of peeling drywall. On 7/25/2023 at 8:01 AM, the floor of the room had black dirty build-up throughout the room. There was scattered trash debris around and under B bed (bed furthest from the door). The bathroom floor had dried brown debris around the toilet base and base of walls. There was a strong urine odor present in the bathroom. On 7/26/2023 at 1:05 PM, the bathroom floor had brown dried debris around the base of the toilet and walls, and there was a strong urine odor in the bathroom. The floors had black build-up throughout the room. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:49 PM, the Administrator confirmed there were multiple areas of peeling drywall in the bathroom. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:05 PM, the ES confirmed the floor throughout the room had black build-up. The ES confirmed the bathroom had brown debris around the base of the toilet and base of the walls, and there was a strong odor of urine in the bathroom. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 9:50 AM, there were multiple streaks of missing paint on the baseboards around the entire room. The bathroom had dried gray streaks of grout and black debris around the base of the walls and dried brown debris in multiple areas. The bathtub had a large rusty area long the outside wall. The shower head and bathtub spout had a thick gray/black build up on the metal covering. The metal handrail in the shower/tub was rusty. On 7/25/2023 at 8:15 AM, the floor had dried black and brown debris in multiple areas. The bathroom floor and base of walls continued to have the black dried debris. The bathtub shower head and spout continued to have the gray and black build up on the metal. The dried black/brown debris was present in multiple areas of the floor of the room and bathroom. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:46 PM, the Administrator confirmed there were multiple areas of missing paint on the baseboards around the room, a large rusty area the length of the bathtub outside wall, a rusty handrail in the shower, gray/black build up on the shower head/spout, and dried gray grout streaks with black dried debris around the wall base in the bathroom. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:08 PM, the ES confirmed there were multiple areas of dried black debris on the floor of the room and bathroom, and gray/black build up on the shower head/spout. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 9:54 AM, the floor in the room and bathroom had dried black/brown debris in multiple areas and the shower curtain rod had multiple rusty streaks. On 7/25/2023 at 8:20 AM, the floor in the room and bathroom had dried areas of black/brown debris. There were areas of dried black/brown debris on the floor of the room and bathroom. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:42 PM, the Administrator confirmed there were multiple rusty streaks on the metal shower curtain rod. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:11 PM, the ES confirmed there were multiple areas of dried black/brown debris on the floor of the room and bathroom. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 9:54 AM, both A and B overbed tables had dried debris present. The drywall behind A bed was damaged and peeling. The bathroom mirror had large spots of desilvering and the drywall was damaged under the paper towel dispenser. The floor of the room and bathroom had areas of dried black/brown debris present along the base of the walls and corners. On 7/25/2023 at 8:25 AM, both A and B overbed tables were dirty and the floors of the room and bathroom had dried black/brown debris present. There was a strong urine odor present in the bathroom. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:39 PM, the Administrator confirmed the areas of desilvering on the bathroom mirror and damaged drywall in the bathroom and behind A bed. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:15 PM, the ES confirmed the dried black/brown debris on the floor of the room and bathroom. The ES confirmed there was dried debris on both A and B overbed tables. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 9:58 AM, the entrance door had scattered black debris and was sticky to touch. Both A and B overbed tables were rusty and had dried food debris present. There was damaged peeling drywall in the bathroom and the emergency call pull string had dried brown debris present. The floor of the room and bathroom had multiple areas of dried black/brown debris and build up of debris in the corners of the room. There was a strong urine odor present in the bathroom. On 7/25/2023 at 8:30 AM, the overbed tables had dried debris on top and bases. The floors continued to have the dried black debris with build up in the corners of the room and bathroom. The pull string on the emergency call station in the bathroom had dried brown debris present. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:35 PM, the Administrator confirmed there was damaged drywall present in the bathroom and the rusted overbed table bases. The Administrator confirmed the entrance door had scattered dried black debris present. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:19 PM, the ES confirmed the dried black/brown debris on the floor of the room and bathroom. The ES confirmed there was dried debris on both A and B overbed tables. The ES confirmed the emergency call station pull string was dirty with brown debris. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 10:04 AM, the entrance door had scattered black debris across the front of the door. The floor in the bathroom and room had dried black debris in multiple areas and build up in the corners of the room and across the floor. An overbed table had rusty areas over the base and the top has damaged laminate. The bathroom mirror has large areas of desilvering. The bathroom had damaged drywall areas. On 7/25/2023 at 8:35 AM, the floor in the bathroom and room continued to have dried black/brown debris in multiple areas and in the corners of the room. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:29 PM, the Administrator confirmed the A bed overbed table base was rusted and dirty. The Administrator confirmed the bathroom had areas of damaged, peeling drywall, and desilvering present on the mirror. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:24 PM, the ES confirmed the A bed overbed table had dried food debris present on the base. The ES confirmed the floors were dirty with black/brown debris across the floor and the bathroom in corners of the room. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 10:09 AM, the base of the overbed table had dried light colored debris areas. The floor in the room and bathroom had black/brown debris dried in areas. The bathroom had brown dried debris around the base of the toilet. The mirror had large areas of desilvering. On 7/25/2023 at 9:20 AM, the floor continued to have dried debris scattered and in the corners, and the overbed table had dried debris present. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:25 PM, the Administrator confirmed the entrance door had scattered black debris and splintered edges along the door. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:29 PM, the ES confirmed the overbed table had dried debris present and the floor in the room and bathroom had dried black/brown debris in multiple places. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 10:10 AM, the base of the entrance door had black debris and was sticky to touch. The A bed overbed table base had dried debris and was rusty. The bathroom mirror had large areas of desilvering. The bathroom wall had damaged drywall peeling, and the emergency station pull string had brown debris. On 7/25/2023 at 9:28 AM, the floor had dried debris scattered in the corners and in multiple areas. The emergency station pull string had brown debris. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:22 PM, the Administrator confirmed the entrance door had scattered black debris and splintered edges along the door. The Administrator confirmed the mirror had areas of desilvering and the drywall damage to the wall. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:34 PM, the ES confirmed the overbed table had dried debris present, and the floor in the room and bathroom had dried black/brown debris in multiple places. The ES confirmed the emergency station pull string had brown debris. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 10:14 AM, the room floor was sticky on B side of room, and the bathroom had black debris in the corners. There was a strong odor of urine in the bathroom, and a black metal pole with a large area of brown debris on the end was standing in the corner beside the toilet. On 7/25/2023 at 9:34 AM, the bathroom floor continued to have dried black debris in the corners, and a black metal pole with dried brown debris on the end was standing next to the toilet. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:18 PM, the Administrator confirmed the black metal pole with dried brown debris should not be present in the bathroom. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:40 PM, the ES confirmed the bathroom had a strong urine odor present and dried black/brown debris in the corners. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 10:18 AM, the front of the entrance door had scatter black debris, was sticky, and had splintered edges. The A bed bedside table was missing handles and had damaged laminate on the front side. The cable connection box and trim were pulled away from the wall and hanging free. The room and bathroom had dried black/brown debris scattered across the floor and in the corners. The drywall behind the toilet was damaged and peeling. The mirror had large areas of desilvering. On 7/25/2023 at 9:40 AM, the entrance door and floors in the room and bathroom had black/brown dried debris present. The overbed table on A side had dried debris present on top. The A bed chair's metal base was rusted. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:13 PM, the Administrator confirmed the entrance door had dried black debris and was sticky. She confirmed the bedside table was missing handles and had damaged laminate. The Administrator confirmed the cable connection box was pulled away from the wall and hanging free. The Administrator confirmed the A bed chair had a rusty metal base. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:44 PM, the ES confirmed the A bed overbed table had a sticky dried substance on the top. The ES confirmed the room and bathroom had black/brown debris across the floor and in the corners. Observations in room [ROOM NUMBER] revealed the following: On 7/24/2023 at 10:24 AM, the entrance door had black debris and sticky areas across the front. The entrance door had splintered wood on the outside edges. There was dried black/brown debris scattered on the room floor and in the bathroom corners. There were multiple areas of damaged, peeling drywall in the room and bathroom. The B bed overbed table had dried debris on top and the base. The bathroom mirror had large areas of desilvering, and the emergency call station pull string had dried brown debris present. During an interview in room [ROOM NUMBER] on 7/31/2023 at 2:08 PM, the Administrator confirmed the entrance door had dried black debris and was sticky. The Administrator confirmed the damaged drywall in the room and bathroom needed repair. During an interview in room [ROOM NUMBER] on 7/31/2023 at 3:49 PM, the ES confirmed the B bed overbed table had a sticky dried substance on the top and on the base. The ES confirmed the room and bathroom had black/brown debris across the floor and in the corners. The ES stated the housekeeper assigned to 100 hall told her she had completed cleaning in all the rooms today. The ES confirmed the rooms had not been adequately cleaned today. The ES stated she was responsible for monitoring the daily cleaning, and she had not been able to monitor the daily cleaning for about a month. She stated she had requested to have the floors in all the rooms be cleaned and buffed about two months prior and was still waiting on approval. The ES confirmed the condition of the floors and cleanliness of the rooms did not represent a clean, homelike environment. Observations in room [ROOM NUMBER] on 7/24/2023 at 10:22 AM, revealed damaged drywall and peeling paint behind the bed. Observations in room [ROOM NUMBER] on 7/24/2023 at 11:15 AM, revealed both wheelchair's padded arm rests were cracked, exposing the inside padding of each arm rest. Observations in room [ROOM NUMBER] on 7/24/2023 at 11:18 AM, revealed both wheelchair's padded arm rests were cracked, exposing the inside padding of each arm rest. During an interview on 7/26/2023 at 11:18 AM, the Maintenance Director confirmed the padded arm rests of wheelchairs in room [ROOM NUMBER] and #516 were cracked and exposed the inside padding of each arm rest. The Maintenance Director stated the arm rests of the wheelchairs should not be cracked and should be replaced as soon as possible. The Maintenance Director stated he did not have a maintenance schedule to routinely check the wheelchairs. Observations in room [ROOM NUMBER] on 8/1/2023 at 11:30 AM, revealed paint peeling on the overbed table base and bathroom door frame. The call station pull string was dirty and discolored. During an interview on 8/1/2023 at 11:30 AM, the ES confirmed the peeling paint and dirty pull string did not represent a clean, homelike environment. Observations in room [ROOM NUMBER] on 8/01/2023 at 11:34 AM, revealed peeling paint on the baseboards. The bathroom call light cover plate had dried brown debris, and the pull string had brown discolorations and dried brown debris. During an interview on 8/1/2023 at 11:34 AM, the ES confirmed the peeling paint on the baseboards, call light cover plate with dried brown debris, and pull string with brown discolorations and dried brown debris did not represent a clean, homelike environment. Observations in room [ROOM NUMBER] on 8/1/2023 at 11:37 AM, revealed the bathroom call station pull string had brown discoloration and dried debris. During an interview on 8/1/2023 at 11:37 AM, the ES confirmed the pull string was dirty and needed to be cleaned. Observations in room [ROOM NUMBER] on 8/1/2023 at 11:40 AM, revealed the base of the overbed table had rusted areas. There were areas of peeling paint on the walls, damaged drywall in the bathroom, and dried brown debris on the call station pull string. During an interview on 8/1/2023 at 11:40 AM, the ES confirmed the overbed table base was rusted, there was peeling paint, and damaged drywall in the bathroom, and the call station pull string had dried brown debris. Observations in room [ROOM NUMBER] on 8/1/2023 at 11:43 AM, revealed the faucet handle was damaged, and the call station pull string had dried brown debris and discoloration. During an interview on 8/1/2023 at 11:43 AM, the ES confirmed the faucet handle was damaged, the call station pull string had dried brown debris was discolored and dirty, and needed to be cleaned. Observations in room [ROOM NUMBER] on 8/1/2023 at 11:46 AM, revealed there was peeling paint on the walls and a discolored, damaged door stop behind the entrance door. During an interview on 8/1/2023 at 11:46 AM, the ES confirmed the wall had peeling paint, and the doorstop was damaged and needed to be repaired. Observations in room [ROOM NUMBER] on 8/1/2023 at 11:49 AM, revealed tape on the wall above the A bed and closet. The bathroom call station pull string had dried brown debris/discoloration. During an interview on 8/1/2023 at 11:49 AM, the ES confirmed the tape on the wall above the A bed and closet should have been removed and the bathroom call station pull string should be cleaned. Observations in room [ROOM NUMBER] on 8/1/2023 at 11:52 AM, revealed the A bed overbed table base was rusted in areas. There was gray tape on the strike plate of the bathroom door frame. The bathroom call station pull string had dried brown debris and discoloration. During an interview on 8/1/2023 at 11:52 AM, the ES confirmed the gray tape on the strike plate of the bathroom door frame and the call station pull string with dried brown debris and discoloration did not represent a clean, homelike environment.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop an individualized comprehensive care plan for 9 of 36 (Resident #15, #17, #23, #32, #53 #55, #65, #66, and #70) sampled residents. The findings include: Review of the facility's policy dated [DATE] titled, Care Plans, revealed, .An indivualized 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 .Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may expect to attain .Each resident's Comprehensive Care Plan has been designed to: .e. Identify professional services that are responsible for each element of care; .Care plans are revised as changes in the resident's condition dictate . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dysphagia, Schizophrenia, and Major Depressive Disorder. Review of the comprehensive care plan for Resident #15 dated [DATE] revealed, .(TUBE FEEDING) Resident has a Gastrostomy tube r/t [related to] Dysphagia .Administer tube feeding as ordered r/t Dysphagia and weight loss . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15's nutritional approaches were mechanically altered diet. Review of the Order Summary Report for Resident #15 dated [DATE] revealed, .Regular diet Pureed texture, thin liquids consistency, for diet order . During an interview on [DATE] at 10:14 AM, Resident #15 stated, I don't have a feeding tube anymore. I am eating by mouth now. During an interview on [DATE] at 12:00 PM, the Director of Nursing (DON) was asked if Resident #15's care plan was accurate that revealed feeding tube status. The DON stated, Well I think she eats by mouth to but still has the gastrostomy tube. The DON and Surveyor went down to Resident #15's room for the DON to assess resident. The DON assessed Resident #15's abdominal area with Surveyor and confirmed Resident #15 no longer had a gastrostomy tube. The DON confirmed the care plan was inaccurate for Resident #15. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, Anxiety Disorder, Alcohol Abuse in remission, and Depressive episodes. Review of the Brief Trauma Questionnaire for Resident #17 dated [DATE], revealed .Have you ever served in a war or served in non-combat job that exposed you to war-related causalities .yes .Has a close family member or friend died from a violent situation .yes . Review of the Quarterly MDS dated [DATE] revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. Review of Resident #17's comprehensive care plan revealed no care plan related to past trauma. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Major Depressive Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side. Review of the Brief Trauma Questionnaire for Resident #23 dated [DATE], revealed, .Have you had a life threatening illness, Cancer, Heart Attack .yes .Have you ever witnessed a situation in which someone was seriously injured or killed .yes .If yes, please explain: I killed a man . Review of the Quarterly MDS dated [DATE] revealed Resident #23 had a BIMS score of 14, which indicated no cognitive impairment. Review of Resident #23's comprehensive care plan revealed no care plan related to past trauma. During an interview on [DATE] with the Social Service Designee (SSD) confirmed that Resident 17's and Resident #23's Brief Trauma Questionnaire was positive for trauma. The SSD confirmed it would be important for this to be part of the residents care plan. SSD confirmed, It would be appropriate for past trauma to be a part of the care plan since it could affect the resident now. Review of the medical record revealed Resident #32 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses which included Anoxic Brain Damage, and Muscle Weakness. Review of the Quarterly MDS dated [DATE], Section G Transfer, revealed Resident #32 required extensive assistance with two plus persons physical assistance. Review of the current Care Plan for Resident #32 revealed at risk for falls, at risk for further decline in Activities of Daily Living (ADLs.) Interventions included assist with transfer as needed, and no guidance on how Resident #32 transfers from one surface to another. There was no care plan problem addressing assistance needed with Activities of Daily Living (ADL) care. Observations in Resident #32's room on [DATE] at 1:05 PM, revealed Resident #32 sitting in wheelchair outside the bathroom door while CNA #1 stood beside the wheelchair. Resident #32 stood up without assistance and ambulated into the bathroom. During an interview on the 300 Hall at the medication cart on [DATE] at 1:26 PM, Licensed Practical Nurse (LPN) #1 stated Resident #32 was a one person assist because Resident #32 could not ambulate safely. When asked where you look to find out how many persons are needed to assist residents with transfers, LPN #1 stated I do the majority of the admissions, I work on a designated hall so I know the residents transfer abilities on admission, so I don't usually look at the care plans to find out how many person assist a resident needs. I do sometimes have the Certified Nursing Assistants (CNAs) log in and look at the Kardex for a resident I have a question about. LPN #1 had to search in the electronic medical record to figure out how to view the Kardex without having a CNA log in. During an interview in the DON office on [DATE] at 4:35 PM, the DON confirmed there was no ADL care plan for Resident #32. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Carotid Arteries, Dysphasia, and Hyperlipidemia. Review of the Quarterly MDS for Resident #53 dated [DATE] revealed a BIMS score of 5, which indicated severe cognitive impairment. Continued review revealed he required limited assistance with assistance of 1 caregiver for transfers (how the resident moves between surfaces.) Review of the Care Plan revealed Resident #53 did not have a care plan for ADL or guidance on how he transfers from one surface to another. During an interview on [DATE] at 3:49 PM, the DON confirmed Resident #53 did not have an ADL care plan. The DON confirmed the transfer status was not on the Kardex (file system that provides a brief overview of each resident) for the CNAs. The DON stated the ADL care plans were not built into the company's electronic health record program. When asked how the CNAs know how to take care of the residents' ADLs, the DON stated, They just know the residents. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Cervical Disc Disorder with Myelopathy, and Fusion of Spine. Review of the Significant Change MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated the resident was unable to complete the interview. Continued review revealed he required extensive assist of 1 caregiver for bed mobility, and extensive assist of 2 caregivers for transfers. Review of the current Care Plan for Resident #55 revealed no care plan for ADL care. Review of the Hospice Care plan revealed no care plan for ADL care. During an interview on [DATE] at 8:00 AM, the Administrator reviewed the current hospice and facility care plan for Resident #55 and stated, I don't see his ADL care plan . After looking in the Electronic Medical Record (EMR), the Administrator stated she did not see an ADL care plan for Resident #55. During an interview on [DATE] at 8:18 AM, CNA #7 stated she was assigned to care for Resident #55 today, but she usually did not have him on her assignment. When asked how she knew how to care for Resident #55, CNA #7 stated he was able to voice how he was to be cared for. She stated if Resident #55 was unable to let her know verbally, she would look at his profile in the EMR when she was charting. There was no ADL care plan for Resident #55. During an interview on [DATE] at 8:22 AM, CNA #8 stated she usually took care of Resident #55. She stated he would let you know what he wanted. CNA #8 stated she could turn Resident #55 by herself, but he complains about his legs hurting, so most of the time she used 2 people to turn him. She stated if no one was available to help, then she did it herself. She stated he was transferred by a [named mechanical lift]. When asked how she knew how to care for him or how to transfer him, CNA #8 stated she knew because she has done it before. CNA #8 stated, We care for him by what is on the care plan. She stated there was a care plan in his chart and she knew how to look at it, but the CNAs were not supposed to. When shown the printed care plan by the surveyor, CNA #8 confirmed Resident #55 did not have an ADL care plan. During an interview on [DATE] at 8:45 AM, the Administrator stated the assistance needed to care for Resident #55 was not on the care plan but confirmed it should be. During a phone interview on [DATE] at 10:00 AM, the MDS Coordinator stated she completed the MDS and care plan for Resident #55. She confirmed the care plan did not address his ADL status. She confirmed the MDS was coded as extensive assist of 2 or more people for transfers and stated the staff should transfer Resident #55 with extensive assistance with at least 2 staff during each transfer. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Lobar Pneumonia, Chronic Obstructive Pulmonary Disease, and Cirrhosis of the Liver. Review of the MDS for Resident #65 dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment. Review of the ADLs revealed extensive assistance of 1 person for transfers between surfaces. Review of the current care plan for Resident #65 revealed no care plan for ADL care. Review of medical record revealed Resident #66 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Sepsis and Dependence on Supplemental Oxygen. Review of Admission MDS dated [DATE] revealed Resident #66 had a BIMS score of 15 indicating cognitively intact. Continued review revealed Resident #66 required extensive assistance with one person physical assist. Review of the current Comprehensive Care Plan for Resident #66 revealed there was no ADL care plan. During an interview on [DATE] at 4:35 PM, the DON confirmed Resident #66 did not have an ADL care plan. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses which included Difficulty in Walking, Muscle Weakness, and Need for Assistance with Personal Care. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 6, which indicated severe cognitive impairment. Continued review revealed he required extensive assistance of 2 or more persons physical assist for transfers. Review of the current Care Plan for Resident #70 revealed there was no ADL care plan. During an interview on [DATE] at 9:48 AM, the LPN Unit Manager/Infection Preventionist confirmed Resident #70's ADLs were not addressed on the care plan. During a phone interview on [DATE] at 10:00 AM, the MDS Coordinator confirmed Resident #70's care plan did not address ADLs. The MDS Coordinator stated the care plan should address a resident's ADLs.

Based on Resident Assessment Instrument (RAI) Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 of 36 (Resident #17 and #55) residents reviewed. The findings include: Review of the Resident Assessment Instrument (RAI) Manual dated 10/2011 revealed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals .the assessment process includes direct observation, as well as communication with the resident and direct care staff . Review of the medical record revealed Resident #17 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Unspecified Side. Review of the Quarterly MDS dated [DATE] revealed .Section G .no limitation in range of motion . Observations and interview on 7/24/2023 at 10:53 AM, revealed Resident #17 was seated in a reclined wheel chair. Resident #17 stated, I am unable to use my right hand since I had my stroke. Resident #17's right hand was laying flaccid (hanging loosely) at his right side. Observations on 7/26/2023 at 12:19 PM, Resident #17 was sitting in the dining room feeding himself using his left hand with his right arm flaccid by his side. During an interview on 7/26/2023 at 9:01 AM, the Rehabilitation Director stated, .[Named Resident #17] has limitation in his right hand after his stroke and eats with his left hand. During a phone interview on 7/26/2023 at 10:36 AM, MDS Coordinator confirmed Resident #17 had a diagnosis of Hemiplegia. The MDS Coordinator stated, Well, his [Named Resident #17] Hemiplegia can vary. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Cervical Disc Disorder with Myelopathy, and Fusion of Spine. Review of the Wound Evaluation and Management Summaries for Resident #55 dated 5/31/2023 revealed assessment and descriptions for, .Site 1: Unstageable of the Left Heel .Site 2: Stage 3 pressure wound of the Left Upper Calf .Site 3: Stage 4 Pressure Wound of the Left Calf . Review of the Significant Change MDS assessment revealed under section M (Skin), 1 stage 2 in house pressure ulcer, 1 DTI [deep tissue injury] in house pressure ulcer. During an interview on 7/25/2023 at 3:46 PM, after reviewing the wound assessments, the Director of Nursing (DON) confirmed Resident #55 had an unstageable to the left heel, a stage 3 to the left upper calf, and a stage 4 to the left calf. After reviewing section M on the significant change MDS dated [DATE], the DON confirmed the assessment for Resident #55's skin documented on the MDS was inaccurate. During an interview on 7/25/2023 at 10:00 AM, the MDS Coordinator confirmed she completed the MDS for Resident #55. She confirmed she coded Resident #55 had 1 stage 2 and 1 Deep Tissue Injury (DTI during the assessment period. The MDS Coordinator confirmed the MDS was not accurate.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide nail care for 1 of 36 (Resident #55) residents reviewed. The findings include: Review of the facility's policy dated 9/1/2011 and revised 10/16/2016 titled, Resident Rights, revealed, .Right to respect and dignity . Review of the facility's document titled Grooming Competency, dated 11/2019, revealed, .Nail Care: 1. Immerses nails in comfortably warm water and soaks for at least five (5) minutes. 2. Dries hands thoroughly, being care to dry between fingers. Gently cleans under nails with an orange stick. 3. Gently pushes cuticle back with orange stick. Files each fingernail . Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Cervical Disc Disorder with Myelopathy, and Fusion of Spine. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was not able to complete the interview. Continued review revealed Resident #55 required extensive assistance of 1 person for grooming. Review of the current Care Plan for Resident #55 revealed no care plan for Activities of Daily Living (ADL) care. Review of the Hospice Care plan revealed no care plan for ADL care. Review of the Kardex (a facility tool used to communicate to nursing staff the care needed by the resident) revealed, .Personal Hygiene/Oral Care .PERSONAL HYGIENE: The resident requires extensive assistance by one person physical assist with personal hygiene . During an interview and observation in Resident #55's room on 7/24/2023 at 2:27 PM, and again on 7/25/2023 at 2:30 PM revealed Resident #55 lying awake in bed with the head of bed elevated. Resident #55's fingernails had dark debris present under the nails. When asked if any one cleaned his fingernails for him, he stated no. During an interview on 7/25/2023 at 2:39 PM, the Licensed Practical Nurse (LPN) Unit Manager/Infection Preventionist confirmed Resident #55's fingernails were not clean. He confirmed, They should be cleaned during daily care and as needed. Bedbaths should be done every day and nails checked. During an interview on 7/26/2023 at 8:22 AM, Certified Nurse Assistant (CNA) #8 stated nail care should be done on residents every day during their bed bath or shower.

Based on facility policy review, medical record review, and interview, the facility failed to provide a bed hold notice for transfer or discharge for 1 of 1 (Resident #53) residents reviewed for discharge. The findings include: Review of the facility's policy titled, Bed-Holds and Returns revised 3/26/2019, revealed, .Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy .Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitation of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed .or to hold a bed beyond the state bed-hold period .d. The details of the transfer . Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Carotid Arteries, Dysphasia, and Hyperlipidemia. Review of the Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Review of the Order Details for Resident #53 revealed an order dated 6/8/2023 at 11:06 AM, Send to [named hospital] ED [Emergency Department] for evaluation and treatment as indicated r/t [related to] abnormal labs and change in condition. Review of the Progress Notes for Resident #53 dated 6/8/2023 at 9:23 AM and 10:31 AM, revealed the Conservator was notified Resident #53 was experiencing a change in condition, had abnormal labs, and was being sent to the ED for evaluation. There were no progress notes which stated the Conservator was offered a bed hold notice. During an interview on 7/27/2023 at 9:27 AM, the Administrator confirmed neither Resident #53 or his Conservator were offered a bed hold notice when Resident #53 was discharged to the hospital on 6/8/2023. The Administrator confirmed any resident transferred to the hospital should be offered a bed hold notice.

Based on facility policy review, observations, record review, and interview, the facility failed to ensure each resident's medical record and health status remained private and confidential for 2 of 36 (Residents #15 and Resident #374) residents reviewed who had sensitive medical data, which had the potential to allow unauthorized individuals access to the residents' private health information. The findings include: Review of the facility policy titled, Resident Rights, dated 9/1/2011 and revised 10/16/2016 revealed, .Right to respect and dignity .Right to personal privacy and confidentiality of his/her own personal medical records .Right to privacy includes accommodations, medical treatment .personal care . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dysphagia, Schizophrenia, and Major Depressive Disorder. Observations on the 500 hall on 7/27/2023 at 8:17 AM, revealed an electronic kiosk (wall mounted touch screen computer charting system) which displayed Resident #15's protected health information record. The information was visible to anyone who passed by the kiosk. During an interview on 7/27/2023 at 8:18 AM, Licensed Practical Nurse (LPN) #2 confirmed resident electronic health records should always be protected. During an interview on 7/27/2023 at 8:28 AM, the Administrator confirmed an electronic kiosk should never be left open to display a resident's electronic health record. Review of the medical record revealed Resident #374 was admitted to the facility on [DATE] with diagnoses which included Transient Cerebral Ischemic Attack, Hyperlipidemia, and Essential Hypertension. Observations on the 300/400 hall on 8/1/2023 at 9:45 AM, revealed a medication cart for 300/400 hall with the computer screen which displayed Resident #374's protected health information record. During an interview on 8/1/2023 at 9:45 AM, the LPN Unit Manager/Infection Preventionist confirmed the electronic medical record should never be left open to display a resident's medical information.

Based on facility policy review, medical record review, facility camera footage review, and interview, the nursing staff failed to inform the Director of Nursing (DON) and Administrator of 1 of 5 elopements (Elopement #1 for Resident #9) reviewed. The findings include: Review of the facility policy titled, Elopement/Wandering, Unsafe Resident, dated 2/1/2009, revealed .Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (include searching) for any resident who us discovered to be missing from the unit or facility . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Post Traumatic Seizures, Schizophrenia, unspecified, Anoxic Brain Damage, Unspecified Abnormalities of Gait and Mobility, Muscle Weakness, and Restlessness and Agitation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed, a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Review of Comprehensive Care Plan for Resident #9 dated 6/13/2023 revealed, a person-centered individualized care plan with appropriate goals and interventions that included .Resident needs assistive devices/enabler siderails wanderguard .The resident has fall risk and potential for injury r/t [related to] Seizures, Schizophrenia, and Anoxic Brain Damage .at risk for visual impairment r/t Seizures, Schizophrenia, and hallucinations .At Risk for Seizure- Potential for Injury r/t Diagnosis of POST TRAUMATIC SEIZURES .at risk for Elopement or Wandering AS EVIDENCED BY exit seeking . Review of the facility camera footage on 8/1/2023 at 10:54 AM, revealed: on 6/16/2023 at 5:01 AM Resident #9, wearing civilian clothes and holding her purse over her shoulder, leaving the facility through the dining room exit, which led to the smoking patio, walking towards the perimeter gate of the patio. At 5:01 AM, Certified Nursing Assistant (CNA) #10 called Resident #9 back inside the dining room. During an interview on 8/1/2023 at 10:57 AM, the Administrator confirmed Resident #9 eloped on 6/16/2023 at 5:01 AM after viewing the facility camera footage. The Administrator confirmed she was not notified about Resident #9's elopement on 6/16/2023 at 5:01 AM, and if she had been notified, she would have put Resident #9 on every 15-minute observation checks (resident safety checks when staff must visualize the resident every 15 minutes.) During a telephone interview on 8/1/2023 at 12:01 PM, CNA #10 stated she had given Resident #9 a shower first before the other group of residents she was assigned to get up or shower on 6/16/2023. CNA #10 stated she escorted Resident #9 to the dining room and then went back to her hall to provide care for the other residents. CNA #10 stated she told Licensed Practical Nurse (LPN #4) she could not watch Resident #9 and give showers to the residents who needed them. CNA #10 stated the nurse was supposed to help watch the residents too. CNA #10 confirmed Resident #9 had gone outside on the smoking patio by herself unattended. CNA #10 stated when she finished giving a shower to another resident, she came back and saw Resident #9 outside. CNA #10 stated she brought Resident #9 back inside and told the nurse she needed to watch Resident #9. During an interview on 8/1/2023 at 12:41 PM, the DON stated she was not aware Resident #9 had eloped on 6/16/2023 at 5:01 AM (Elopement #1 for Resident #9). The DON stated that if staff had made her aware of the elopement, she would have put Resident #9 on every 15-minute observation checks or one-to-one (1:1) observations (continuous staff observation for resident safety). The DON stated she expected staff to call and let her know of any elopements, falls, deaths, or a resident leaving against medical advice (AMA). The DON stated the facility could have prevented further elopements by Resident #9 if she had been notified of the elopement on 6/16/2023 at 5:01 AM.

Based on facility policy review, medical record review, observation, and interview, the facility failed to promote care that maintained a resident's dignity, respect, and quality of care when staff failed to provide a privacy bag for 1 of 5 (Resident #55) residents reviewed with indwelling urinary catheters. The findings include: Review of the facility policy titled, Resident Rights, dated 9/1/2011 and revised 10/16/2016 revealed, .Right to respect and dignity .Right to personal privacy and confidentiality of his/her own personal medical records .Right to privacy includes accommodations, medical treatment .personal care . Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Cervical Disc Disorder with Myelopathy, and Fusion of Spine. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to compete the interview. Continued review revealed he had and indwelling urinary catheter. Review of the Order Summary Report for Resident #55 revealed an order dated 5/18/2023, .[Named brand of indwelling urinary catheter] size 16/20 fr. [French] to BSB [bedside bag] every shift for Retention . Review of the undated Care Plan revealed Resident #55 was assessed for an indwelling urinary catheter and was at risk for infection due to paraplegia with urinary retention. Observations in Resident #55's room on 7/24/2023 at 2:23 PM and again on 7/31/2023 at 9:02 AM, revealed Resident #55 lying in bed with a indwelling urinary catheter bedside collection bag with dark yellow colored urine visible to any other resident or visitor, hanging on the left side of the bed facing the hallway. The collection bag was not covered with a privacy cover. During an interview on 7/31/2023 at 9:06 AM, Licensed Practical Nurse (LPN) Unit Manager/Infection Preventionist confirmed Resident #55's urine collection bag was not covered with a privacy cover, and it should have been.

Based on review of facility policy, Quarterly Payroll Based Journal (PBJ), and interview the facility failed to report PBJ for Quarter 1 2023 (October 1 - December 31). The findings include: Review of the facility policy titled, Nursing Services and Sufficient Staff revealed, .It is the policy of this facility to provide sufficient staff .The facility is responsible for submitting timely and accurate staffing data through the CMS [Center for Medicare/Medicaid Services] Pay-Based Journal (PBJ) system . Review of the Quarterly Payroll Based Journal (PBJ) dated 10/1/2022 - 12/31/2022 revealed, .Failed to Submit Data for the Quarter . During an interview on 7/24/23 at 1:10 PM, the Administrator confirmed the facility failed to submit PBJ data by the required deadline for the first quarter of 2023.

Based on facility policy review, medical record review, facility investigation and interview, the facility failed to report within 5 working days investigation outcome findings on 1 Facility Reported Incident (FRI) #20221024113619 reviewed. The findings include: Review of the facility's policy titled, Abuse Investigation and Reporting dated 12/12/18 revealed, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . Review of the FRI #20221024113619 dated 10/24/2022, revealed an allegation of verbal abuse involving Resident #2 and Certified Nursing Assistant (CNA) #1 was reported through the State Agency. Continued review revealed an investigation was conducted which included skin assessments and interviews with residents assigned to CNA #1. No concerns related to abuse were noted. An abuse in-service was completed for all staff. As a result of the investigations, CNA #1 was suspended pending the investigation. During an interview on 11/21/2022 at 10:00 AM, the Administrator stated he reported the allegation of abuse on 10/24/2022 at 11:36 AM. The Administrator confirmed the report and investigation was not successfully submitted until November 1, 2022.

Based on hospital medical record, facility medical record review, facility documentation review, and interview, the facility failed to provide adequate supervision to prevent falls for 1 of 3 residents (Resident #1) reviewed, with a history of falls. The findings include: Review of the hospital Palliative Care Progress Note dated 10/3/2022 at 11:42 AM, revealed Resident #1, is unable to work with PT [Physical Therapy]/OT [Occupational Therapy] due to confusion and placement at SNF [Skilled Nursing Facility] is limited due to needing a sitter and psych [psychotropic] medications. Palliative care following up for continued hospice discussions . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Myocardial Infarction, Dementia with Agitation, Palliative Care, Malignant Neoplasm of the Prostate, Anemia, Depression, Anxiety, Hypertension, and Atherosclerotic Heart Disease. Review of the Baseline Care Plan, dated 10/8/2022, revealed Resident #1 was care planned for health-related complications due to Risk for Urinary Tract Infection (UTI), Altered Cardiovascular Status, Cognitive Deficit, Risk for Falls, Risk for Further Decline in Activities of Daily Living, Hospice, Impaired Nutritional Status, Anemia, Skin Problem, Depression, Risk for Discomfort, Risk for Cardiac Distress, Pacemaker, and use of Psychotropic Medications. Review of a Health Status Note dated 10/10/2022 at 3:54 AM revealed, .Resident has been awake, restless and agitated, always try to climb out the bed, taking off clothes and briefs. The bed was in lowest position and Lorand [lower] 1/3 of the siderails was on. To prevent Fall and keep resident safe, CNT [Certified Nursing Technician] was assigned to monitor resident one on one. Will continue to monitor . Review of a Health Status Note dated 10/10/2022 at 8:00AM revealed, .This AM at 7:25, this writer was called to resident's room as he was seen on the floor by another staff nurse. Upon entering room resident was found to be on the floor next to his bed. There was feces and a moderate amount of blood on the floor and resident's hands. Resident denied pain and was able to move all extremities. He was noted to have a large skin tear to his Lt. [left] arm. He was assisted to the shower chair and two staff showered him. This writer was called to shower room as resident was noted to have large amount of blood and clots coming from rectum. After shower skin tear was cleaned and drsg. [dressing] applied. This writer made MD [Medical Doctor], DON [Director of Nursing] and resident's wife aware. MD Resident's wife provided a phone number for [Named Hospice Agency]. This writer called and spoke with on call rep. [representative]. No return call from Hospice. DON to follow up . Review of a Health Status Note dated 10/10/2022 at 8:15 AM revealed, .As reported per CNT resident was sitting in shower chair as she and another staff were giving him a shower when he jumped out of the shower chair and fell to the floor. No injuries noted at this time . Review of a Health Status Note dated 10/10/2022at 9:01 AM revealed, .At 8:50 AM this morning resident was sitting in the main dining room awaiting transport per 911 to take him to [Named Hospital Emergency Room] for Eval. [evaluation] and Tx. [treatment] after two falls this morning. When EMTs [Emergency Medical Technicians] approached the nurses station, this writer pointed resident out and as EMTs headed towards the dining room one of them yelled out he fell , this was resident's third fall. He said he was not hurt but was rubbing his head. EMTs assessed resident and assisted him to stretcher and proceeded with transport . Review of a Health Status Note dated 10/10/2022 at 10:03 AM revealed, Notified spouse. 911 notified of imminent transfer. Report called to ER [emergency room ] . Review of a Health Status Note dated 10/10/2022 at 2:01 PM revealed, .IDT [Interdisciplinary Team] team met for Admission plan of care meeting [Named Resident #1]'s sister, spouse, daughter-in-law and Hospice Representative participated in the plan of care meeting .He was admitted to facility for long term care, however the family requests for resident to be discharged back to the hospital due to multiple falls and him not being appropriate for Nursing home placement due to his health status he was 1:1 at the hospital and had a sitter twenty-four hours a day . Review of the revised Care Plan revealed, .Resident is at risk for fall .10/10/2022 Fall-no injury: Offer resident toileting every 2 hour .10/10/2022 Fall-minor injury, bleeding noted from rectum-Sent to ER for eval and tx as necessary .10/10/2022 Fall-minor injury, skin tear-Have resident at nurse's station when up in chair .Anticipate needs and provide appropriate level of supervision as needed . Review of the Discharge Minimum Data Set assessment for Resident #1 dated 10/11/2022, revealed no Brief Interview for Mental Status (BIMS) assessment obtained. Review of the hospital ER notes dated 10/10/2022, revealed Resident #1, .is a 78 yo [year old] male .who presents from palliative care facility following multiple falls this AM. Review of the hospital CT [computed tomography] Scan obtained in the ED on 10/11/2022 revealed, .likely subacute subdural hemorrhages. All of these hemorrhages are new from 9/28/2022 . The Discharge Summary dated 10/14/2022 revealed, CT Scan in the ED showed: Findings consistent with possible Subdural hemorrhage . Review of the facility's Incident/Accident Report dated 10/10/2022 at 7:35 AM, revealed, .[Resident #1] was found on the floor, small amount of blood and feces noted. He was next to his bed he was able to move all extremities, has skin tear to Lt. arm . Review of the facility's Incident/Accident Report dated 10/10/2022 at 8:00 AM, revealed, .As per CNT resident [Resident #1] was sitting in the shower chair about to get a shower when he suddenly jumped from the chair and fell to the floor . Review of the facility's Incident/Accident Report dated 10/10/2022 at 8:50 AM, revealed, .[Resident #1] was sitting in the main dining room in a chair waiting to be transported to the hospital for two prior falls. The EMT yelled upon their arrival he's falling. Staff could not get to him in time . Review of a witness statement [signed by Licensed Practical Nurse (LPN) #1] from the facility's fall investigation dated 10/10/2022, revealed, .I had asked the hospice nurse about one-on-one. She didn't give me a clear answer. So I went down to the cart to call the DON [Director of Nursing] to clarify about the one-on-one. She told me that the hospital strongly suggested having him one-on-one for the night . The facility failed to provide adequate supervision (for Resident #1) after the first fall to prevent subsequent falls. Resident #1 hit his head during the second fall on 10/10/2022 at approximately 8:15 AM. There was no documentation found if Resident #1 hit his head during the third fall, but facility staff documented Resident #1 was rubbing his head after the third fall. During a phone interview on 10/24/2022 at 12:04 PM, Family Member #1 stated, My dad was transferred to [Named Facility] from [Named Hospital] on a Friday. On Monday, my mom was notified he had fallen. They told her he had fallen and had some bleeding from his mouth, but he was okay. They called back later and told her that he was being transferred to the hospital. They told he that he had fell again while they had him in the shower cleaning him up. We weren't told he had fallen three times until Hospice told us. I spoke to the ER doctor, and he said that they did a CT and blood work and an abdominal scan and cleared him and sent him back to [Named Facility]. After he got back there, we got into a confrontation with one of the nurses there. She told us that we had to stay the night with him. We were told there wasn't enough staff to sit one-on-one with him. The next day they wanted to have a Care Plan meeting with us. My mom went and I was on the phone. They basically asked why we couldn't sit with him, and we were told by the DON that they would send him back to the hospital. We told them that we wanted him sent back if they couldn't take care of him. He had a skin tear on his arm and was complaining of his head hurting. After he went back to the hospital, they did another CT scan and more blood work. At that point we didn't get the results, so they admitted him. They told us he was losing blood but thought it was due to his hernia. I was told the next day he had a brain bleed. They said it was possible it could have been from the fall on that Monday or could have been another incident. They keep doing CT scans and they told us the brain bleed wasn't any worse but there was no change. My mom had signed a DNR [Do Not Resuscitate], so the hospital didn't feel like he needed to be monitored further and he wasn't a candidate for surgery to resolve it, so on 10/14 he was transferred to [Named Hospice]. Then early Sunday morning, 10/16, I got a call saying he had passed away unexpectedly. Mom called the Medical Examiner's Office and asked about the Death Certificate, and she was told it would be reported as an accidental death because of the brain bleed. On the Death Certificate, it just says pending, and we were told it could be 2 to 3 months before we get anything. We visited with him on 10/14 and he was alert and talking but confused. He had had CT scans prior to the first hospital stay and they were fine. The ER Physician even said that he called the facility about why he was allowed to fall 3 times that morning. We finally found out that he had had 3 falls that morning, instead of just 1. He was first found on the floor, then while in the shower, we were told the girl left him in the shower and he fell , then we were told that he was left unattended in the dining room while they were waiting for the ambulance to come get him to take him to the hospital. During an interview on 10/25/2022 at 1:55 PM, LPN #2 stated, that Resident #1 had his first fall on 10/10/2022, right after shift change [end of night shift and start of day shift]. LPN #2 stated, Night shift was coming back down the hall and saw him and said he was in the floor. We went in his room, and he was on the floor next to his bed. He had poop and blood on him. He had a skin tear on his arm and the blood was coming from his arm. I helped the tech [technician] get him to the shower to clean him up and another male staff member went in to help her. The CNA [Certified Nursing Assistant] told me that he was in the shower chair, and he stood up and fell while she was reaching for something to wash him with. After that is when she noticed blood coming from his rectum. I called the wife and told her and I called Hospice. I called the overnight Hospice number. The DON came in and Hospice had never called me back by that time. I called the wife back and told her we were going to send him to the hospital and that Hospice had not called us back at that time. I told her that he had the skin tear and blood coming from his rectum. She said I had told her that he had blood coming from his mouth, but I told her that she must have heard me wrong because I had said it was his rectum. While I was getting the paperwork ready for him to go to the hospital, 2 techs brought him in the dining room in a Geri-chair [geriatric chair] and sat him at a table. I was handing EMS [Emergency Medical Services] the paperwork and they went in the dining room, and they saw him and one EMT yelled he is falling but they couldn't get to him in time. He had pushed the table out and fell forward. A staff member was in the dining room but couldn't get to him fast enough. The EMT saw him falling but couldn't get to him fast enough either. He verbalized no pain with the falls, but he was rubbing his head with the third fall. I assessed him and there were no knots or bruises on his head. EMS checked him out also before they transported him to the ER. He came back from the ER late that night. The next day the family came in. I was giving him his meds [medications] and the wife wanted to know what he was taking. I told her it was Ativan [medication used for agitation] for fidgeting and the wife said she didn't want him to have it. I explained to her that it was to help him calm down. The son-in-law went and got the Social Worker and wanted him transferred out. During an interview on 10/25/2022 at 2:40 PM, LPN #1 stated that she was working the night on 10/10/2022, when Resident #1 returned to the facility, from the ER. LPN #1 stated, The family told us that they highly recommended one-on-one when he came back. I knew we would need help to provide that. The Hospice nurse came in shortly after he came back from the hospital. I told her his meds weren't in the right place, but I found them, and I was getting them ready now. I gave him his meds with no problems. The Hospice nurse had increased his Ativan. The family was upset because he fell 3 times that morning. I told Hospice that he needed one-on-one and told them someone would need to sit with him. The family misunderstood and thought I was telling them they needed to sit with him. I told them I did not say they needed to, I said somebody. I did not say family. I called the DON and put her on speaker; they were yelling at her also. She said they could send him back to the hospital or refer him somewhere else. The son then came and asked for his med list and said they were going to have a meeting in the morning with the Administrator and get me fired. They wanted to know how he fell 3 times that morning and why we took him if we couldn't accommodate him. A tech sat by his room that night, to monitor him that night but they had other patients too. During an interview on 10/25/2022 at 4:10 PM, the DON stated the morning Resident #1 fell [10/10/2022], she was on her way to the facility. She stated, I got a text from the nurse that said he had a fall and had a large skin tear and blood coming from his rectum. I told her to call Hospice and the Doctor. We called Hospice at 8:54 AM and call again at 9:10 AM. We also called the Doctor and he said to send him out to the ER. I finally got a called back from Hospice at 9:15 AM and was told a nurse would be there in an hour. I told him we were going to send him to the ER. After the first fall, they took in in the shower to clean him up and he tried to stand up and the CNA sat him down in the shower. EMS was coming in the door, and we were directing EMS to the dining room and one of them yelled he was falling. I think he was in a wheelchair not a Geri-chair. Staff was in the dining room with him but was getting ready to take the smokers out. EMS yelled he is falling. We were at the door trying to get to him, but we just couldn't get to him in time. We weren't told that he had been in restraints at the hospital and had to have a sitter. I don't think we put him on a one-on-one. The aide pulled her chair up by his door the night he came back to watch him but had other residents to take care of. Having a one-on-one sitter is not sustainable. I don't think Hospice does one-on-one either. When he was in the dining room waiting on EMS to come, he wasn't one-on-one. There was an aide in there and she was turned around letting the smokers out the door and he fell . He wasn't unsupervised after the first fall but not a one-on-one. The DON confirmed that Resident #1 was sitting up in a chair, in the dining room and did not receive one-on-one supervision, after sustaining 2 falls on the morning of 10/10/2022, and then sustained a third fall before being transported to the ER. The DON also confirmed that Resident #1 did not receive one-on-one supervision after returning, to the facility, from the ER, the night of 10/10/2022. During a phone interview on 11/8/2022 at 11:06 AM, CNA #7 stated that she was assigned to care for Resident #1 the morning of 10/10/2022. She stated that Resident #1's 1st fall was early that morning. CNA #7 stated, It was right after shift change. When I checked on him previously, he was asleep. I went down the hall to pick up some breakfast trays, and when I came back up the hall, I looked in his room and saw him standing up beside his bed. I went in and sat him down on the bed. He had blood on him, and he had pooped, and it was all over his hands and all over him. There was poop everywhere and blood. He had to have been by the window at some point because there was some blood on the window seal. I got the nurse to come in and look at him. She came in and checked on him and he said he wasn't hurt. He did have a skin tear to his arm, and I'm sure that's probably where the blood was from. After the nurse got through checking him out, I took him into the shower room to get him cleaned up. I sat him on the shower chair and had someone hand me some PPE [Personal Protective Equipment] because of all the poop and blood. He was just sitting on the shower chair. I was putting my gloves on and just all of a sudden, he jumped straight up out of the chair, and I was reaching for him, and he still fell backwards. When he fell backwards, he did bump his head. I asked him if he was okay and did he hurt his head but he said he was ok and he didn't hurt his head. I called for help and 3 others came in to help me bathe him. The nurse checked him out and got his vital signs and checks on him. He was okay and there wasn't any knots of bruises on his head or anywhere else and he said he was okay. After that, 2 others stayed in the shower room and helped me bathe him. After we got done, we put his clothes on and I helped him with his breakfast. The nurse had already told me before his other fall, that he was going out to the hospital. After he was finished eating, the nurse told me to put him in a chair and put him in the dining room by the window so they could see him from the nurses' station, until they came to get him to take him to the hospital. I took him in there and set him by the window. I saw him one other time and he was still sitting in the chair in the dining room. I did not see him fall that last time. I think the EMTs are the ones that either saw him falling or saw him in the floor. They got him out of the floor and checked him out again. There was a staff member in there when he fell , I'm not sure which one it was, but I think she was letting the smokers out when he fell that time. The took him on to the hospital and got him checked out and he must have been okay, because he came back later that night. After he got back, the family stayed with him until after 9 [pm]. He was more calm, and in bed but I did sit close after that. I did sit outside his door to watch him after that, and he slept all night until they got him up the next morning. After that he I think the family wanted him sent out again. During an interview on 11/9/2022 at 12:03 PM, CNA #5 stated that she was in the dining room on 10/10/2022, when Resident #1 fell while waiting for the ambulance to pick him up. CNA #1 stated, I was doing activities in the dining room. He had already had a fall that morning, so they brought him in the dining room. I was sitting beside him going through a magazine and trying to give him something to do. It was smoke break and some of the smokers were at the door wanting out. He was looking through the magazine when I had just stood up for a few seconds and walked over to the door and I reached up to unlock the door and he just stood up and fell out of his chair. It was just a few seconds; it wasn't far to the door. The Paramedics were walking through the door right at the same time and other staff immediately came in too. It's been a while since then, but the best I can remember he was laying on his back like maybe the chair went back when he stood up. I'm not sure. I didn't see him actually fall. It just happened so fast. I mean it was just a few seconds. I just feel bad that he fell . They checked him out and took him on to the hospital after that.

Based on facility documentation review, facility's policy review, medical record review and interview the facility failed to protect 1 Resident out of 2 sampled Residents (Resident #5) for Elopement. Resident #5 was found outside the facility between 100 and 200 Halls exit doors by a staff member lying on the ground by the sidewalk on 6/21/2022 at 3:05PM. Unknown how long Resident #5 was outside the facility or how he exited the building. The Elopement was unwitnessed. Resident #5 had a Wander Guard in place. The weather on 6/21/2022 was 98 degrees placing Resident #5 in an Immediate Jeopardy IJ (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 was notified of the Immediate Jeopardy on 8/2/2022 at 9:30AM in the conference room. F-689 was cited at the scope of J. The facility was cited at F-689 at the scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective 6/21/2022 to 8/2/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 8/2/2022. The corrective actions were validated by the surveyors on 8/2/2022 at 4:45PM. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The Facility is required to submit a Plan of Correction. The finding include: Review of the facility policy titled, Abuse Investigation and Reporting, revised 12/13/2018, revealed, .All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Finding of abuse investigations will also be reported .The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation . Review of the facility policy titled, Resident Rights, effective 9/1/2011 and revised 10/16/2016, revealed, .Right to an environment that is safe, clean, comfortable, and homelike environment. Right to receive treatment and supports for safe daily living . Review of the facility's policy titled, Elopement/Wandering, Unsafe Resident, dated 2/1/2009, revealed, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The resident's care plan will indicate the resident is at risk for elopement or other safety issues .Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident .All residents admitted to the facility will have an elopement assessment done within the first 24 hours .An elopement Assessment will then be completed every 90 days and interventions updated as needed .Staff will notify the Administrator and the Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered to be missing from the unit or facility . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Schizoaffective Disorder, Unspecified, Aphasia Following Cerebral Infarction and Unspecified Abnormalities of Gait and Mobility. Review of the Annual MDS assessment dated [DATE], revealed Resident #5 scored 3 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive functioning. The MDS also revealed Resident #5 required supervision with bed mobility, transfer, locomotion on and off the unit; limited assistance with walking dressing, eating; as well as extensive assistance with toilet use and personal hygiene. Review of the comprehensive Care Plan for Resident #5 dated 4/19/2022 revealed a person-centered individualized care plan that included Cognitive Deficit In Decision Making, Communication Deficit, Fall Risk, Mood and Behaviors, Visual Impairment, Wandering, At risk For Elopement, History Of Attempts To Leave The Facility, and Wander Guard Device. Review of the Incident Report on Resident #5 dated 6/21/2022 at 15:30 (3:30PM) Resident #5 was .Found outside of the building on the ground by the walkway. Unknown how resident got outside .no injuries noted .Resident was confused .was redirected and returned inside and back to his room . Attempted to interview staff that found Resident #5 outside the facility but was not working that day and could not be reached by phone. Review of a nurse's noted for Resident #5 dated 6/21/2022 at 21:48 (9:48PM) revealed .Resident was seen by staff outside of the facility on the ground between 100 and 200 hall exit doors beside walkway. Resident confused and not able to tell staff why he was outside. Was able to get up with staff assist and redirectable to the entrance. Returned resident to his room and laid down. No injuries noted at this time. VS (Vital Signs) WNL (Within Normal Limits). Educated staff on need to be aware of resident's location at all times for safety. Left message for family and Dr made aware. Fall precautions in place. Call light in reach. Will continue to monitor . Attempted to interview this nurse. The DON stated she works on the weekend only. Unable to reach by phone. During an interview on 8/2/2022 at 9:30AM with the facility Administrator in the conference room revealed when asked about Resident #5 being found outside the facility she stated, I had COVID and was out at that time. I did hear about it because they called me, and I thought someone always had eyes on him. When asked about the wander guard and how that works with the exit door alarms the Administrator stated, The wander guard only works on the front door. The service door and courtyard doors require a code to open those doors. The other doors have alarms between hall 100 and 200. When opened they will sound an alarm at the nurse's station and must be manually disarmed at the nurse's station after the door is closed. When Housekeeping propped open the service door to take out the trash, we assumed that Resident #5 went outside behind her, and she did not see him. The Administrator confirmed Resident #5 was found outside the facility on 6/21/2022 at 3:05PM by a staff member between 100 and 200 halls which is around the corner of the building from the service entrance lying on the ground next to the sidewalk. The Administrator confirmed no report was filed to the state agency and a thorough investigation was not completed. During an observation and interview on 8/2/2022 at 10:00 AM near the laundry and maintenance departments, there were 2 doors going to the outside, each door has a keypad that must have a code to open the door. One door exited into a courtyard and the other door; the Service Door exited into a parking lot which contained the dumpsters. Observation of the ground outside of the Service Door revealed a brick and 2 wooden wedges near the door. Interview with Laundry Person #1 she stated, You have to push the code in on this door, [the door exiting to the courtyard] and it unlocks the door to the courtyard and the same code is used on the keypad that unlocks the service door. When asked if an alarm sounds when the doors are opened with a code, she stated, no. When asked what the brick and the wooden wedges were used for, she stated, We must use them to prop the door open when we take out the trash. If the door closes, we can't get back in because there is no keypad on the outside so we would have to walk all the way around the building. When asked is this the normal practice of everyone who takes the trash out, she stated, yes. The surveyors verified the acceptable Immediate Action Removal Plan on 8/2/2022 at 4:45PM as follows: The surveyors verified the Medical Director was notified of the Immediate Jeopardy on 8/2/2022. The surveyors verified the facility assigned a staff member to monitor Resident #5 one on one. The conservator was informed on 8/2/2022. Resident's care plan was updated accordingly. The surveyors verified in-service training was given to all staff on duty on Elopement Risk beginning 8/2/2022 and will be ongoing to ensure 100% compliance. The surveyors verified staff on duty will pass the post elopement test after completion of the in-service with 100 percent accuracy. The surveyors verified staff on duty was educated to alert personnel of a missing resident using code gray and notify the Administrator/Assigned Designee immediately. Also notify Physician and Family. If Physician does not respond in a timely manner, the resident will be transferred 911 to the hospital for evaluation and treatment. The surveyors verified Resident #5 elopement has been thoroughly investigated by the Interdisciplinary Team and recommendations were added to the care plan. The surveyors verified 100 percent of all facility residents will be screened for Elopement Risk and those Residents identified will receive a wandering device. Completed 8/2/2022. The surveyors verified the Director of Nursing and Assistant Director of Nursing reviewed and/or updated all wander/elopement assessments on all residents on 8/2/2022. The surveyors verified all staff were educated on 8/2/2022 and ongoing until 100 percent compliance by Staff Development Coordinator, Administrator and on Elopement Risk, Abuse, Neglect, Accidents and Reporting incidents. No employee allowed to work until in-serviced. The surveyors verified the facility will conduct an elopement drill 08/02/22 and will provide one weekly times 4 weeks and then once a month for 6 months thereafter. The drill will be used as a return demonstration for the education that has been delivered. Each shift will get one over the next four weeks including over the weekend by designated staff/ Manager on Duty. The Staff Development coordinator will conduct an audit of the sign in sheets to ensure all employees have attended and report the results of the audit to the QAPI committee. The surveyors verified the facility placed a sign on the Service Entrance Door stating: NO ONE ALLOWED TO OPEN THIS DOOR WITHOUT 2 PEOPLE PRESENT. (EMPLOYEES THAT DON'T COMPLY WILL BE IMMEDIATELY TERMNATED.) Surveyors verified education was provided to all staff on duty and education will be provided to oncoming staff before their shift begins as follows: Rather than propping any exit door open one person will stand at the open door for monitoring and the other person will take out the trash.

Based on facility policy review, medical record review, and interviews, the facility failed to identify and provide needed care and services that are resident centered in accordance with professional standards of practice that resulted in harm from elevated Potassium levels and elevated blood glucose readings for #1 of #5 sampled residents (Resident #1) reviewed. The finding include: Review of the facility policy titled, Resident Rights, effective [DATE] and revised [DATE], revealed, .Right to an environment that is safe, clean, comfortable, and homelike environment. Right to receive treatment and supports for safe daily living . Review of the facility policy titled, Medication Administration, dated [DATE], revealed, .Medications shall be administered in a timely manner and as prescribed .Medications must be administered in accordance with the orders, including any required time frame .Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document on the MAR [Medication Administration Record] space provided for that drug and dose . Review of the facility's policy titled, Physician Services, dated [DATE], revealed, .The medical care of each resident is under the supervision of a Licensed Physician .The resident's Attending Physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, and providing consultation of treatment when called by the facility .The resident's Attending Physician is responsible for prescribing new therapy, ordering a transfer to the hospital, conducting required routine visits, delegating and supervising follow-up visits from Nurse Practitioner or Physician Assistants, etc., to ensure that the resident receives quality care and medical treatments . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 expired in the facility on [DATE]. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored 3 on the BIMS which indicated severe cognitive functioning. The MDS also revealed Resident #1 required total dependence in all ADLs (Activities Of Daily Living). Review of the Comprehensive Care Plan Dated [DATE] for Resident #1 revealed a person-centered individualized care plan. Review of lab results for Resident #1 dated [DATE] revealed Potassium 6.4 (HH) (Critical High) and Glucose 516 (HH) (Critical High). No documentation in nurse's notes that Physician was notified of abnormal labs. Review of lab results for Resident #1 dated [DATE] revealed Potassium 8.1 (HH) (Critical High) and Glucose 1115 (HH) (Critical High). Review of a nurse's note dated [DATE] at 22:45 (10:45PM) on Resident #1 revealed a critical lab value of Glucose 1115 and a Kt (Potassium) of 8.1. MD was notified of critical lab values and received a verbal order for: 1). 25 Units Lantus BID (Twice Daily), 2). Accu checks (Glucose Fingerstick) with Novolog Sliding Scale Insulin, 3). NS (normal Saline) 1L (Liter) via IV at 150ml/hr STAT, 4). Kayexalate 60 mls (Milliliters), administer 1 dose via peg tube or rectally, 2nd dose after 8 hours and repeat CMP (Comprehensive Metabolic Panel). Orders noted and faxed to pharmacy manually, Insulin administered per order. Resident #1 responsive to verbal stimuli, VS (Vital Signs) remain stable. Will continue to monitor. Order received to give 25 units Lantus and 14 units Novolog now. Review of a nurse's note dated [DATE] at 10:30AM on Resident #1 revealed .Report was received from night shift nurse that resident has been with elevated blood sugar, and she has order of IV (Intravenous) 0.9% normal saline, but it was impossible to get IV access. Doctor notified and he ordered GT (Gastro Tube) 250 ml of water every hour times four and monitor residual. Morning nurse checked blood sugar and still high and administered her insulin schedule .After 15 minutes checked blood sugar again and still high. Supervisor called doctor .Report to ambulance including abnormal potassium result .called residents family .Resident went to ER . Review of the MAR (Medication Administration Record) for Resident #1 dated ,d+[DATE] revealed Novolog Insulin 25 Units was administered on [DATE] at 11:30 AM, Bolus of 250/ML water was given via G-Tube on [DATE] at 8:00AM, 9:00AM, 10:00AM, and 11:00AM. The MAR revealed Kayexalate was received at the facility on [DATE] at 2:35PM. It was documented on the MAR by the day shift nurse Kayexalate was available to give but Resident #1 was already at the ER. Attempted to interview this nurse by phone. Unable to reach by phone after several attempts. Review of a nurse's note dated [DATE] at 11:18AM on Resident #1 revealed, .Patient now lethargic, blood sugar still registering Hi. NP (Nurse Practitioner) notified to transfer to ER for evaluation and treatment . Review of a hospital ER note dated [DATE] at 12:07PM for Resident #1 revealed she was received in the ER for evaluation. The notes revealed, [AGE] year old female presents to the emergency department for altered mental status .The patient has had decreased responsiveness throughout the day today, unknown last well time .Primary impression: Septic Shock, Secondary Impression: Acute Renal Failure, DKA (Diabetic Ketoacidosis), Pneumonia, UTI (Urinary Tract Infection) .Patient was critically ill due to: Septic shock, DKA, Acute Renal Failure with Hyperkalemia, numerous medical conditions that could result in rapid clinical deterioration and death .initiation of insulin drip, aggressive IV fluids, coordination of care with intensivist, discussion with her husband, numerous re-evaluations at bedside . Review of a hospital note dated [DATE] at 8:12AM for Resident #1 revealed .On arrival to ER she was hypotensive, hyperglycemic, and with metabolic acidosis. She was given volume and started on an Insulin ggt (drip) .On arrival she was only withdrawing to pain . During an interview on [DATE] at 12:45 PM with the Admissions LPN, she confirmed there is no Kayexalate in the Pyxis machine. She stated if the doctor ordered a medication and it was not available, the nurse should call the doctor back and tell him it was not available and see if he wanted to order another medication, they had access to. When asked if the pharmacy would have sent the Kayexalate STAT at 10:30 PM, she confirmed they would not have. During an interview on [DATE] at 1:00PM regarding Resident #1 with the Assistant Director of Nursing (ADON) in the conference room revealed she stated, I came in early that morning, probably around 2:00 AM to help cover a shift. I helped [Named night nurse] put the orders in for the IV [intravenous needle]. I asked him about the blood glucose, and he said it said it was registering HI. He asked me to do the orders. I asked if they had put the orders in and asked if he started to IV. He said he couldn't get the IV in. I asked if he got an order for a bolus, and he said no. I told him to call and get an order for a bolus. He called and got the order. When the DON got here, I reported to her everything that was going on. From that point, there was a meeting going on that morning, Emergency Preparedness, that they had to go to. I reiterated how important this situation with the resident was and even wrote it on a sticky note. I wrote on the sticky note, Blood Glucose was 1000 and gave it to the DON. The DON assessed the resident and called the NP and told her she needed to be sent to the ER. This all happened around 11:30 AM. I put the order in and helped with the paperwork to send her to the ER. The DON confirmed, The resident should have been sent to the ER if they facility couldn't get Kayexalate or get the IV started. The Director of Nursing, who was present during the interview, agreed with the Assistant Director of Nursing the resident should have been sent to the ER. During an interview on [DATE] at 8:20AM with the DON in the conference room she confirmed Resident #1 did not receive any doses of Kayexalate as ordered on [DATE] by the night shift nurse at 10:45PM. She stated she checked the Pyxis machine, and no Kayexalate was available to be dispensed that night. Kayexalate was received at the facility on [DATE] at 2:35PM but Resident #1 was already in the ER. During an interview on [DATE] at 2:50PM with LPN #5 in the conference room revealed he recalled the night Resident #1 had critical labs, LPN confirmed, I remember getting critical labs on her. I remember I did call the doctor and got verbal orders. After LPN #5 reviewed his charting that night he confirmed, I did chart the verbal orders. When asked if he charted a phone call with the Physician that Kayexalate was not available in the facility he confirmed, No doesn't look like I did. I think I told him it would not be available until the morning, but I didn't put that in my notes. When ask about Resident #1's decline during the night with elevated glucose reading and altered mental status, if he called the Physician back, LPN #5 confirmed, No I had already called to him and got verbal orders. When asked about charting further decline in Resident #1's condition LPN #5 confirmed, No I only charted the verbal orders.

Based on medical record review and interview, the facility failed to provide pain management post-fall with a fracture (HARM) after verbal complaints of pain for 1 of 27 sampled residents (Resident #239) reviewed. Findings include: Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. Continued review revealed the resident had vocal complaints of pain during the assessment review period. Further review revealed Resident #239 had a fall with major injury since admission. Medical record review of facility investigation dated 3/26/18 revealed at 5:00 AM Resident #239 was found sitting on the floor behind a couch in a room across the hall from her room. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh to the Physical Therapist (PT). Medical record review of a statement dated 3/26/18 written by Physical Therapist #1 revealed .Brought patient to P.T. (physical therapy) gym to stand in parallel bars. Patient unable to secondary to pain. Patient then told therapist she had fallen. Therapist took patient back to nurse and told nurse of patient's pain . Medical record review of a statement dated 3/26/18 written by Licensed Practical Nurse #6 revealed .(at) approximately 7AM patient was in dining room and complained of pain to right leg (upper) to the therapist when she tried to stand her up. Pain was reported to this writer by the therapist. Endorsed the c/o (complaint of) pain to right leg to incoming nursing supervisor to f/u (follow-up) (with) MD . Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30 AM with no response documented. Review of a physician's orders [REDACTED]. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Medical record review of the Medication Administration Report for (MONTH) (YEAR) revealed an order dated 3/23/18 for pain to be assessed every shift. Continued review revealed a pain level of .4 . documented on the evening shift of 3/26/18. Continued review revealed no documentation of pain management interventions. Further review revealed Resident #239 was not provided with any pain interventions or medications from the first complaint of pain (6:30 AM) until arrival at hospital (2305 or 11:05 PM). Medical record review of a hospital Emergency Provider Report revealed, Initial Greet Date/Time 3/26/18 2243 (10:43PM). Medical record review of a hospital note dated 3/27/18 revealed Resident #239 was administered [MEDICATION NAME] (opioid pain medication) 2 milligrams on 3/26/18 at 11:05 PM for pain. Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed she was made aware of Resident #239's fall on morning it occurred. The DON said she was also notified of the resident's complaint of pain. The DON confirmed the facility failed to provide pain management after verbal complaints of pain after a fall which resulted fracture for Resident #239. Refer to F-580, F-655, and F-689

Based on medical record review, Physician's Orders, Radiology Report, Nurse's Notes, facility investigation and interview, the facility failed to prevent an accident which resulted in a fracture for 1 of 27 sampled residents (Resident #239) resulting in a HARM. Findings include: Review of facility policy Fall Prevention and Investigation dated 11/28/16 revealed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a facility investigation revealed on 3/26/18 at 5:00 AM Resident #239 was found in a room across from her room, sitting on the floor behind a couch. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh. Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30AM with no response documented. Review of a Physician's Order dated 3/26/18 at 1449 (2:49PM) revealed a phone order received by the Attending Physician for, x ray right femur, pelvis, pelvis (sic), and right hip r/t pain. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed she was made aware of Resident #239's fall on the morning it occurred. The DON said she was notified by the second shift nurse of the X-ray results. The DON confirmed the facility failed to implement measures to prevent an accident which resulted in a fracture for Resident #239 (HARM).

Based on facility policy review, medical record review and interview, the facility failed to identify interventions on a baseline Care Plan for 1 of 27 sampled residents (Resident #239) reviewed which resulted in a HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services) for the facility's failure to provide fall interventions to keep the Resident safe after identification as 'high' falls risk. Findings include: Review of facility policy Baseline Care Plans dated 11/28/17 revealed .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating mild cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a Morse Fall Scale (an evidence based tool used to provide a quick and simple assessment of a patient's likelihood of falling) dated 3/23/18 at 2349 (11:49 PM) revealed Resident #239 had a score of 90 (Scoring: Low Risk 0-24, Moderate Risk 25-44, High Risk 45 or higher) indicating High Risk. Continued review revealed the following risk factors were documented: 1. Yes, the Resident has fallen before. (History) 2. Yes, the Resident has more than one [DIAGNOSES REDACTED]. 3. Yes, the Resident uses crutches, cane or walker. (Ambulatory Aid) 4. No, the Resident does not have an intravenous apparatus or [MEDICATION NAME] lock inserted. (IV or IV Access) 5. Resident is Impaired: 5a. difficulty rising from chair, uses chair arms to get up, bounces to rise. 5b. keeps head down when walking, watches the ground. 5c. grasps furniture, person or aid when ambulating. Cannot walk unassisted. 6. Yes, the Resident overestimates or forgets limits. RESULTS: High Risk for Falling SCORE: 90 Medical record review of Resident #239's Baseline Care Plan dated 3/23/18 revealed the facility had identified falls as a safety concern. Further review revealed no identified interventions documented throughout Resident record regarding falls. Medical record review revealed Resident #239 had a fall on 3/26/18 which resulted in a femur fracture (HARM). Further review revealed the resident was admitted to the hospital on [DATE] and received surgery on 3/28/18 to repair the right [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed Resident #239 had been identified as a high fall risk. The DON confirmed the facility failed to identify fall interventions on the Baseline Care Plan for Resident #239.

Based on medical record review, Nurse's Notes, Physician's Orders, review of facility investigation and interview, the facility failed to provide goods and services necessary to treat pain and provide prompt medical attention which resulted in a fracture for 1 of 27 sampled residents (Resident #239) resulting in HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a facility investigation revealed on 3/26/18 at 5:00 AM Resident #239 was found in a room across from her room, sitting on the floor behind a couch. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh. Medical record review of a statement dated 3/26/18 written by Licensed Practical Nurse #6 revealed .(at) approximately 7AM patient was in dining room and complained of pain to right leg (upper) to the therapist when she tried to stand her up. Pain was reported to this writer by the therapist. Endorsed the c/o (complaint of) pain to right leg to incoming nursing supervisor to f/u (follow-up) (with) MD . Medical record review of a statement dated 3/26/18 written by Physical Therapist #1 revealed .Brought patient to P.T. (physical therapy) gym to stand in parallel bars. Patient unable to secondary to pain. Patient then told therapist she had fallen. Therapist took patient back to nurse and told nurse of patient's pain . Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30 AM with no response documented. Review of a Physician's Order dated 3/26/18 at 1449 (2:49PM) revealed a phone order received by the Attending Physician for, x ray right femur, pelvis, pelvis (sic), and right hip r/t pain. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Medical record review of the Medication Administration Report for (MONTH) (YEAR) revealed no documentation of pain management interventions after the fall with injury occurred. Further review revealed Resident #239 was not provided with any pain interventions or medications from the first complaint of pain (6:30 AM) until arrival at hospital (2305 or 11:05 PM), approximately 11 hours after the fall with injury occurred. Medical record review of a hospital Emergency Provider Report revealed, Initial Greet Date/Time 3/26/18 2243 (10:43PM). Medical record review of a hospital note dated 3/27/18 revealed Resident #239 was administered [MEDICATION NAME] (opioid pain medication) 2 milligrams on 3/26/18 at 11:05 PM for pain. Further review revealed 16 hours had passed since Resident #239 received treatment or pain interventions for a fracture which occurred on 3/26/18 at 5:00 AM. Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed she was made aware of Resident #239's fall on the morning it occurred. The DON said she was notified by the second shift nurse of the X-ray results. The DON confirmed the facility failed to implement measures to prevent an accident which resulted in a fracture for Resident #239 (HARM).

Based on facility policy review, medical record review, facility investigation review, Physician Order, Nurse's Notes, Radiology Report and interview, the facility failed to notify the Medical Director/Attending Physician immediately after 1 fall by 12 residents (Resident #239) sampled/reviewed for falls. The facility's failure to notify the Physician in a timely manner resulted in prolonged pain to the Resident and HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). Findings include: Review of facility policy Notification of Physician & Family - Change in Resident's Condition or Status revised 11/28/16 revealed, .Our facility shall promptly notify the .Attending Physician .of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician .when there has been a(an) .accident or incident involving the resident . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating mild cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission (3/23/18). Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30AM with no response documented. Review of a physician's orders [REDACTED]. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Medical record review revealed Resident #239 had a fall on 3/26/18 which resulted in a fracture (HARM). Further review revealed the resident was admitted to the hospital and received surgery on 3/28/18 to repair the fracture. Interview with the Medical Director/Attending Physician on 4/18/18 at 5:00 PM by telephone revealed he expected to be called immediately for all falls. Interview with the DON on 4/18/18 at 5:45 PM in the conference room confirmed all falls should be reported immediately to the Medical Director/Attending Physician. Continued interview revealed the survey team reviewed the above referenced fall and the DON confirmed the facility failed to notify the Medical Director/Attending Physician immediately for 1 fall for 12 residents (Resident #239).

Based on policy review, medical record review, review of in-service record, observation and interview, the facility failed to provide supervision to prevent falls and failed to investigate falls per the facility's policy for 10 of 22 (Residents #35, 149, 9, 16, 25, 57, 113, 129, 150, 151 and 153) sampled residents of the 57 residents included in the stage 2 review. Three (3) of the 22 residents sustained harm following a fall or an elopement. The facility failed ensure a safety device was in place and operational to prevent falls resulted in actual harm when Resident #35 fell sustaining a hip fracture. The facility failed to supervise a resident for elopement and falls risk caused actual harm when Resident #149 cut a finger and sustained ribs fractures of an unknown origin. The facility failed to provide supervision, thoroughly investigate falls or ensure a fall mat was in place resulted in actual harm when Resident #9 sustained a hip contusion and a sprained elbow. The findings included: 1. Review of the facility's Elopement/ Wandering policy dated 2/1/09 documented, "...will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering..." Review of the facility's accidents/incidents investigations policy, revision date 6/1/12 documented, "...any accident/incident that results in an injury... falls... must be reported to the immediate supervisor... an investigation of the accident/incident will be made by the designated staff person..." Review of the facility's fall protocol dated 4/22/10 documented, "...Interdisciplinary Team (IDT) Fall Assessment to begin immediately... In-Service all personnel involved... Alter the Care Plan accordingly... Document in... Licensed Progress Notes x (times) 72 (hours)... Occurrence of another fall require further assessment and action immediately with documentation of the assessment as well as the action... If the Fall Assessment score is > (greater than) 10 place a Sunflower Sign on the door... If the Resident has experienced falls... a. Place a pink dot... on the sunflower sign on the door... b. The Resident will be on fall monitoring every 2 hrs (hours) x 60 days..." Review of the facility's "Protocol for Neurological (Neuro) Checks" documented "...neurological checks... performed on all residents with a suspected or known head injury..." 2. Review of the facility's "PROTOCOL FOR PSA (Personal Safety Alarm) USAGE AND MONITORING" policy documented, "...2. Place a PSA on a residents' bed and wheel chair if the resident falls after being admitted to facility... 3. Monitor all residents with a PSA during your shift for proper placement and good working condition..." Medical record revealed Resident #35 was admitted to the facility on [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score was 2, which indicated Resident #35 was severely cognitive impaired. Resident #35 was assessed with [REDACTED]. Review of a care plan dated 1/21/15 documented, "...PROBLEM: RESIDENT FOUND ON FLOOR... Other interventions applied: Bed PSA alarm to warn staff for attempts to get out of bed..." Review of a nurses note dated 2/6/15 at 8:37 AM documented, "At 10:45 pm (2/5/15) CNT (certified nursing technician) (#17) approached this nurse (#19), informing that patient is on the floor... No complains of pain or discomfort noted..." Review of a nurses note dated 2/6/15 at 23:07 (11:07 PM) documented, "cnt's reported resident in a lot of pain while transferring to bed and that resident had to be lifted to bed. MD (Medical Doctor) notified order received to transfer resident to ER (emergency room ) for evaluation." Review of an incident/accident report dated 2/5/15 documented, "CNT (Certified Nursing Technician #17) reported resident (#35) noted sitting on the floor in the hallway (500 Hall). upon this writer assessment resident have a skin tear to left elbow..." Review of a written statement dated 2/5/15 signed by Certified Nursing Assistant (CNA) #5 documented, "...Before I clocked out (named Resident #35) was resting in... bed. (Named CNA #17) was coming down the hall and I asked (named CNA #17) would... put (named Resident #35) in the bed and (named CNA #17) did..." Review of a written statement dated 2/5/15 signed by CNA #17 documented, "...I agreed pushed pt. (patient) to room, undressed... put on a clean brief, placed her in bed, covered pt up, pulled up both side rails..." Review of a statement obtained from CNT #17, who was assigned to care for Resident #35, on 2/5/15 at the time of the incident documented, "...PSA alarm to bed, alarm was not connected at the time of incident..." Review of an admission physician order [REDACTED]. Observations and interview with Resident #35 on 2/11/15 at 2:37 PM, in the dining room, revealed Resident #35 sitting in a gerichair listening to singing. Resident #35 was alert and was asked if resident had sustained a broken hip. Resident #35 stated, "They tell me I did" and patted the left hip. Interview with CNA #17 on 2/10/15 at 9:15 AM, in conference room #1, CNA #17 was asked to verify her written statement. CNA #17 read, confirmed, signed and dated her written statement as true. CNA #17 was asked about putting Resident #35 to bed on the evening of 2/5/15. CNA #17 confirmed she did put Resident #35 to bed and she did not see a PSA alarm and she did not connect it (PSA), nor did she hear any beeps from a PSA on her bed..." Telephone interview on 2/10/15 at 9:21 AM, Nurse #19 was asked about Resident #35's fall on the evening of 2/5/15. Nurse #19 confirmed she was assigned to Resident #35 on the 2nd shift. Nurse #19 confirmed the fall occurred at change of shift (2/5/15) at 10:45 PM. Nurse #19 stated, "...I went into the room right after it happened and I saw the PSA box on the floor and it was disconnected. I did not hear any alarm..." Interview with the Director of Nursing (DON) on 2/11/15 at 9:30 AM, in the DON's office, the DON was asked what is the expectation when there is an order for [REDACTED]. The DON stated, "To make sure it is functioning and sounding... and it is functioning properly if they are in the wheelchair or bed." The facility failed ensure a safety device was in place and operational to prevent falls resulted in actual harm when Resident #35 fell sustaining a fractured hip. 3. Medical record review revealed Resident #149 was admitted to the facility on [DATE] and readmitted on [DATE] and 9/26/14, with [DIAGNOSES REDACTED]. Review of a care plan dated 7/15/13 with last review date of 1/15/14 documented, "...Fall Risk... Potential for Injury... Approaches... wheelchair alarm to alert staff of resident's trying to get up from the wheelchair... fall monitoring for at risk resident every hour..." An additional intervention documented, "...11/16/13... anti-tipper to w/c (wheelchair) ... 3/10/14... d/c (discontinue) PSA to w/c... apply SRSB (self release seat belt) to w/c when up..." Review of an admission MDS dated [DATE] documented a BIMS score of 8, indicating moderate cognitive impairment; required extensive assistance of one person for dressing, hygiene, locomotion; and extensive assistance of two people for transfers, and assistive devices used were a wheelchair and walker. Review of Resident #149's January 2014 physician orders [REDACTED]. Review of an incident investigation form dated 1/2/14 documented, "...Type of Incident: Fall... unwitnessed... Location: Patio..." The in-service meeting minutes, attached to the incident Investigation documented, "...Topic: Elopements... Brief Summary... answer alarms promptly... be watchful of resident who are elopement risks..." Review of a care plan dated 1/2/14, attached to the facility investigation form, dated 1/2/14 documented, "...Problem... Resident Found on Floor... Approaches... send to ER (emergency room ) for eval (evaluation) & tx (treatment)..." and returned to the facility after ER evaluation. The interventions in place at the time of the incident were a PSA to bed and wheelchair and a wanderguard. Review of a post fall assessment form dated 1/2/14 documented, "...Result of Fall... Transfer to hospital... laceration..." and returned to the facility after the ER evaluation. Review of a physician's telephone order dated 1/2/14 documented "...Cleanse lacerations to bilateral hands with NS (Normal Saline) & (and) 4 x (by) 4 (a gauze pad)... apply TAO (Triple Antibiotic Ointment) & cover with Coban (an adhesive wrap)..." Review of a nurses note dated 3/7/14 at 9:00 PM for Resident #149 documented, "...has been attempting to elope x (times) 3, tries to go through front door, the back door and also at the 200 hall... redirection was unsuccessful... kept at the nurses station for 1 on 1 monitoring..." Review of an incident/accident report dated 3/8/14 at 5:10 PM documented, "...Type of Incident... Found on the floor... witnessed... Location... at front-parking area..." Review of a nurses note dated 3/8/14 documented, "...resident was noted at the nurse's station monitor (a television surveillance screen)... as found sitting on the floor at the front of the door in the parking area..." Review of a care plan dated 3/8/14 documented, "...Problem... Resident Found on Floor..." There was no new intervention implemented after the resident's attempted elopement from the facility on 3/8/14. Review of a nurses note dated 3/10/14 at 7:50 PM documented, "...resident continue to wander throughout facility and through exit doors... noted... at facility exit fence... attempting to climb... cut... left hand, 3rd finger..." Review of an incident investigation dated 3/10/14 at 7:50 PM documented, "...Type of incident... elopement... witnessed... location... courtyard/ patio... " Review of "Statement of CNT" attached to the incident investigation, dated 3/10/14 documented, "...resident was on side of building hooked to the fence... finger was caught in the fence... supervisor was out their to remove..." Review of a physician's telephone order dated 3/10/14 for Resident #149 documented, "...Ativan 0.5 mg (milligram) one PO (by mouth) q (every) 4 (hours)/ PRN (as needed)..." Review of a nurses note dated 3/12/14 at 12:15 AM documented, "...still restless propelling self towards 300 hallway... was seen @ (at) nurse station monitor opening the front door... managed to walk a few steps from doorway outside..." Review of a nurses note dated 3/12/14 at 3:05 PM documented, "...call placed to MD (Medical Doctor) office... regarding fall..." The facility was unable to provide an incident report or investigation for the fall Resident #149 sustained on 3/12/14. Review of a nurses note dated 3/13/14 at 8:00 PM documented, "...resident c/o (complaining of) pain to right upper rib... MD paged x (times) 2 pending return call... given Tylenol per PRN order.. " Review of a nurses note dated 3/14/14 at 7:30 PM documented, "...Notified Dr (Doctor) of resident c/o pain to left ribcage... order received for x-ray of left ribcage..." Review of an X-Ray report dated 3/14/14 documented, "...exam... ribs uni-lat (unilateral) 2 v (view), left (L)... Results... acute fractures of left lateral 6th & 7th ribs..." The facility was unable to provide an incident report or investigation for the incident related to fractured ribs identified on 3/14/14. Review of a nurses note dated 3/27/14 at 6:45 PM documented, "...resident eloped & fell on left side... unhooked self-release w/c (wheelchair) belt & refastened belt so alarm would not sound... walked out front door & fell over in flower bush injuring left knee & L (left) middle finger..." Review of an incident investigation dated 3/27/14 at 6:45 PM documented, "...type of incident... fall... unwitnessed... location... hallway... abrasion to Left knee and 3rd knuckle (L) hand... c/o (complaint of) pain to pelvis, hip, thigh, knee (L) side... Interventions... X-ray..." Review of a care plan attached to the incident investigation, dated 3/27/14 documented, "...Problem... Resident Found on Floor..." There was no new intervention added to the care plan after the fall on 3/27/14. Review of interdisciplinary team (IDT) care plan meeting note dated 3/28/14 at 2:00 PM documented, "...Discussions... IDT meeting held regarding fall on 3/27/14... Drug regimen... continue with SRSB (Self Release Seat Belt)... keep res (resident) at nurse's station..." Review of a nurses note dated 3/28/14 at 9:00 PM documented, "...confused and agitated... tries to get out... brought to nurse's station for close monitoring..." Review of a physician's telephone order dated 4/18/14 documented, "apply wanderguard for elopement." Review of Resident #149's nurses notes documented the following: a. 4/18/14 7:00AM - 3:00PM shift - "...at door attempting to go out several times..." b. 4/30/14 at 9:30 PM - "...OOB (out of bed) in w/c... made attempt elopement (2 x)..." c. 5/12/14 at 6:30 AM - "...went to front door walking, pushed exit button and walked out..." At 6:40 AM "...resident at front door pushed green (exit) button... alarm going off... made it out the door..." 5/12/14 at 11:30 PM - "...attempting to leave area to go home x 3..." Interview with the DON on 1/26/15 at 2:33 PM, in the fine dining room the DON was asked if an incident investigation had been completed related to the rib fractures. The DON stated, "...no... report was not done... don't know what happened..." Discussion with the DON about the 13 documented elopement attempts from 3/7/14 to 5/12/14, the DON confirmed that no other interventions had been put into place to prevent elopement attempts. The DON confirmed there was no additional incident investigations located for falls on 3/12/14 and 3/14/14 and that no follow up had been done regarding Resident #149's complaint of right rib pain on 3/13/14. Interview with Nurse #11 on 2/5/14 at 9:15 AM at the nurse's station, Nurse #11 was asked about interventions for elopement. Nurse #11 stated, "...didn't have a wanderguard at first... then... learned he was an escapee... eloped more at night..." Telephone interview with the Medical Director on 2/5/15 at 3:35 PM in conference room #1, the Medical Director was asked if Resident #149 had elopement attempts. The Medical Director stated, "...yes... absolutely..." The Medical Director was asked if he remembered Resident #149 having rib fractures. The Medical Director stated, "...I vaguely remember that... would have assumed it occurred somewhere in a traumatic situation..." The Medical Director was asked if he would have expected the facility to conduct an investigation. The Medical Director stated, "...yes definitely..." Interview with the Administrator on 2/5/15 at 4:55 PM in conference room #1, the Administrator was asked if there was an injury of unknown origin would you expect an investigation to be conducted and reported to the State. The Administrator stated, "...yes, need to investigate..." Due to multiple elopement attempts, exit seeking behaviors, falls resulting in injuries with no investigation, the facility's failure to supervise and prevent injuries, and the facility's failure to investigate injuries of an unknown origin resulted in actual harm when Resident #149 cut a finger and sustained ribs fractures of an unknown origin. 4. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #9 had short and long term memory impairment and was inattentive continuously. The resident required extensive 1 person assistance with Activities of Daily Living (ADL) for bed mobility, walking in room/corridor, and toilet use. Further review documented total dependence with two person assist for transfers. Review of the quarterly MDS dated [DATE] documented a BIMS score of 2, indicating the resident was severely cognitively impaired. Review of the fall risk assessments dated 9/7/13, 12/7/13, 3/10/14 and 6/7/14 documented Resident #9 was a high risk for falls. Review of the Morse fall screening scored the resident as "75", which indicated Resident #9 was a high risk for falls and had a history of [REDACTED]. Review of Resident #9's nurses notes documented the following: a. 1/5/14 7-3 shift - "...mat on floor when resident is in bed resident will attempt to climb out without assistance. Call light is within reach but d/t (due to) confusion unable to use..." b. 1/9/14 3-11 shift - "...mat @ (at) BS (bedside) when in bed--d/t resident will crawl out. SR (side rails) up..." c. 1/25/14 3-11 shift - "...mat on floor beside bed when resident is in bed d/t resident will crawl out--memory forgetfulness will not allow the resident to remember to use call light..." d. 1/29/14 2:00 AM - "...confused, climbing out of bed..." e. 2/8/14 3-11 shift - "...resident climbed out on mat beside bed @ (change) of shift..." f. 3/3/14 3-11 shift - "...PSA to bed..." g. 3/11/14 1:00 AM - "...PSA to bed-resident taking gown off and attempts to get out of bed x (times) 3... " at 2:15 AM - "...resident attempting to get out of bed..." h. No nursing notes for Resident #9 from 5/28/14 through (-) 6/30/14. Review of facility's incident investigations revealed there was no incident investigation completed for a fall on 6/8/14 for Resident #9 and there was no documentation on the 24 hour endorsement sheet located in the communication book regarding this fall. Review of Resident #9's nurses notes dated 7/1/14 at 5:50 PM documented, "...found... on floor sitting up next to bed. Resident was assessed & (and) neuro check done... c/o (complained of) R (right) hip pain & pain of arm..." At 11:05 PM - "...received report from ER (emergency room )... contusion to right hip and sprained right elbow..." Review of the incident/accident report dated 7/1/14 documented Resident #9 had a fall at 5:45 PM, "...resident's roommates' (spouse) notified staff that a noise was heard and noticed the resident on the floor with the back propped against bed... resident c/o right hip pain and right arm pain..." The investigation documented the fall was witnessed, the bed was down and the side rails were down and the fall mat was not in place. In-service meeting minutes documented "...please be mindful when feeding resident who has mat beside bed to place mat back beside bed when leaving resident at any given time..." The recommendations to prevent further falls section of the investigation was left blank. The resident was sent to the hospitalER on [DATE] at 6:20 PM for evaluation and treatment. Observations in Resident #9's room on 1/12/15 at 10:30 AM and 12:35 PM, revealed Resident #9 in a low positioned bed, on an air mattress, with the right side of the bed pushed up against the wall. The left upper and left lower half side rails were in the up position, a fall mat was on the floor by the bed, a bed alarm was under the resident and the call light was on the left upper side rail toward resident's back. Telephone interview with a family member of Resident #9 on 1/13/15 at 8:37 AM the family member confirmed, upon entering the facility on 6/8/14 at 5:00 PM, found Resident #9 in a wet brief seated on the fall mat with the back against the bed. The family member went to find assistance and spoke to Nurse #17, in the dining room, and told Nurse #17 the resident had fallen and assistance was needed to help get the resident back to bed. The family member confirmed Nurse #17 asked a Certified Nursing Assistant (CNA #9) to assist the resident. The family member confirmed Nurse #17 did not assess the resident after the fall. Telephone interview with CNA #9 on 1/15/15 at 10:05 AM, CNA #9 confirmed she was in the dining room when a family member told Nurse #17 that Resident #9 was on the floor in the resident's room. Nurse #17 asked CNA #9 to "...go and get (Resident #9) up..." CNA #9 entered Resident #9's room and found the resident seated on the fall mat with the back to the bed. Interview with the Administrator, on 1/15/15 at 1:50 PM, in the Administrator's office, the Administrator confirmed he was made aware of Resident #9's fall on 6/8/14 after a family member texted him regarding the incident. The Administrator confirmed when a resident was found on a fall mat, it was not deemed a fall "...because the fall mat is the intervention for a fall risk resident..." Interview with Nurse #17, on 1/17/15 at 4:35 PM, in conference room #1, Nurse #17 confirmed the family member of Resident #9 came to the dining room on 6/8/14, to inform Nurse #17 the resident was wet and on the floor mat. Nurse #17 confirmed CNA #9 was in the dining room and was instructed to go to Resident #9's room. Nurse #17 informed Nurse #14 of the resident on the floor mat. Nurse #17 stated if the resident was found on the floor mat there was no need for a fall investigation. Interview with Nurse #14 on 1/17/15 at 4:50 PM, in conference room #1, Nurse #14 stated neither Nurse #17 or CNA #9 had informed Nurse #14 of Resident #9 being found on the floor mat. Nurse #14 stated, she was never made aware of Resident #9 being found on the floor mat. Nurse #14 stated, she heard the family member was "upset" and went to check on the resident and family at approximately 6:00 PM. Nurse #14 stated the family member told her the resident did not need anything. Nurse #14 confirmed she did not assess Resident #9 or fill out a fall report for this incident. Telephone interview with Resident #9's primary care physician / Medical Director (PCP/MedDir) on 1/22/15 at 1:00 PM, in conference room #1 the PCP/MedDir confirmed if a resident was found on the floor unwitnessed, the facility was expected to notify the physician. The PCP/MedDir confirmed if a resident was known to climb out of bed, "we should brain storm for causes and interventions that are appropriate..." The PCP/MedDir confirmed the PCP/MedDir had never been notified of Resident #9 being found on the floor on 6/8/14. The PCP/MedDir confirmed the resident's attempts of climbing out of bed were related to behaviors and "...with this type of dementia, there is no doubt that in (Resident #9's) mind... thinks... has to go somewhere, or do something for the baby or... family..." The PCP/MedDir would expect the facility to find the cause of the resident trying to climb out of bed and to find appropriate interventions. Interview with the DON on 1/22/15 at 3:40 PM, in conference room #1, the DON confirmed the facility failed to complete a fall investigation for Resident #9's fall on 6/8/14. The DON confirmed the facility had not considered a resident sliding out of bed onto a fall mat witnessed or unwitnessed as a "fall". Interview with the DON on 2/5/15 at 12:00 PM, in conference room #2, the DON confirmed the fall investigation dated 7/1/14 documentation of a witnessed fall was inaccurate. The DON confirmed no documentation of neuro checks was present per facility policy. The DON confirmed the fall mat was not next to the bed at the time of the fall resulting in Resident #9 sustaining a contusion to the right hip and a sprained right elbow. The DON stated, "...CNA #11 forgot to put the mat back after feeding (Resident #9)..." Interviews with facility staff were conducted to determine the staffs knowledge of the facility falls protocol/policy. The interviews revealed the following: a. Interview with Nurse #1 on 1/12/15 at 8:45 AM, in the 400 hall, Nurse #1 stated the yellow sunflower sign represented the resident was on thickened liquids and the pink dot represented the resident was receiving therapy. b. Interview with the Director of Staff Development (DSD) on 1/12/15 at 8:50 AM, in the 400 hallway, the DSD stated the yellow sunflower sign represented the resident was receiving thickened liquids... the pink dot represented the resident was receiving therapy, the yellow star represented the resident had a fall. c. Interview with CNA #2 on 1/14/15 at 1:15 PM, in the fine dining room, CNA #2 stated, "...catching a resident before they hit the floor..." was not considered a "fall." CNA #2 stated, "...it has happened that the nurse did not initiate an incident report..." after a resident has been found on a mat. d. Interview with Nurse #12 on 1/14/15 at 2:45 PM, in the 400 hallway, Nurse #12 stated, when a resident was found on the fall mat beside the bed, it was not considered a fall. Nurse #12 stated when a resident was witnessed sliding out of the bed, it was not considered a fall as "...it was witnessed and there was no injury..." Nurse #12 confirmed a facility falls investigation would not be completed for a resident found on the mat, or witnessed sliding out of the bed with no injury. e. Interview with CNA #13 on 1/14/15 at 3:10 PM, in the 400 hallway, CNA #13 stated, the yellow sunflower sign on the resident's door "...doesn't mean anything..." and the pink dot signified the resident was on thickened liquids. The facility failed to provide supervision, thoroughly investigate falls and ensure a fall mat was in place resulted in actual harm when Resident #9 sustained a hip contusion and a sprained elbow. 5. Medical record review revealed Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE], documented the resident had a BIMS score of 10, which indicated moderate cognitive impairment; resident required two person assist for transfers; was dependent for dressing and grooming; required extensive assistance with bathing; required assistance with eating and was always incontinent of bowel and bladder. Review of a nurses note dated 10/4/14 documented, the resident was being pushed to the dining room by a CNA when the resident's knee was caught in the wheelchair. The resident's knee was x-rayed and there was no injury noted. Review of a nurses note dated 10/11/14, documented the resident was heard hollering "help" and staff found the resident lying on the right side beside the bed, with no injury noted. Review of an incident investigation report, dated 10/11/14, for Resident #16 documented, probable causes of the incident included climbing out of bed; uncontrollable body movement; unsteady gait; impaired mental status and poor safety awareness. The investigation documented interventions included drug regimen review; therapy referral; personal safety alarm to chair and bed; resident to be up near nurses' station when awake and encourage resident to use call light. Review of the care plan dated 10/23/14, documented the interventions discussed in the incident investigation as well as those on the plan for "Found on Floor" were not incorporated into the care plan. Review of a nurses note dated 12/8/14, documented Resident #16 was found lying on the floor on the right side next to the bed with feet facing head of the bed and head facing foot of bed. Review of an incident investigation report, dated 12/8/14, documented probable cause of the fall was impaired mental status and poor safety awareness. Interventions included drug regimen review; continue personal safety alarm; physical therapy referral and remind resident to use call light. There was no documentation if the personal safety alarm, ordered after the fall on 10/14/14, was in place and functioning at the time of this fall. Interview with the DON on 1/27/14 at 3:30 PM, in the DON's office, the DON confirmed the incident in which the resident's knee was caught in the wheelchair did not have an incident report, investigation or care plan update. The DON confirmed the interventions determined in the incident investigations of 10/11/14, and 12/8/14 were not transferred to the care plan. 6. Medical record review revealed Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], documented Resident #25 had short and long term memory problem, moderately impaired decision making skills, required limited assistance with one person assistance for bed mobility, transfers, walk in room and corridor, toilet use and personal hygiene. The resident was assessed not to have falls since admission, readmission nor prior assessment. Review of the care plan initiated 8/27/13 and updated on 11/29/13 and 2/25/14 for Resident #25 documented, "...Fall Risk related to Cognitive Deficit and Weakness as evidenced by History of Falls..." The approaches included "...Monitor for possible side effects of medications, Keep call light and personal items within easy reach, Always remind resident to use call light for assistance, Bed alarm (Personal Safety Alarm (PSA) to bed)... PT (Physical Therapy) / OT (Occupational Therapy) eval (evaluation) or Restorative nursing for strength training, gait, or transfer, Low bed or bed in lowest position, side rails up x (times) 2... Fall monitoring for at risk resident every hour..." Review of the fall risk assessment dated [DATE], documented a score of 16, indicating the resident was a high risk for falls. Review of a nurses note dated 4/26/14, documented Resident #25 was "...noted on the floor outside the main Dining Room laying on right side walker beside (resident), noted with skin tear to left shin... C/O (complained of) L (left) knee + (and) L shoulder pain. MD (Medical Doctor) notified with orders to send to ER (emergency room )..." Review of the hospital ER visit dated 4/26/14, documented "...fall... no injury..." Review of the post fall assessment with incident date of 4/26/14 documented, "...Resident's description of fall: No description given due to confusion..." The recommended interventions were "Fall Screen, Picked up for Rehab (Rehabilitation)." Review of a physician's telephone order dated 5/1/14 documented, for PT 7xwkx30 days (7 times a week times 30 days)..." Review of a nurses note dated 5/15/14 at 8:30 AM documented, Resident #25 "...fell , PSA sounding... no complaint of pain... Right arm redness upper from elbow to armpit... x-ray ordered..." Review of the incident/accident report dated 5/15/14 at 8:30 AM do

Based on policy review, review of incident/accident investigations, medical record review and interview, the facility failed to identify behaviors of climbing out of bed, implement pertinent interventions and identify the cause of the behaviors for 1 of 5 (Resident #9) sampled residents of the 57 residents in the stage 2 review. The facility failed to identify causes of behaviors and implement appropriate interventions for behaviors resulted in actual harm when Resident #9 fell sustaining a contusion to the right hip and a sprained right elbow. The findings included: 1. Review of the facility's policy titled "Behavior Management and Assessment" dated 5/1/10 documented, "...problematic behavior will be identified and managed appropriately... the staff will identify, document and inform the physician... about an individual's mental status, behavior, and cognition... The staff will identify pertinent interventions, other than medications, for the nature and cause of the individual's problematic behavior... an individualized Plan of Care will be developed... to reflect... resident's condition... Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of "99", indicating the resident was severely cognitively impaired and unable to complete the interview. The behavior section of the MDS documented no behavioral symptoms or rejection of care were exhibited by Resident #9. The resident required extensive assistance with Activities of Daily Living (ADL) with assistance needed by 1 person and transfers required assistance from 2 people. Review of the annual MDS dated [DATE] documented no behavioral symptoms were exhibited by Resident #9. Review of Resident #9's nurses notes documented the following: a. 1/5/14 7AM-3PM shift - "...call light is within reach but d/t (due to) confusion unable to use..." b. 1/25/14 3PM-11PM - "...memory forgetfulness will not allow... to remember to use call light..." c. 3/20/14 (1:00 PM) - "...refused to lay down after lunch..." d. 4/2/14 (1:00 PM) - "...refused to lay down after lunch..." e. 4/25/14 (11:00 PM) - "...extremely restless..." f. 8/23/14 (1:26 AM) - "...extremely agitated at this time-attempting to get oob (out of bed) s (without) assist..." g. 8/30/14 (12:48 AM) - "... increased agitation-attempting to remove wedge and get oob (out of bed)..." h. 8/31/14 (1:26 AM) - "...resident up in WC (wheelchair) r/t (related to) increased agitation..." Review of the 24 hour communication endorsement sheet documented the following: a. 6/24/14 11PM-7AM shift - "...up in WC 2 (secondary) to coming out of bed..." b. 6/27/14 11PM-7AM shift - "...restless up in WC..." Review of the weekly summary nurses notes documented the following: a. 5/31 through (-) 6/6/14 - "...verbally abusive..." b. 6/21/-6/27/14 - "...verbally abusive..." c. 10/4/-10/10/14 - "...climbs oob..." d. 11/1/-11/7/14 - "...attempts to get oob s assistance..." Review of a social service progress note dated 4/14/14 documented, "...uncoop (uncooperative) /combative toward staff..." Review of an incident/accident investigation dated 7/1/14 at 5:45 PM documented, Resident #9 fell from the bed onto the floor. There was no floor mat in place next to the bed at the time of the fall. The resident sustained [REDACTED]. Review of the care plan dated 9/7/13 with review dates of 12/7/13, 3/7/14, 6/7/14, 9/12/14 and 12/12/14 documented a problem of alteration in mood and behavior pattern with interventions included "...determine causative factor for current behavior and address..." Interview with the Director of Staff Development (DSD), on 1/14/15 at 9:05 AM, in the DSD's office the DSD stated, "...staff is trained to monitor the care and the behaviors of each resident. The staff should allow the behavior to continue as much as possible and it should be documented in the care plan, discussed at the care plan meetings, documented in the Social Workers notes, Nurses Notes as well as the Communication Book..." Interview with certified nursing assistant (CNA) #13, on 1/14/15 at 3:10 PM, in the 400 hallway, CNA #13 confirmed she cared for Resident #9 on a regular basis. CNA #13 stated Resident #9 had behaviors in the evenings and nights and said things like "...I have to get the baby and I have to get up to cook..." CNA #13 stated, when the resident exhibited these behaviors, the resident will "...continue to try to come out of the bed..." Telephone interview with the Medical Director, on 1/22/15 at 1:00 PM, in conference room [ROOM NUMBER], the Medical Director was asked about a resident climbing our of bed. The Medical Director stated when a resident was known to climb out of bed, "...we should brain storm for causes and interventions that are appropriate..." The Medical Director stated, "...with this type of dementia, there is no doubt that in (Resident #9's) mind... thinks... has to go somewhere, or do something for the baby or her family." The Medical Director confirmed the expectation was for the facility to find the cause of the resident climbing out of the bed and to find appropriate interventions. The Medical Director confirmed Resident #9's attempts of climbing out of the bed were behavioral issues. The Medical Director was asked if interventions had been put in place could the fall on 7/1/14 been avoided. The Medical Director stated, "...I most certainly do..." Interview with the Director of Nursing (DON) on 1/22/15 at 3:40 PM, in conference room [ROOM NUMBER] the DON stated the resident's attempts of climbing out of bed were related to behaviors. The DON confirmed no additional interventions or updates to the care plan had been made after the 6/8/14 fall or the 7/1/14 fall. The DON stated that besides the nursing notes, "...no actual behavior monitoring sheets exist in the facility..." The DON explained the only "monitoring" documented for the resident was completed on the Medical Administration Record (MAR) as it related to the administration of [MEDICAL CONDITION] medicines and monitoring for any possible side effects or adverse reactions. The DON confirmed the documentation for behaviors was not adequate and not individualized. The DON stated Resident #9 still exhibited behaviors of attempting to climb out of bed, restlessness and agitation and there were no changes noted to the care plan last updated 12/12/14. The facility failed to identify causes of behaviors and implement appropriate interventions for behaviors resulted in actual harm when Resident #9 fell sustaining a contusion to the right hip and a sprained right elbow.

Based on policy review, medical record review, observation and interview, the facility staff failed to follow up on dental orders and failed to notify the attending physician of a dental procedure while the resident was on anticoagulation medications; and failed to follow the facility's [MEDICATION NAME] therapy protocol for 1 of 4 (Resident #155) sampled residents reviewed with anticoagulation medication and dental procedures of the 57 residents included in the stage 2 review. The facility failed to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio (PT/INR) levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction. The facility failed to ensure 1 of 4 (Nurse #19) nurses followed the facility's policy for [MEDICATION NAME] drug delivery system application by failing to clean the site of the old [MEDICATION NAME]. The findings included: 1. Review of the facility's policy entitled [MEDICATION NAME] Protocol effective date 6/1/10 documented, "...8. The physician will be informed when residents are taking the following medications while on [MEDICATION NAME]. These medications have the potential to significantly increase the PT/INR ([MEDICATION NAME] time - how quickly blood clots - normal range of 10 to (-) 13) INR - normal range 0.8 - 3.50) value while taking [MEDICATION NAME]. The physician will be encouraged to order a PT/INR every other day while taking one of these meds (medications) with [MEDICATION NAME] due to potential for significant increase in INR and risk for bleeding..." Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses notes dated 12/6/13, documented the resident developed a [MEDICAL CONDITION] of the right thigh and was started on [MEDICATION NAME] (blood thinner) 7.5 milligrams (mg) daily. The resident had received [MEDICATION NAME] with PT/INR levels being done as ordered with physician intervention as needed. The last PT/INR done on 4/2/14 revealed the PT was 26.0 with an INR of 2.24 with the INR being in a subtherapuetic range; [MEDICATION NAME] 7.5 mg was continued. Review of the physician's orders, laboratory results and nurses notes revealed no further orders for PT/INR after 4/2/14. Review of a physician's order dated 4/4/14, documented to increase the [MEDICATION NAME] dose from 300 mg to 400 mg each evening. The facility did not provide documentation the physician was notified of the facility's [MEDICATION NAME] protocol to encourage a PT/INR every other day when Resident #155's [MEDICATION NAME] dose was increased on 4/4/14. Review of a nurses note dated 4/8/14, documented the resident was "...crying, indicating a tooth was hurting. Dental assistant was notified. Dentist examined tooth..." Review of the dental service note dated 4/8/14 documented, "...Hold blood thinner and extract (tooth)..." Review of a nurses note from 4/8/14, forward, revealed no documentation the physician was notified of the dentist's statement to hold the [MEDICATION NAME] before extraction nor was there any documentation nursing staff made an appointment for the tooth extraction. Review of a nurses note dated 4/28/14 documented, the "...Conservator requested dental eval (evaluation) due to resident c/o (complaining of) tooth pain..." The resident was receiving scheduled pain medication of [MEDICATION NAME] 7.5/325 mg three times daily. Review of a nurses note dated 4/29/14 at 11:00 AM, written by Nurse #11, documented "...Called (dentist's office) to have dentist to look at resident's mouth to evaluated (evaluate) not to pull teeth. Because resident is on [MEDICATION NAME] talked to conservator aware (teeth) not to be pulled but to evaluate..." Review of a nurses note dated 4/30/14 at 2:00 PM, written by Nurse #11 documented, "...Dentist arrived talked to assistance (assistant). Said they were only to evaluate not pull because resident was on [MEDICATION NAME] (the dental assistant) said it was OK (okay) the Dr. (Doctor) is comfortable pulling teeth on [MEDICATION NAME] and then handed me the papers to sign teeth was (were) already extracted at this time..." Review of a nurses note dated on 4/30/14 at 2:00 PM, written by Nurse #4 documented, "...Dentist at bedside with resident draped. When asked if... was going to do an extraction today... (Dentist) replied in the affirmative." Dental assistant then entered room and stated, "I know we haven't held the blood thinner but we're going to stay here for a little while to make sure (Resident #155)... doesn't bleed or anything." The facility failed to provide documentation the nurse called the resident's attending physician before the dentist preformed teeth extractions while the resident was still receiving [MEDICATION NAME]. Review of the dental progress note dated 4/30/14 documented, "...Patient complaining lower right. Patient tolerated tx (treatment) well. Minimum bleeding. Already clotting..." There was one tooth surgically removed requiring elevation, and two residual teeth roots were extracted. Review of Resident #155's nurses note dated 4/30/14 documented the following: a. At 4:00 PM - "...Resident gauze out blood on face, gown, and linens. Resident cleaned up and gauze replaced clots noted..." b. At 5:00 PM - "...Resident removal gauze or gauze came out. Gauze in resident's hand. Bleeding continued. MD (Medical Doctor) called. Waiting for answer..." c. At 5:30 PM - "...No response from MD calls. Continue to monitor resident for bleeding..." d. At 6:00 PM - "...Resident bleeding continues. Resident unable to keep gauze in mouth..." e. At 6:15 PM - "...MD called again. All available numbers called. Resident continued monitoring at this time..." f. At 6:25 PM - "...Order received to transfer to ER (emergency room ) for eval (evaluation)..." Review of the emergency department (ED) notes for Resident #155 dated 4/30/14 at 8:19 PM documented, the resident had presented with persistent bleeding from gums since teeth extraction. The resident's PT was greater than (>) 100 while the INR was >14, with oozing blood from the extraction sites. Resident #155 received Vitamin K (medication to enhance clotting of blood) 5 mg to counteract the [MEDICATION NAME]. The resident was admitted to the hospital. Review of the hospital discharge summary dated 5/6/14, documented Resident #155 was admitted for coagulopathy (problem with blood clotting) and acute blood loss [MEDICAL CONDITION]. The resident received two units of fresh frozen plasma as well as two units of packed red blood cells. The PT/INRs were stable after the infusions. Interview with Nurse #11 on 1/15/15 at 7:30 AM, in the chart room, Nurse #11 stated, called the dentist's office to be sure the dentist would be coming to the facility on [DATE]. Nurse #11 spoke with the office nurse and made sure the office nurse knew Resident #155 was on [MEDICATION NAME] and only an evaluation was to be done. The dentist talked to Nurse #4 on 4/30/14. Nurse #11 confirmed the dentist came out of the resident's room with the assistant who said they had extracted three teeth. Nurse #11 stated the dental assistant stated, "We are not concerned about [MEDICATION NAME]. We do it all the time (extract teeth on patients receiving [MEDICATION NAME])." Nurse #11 stated she assessed the resident and there was no bleeding noted, but three hours later the resident began bleeding. Interview with the Director of Nursing (DON), on 1/20/15 at 2:00 PM, at the nurses' station, the DON stated, "...It is my expectation [MEDICATION NAME] is held prior to a procedure. I would notify the physician of the upcoming procedure and the need to hold the [MEDICATION NAME]" The DON stated, have only been in the DON position for a few months and was really not familiar with the events with Resident #155. Telephone interview with the Medical Director, on 1/22/15 at 1:00 PM, the Medical Director was asked about holding [MEDICATION NAME] before a dental procedure. The Medical Director stated, "If [MEDICATION NAME] is to be held before a dental procedure it depends on the type of procedure... three extractions would qualify as a procedure to hold [MEDICATION NAME] before the procedure... would expect a dentist who is doing the procedure to hold the [MEDICATION NAME] would not pull teeth on any patient unless... knew what medication the resident was on." Interview with Resident #155's attending physician, on 1/22/15 at 3:50 PM, in conference room [ROOM NUMBER], Resident #155's attending physician confirmed [MEDICATION NAME] has a long half life and should be held three to four days before a procedure. Resident #155's attending physician stated, "...I expect nursing to notify me of patient scheduled for procedures and ask me if I want the [MEDICATION NAME] held... would have expected a PT/INR to be done before the procedure..." Resident #155's attending physician confirmed the staff had called about the resident bleeding and orders were given to send the resident to the hospital. Telephone interview with the dentist, on 1/27/15 at 10:46 AM, the dentist confirmed the dental assistant had an understanding residents have to be off [MEDICATION NAME] so the statement was made on 4/8/15, that extraction was not possible until the [MEDICATION NAME] was stopped. The dentist stated, "...That is something I would not do and x-rays showed an infection at the roots of the teeth... would not hold [MEDICATION NAME] for a simple extraction but would hold it ([MEDICATION NAME]) if there was a more extensive procedure." The dentist confirmed he was called back to the facility because the resident still had pain and had been completely evaluated three weeks earlier so there was no sense to come back for an evaluation because the same things would be done... has to schedule the appointment and bring all the equipment so the dentist will go ahead and do the procedure... the dental assistant went out to check with the nurse who said to go ahead." The nurses deny saying to go ahead with the extraction. Interview with Nurse #1 who cared for the resident after the teeth extraction, on 1/27/15 at 2:45 PM, in conference room [ROOM NUMBER], Nurse #1 confirmed she received report from Nurse #11, who said the resident had teeth pulled. Nurse #1 stated she called the resident's physician who stated the extraction should not have been done while the resident was on [MEDICATION NAME]. Nurse #1 stated, "...the resident started bleeding and I knew it was not going to stop..." Nurse #1 stated, Nurse #4 should have called the resident's physician to notify the physician the resident was having an extraction and the resident was still on [MEDICATION NAME]. Nurse #1 stated, Nurse #4 also should have notified the DON and physician before the procedure started. Nurse #1 denies saying to go ahead with the extraction. Telephone interview with Nurse #4, on 1/28/15 at 9:50 AM, Nurse #4 stated she questioned the dentist's decision to extract teeth because the resident was on [MEDICATION NAME] and the nurse was concerned for bleeding. Nurse #4 stated, "...I think I documented in the nursing notes that I questioned the dentist..." Nurse #4 stated she could not say whether the resident's physician was notified. Nurse #4 stated, "...I did not give the dentist permission to do anything since the dentist had authority over me. The dentist was going to do it whether the resident was on [MEDICATION NAME] or not..." Nurse #4 stated, "...was certain the DON was notified... (Nurse #4) looked at the resident after the procedure and the resident did not appear to be bleeding... opened the resident's mouth and saw a considerable amount of gauze but did not disturb it... later learned the gauze was full of blood and the resident had to go out to the hospital." Nurse #4 denies saying to go ahead with the extraction. Telephone interview with the Pharmacist on 2/9/15 at 9:45 AM, the Pharmacist stated, the use of [MEDICATION NAME] and [MEDICATION NAME] concurrently "can definitely increase the PT/INR". Interview with Nurse #11, on 2/10/15 at 2:30 PM, at the nurses' station Nurse #11 confirmed there was no follow-up on the dental orders dated 4/8/14. Nurse #11 stated, "The physician should have been notified of the planned dental extractions; the fact the resident was on [MEDICATION NAME] and [MEDICATION NAME]; and requested blood work." The facility failed to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio (PT/INR) levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction. 2. Review of the facility's "[MEDICATION NAME] DRUG DELIVERY SYSTEM (PATCH) APPLICATION PROCEDURES" policy documented, "...3...Cleanse area of old patch with alcohol wipe..." Observations in Resident #78's room on 2/3/15 at 8:33 AM, revealed Nurse #19 removed the [MEDICATION NAME] from Resident #78's left upper back and placed the new [MEDICATION NAME] on the left upper chest without cleaning the site of the old patch. Interview with Nurse #19, on 2/5/15 at 3:16 PM, at the nurses' station Nurse #19 was asked if she cleaned the site after removing the patch on Resident #78. Nurse #19 stated, "I know I forgot to clean the site where the patch had been... I just forgot..." During an interview with the DON, on 2/10/15 at 4:56 PM, in the DON's office the DON was asked if the nurses were expected to clean a resident's skin after removing a patch. The DON stated, "Yes."

Based on policy review, medical record review, and interview, the facility failed to prevent neglect when staff failed to follow up on dental orders and failed to notify the attending physician of a dental procedure while the resident was on anticoagulation medications; and failed to follow the facility's [MEDICATION NAME] therapy protocol for 1 of 4 (Resident #155) sampled residents reviewed with anticoagulation medication and dental procedures. The facility neglected to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio (PT/INR) levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction. The findings included: Review of the facility's policy entitled [MEDICATION NAME] Protocol effective date 6/1/10 documented, "...8. The physician will be informed when residents are taking the following medications while on [MEDICATION NAME]. These medications have the potential to significantly increase the PT/INR ([MEDICATION NAME] time - how quickly blood clots - normal range of 10 to (-) 13) INR - normal range 0.8 - 3.50) value while taking [MEDICATION NAME]. The physician will be encouraged to order a PT/INR every other day while taking one of these meds (medications) with [MEDICATION NAME] due to potential for significant increase in INR and risk for bleeding..." Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses notes dated 12/6/13, documented the resident developed a [MEDICAL CONDITION] of the right thigh and was started on [MEDICATION NAME] (blood thinner) 7.5 milligrams (mg) daily. The resident had received [MEDICATION NAME] with PT/INR levels being done as ordered with physician intervention as needed. The last PT/INR done on 4/2/14 revealed the PT was 26.0 with an INR of 2.24 with the INR being in a subtherapuetic range; [MEDICATION NAME] 7.5 mg was continued. Review of the physician's orders, laboratory results and nurses notes revealed no further orders for PT/INR after 4/2/14. Review of a physician's order dated 4/4/14, documented to increase the [MEDICATION NAME] dose from 300 mg to 400 mg each evening. The facility did not provide documentation the physician was notified of the facility's [MEDICATION NAME] protocol to encourage a PT/INR every other day when Resident #155's [MEDICATION NAME] dose was increased on 4/4/14. Review of a nurses note dated 4/8/14, documented the resident was "...crying, indicating a tooth was hurting. Dental assistant was notified. Dentist examined tooth..." Review of the dental service note dated 4/8/14 documented, "...Hold blood thinner and extract (tooth)..." Review of a nurses note from 4/8/14, forward, revealed no documentation the physician was notified of the dentist's statement to hold the [MEDICATION NAME] before extraction nor was there any documentation nursing staff made an appointment for the tooth extraction. Review of a nurses note dated 4/28/14 documented, the "...Conservator requested dental eval (evaluation) due to resident c/o (complaining of) tooth pain..." The resident was receiving scheduled pain medication of [MEDICATION NAME] 7.5/325 mg three times daily. Review of a nurses note dated 4/29/14 at 11:00 AM, written by Nurse #11, documented "...Called (dentist's office) to have dentist to look at resident's mouth to evaluated (evaluate) not to pull teeth. Because resident is on [MEDICATION NAME] talked to conservator aware (teeth) not to be pulled but to evaluate..." Review of a nurses note dated 4/30/14 at 2:00 PM, written by Nurse #11 documented, "...Dentist arrived talked to assistance (assistant). Said they were only to evaluate not pull because resident was on [MEDICATION NAME] (the dental assistant) said it was OK (okay) the Dr. (Doctor) is comfortable pulling teeth on [MEDICATION NAME] and then handed me the papers to sign teeth was (were) already extracted at this time..." Review of a nurses note dated on 4/30/14 at 2:00 PM, written by Nurse #4 documented, "...Dentist at bedside with resident draped. When asked if... was going to do an extraction today... (Dentist) replied in the affirmative." Dental assistant then entered room and stated, "I know we haven't held the blood thinner but we're going to stay here for a little while to make sure (Resident #155)... doesn't bleed or anything." The facility failed to provide documentation the nurse called the resident's attending physician before the dentist preformed teeth extractions while the resident was still receiving [MEDICATION NAME]. Review of the dental progress note dated 4/30/14 documented, "...Patient complaining lower right. Patient tolerated tx (treatment) well. Minimum bleeding. Already clotting..." There was one tooth surgically removed requiring elevation, and two residual teeth roots were extracted. Review of Resident #155's nurses note dated 4/30/14 documented the following: a. At 4:00 PM - "...Resident gauze out blood on face, gown, and linens. Resident cleaned up and gauze replaced clots noted..." b. At 5:00 PM - "...Resident removal gauze or gauze came out. Gauze in resident's hand. Bleeding continued. MD (Medical Doctor) called. Waiting for answer..." c. At 5:30 PM - "...No response from MD calls. Continue to monitor resident for bleeding..." d. At 6:00 PM - "...Resident bleeding continues. Resident unable to keep gauze in mouth..." e. At 6:15 PM - "...MD called again. All available numbers called. Resident continued monitoring at this time..." f. At 6:25 PM - "...Order received to transfer to ER (emergency room ) for eval (evaluation)..." Review of the emergency department (ED) notes for Resident #155 dated 4/30/14 at 8:19 PM documented, the resident had presented with persistent bleeding from gums since teeth extraction. The resident's PT was greater than (>) 100 while the INR was >14, with oozing blood from the extraction sites. Resident #155 received Vitamin K (medication to enhance clotting of blood) 5 mg to counteract the [MEDICATION NAME]. The resident was admitted to the hospital. Review of the hospital discharge summary dated 5/6/14, documented Resident #155 was admitted for coagulopathy (problem with blood clotting) and acute blood loss [MEDICAL CONDITION]. The resident received two units of fresh frozen plasma as well as two units of packed red blood cells. The PT/INRs were stable after the infusions. Interview with Nurse #11 on 1/15/15 at 7:30 AM, in the chart room, Nurse #11 stated, called the dentist's office to be sure the dentist would be coming to the facility on [DATE]. Nurse #11 spoke with the office nurse and made sure the office nurse knew Resident #155 was on [MEDICATION NAME] and only an evaluation was to be done. The dentist talked to Nurse #4 on 4/30/14. Nurse #11 confirmed the dentist came out of the resident's room with the assistant who said they had extracted three teeth. Nurse #11 stated the dental assistant stated, "We are not concerned about [MEDICATION NAME]. We do it all the time (extract teeth on patients receiving [MEDICATION NAME])." Nurse #11 stated she assessed the resident and there was no bleeding noted, but three hours later the resident began bleeding. Interview with the Director of Nursing (DON), on 1/20/15 at 2:00 PM, at the nurses' station, the DON stated, "...It is my expectation [MEDICATION NAME] is held prior to a procedure. I would notify the physician of the upcoming procedure and the need to hold the [MEDICATION NAME]" The DON stated, have only been in the DON position for a few months and was really not familiar with the events with Resident #155. Telephone interview with the Medical Director, on 1/22/15 at 1:00 PM, the Medical Director was asked about holding [MEDICATION NAME] before a dental procedure. The Medical Director stated, "If [MEDICATION NAME] is to be held before a dental procedure it depends on the type of procedure... three extractions would qualify as a procedure to hold [MEDICATION NAME] before the procedure... would expect a dentist who is doing the procedure to hold the [MEDICATION NAME] would not pull teeth on any patient unless... knew what medication the resident was on." Interview with Resident #155's attending physician, on 1/22/15 at 3:50 PM, in conference room [ROOM NUMBER], Resident #155's attending physician confirmed [MEDICATION NAME] has a long half life and should be held three to four days before a procedure. Resident #155's attending physician stated, "...I expect nursing to notify me of patient scheduled for procedures and ask me if I want the [MEDICATION NAME] held... would have expected a PT/INR to be done before the procedure..." Resident #155's attending physician confirmed the staff had called about the resident bleeding and orders were given to send the resident to the hospital. Telephone interview with the dentist, on 1/27/15 at 10:46 AM, the dentist confirmed the dental assistant had an understanding residents have to be off [MEDICATION NAME] so the statement was made on 4/8/15, that extraction was not possible until the [MEDICATION NAME] was stopped. The dentist stated, "...That is something I would not do and x-rays showed an infection at the roots of the teeth... would not hold [MEDICATION NAME] for a simple extraction but would hold it ([MEDICATION NAME]) if there was a more extensive procedure." The dentist confirmed he was called back to the facility because the resident still had pain and had been completely evaluated three weeks earlier so there was no sense to come back for an evaluation because the same things would be done... has to schedule the appointment and bring all the equipment so the dentist will go ahead and do the procedure... the dental assistant went out to check with the nurse who said to go ahead." The nurses deny saying to go ahead with the extraction. Interview with Nurse #1 who cared for the resident after the teeth extraction, on 1/27/15 at 2:45 PM, in conference room [ROOM NUMBER], Nurse #1 confirmed she received report from Nurse #11, who said the resident had teeth pulled. Nurse #1 stated she called the resident's physician who stated the extraction should not have been done while the resident was on [MEDICATION NAME]. Nurse #1 stated, "...the resident started bleeding and I knew it was not going to stop..." Nurse #1 stated, Nurse #4 should have called the resident's physician to notify the physician the resident was having an extraction and the resident was still on [MEDICATION NAME]. Nurse #1 stated, Nurse #4 also should have notified the DON and physician before the procedure started. Nurse #1 denies saying to go ahead with the extraction. Telephone interview with Nurse #4, on 1/28/15 at 9:50 AM, Nurse #4 stated she questioned the dentist's decision to extract teeth because the resident was on [MEDICATION NAME] and the nurse was concerned for bleeding. Nurse #4 stated, "...I think I documented in the nursing notes that I questioned the dentist..." Nurse #4 stated she could not say whether the resident's physician was notified. Nurse #4 stated, "...I did not give the dentist permission to do anything since the dentist had authority over me. The dentist was going to do it whether the resident was on [MEDICATION NAME] or not..." Nurse #4 stated, "...was certain the DON was notified... (Nurse #4) looked at the resident after the procedure and the resident did not appear to be bleeding... opened the resident's mouth and saw a considerable amount of gauze but did not disturb it... later learned the gauze was full of blood and the resident had to go out to the hospital." Nurse #4 denies saying to go ahead with the extraction. Telephone interview with the Pharmacist on 2/9/15 at 9:45 AM, the Pharmacist stated, the use of [MEDICATION NAME] and [MEDICATION NAME] concurrently "can definitely increase the PT/INR". Interview with Nurse #11, on 2/10/15 at 2:30 PM, at the nurses' station Nurse #11 confirmed there was no follow-up on the dental orders dated 4/8/14. Nurse #11 stated, "The physician should have been notified of the planned dental extractions; the fact the resident was on [MEDICATION NAME] and [MEDICATION NAME]; and requested blood work." The facility failed to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction.

Based on policy review, review of investigations, review of accident/incident reports, medical record review and interview, the facility failed to thoroughly investigate and report incidents with injuries of unknown origin for 2 of 22 (Residents #149 and 35) sampled residents reviewed for accidents of the 57 residents included in the stage 2 review. The facility failed to report injures of unknown origin to the state survey and certification agency. The facility failed to thoroughly investigate wandering and injuries of unknown origin resulted in actual harm when Resident #149 sustained a laceration and fractured ribs. The findings included: 1. Review of the facility's Abuse, reporting policy dated 6/1/12 documented, "...Should a suspected violation or or substantiated incident... injuries of an unknown source... be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: The State licensing/certification agency responsible for surveying/licensing the facility... Notification to the above agencies will be made as soon as it has been substantiated within 5 working days of the occurrence of such incident..." 2. Medical record review revealed Resident #149 was admitted to the facility on [DATE], with readmitted s of 4/16/14 and 9/26/14 with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 8, indicating Resident #149 had moderate cognitive impairment; resident required extensive assistance of one person for dressing, hygiene, locomotion and extensive assistance of two people for transfers. Resident #149's assistive devices used were a wheelchair and a walker. Review of nurses notes dated 3/10/14 at 7:50 PM documented, "...resident continue to wander throughout facility and through exit doors... noted... at facility exit fence... attempting to climb... cut... left hand, 3rd finger..." Review of nursing notes dated 3/10/14 at 8:00 PM documented, "...continues to exit the facility and wander around the hallways... continuous redirection... (resident) very agitated... confused... continues to stand & (and) walk unassisted..." Review of a care plan dated 3/10/14 documented, "...Problem... Actual Presence of Skin Problem... cut/wound... site... (L) (Left) hand 3rd finger..." Review of a physician's telephone order dated 3/10/14 documented, "[MEDICATION NAME] 0.5 mg (milligram) one PO (by mouth) q (every) 4 (hours)/ PRN (as needed)..." Review of an incident/accident report dated 3/10/14 at 7:50 PM documented, "...Type of incident... Elopement... Witnessed... Location... Courtyard/ Patio..." There was no additional investigation provided in regard to this incident. Review of "Statement of CNT (Certified Nurse Technician)" form dated 3/10/14 documented, "...resident was on side of building hooked to the fence... finger was caught in the fence..." Review of nursing notes dated 3/12/14 at 12:15 AM documented, "...still restless propelling self towards 300 hallway... was seen @ (at) nurse station monitor opening the front door... managed to walk a few steps from doorway outside..." Review of nursing notes dated 3/12/14 at 3:05 PM documented, "...call placed to MD (Medical Doctor) office... regarding... fall..." The facility was unable to provide an incident report or investigation for the fall documented on 3/12/14. Review of nursing notes dated 3/13/14 at 8:00 PM documented, "...resident c/o (complaining of) pain to right upper rib... MD paged x (times) 2 pending return call... given Tylenol per PRN (as needed) order..." Review of a nurses progress note dated 3/14/14 at 7:30 PM documented, "...Notified Dr (Doctor) of resident c/o pain to left ribcage... order received for x-ray of left ribcage..." Review of the x-ray report dated 3/14/14 documented "...exam... ribs uni-lat (unilateral) 2 v (view), left... Results... acute fractures of left lateral 6th & (and) 7th ribs..." The facility was unable to provide an incident report or investigation for the fractured ribs that were noted on 3/14/14. Interview with the Director of Nursing (DON), in the fine dining room on 1/26/15 at 2:33 PM, the DON was asked if an incident investigation had been completed related to the rib fractures. The DON stated, "...no... report was not done... don't know what happened..." The DON confirmed there was no additional incident investigations located for the incidents that occurred on 3/10/14, 3/12/14 and 3/14/14 and that no follow up had been done regarding resident's complaint of right rib pain on 3/13/14. A telephone interview with Resident #149's MD on 2/5/15 at 3:35 PM in conference room [ROOM NUMBER], Resident #149's MD was asked if Resident #149 had elopement attempts. Resident #149's MD state, "...yes... absolutely..." Resident #149's MD was asked if he remembered Resident #149 having rib fractures and reviewing of that incident. Resident #149's MD stated, "...I vaguely remember that... would have assumed it occurred somewhere in a traumatic situation..." Resident #149's MD was if he would have expected the facility to conduct an investigation. Resident #149's MD stated, "...Yes definitely..." Interview with the Administrator, on 2/5/14 at 4:55 PM, in conference room [ROOM NUMBER], the Administrator was asked if there was an injury of unknown origin would you expect an investigation to be conducted and reported to the state. The Administrator stated, "...yes... the investigation was started when the physician ordered the x-ray..." The Administrator was asked about the fracture and an investigation for the fracture. The Administrator state, "...no... need to do proper investigation..." The facility failed to thoroughly investigate injuries of unknown origin resulted in actual harm when Resident #149 sustained a laceration and fractured ribs. 3. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS dated [DATE] documented a BIMS score of 2 which indicated severe cognitive impairment. Review of nursing notes dated 8/17/14 documented, "...Observed large hematoma on the left side of (Resident #35) forehead... No possible cause found..." Review of an incident investigation form dated 8/17/14 documented, "...TYPE OF INCIDENT... hematoma... unwitnessed..." Review of a nurses note dated 9/26/14 documented, "Hematoma on left forehead noted by CNA (Certified Nurse Assistant) while doing ADLs (Activities of Daily Living)..." Review of an incident investigation form dated 9/26/14 documented, "...TYPE OF INCIDENT... hematoma... unwitnessed..." The facility failed to report hematoma injuries of unknown origin to the state survey certification agency within 5 days of the occurrence. 4. Interview with the Administrator on 2/11/15 at 9:30 AM in the DON's office the Administrator was asked if there was an injury of unknown origin should it be reported to the State. The Administrator stated, "If it is unknown origin we have to follow the rules to report. We have to do an investigation to make sure. All possibilities have to be looked at, until a cause is found. Then you follow the guidelines."

Based on policy review, review of incident/accident reports, review of incident investigations, medical record review and interview, the facility failed to revise the care plan to reflect the current status related to risk of falls, fall prevention, behaviors, incontinence with bowel and bladder training and/or vision for 10 of 45 (Residents #149, 9, 25, 57, 61, 113, 114, 117, 150 and 151) sampled residents of the 57 residents in the stage 2 review. The facility's failure to revise the care plan after falls resulted in actual harm when Resident #149 sustained a laceration and abrasion and Resident #9 sustained a contusion to the right hip and a sprained right elbow. The findings included: 1. Review of the facility's care plan policy, with the effective date of 9/1/11, documented "An 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... Care plans are revised as changes in the resident's condition dictate..." 2. Medical record review revealed Resident #149 was admitted to the facility on [DATE] and readmitted on [DATE] and 9/26/14 with [DIAGNOSES REDACTED]. Resident #149 was discharged from the facility on 10/1/14. Review of an admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment; resident required extensive assistance of one person for dressing, hygiene, locomotion; and extensive assistance of two people for transfers, and assistive devices used were a wheelchair and walker. Review of the January 2014 physician orders [REDACTED]. Review of an incident/accident report dated 3/8/14 at 5:10 PM documented, "...Type of Incident... Found on the floor... witnessed... Location... at front-parking area..." Review of a care plan dated 3/8/14 documented, "...Problem... Resident Found on Floor..." There was no new intervention implemented after the resident's attempted elopement from the facility on 3/8/14. Review of nurses notes dated 3/10/14 at 7:50 PM documented, "...resident continue to wander throughout facility and through exit doors... noted... at facility exit fence... attempting to climb... cut... left hand, 3rd finger..." Review of "Statement of CNT (Certified Nurse Technician)" form dated 3/10/14 documented, "...resident was on side of building hooked to the fence... finger was caught in the fence..." Review of a nurses note dated 3/27/14 at 6:45 PM documented, "...resident eloped & fell on left side... unhooked self-release w/c (wheelchair) belt & (and) refastened belt so alarm would not sound... walked out front door & fell over in flower bush injuring left knee & L (left) middle finger..." Review of an incident/accident report dated 3/27/14 at 6:45 PM documented, "...type of incident... fall... unwitnessed... location... hallway... abrasion to Left knee and 3rd knuckle (L) hand... c/o (complaint of) pain to pelvis, hip, thigh, knee (L) side... Interventions... X-ray..." Review of a care plan attached to the incident/accident report, dated 3/27/14 documented, "...Problem... Resident Found on Floor..." There was no new intervention added to the care plan after the fall on 3/27/14. Review of interdisciplinary team (IDT) care plan meeting note dated 3/28/14 at 2:00 PM documented, "...Discussions... IDT meeting held regarding fall on 3/27/14... Drug regimen... continue with SRSB (Self Release Seat Belt)... keep res (resident) at nurse's station..." Interview with the Director of Nursing (DON) on 1/26/15 at 2:33 PM, in the fine dining room, the DON confirmed the care plan had not been revised after incidents on 3/8/14 and 3/27/14. The facility's failure to revise the care plan to address elopement seeking attempts and falls resulted in actual harm when Resident #149 sustained a laceration and abrasion. 3. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] documented a BIMS score of 2, indicating the resident was severely cognitively impaired. The resident required extensive assistance with Activities of Daily Living (ADL) requiring assistance from one person. The resident required assistance from 2 people for transfers. Review of the Morse fall screening scored the resident as "75", which indicated Resident #9 was a high risk for falls and had a history of [REDACTED]. Review of the fall risk care plan dated 9/10/13 and reviewed 12/7/13, 3/7/14 and 6/7/14 for Resident #9 documented a potential for injury related to "...cognitive deficit, and bilateral [MEDICAL CONDITION]." Interventions included, "...keep call light within reach; low bed or bed in lowest position; side rails up x (times) 2; rubber floor mattress; bed alarm; wheelchair alarm; train resident how to use call light; always remind resident to use call light for assistance; fall monitoring for at risk resident every (q) hour..." The non accessible safety belt (NASB) was added to the care plan on 11/2/13. Review of the fall risk care plan dated 9/12/14 and reviewed 12/12/14 documented the potential for injury related to "...poor safety awareness; use of psyche (psychiatric) meds (medications); impaired mobility; history of falls; unable to ambulate w/o (without) assistance; unable to transfer w/o assistance; cognitive deficit and bilateral [MEDICAL CONDITION]" The interventions remain the same as the original care plan dated 9/10/13 with the addition of, "... shoes well-fitting with non-slip soles..." Review of the alteration in mood and behavior care plan dated 9/7/13 and reviewed 12/7/13, 3/7/14 and 6/7/14 documented behavior was manifested by "...non-compliance to daily care..." Interventions included, "...administer medications as ordered and monitor for effectiveness... adverse reactions; reduce environmental stimuli when agitated; redirect topics; give opportunity to verbalize feelings; attend and provide basic needs; and determine causative factor for current behavior and address as needed with assistance..." Review of the alteration in mood and behavior care plan dated 9/12/14 and reviewed 12/12/14 for Resident #9 documented behavior was manifested by "...agitation...non-compliance to daily care..." The interventions remain the same as the comprehensive care plan dated 9/7/13 with the addition of, "...Interdisciplinary Team (IDT) meeting as needed; [MEDICATION NAME] 10mg (milligrams) PO (by mouth) q (every) AM (morning); [MEDICATION NAME] 7.5mg po q HS (hour of sleep); and [MEDICATION NAME] 0.75mg po q HS..." Review of an incident/accident report dated 7/1/14 at 5:45 PM documented, "...resident on floor c (with) back propped against bed. Resident c/o (R) (right) hip pain & (R) arm pain..." The resident was sent to the emergency room (ER) for evaluation and treatment and returned to the facility with a [DIAGNOSES REDACTED]. Review of the care plan dated 7/1/14 documented a problem of resident found on floor with interventions to include; "...prompt toileting needs; place water pitcher within easy reach; offer fluids adequately..." Review of Resident #9's nurses notes documented the following: a. 1/5/14 7AM-3PM shift - "...call light is within reach but d/t (due to) confusion unable to use..." b. 1/25/14 3PM-11PM - "...memory forgetfulness will not allow... to remember to use call light..." c. 3/20/14 (1:00 PM) - "...refused to lay down after lunch..." d. 4/2/14 (1:00 PM) - "...refused to lay down after lunch..." e. 4/25/14 (11:00 PM) - "...extremely restless..." f. 8/23/14 (1:26 AM) - "...extremely agitated at this time-attempting to get oob (out of bed) s (without) assist..." g. 8/30/14 (12:48 AM) - "...increased agitation-attempting to remove wedge and get oob..." h. 8/31/14 (1:26 AM) - "...resident up in WC (wheelchair) r/t (related to) increased agitation..." Review of the 24 hour communication endorsement sheet documented the following: a. 6/24/14 11PM-7AM shift - "...up in WC 2 (secondary) to coming out of bed..." b. 6/27/14 11PM-7AM shift - "...restless up in WC..." Review of the weekly summary nurses notes documented the following: a. 5/31 through (-) 6/6/14 - "...verbally abusive..." b. 6/21/-6/27/14 - "...verbally abusive..." c. 10/4/-10/10/14 - "...climbs oob..." d. 11/1/-11/7/14 - "...attempts to get oob s assistance..." Review of a social service progress note dated 4/14/14 documented, "...uncoop (uncooperative) /combative toward staff..." Interview with the Director of Staff Development (DSD), on 1/14/15 at 9:05 AM, in the DSD's office, the DSD confirmed when a resident is known to frequently attempt to climb out of bed, and has been found on the fall mat, the behavior should be addressed in the care plan. The DSD stated, "Yes, if it is a frequent behavior, it should be care-planned." Interview with certified nursing assistant (CNA) #13, on 1/14/15 at 3:10 PM, in the 400 hallway, CNA #13 confirmed she cared for Resident #9 on a regular basis. CNA #13 stated Resident #9 had behaviors in the evenings and nights and said things like "...I have to get the baby and I have to get up to cook..." CNA #13 stated, when the resident exhibited these behaviors, the resident will "...continue to try to come out of the bed..." Telephone interview with the Medical Director, on 1/22/15 at 1:00 PM, in conference room [ROOM NUMBER], the Medical Director was asked about a resident climbing our of bed. The Medical Director stated when a resident was known to climb out of bed, "...we should brain storm for causes and interventions that are appropriate..." The Medical Director confirmed the expectation was for the facility to find the cause of the resident climbing out of the bed and to find appropriate interventions. The Medical Director confirmed Resident #9's attempts of climbing out of the bed were behavioral issues. In a subsequent interview with the DSD, on 1/22/15 at 2:00 PM, in conference room [ROOM NUMBER], the DSD confirmed no additional or appropriate interventions were documented on Resident #9's care plan from 8/14, through the present time. Interview with the DON, on 1/22/15 at 3:00 PM, in conference room [ROOM NUMBER], the DON confirmed there were no additional, or appropriate interventions documented on Resident #9's care plan after the 6/8/14 or the 7/1/14 falls. The DON, confirmed the care plans were not specific or individualized to the resident's needs. The DON confirmed the resident continued to exhibit behaviors of attempting to climb out of bed, restlessness and agitation and there were no changes noted to address these behaviors on the care plan last updated 12/12/14. In a subsequent interview with the DON, on 1/27/15 at 10:45 AM, in the DON's office, the DON stated the interventions on the care plan dated 9/10/13 and reviewed every quarter were "...not appropriate or specific for cognitively impaired residents..." Continued interview confirmed the intervention of "shoes well-fitting with non-slip soles" on the care plan dated 9/12/14 and reviewed on 12/12/14 was not appropriate for the resident with a [DIAGNOSES REDACTED]. goals or optimal interventions to aid in the risk for falls for the resident. The facility failed to revise the care plan with appropriate interventions related to behaviors which resulted in actual harm when Resident #9 fell sustaining a contusion to the right hip and a sprained right elbow. 4. Medical record review revealed Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan initiated 8/27/13 and updated on 11/29/13, 2/25/14 and 5/25/14, documented Resident #25 was a "...Fall Risk related to Cognitive Deficit and Weakness as evidenced by History of Falls..." The approaches were to "...Monitor for possible side effects of medications, Keep call light and personal items within easy reach, Always remind resident to use call light for assistance, Bed alarm... PT (Physical Therapy) / OT (Occupational Therapy) eval (evaluation) or Restorative nursing for strength training, gait, or transfer, Low bed or bed in lowest position, side rails up x (times) 2... Fall monitoring for at risk resident every hour..." Review of the care plan initiated 8/27/13 and updated on 11/29/13, 2/25/14 and 5/25/14, documented Resident #25 was "...At risk incontinence bowel and bladder related to cognitive deficit, impaired mobility..." The approaches were to "...provide pericare every shift and as needed, keep call light within reach, and remind resident to call for assistance, monitor for signs and symptoms of urinary tract infection..." Review of the bowel and bladder (B&B) assessment dated [DATE], documented Resident #25 was a candidate for B&B training. Review of a nurses note dated 5/31/14, documented Resident #25 "...was sitting on floor upright @ (at) the end of resident's bed..." Review of the incident investigation dated 5/31/14 at 12:45 PM, documented the "...Probable Cause was due to Trying to use toilet without assistance... Interventions/Action Taken... mat beside bed to floor..." Review of the facility post fall assessment for the 5/31/14 incident documented "...Interventions Initiated... mat beside bed on floor..." Review of the incident investigation dated 5/31/14 at 8:50 PM, documented the "...Location (of fall) between Bathroom and bed... Probable Cause... Climb out of bed, Trying to use toilet without assistance..." Review of the POS [REDACTED]" The resident's description of the incident was "...had to go to bathroom..." Review of the care plan dated 5/31/14, documented approaches included "...check for incontinence... prompt toileting needs... Mat to floor beside bed..." Review of a physician telephone order dated 6/6/14 documented, "DC (discontinue) floor mat." Interview with the DON and MDS Nurse #1 on 2/4/15 at 11:10 AM, and 5:45 PM, in the DON's office and/or nursing station and/or conference room [ROOM NUMBER], the DON and MDS Nurse #1 confirmed Resident #25 was a B&B training candidate as of 5/25/14 and the care plan for at risk incontinence was not revised to address the B&B training. The DON and MDS Nurse #1 confirmed the two falls on 5/31/14, were related to toileting and could have been prevented had the facility initiated the B&B training and the care plan dated 5/31/14 and the care plan was not revised to reflect the discontinued use of the floor mat as ordered on [DATE]. 5. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] documented a BIMS score of 1, indicating the resident was severely cognitively impaired and Resident #57 required extensive assist with all ADL's, transfers and ambulation. Review of the care plan dated 12/27/14, documented interventions to "...remind resident to call for assistance... keep call light within reach... keep eyeglasses fit and clean... shoes well fitting with non slip soles... maintain room and pathways free of clutter..." Review of incident/accident reports for Resident #57 documented the following: a. 12/27/14 at 7:15 PM - resident was found on the floor at the nurse's station with interventions to "...in-service staff, drug regimen review, let supervisor or charge nurse know if unable to monitor residents at the nurses station..." b. 1/8/15, with no time of occurrence - resident was found lying on the floor mat of... room, wet with urine and included no new interventions. c. 1/21/15 at 5:00 AM - resident was found on the floor of... room, wet with urine with interventions to "...prompt toileting, Q2H (every two hour) monitoring, place resident at nurses station when not in a deep sleep, not left in room..." Interview with Nurse #11, on 1/20/15, at 1:40 PM, in conference room [ROOM NUMBER], Nurse #11 stated the resident's fall risk care plans "...were not consistently revised..." Interview with the DON, on 1/22/15 at 2:45 PM, in conference room [ROOM NUMBER], the DON stated, "...no toileting plan was put into place... bad nursing documentation... not showing what precautions are in place... same interventions on post fall assessments... would expect neuro (neurological) checks to be done if an unwitnessed fall..." The DON stated, "...there were no new interventions for the fall on 1/8/15... some current interventions are not appropriate or effective for this resident.... no care plan revisions for prompt toileting or putting resident at nurses station..." Interview with the DSD, on 1/26/15 at 2:20 PM, in the fine dining room, the DSD stated the care plans have not been updated with the current interventions in place "...too much paperwork... need one care plan reflecting interventions and changes..." 6. Medical record revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE], documented a BIMS score of 14, indicating the resident was fully oriented and required assistance with bathing, dressing, grooming, transfer, eating and ambulation. Review of a nurses note dated 7/4/14, documented Resident #61 was found sitting on the bathroom floor; lost balance when ambulating to the bathroom. Review of the facility incident report dated 7/4/14 documented, the probable causes of the fall was trying to use toilet without assist; muscle weakness; and unsteady gait. Interventions included in-service to staff; continue to remind resident to use call light and drug review. The investigation also documented an in-service titled "Please check patient frequently. Assist patient with ADLs. Place call light within patient's reach" there were two CNAs present at the inservice. Review of the care plan dated 7/4/14, documented the interventions to in-service staff; continue to remind resident to use call light and drug review were not included on the care plan. Review of a nurses note dated 8/9/14, documented Resident #61 was found on the floor and resident stated, "I was in a hurry to transfer myself from the wheelchair to the bed and I slid." Review of the facility investigation dated 8/9/14, documented probable causes of the fall included transferring from bed to wheelchair unassisted as well as transferring from wheelchair to bed unassisted and poor safety awareness. The interventions documented physical therapy referral; drug review and resident refuses personal safety alarm. The facility investigation also documented a note from physical therapy stating the resident was on rehabilitation services. Review of the care plan dated 8/9/14, revealed the interventions for physical therapy referral, drug review and resident refuses personal safety alarm were not included on the care plan. Review of a nurses note dated 9/8/14, documented the Resident #61 attempted to ambulate to the restroom, lost balance and was found sitting on floor. Review of the facility investigation dated 9/8/14, documented the probable causes included trying to use toilet without assistance. The interventions included drug review; refuses personal safety alarm; remind resident to use call light; x-ray right hip. Review of the care plan dated 8/20/14, revealed the interventions for drug review, refuses personal safety alarm and remind resident to use call light were not included on the care plan. Interview with the DON on 1/27/15 at 3:30 PM, in the DON's office the DON confirmed the interventions determined after each fall were not included on the care plan. 7. Medical record review revealed Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change MDS with an assessment reference date of 4/25/14 documented a BIMS score of 2, indicating the resident was severely cognitive impairment and required total assistance for ADL's. Review of fall risk assessments dated 3/6/14, 4/25/14, 7/25/14 and 10/25/14 documented scores greater than 10, indicating the resident was a high risk for falls. Review of nurses notes documented the following: a. 3/21/14 - "...resident was found on the floor mat x 2..." b. 4/24/14 an unidentifiable time - "...noticed... on the floor sitting next to the bed..." c. 11/25/14 at 6:16 AM - "...coming out of bed x 3 this early am... put to bed from mat with two person assist... (resident) very confused..." Review of the care plan with a start date of 3/6/14 documented, "Fall Risk... Potential for Injury... Resident will remain free from falls and injury..." There were no updates to the care plan after 4/25/14. Interview with the DON, on 1/26/15 at 3:05 PM, in the fine dining room the DON stated, "...it (care plan) should have been updated... nothing was done after either fall..." 8. Medical record revealed Resident #114 was admitted to the facility ob 9/24/14 with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] and the quarterly MDS dated [DATE] documented, Resident #114 had impaired vision and could not see regular print. The quarterly MDS documented that Resident #114 had a BIMS score of 14, indicating that resident was cognitively intact. Review of a physician's orders [REDACTED]. Resident #114's care plan did not address vision impairment. Interview in MDS Nurse #2, on 2/5/15 at 8:27 AM, the MDS office MDS Nurse #2 was asked if there was a care plan for vision for Resident #114. MDS Nurse #2 stated, "...it should be here... this one doesn't have one..." 9. Medical record review revealed Resident #117 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the significant change MDS dated [DATE], documented a BIMS score of 5, indicating the resident was fully oriented on and required extensive assistance with transfers, dressing, bathing, and grooming; had a foley catheter in place and was occasionally incontinent of bowel. Review of a nurses note dated 9/27/14 documented the resident was found sitting on the floor on the buttocks with the foley catheter pulled out, bulb inflated. The resident could not remember what occurred and stated "...I thought I could just walk to the bathroom..." Review of the incident report dated 9/27/14 documented the probable cause of the incident included climbing out of bed; unsteady gait; weakness; and poor safety awareness. The interventions included drug review; personal safety alarm to bed and wheelchair and referral to physical therapy. Review of a nurses note dated 12/8/14 documented, Resident #117 stated, "...I fell and picked myself up..." on the way to the bathroom; was found sitting on edge of bed. Complaining of knee pain, right knee and left ankle. Review of the incident report dated dated 12/8/14 documented, the probable causes of the fall included climbing out of bed; transferring bed to chair without assist; trying to use toilet without assist; muscle weakness; unsteady gait; non compliant with care; and poor safety awareness. The interventions included x-ray both knees and ankle; right ankle fracture - sent to hospital; remind resident to use call light; drug regimen review. The incident report and x-ray report documented the resident suffered an acute fracture distal fibula. Review of the physician's progress note dated 12/8/14, documented "...due to comorbid conditions, lack of ambulatory status, and non-displaced fracture, resident been placed in a walker boot..." Review of the care plan dated 9/27/14, revealed the interventions for drug review; personal safety alarm to bed and wheelchair and referral to physical therapy were not transferred to the care plan. The care plan did not include the use of walker boot; to observe the condition of the skin or the removal of the boot for bathing. Interview with the DON, on 1/27/15 at 3:30 PM, in the DON's office, the DON confirmed the interventions were not transferred from the incident report to the care plan. The DON also confirmed information about the boot and care of the skin under the boot, were not included on the care plan. 10. Medical record review revealed Resident #150 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] documented a BIMS of "11", indicating the resident was moderately cognitively impaired. The behavior section of the MDS documented the resident had rejected care 1-3 days since admission. The functional status documented the resident to require 2 person assistance with transfers and moving in bed, and 1 person assistance with all other ADL's. The resident was confined to a wheelchair or used a walker with assistance. Review of a fall risk assessment score dated 2/28/14 was "13", indicating Resident #150 was a high risk for falls. Review of a social worker (SW) progress notes dated 3/31/14 documented, "...CP (care plan) meeting held c (with) resident family and resident present... IDT (interdisciplinary team) staff discussed medical condition and reviewed meds purpose side effect..." Review of the care plan dated 2/18/14 documented, "...manifested by refusing meds, refusing labs (laboratory testing)..." Goals included "...being more cooperative and compliant..." Interventions included "...monitor for side effects of medications, involve the resident in the plan of care, and praise the resident for compliant behavior..." Review of the care plan dated 2/28/14 documented, "...potential for injury d/t (due to) unsteady gait, weakness, use of psyche (psychiatric) meds (medications) and a history of falls..." The interventions included, "...train/demonstrate... how to use the call light... fall monitoring for at risk resident every hour..." Review of the care plan dated 3/5/14 documented, "...manifested by non-compliance to daily care, resisting meds, resisting care and verbal abuse to staff..." Interventions included, "...assist to activity room, individual attention for reassurance, IDT meeting as needed, and determine causative factor for current behavior and address as needed..." Review of Resident #150's nurses notes documented the following behaviors: a. 4/2/14 7AM-3PM shift - "...verbally abusive..." b. 4/3/14 7AM-3PM shift - "...verbally offensive to staff, non-compliant with assistance and ADL's. Other residents complain of verbally offensive words spoken... verbally abusive..." 4/3/14 3PM-11 PM shift - "...continues to be verbally offensive to staff, non-compliant with ADL assist... verbally abusive..." c. 4/11/14 11PM-7AM shift - "...inappropriate sexual comments to nurses..." d. 4/15/14 7AM-3PM shift - "...Noncompliant with care..." e. 4/23/14 7AM-3PM shift - "...can be non-compliant with staff... ...noncompliant with care, patient choice..." f. 4/30/14 7AM-3PM shift - "...Declines [MEDICATION NAME] Patch (a pharmaceutical topical medicine for the treatment of [REDACTED]. Review of the care plan dated 4/1/14 documented the contributing factors included, "...Resident stands up unassisted; Unmindful of safety; Unsafe mobility and Poor standing balance..." Interventions included, "...remind resident to ask for assistance; prompt toileting need; and maintain call light within easy reach..." Review of the care plan dated 4/7/14 documented the contributing factors included, "...Resident stands up unassisted; Unmindful of safety; Unsafe [MEDICAL CONDITION]; DM (Diabetes Mellitus);[MEDICAL CONDITION](Hypertension) and Dementia..." The interventions remained the same as the intervention on the care plan dated 4/1/14 with no new interventions noted to prevent a future fall. Interview with the DON, on 1/28/15 at 9:50 AM, in conference room [ROOM NUMBER] the DON confirmed the IDT meeting on 3/31/14 did not discuss the residents preferences or treatment plans for care. the DON confirmed the care plan dated 4/1/14 and 4/7/14 did not have any pertinent or appropriate interventions documented specific to Resident #150. The DON confirmed there were no additional interventions or updates documented to the care plan after the falls on 4/1/14 and 4/7/14. The DON confirmed the interventions on the care plan were not specific or individualized for the residents behaviors or functional status. The DON confirmed there was no documentation the resident was provided individual attention or reassurance or praising the resident for compliant behavior; the facility trying to determine the cause for the behaviors or encouraging the resident to use the call light to ask for assistance. 11. Medical record review revealed Resident #151 was admitted to the facility on on 6/19/14, readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS dated [DATE] documented a BIMS of 5, indicating the resident was severely cognitively impaired. The overall presence of behavioral symptoms section revealed a "0", indicating no behaviors were assessed for the resident. Review of the care plan dated 6/19/14 documented the following: a. "...Potential for Injury as evidenced by, History of falls and fractures; Unable to ambulate w/o assistance; Forgets to use assistive device; Unable to transfer without assistance; and Verbalizes dizziness..." The interventions included "...bed and wheelchair alarm; call light within reach; remind resident to call for assis