Every finding on record at Arrowhead Post Acute LLC

Based on observations, staff interview, and review of the facility's policy titled, Ice Machines and Ice Storage Chests F880, the facility failed to ensure food items in the walk-in cooler were labeled and dated, maintain the kitchen in a clean and sanitary manner, and keep the ice scoop clean and covered. The deficient practices had the potential to place the 77 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: Review of the facility's policy titled, Ice Machines and Ice Storage Chests F880, reviewed 10/2024, revealed, . Ice machines and ice storage distribution containers will be used and maintained and to assure safe and sanitary supply of ice . To help prevent contamination of . ice storage chests/containers or ice, staff should follow these precautions. e. Keep the ice scoop/bin in a covered container when not in use. f. Clean and sanitize the tray and scoop daily . 1. During the initial tour of the kitchen with the Dietary Manager (DM) on 6/9/2025 at 8:43 am, the following observations were made: a. An undated bag of shredded lettuce and an undated container of English peas were found on shelves in the walk-in cooler. The DM verified that the two items were undated at the time of the observation and discarded them. b. A portable air conditioning unit was observed sitting on top of the counter where dishes exited the dishwasher. The unit was vented through the ceiling. The portable air conditioning unit had an accumulation of dust and grease buildup on the air intake or the back side of the unit. The vent was observed with an accumulation of dust along the tubing. The portable unit's air vent on the front side was held open by paper towels so the vent would stay open for air flow. c. Two vents below the clock on the wall at the three-compartment sink and the dishwasher counter were observed with an accumulation of grease and dust buildup. The DM explained that one was an exhaust vent and one was for airflow coming into the building. d. The back of the oven, cooktop, and fryers were observed with an accumulation of grease and dust. e. The ceiling tiles throughout the kitchen were observed with brownish discoloration and areas of splatter. Above the vent hood, there was one ceiling tile that was observed sagging. During an observation and interview on 6/9/2025 at 1:11 pm, after the meal service and during dishwashing, the DM was asked to show where staff monitoring logs of temperatures taken from the dish machine to ensure the temperatures for sanitizing dishes were in the correct range. The temperature log was retrieved, and there were no temperatures logged for 6/8/2025 and 6/9/2025 before washing dishes. The DM stated the temperatures should have been checked and logged. During an observation and interview on 6/10/2025 at 2:31 pm, the following observations were made: a. A large fan was blowing air into the kitchen. The fan was found with an accumulation of sticky dust. The DM stated that the air conditioning had been out for a long time, and when asked how long, she did not say. When asked if it had been since the last survey, she stated yes. The thermostat above the three-compartment sink read 84 degrees. b. A ceiling vent over the food serving table/steam table was observed not fully covering the area in the ceiling that it is intended to cover. There were gaps between the ceiling and the edges of the vent. c. The portable air conditioning unit remained in the dishwashing area, with the accumulation of dust and grease still noted. The DM was asked about reporting maintenance issues in the kitchen. The Dietary Manager stated that any maintenance needs were entered through the computerized communication tool for maintenance needs and that communication went to maintenance, then to the Administrator, and then to Corporate, depending on the amount of the needed repair. During an interview on 6/12/202025 at 9:30 am, the Administrator was asked to provide any maintenance requests sent through the computerized communication system for the last year. The Administrator and Regional [NAME] President of Operations (RVPO) were notified that the DM reported that the air conditioner in the kitchen had not been working. The Corporate consultant stated she was not aware of the air conditioner being out until this survey. On 6/12/2025 at 11:08 am, the computerized communication reports were received via email from the Administrator. There were no entries of kitchen maintenance requests in the report. 2. During an observation and interview on 6/9/2025 at 12:48 pm with the Assistant Director of Nursing (ADON), an uncovered ice scoop was noted inside a clear plastic container on the ice chest cart. The scoop and container were visibly dirty, the container was cracked, and the lid was broken off. The ADON stated, This all needs to be changed out. The container has a large crack, and the lid is broken off. The ice scoop should be covered and left open to the air. I don't know how long it's been like this, but I'm going to replace it right now. The ADON returned at 12:52 pm and stated, We have to order some because we don't have any in stock right now. We're going to put it in a baggie for now since it should be covered until the new ones come in. During an interview on 6/12/2025 at 8:20 am, the Administrator stated, The ADON did show me the dirty, broken ice scoop and container. The scoops should always be covered, and the entire ice chest and cart should be cleaned regularly, and staff should know this. I ordered new ice scoops and containers for both halls.

Based on observations, staff interviews, and policy review, the facility failed to maintain a safe, functional, and sanitary environment in 16 of 47 resident rooms (rooms 101, 104, 105, 106, 125, 128, 129, 131, 132, 133, 137, 138, 139, 142, 143, 147), the main dining room, and the right and left wing day rooms. These failures had the potential to lead to injury or accidents, the spread of infection, or feelings of discomfort and dissatisfaction among residents. Findings include: Review of the facility policy titled Other Environmental Conditions, dated October 2024, revealed, The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Observations of the Left Wing of the facility during resident screening/initial pool on 6/9/2025 and again during an environmental tour of the facility with the Administrator, Director of Nursing (DON), Maintenance Director Assistant (MDA), Housekeeping Director (HKD), Regional Director of Clinical Services (RDCO), and Regional [NAME] President of Operations (RVPO) on 6/12/2025 revealed: 1. On 6/9/2025 at 9:11 am in room [ROOM NUMBER], bed A was at its lowest setting, exposing a hole in the wall next to the bed where an electrical outlet once was. During the environmental tour on 6/12/2025 at 1:10 pm, the MDA stated he planned on putting a cover over the hole so that it could be used as an outlet later if needed. He stated the hole had been uncovered for a couple of weeks. 2. On 6/9/2025 at 9:12 am in room [ROOM NUMBER], the nightstand next to Bed B had veneer peeled off with the veneer's jagged edges sticking up. Additionally, there were two long pieces of wood that had been taken off the wall next to Bed B and were lying on top of the air conditioner unit. The wood had several nails sticking straight up. Also, the tile of the windowsill on the left corner was broken and crumbling. During the environmental tour on 6/12/2025 at 1:12 pm, the MDA stated the nightstand needed to be replaced as the veneer was peeling off. The MDA and HKD stated they were not aware of how the pieces of wood came off the wall or why they were on top of the air conditioner (AC) unit. The MDS stated the nails posed an accident hazard, and they needed to be removed from the room. The HKD stated that the crumbling tile on the windowsill needed to be replaced. 3. On 6/9/2025 at 9:17 am in room [ROOM NUMBER], the tiles on the floor near the sink were water-damaged and were pulling up off the floor and sticking up jaggedly. Next to the sink was a large black stain on the wall above the water-damaged tiles. The four nightstands in the room had missing or peeling veneer. In the bathroom, there were black stains on the ceiling tile around the sprinkler head and black stains around the edges of the floor under the sprinkler. The toilet paper holder was missing, and a plunger was on the floor, not stored in a bag or covered. The toilet was unsecured on the left side, leaving it loose and wobbly and able to be moved approximately three inches side to side. During the environmental tour on 6/12/2025 at 1:13 pm, the MDA stated there was water damage on the wall and the floor next to the sink. He stated the black stains were mildew and not mold, although he stated he had not tested for mold. The MDA stated the leak in the wall had been fixed, but nothing had been done to clean up the damage. The MDA added that this needed to be cleaned as mildew can affect resident health. The HKD confirmed the nightstands were in disrepair and needed to be replaced. The MDA stated that the ceiling tiles and floor in the bathroom were stained from dirty water that sprayed when the sprinkler head was replaced. He stated this was just dirt, not mildew or mold, but confirmed he had not tested for mold. The MDA confirmed there was no toilet paper holder in the bathroom and stated he was not aware it was missing. The HKD stated the plunger should be stored in a bag, not directly on the floor, to prevent the spread of infection. The MDA stated the toilet was loose and needed to be secured. He stated he was not aware of this condition. 4. On 6/9/2025 at 9:25 am in room [ROOM NUMBER], the cove base was missing under the AC unit, exposing a peeling wall under the unit. During the environmental tour on 6/12/2025 at 1:00 pm, the MDA confirmed the missing cove base in room [ROOM NUMBER], stated he was not aware of the missing cove base, and stated it needed to be repaired. 5. On 6/9/2025 at 10:13 am, the Left-Wing day room had numerous areas of scratched or peeling paint on the walls and on the railings surrounding the TV areas. There were multiple stains and areas of dried debris on the walls. The countertops holding the TVs and other supplies had multiple sticky areas of red and brown substances, dust, dirt, and dried debris. During the environmental tour on 6/12/2025 at 12:56 pm, the HKD stated the housekeeping staff was expected to wipe down the walls, countertops, and other surfaces in the common areas, and added that he audited the housekeeper's work twice daily. He stated the countertops and walls should have been clean. The Administrator added that the facility had been without a Maintenance Director and had just recently hired someone to take the position, which would help with getting projects and repairs done. Observations on 6/9/2025, beginning at 9:09 am, on the Right Wing identified the following maintenance and environmental concerns: 1. The main dining room was observed with an accumulation of more than a day's worth of dust on top of the piano, the chair in front of the piano had cobwebs on the back leg/left, and the tiles on the side near the kitchen were broken with missing pieces. There was also an area where quarter-round trim was missing at the dining room entry, along the wall under the wall display. 2. room [ROOM NUMBER] - A buildup of dust and grime was observed around the baseboards, the cabinet under the sink was observed with a drawer off track, and underneath the cabinet, dirt and crumbs were observed in the right corner. 3. The exit door in the hallway near rooms [ROOM NUMBERS] was observed with a gap at the bottom and sides of the door, allowing light to come through. The gaps were large enough for pests to enter. At the sides of the door, along the baseboards, there was more than one day's accumulation of dirt and dust buildup and cobwebs. 4. room [ROOM NUMBER] - The chair rail above the head of the bed was observed to be cracked. In the bathroom, there was a buildup of dirt and grime in the corners and behind the toilet, and a urine odor was present. 5. room [ROOM NUMBER] - There was no light covering to light above the sink in the bedroom. The corners and along the baseboards were observed to have a buildup of dirt and dust. The ceiling tiles near the bathroom door and above the sink had watermarks around a pipe going into the ceiling. The toilet lid was observed broken and lying on the floor of the bathroom. The floor in the bathroom was observed with a buildup of more than a day's worth of dirt and grime in all four corners. The toilet tank did not have any water in the tank, and the ceiling's light cover was hanging down, not covering the light bulb. 6. room [ROOM NUMBER] - The faucet to the sink located at the entrance to the room was observed loose and not secured to the sink. The ceiling tiles above the sink were discolored with brown spots, and the sheetrock outside the bathroom had areas of missing sheetrock in need of repair. The floors along the baseboards had more than a day's worth of accumulation of dirt and grime. In the bathroom, the commode seat was observed to have brownish colored stains on it. The plunger in the bathroom was observed without a cover and sitting on the floor of the bathroom. The light cover was observed with an accumulation of black debris on the inside. 7. In front of room [ROOM NUMBER], along the Therapy Department wall, there was brownish colored spillage on the column and baseboard. 8. room [ROOM NUMBER] - There was dust buildup on the vent fan, and the light cover had a buildup on the inside. The flooring behind the door had a buildup of an accumulation of dust and dirt, more than a day's worth. 9. 139 B- The head and foot boards were observed not fully attached, with each having one side making contact with the floor. A heavy buildup of dust and dirt was observed on the inside of the AC vent of the AC unit. A gap in the sheetrock was observed along and between the top of the AC unit and the wall. Two tiles on the windowsill were observed to be broken and loose. The bathroom door was also observed to have paint scuffed off at the bottom, as well as paint missing from the door frame. 10. room [ROOM NUMBER] - The privacy curtain for Bed A was soiled with a brown substance, and the privacy curtain track in the middle of the room was not secured to the ceiling. There was a drawer underneath the sink that was observed off track, and the baseboard between the closet and the sink was observed missing. The wall area where the baseboard was missing was observed to be black. 11. Outside the door of room [ROOM NUMBER], in the hallway, there was an accumulation of dirt and dust in the corners and along the baseboards. There were two broken tiles at the door of the room. 12. room [ROOM NUMBER] was observed with a newer laid gray plank-type flooring. At Bed B, the flooring was not secured, with portions of the flooring having loose, raised edges, the wall behind the headboard was scuffed, and paint was removed from the wall in the scuffed areas. The top of the bedside table for Bed B had veneer missing from all four edges. At the entry to the room, the tile flooring from the hallway to the new plank flooring in the bedroom was higher than the hallway tile. There was no transition between the two different types of flooring. 13. room [ROOM NUMBER] - The attached headboard of Bed B was observed broken, with a portion missing. The bedside table was observed with all three drawers off track, and pieces of veneer were missing or loose from the bottom, sides, and back edges. 15. 138 - The faucet was observed with a continuous drip of water, and the right-side water nozzle was observed to be broken with a piece missing. 16. During an observation on 6/9/2025 at 9:34 am, tiles were noted to be missing from the floor of the right-wing day room. 17. room [ROOM NUMBER] had an open area under the sink, and a wash pan was under the sink to catch dripping water. Tiles were missing on the floor as you entered the bathroom. 18. The hallway walls had missing paint, and wheelchair marks were noted on the walls. 19. room [ROOM NUMBER] had a leak in the room, and the dresser was warped. On 6/12/2025 12:45 pm, the HKD, MDA, Corporate Staff, the Administrator, and the DON accompanied the surveyors on a tour of the Right Wing to observe the identified housekeeping and maintenance issues. As issues were confirmed by staff, notes were taken to address them.

Based on record review, resident and staff interviews, the facility failed to maintain an effective pest control program for seven of 34 sampled residents' rooms (R) (R71, R15, R70, R59, R52, R184, and R20). This failure had the potential to lead to further pest infestation in the facility and feelings of discomfort or spread of infection among the residents. Findings include: Review of the facility's policy titled, Pest Control, dated October 2024, revealed, The community maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's Resident Council Minutes for the past year, provided by the facility on paper, revealed: -On 6/26/2024, several residents complained of roaches in the facility. The facility's response was to schedule an exterminator on a monthly basis. -On 5/28/2025, several residents complained of water bugs in the facility. The facility's response was to schedule an exterminator. Review of the facility's pest control logs, provided on paper, revealed pest control services were provided on: -1/8/2024 - full exterior and interior service. Pest activity was noted. -4/1/2024 - fly machine maintenance, rodent monitoring, and full interior treatment for general pests. Pest activity was noted. -12/10/2024 - bait station inspection, exterior treatment for general pests, and fly trap service. -6/6/2025 - pest elimination services, fly control service, rodent control service, and roach clean outs of rooms 114, 115, 116, 117, 118, 142, and 146. There was no evidence of monthly extermination services as outlined in the facility's resolution to the Resident Council's grievance, and there were no records of services between December 2024 and June 2025. 1. Review of R71's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/27/2025, revealed he was admitted to the facility on [DATE]. R71 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 6/9/2025 at 9:54 am, R71 stated he has seen water bugs or roaches throughout the facility. R71 stated he tried to step on the bugs, but they were too fast and usually got away. 2. Review of R15's annual MDS, with an ARD of 3/213/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility on [DATE]. R15 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 9:53 am, R15 stated that the trash bins were kept in the hall right outside his room door, and this attracted bugs to his room. 3. Review of R70's quarterly MDS, with an ARD of 5/7/2025 and located under the MDS tab of the EMR, revealed she was admitted to the facility on [DATE]. R70 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 9:25 am, R70 stated there were roaches in her room and she saw them every day. R70 stated her roommate often put food on the floor, and this attracted the bugs. 4. Review of R59's quarterly MDS, with an ARD of 3/21/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility 12/21/2021. R59 scored 13 out of 15 on the BIMS, indicating moderately impaired cognition. During an interview on 6/9/2025 at 2:34 pm, R59 stated there were roaches or water bugs in her room. She stated she was afraid to go to sleep and have the bugs crawl on her, so she had her family member spray the room for bugs. R59 stated, I had a good night's sleep after that. 5. Review of R52's annual MDS, with an ARD of 3/19/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility on [DATE]. R52 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 10:04 am, R52 stated there were small flying bugs in the facility, and he had seen roaches now and then. 6. Review of R184's admission MDS, with an ARD of 6/10/2025 and located under the MDS tab of the EMR, revealed she was admitted to the facility on [DATE]. R184 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/9/2025 at 12:00 pm, R184 stated there were gnats in the bathroom and shower room, and she had seen roaches in her room. 7. Review of R20's quarterly MDS, with an ARD of 4/4/2025 and located under the MDS tab of the EMR, revealed he was admitted to the facility on [DATE]. R20 scored 15 out of 15 on the BIMS, indicating intact cognition. During an interview on 6/11/2025 at 4:00 pm, R20 stated the shower room was full of roaches and gnats. He stated there were roaches in resident rooms as well, especially inside the closets. During an interview on 6/12/2025 at 1:27 pm, the Administrator stated a new extermination company was hired recently and serviced the facility on 6/6/2025. She stated the previous extermination company was not completing services in a timely manner, so she had reached out to sister facilities to hire a more reliable company. The Administrator stated the new company would be completing regular visits. The Maintenance Director Assistant (MDS) stated that to address resident concerns when pest control services did not come in, he bought approved insecticides and treated rooms as they were brought to his attention.

Based on observation, staff interview, record review, and review of the facility policy titled Guidelines for Charting and Documentation, the facility failed to ensure the clinical record accurately reflected the status of one of 34 residents (R) (R8) related to use of a wander guard (departure alert system). This failure created a misrepresentation of care being provided. Findings include: Review of the facility policy titled Guidelines for Charting and Documentation, dated June 2024, revealed, Be concise, accurate, and complete and use objective terms . Document only the facts. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above the knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms, including wandering, and was dependent on staff with mobility and all activities of daily living. Review of R8's Wandering and Elopement Evaluation, dated 4/16/2025 and located under the Assessments tab of the EMR, revealed he was unable to ambulate or to self-propel his wheelchair, and he had no wandering or exit-seeking behaviors and no risk factors for elopement. The evaluation documented, Resident no longer self-propels and is not a wander risk at this time, wander [guard] removed. Review of R8's EMR under the Care Plan tab revealed it did not address the potential for wandering or eloping. Review of R8's May 2025 and June 2025 Medication Administration Records (MARS), located under the Orders tab of the EMR, revealed a physician's order, dated 11/8/2024, to check the function of the wander guard every day. The nursing staff initialed that this was completed daily. During an observation on 6/11/2025 at 1:03 pm, R8 was seated in his geriatric chair in the day room. He did not have a wander guard device on. In a concurrent interview, Certified Nurse Aide (CNA) 2 stated R8 did not have a wander guard and was no longer able to get around on his own, so it was not necessary. CNA11 confirmed R8 did not have a wander guard. During an interview on 06/11/25 at 4:40 PM, Licensed Practical Nurse (LPN) 3 and LPN4, who served as the left side Unit Manager, stated R8 did not use a wander guard as he was dependent on staff for mobility. LPN3 and LPN4 confirmed they removed his wander guard and the order for the device when his mobility status changed, as he no longer needed it. LPN3 and LPN4 stated they were unaware that the order to check for placement was still active and reflected as implemented on the MAR. LPN3 stated this was due to staff not reading what they were signing off, and it was inaccurate.

Based on staff interview, record review, and review of the facility's policy titled Evaluations, the facility failed to ensure one of one resident (R) (R184) reviewed for rehabilitation out of a sample of 34 residents received timely speech therapy services when ordered to address a swallowing problem. This failure had the potential to place R184 at risk of a decline in swallowing function and dissatisfaction with pureed meals, which could contribute to weight loss or malnutrition. Findings include: Review of the facility's policy titled Evaluations, dated 10/4/2024, revealed, Evaluations will be initiated within a reasonable amount of time following receipt of a physician's order, authorization, or according to facility policy. Review of R184's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses that included dysphagia, anxiety, depression, and failure to thrive. Review of R184's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/10/2025 for Section C (Cognitive Patterns) revealed, she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition and Section K (Swallowing/Nutritional status) revealed, she received a mechanically altered diet. Review of R184's Care Plan, dated 6/5/2025 and located under the Care Plan tab of the EMR, revealed she was on a mechanically altered diet. Review of R184's EMR under the Orders tab revealed a physician's order, dated 5/28/2025, for the Speech Therapist (ST) to evaluate and treat as indicated. There was also a physician's order, dated 5/28/2025, for a pureed texture diet. During an interview on 6/9/2025 at 12:00 pm, R184 stated she was admitted to the facility specifically for speech therapy, as she had trouble eating and had to eat pureed foods. She stated she had not yet seen the ST, and this made her angry, as she wanted to work on getting back to eating regular foods. She stated she did not like eating pureed foods and typically did not eat very much at meals. She stated the pureed food looked like baby food. During the interview, R184's speech was unclear, and statements had to be repeated several times. She was drooling and was unable to control the loss of saliva from her mouth. In an interview on 6/11/2025 at 2:48 pm, the Rehab Director (RHD) stated he was just alerted on 6/9/2025 that R184 needed a speech therapy screening. He stated the screening was completed on 6/11/2025, and typically, screenings had to be completed within 48 hours of notification of the order. The RHD stated he was not aware of the order for a speech therapy evaluation on 5/28/2025, as nursing entered the orders into the EMR, then communicated any new orders to therapy via a screening request form. The RHD stated he received a screening request form for R184 on 6/9/2025. In an interview on 6/11/2025 at 3:34 pm, the ST stated she was unaware R184 had a speech therapy evaluation ordered on 5/28/2025, as it was never communicated to her. She stated she received a request for screening from nursing on 6/9/2025 because R184 was upset with her food texture. She stated R8 was screened on 6/11/2025 and was unsafe with any texture other than puree due to problems with swallowing and a risk for aspiration. The ST stated she would need to conduct an evaluation to determine if R184 could benefit from speech therapy treatment. The ST stated that the screening determined if an evaluation was warranted, and an evaluation was a more thorough, hands-on assessment to determine if further treatment was warranted. The ST stated she would have evaluated R184 on 5/28/2025 if she had known about the order. In an interview on 6/12/2025 at 9:07 am, Licensed Practical Nurse (LPN) 4, who served as the left side Unit Manager, stated she did not know how R184's 5/28/2025 order for ST was missed, and it should have been communicated via a screening request form to the therapy department.

Based on observations and staff interviews, the facility failed to maintain proper ventilation in six resident rooms and on the main hall of the facility to ensure adequate air circulation and environmental hygiene. This failure had the potential to contribute to residents' discomfort and poor air quality for all 80 residents currently residing in the facility. Findings include: 1. Observations made beginning on 6/9/2025 at 9:09 am on the right wing of the facility identified bathroom ventilation fans were found not operational in rooms 125, 131, 133, and 137. On 6/12/2025 at 12:45 pm, the Maintenance Director Assistant (MDA), the Housekeeping Director (HKD), the Administrator, Director of Nursing (DON), and Corporate staff accompanied the surveyors on a tour of the building and confirmed identified concerns, including rooms where the ventilation fans were not working. The MDA verified that the ventilation fan was not working in room [ROOM NUMBER], with tissue paper, as there was no updraft of the paper. During an observation on 6/9/2025 at 2:32 pm in the shared bathroom for the four residents in rooms [ROOM NUMBERS], there was a heavy urine odor in the bathroom. The exhaust vent in the bathroom was not working and would not draw up a piece of toilet tissue. During an observation with the Maintenance Director Assistant (MDA) on 6/12/2025 at 12:50 pm, the shared bathroom between rooms [ROOM NUMBERS], the MDA confirmed a heavy urine odor in the bathroom. The MDA checked the function of the exhaust vent and stated it was not drawing air. During an observation on 6/9/2025 at 12:48 pm, the hallway ceiling vent and grate outside of the Administrator's office were observed to be covered in excessive dirt and debris consisting of a blackened substance with visible thick, white, and gray furry matter. During an observation and interview on 6/12/2025 at 1:00 PM while completing a walk-through of the left wing of the facility with Maintenance Director Assistant (MDA), he stated, We change out the filters every month. This one is pretty dirty, and it's caked with dirt. To clean them, we would replace all three vents and clear off the grate that is covered with dirt and the loose strings of dirt and lint hanging from the grate. During an interview on 6/12/2025 at 1:30 pm, the Administrator stated, We were down to one maintenance person for a while. The previous maintenance person worked here for one year but has been gone for three to four weeks. It's been difficult to keep up with all the maintenance. Review of the facility's maintenance records for the past 12 months revealed that the filters were changed monthly, but no other details were provided.

Based on record review, staff interview, and review of facility's policy titled Infection Control Program - Antibiotic Stewardship, the facility failed to ensure that antibiotics were not used without the presence of a diagnosed infection for one of three residents (R) (R53) reviewed for antibiotic stewardship out of a total sample of 34 residents. The failure had the potential to lead to increased antibiotic resistance or adverse side effects related to unnecessary antibiotic usage. Findings include: Review of the facility's policy titled Infection Control Program - Antibiotic Stewardship, dated October 2024, revealed, After order has been received, the Infection Control Coordinator or designee should complete the surveillance document, utilizing the McGeer criteria, noting evidence for the infection. If the antibiotic does not fit the criteria, the physician will be contacted. Review of the facility's Infection Control Log, used to track infections and antibiotic usage, revealed R53 was listed with a urinary infection with an onset date of 5/10/2025. The log documented that R53 was taking the antibiotic doxycycline, and this was a facility-acquired infection. The area to document the organism, the x-ray result, and/or the lab/culture result was left blank. There was no place to document symptoms on the log and no place to document whether the infection met criteria. The log documented one urinary tract infection and no upper respiratory infections for the month. Review of R53's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE]. Review of R53's Medication Administration Record (MAR), dated May 2025 and located under the Orders tab of the EMR, revealed a physician's order dated 5/6/2025 for doxycycline (antibiotic), 100 milligram tablet twice daily for URI [upper respiratory infection]. Review of R53's EMR under the Notes tab revealed an eInteract SBAR Summary for Providers, dated 5/6/2025, which documented that R53 experienced a cough and had new orders for a chest x-ray, antibiotic, and cough syrup. Subsequent Nursing Infection Notes, dated 5/9/2025, 5/10/2025, and 5/11/2025 documented, ABT[antibiotic]/URI in progress. Review of R53's Radiology Report, dated 5/7/2025 and located under the Miscellaneous tab of the EMR, revealed his chest x-ray indicated, No active disease. No evidence of pneumonia. Review of R53's EMR revealed no communication with or rationale from the physician regarding continued use of an antibiotic in the absence of any active infection. During an interview on 6/12/2025 at 2:56 pm, the Infection Preventionist (IP) stated she started working in her current position in April 2025. She stated her antibiotic stewardship program included determining whether an infection met criteria to require treatment and determining whether an antibiotic was effective. The IP stated that the Infection Control Log listed the onset date, site, infection diagnosis, antibiotic, and date resolved. The IP stated she did not have access to lab results yet, so she had not yet been reviewing labs and/or x-rays as part of her antibiotic stewardship program. The IP stated she would determine whether an antibiotic was effective by reading nurses' notes to determine if symptoms had improved. The IP stated she did not have a way to determine if an organism is susceptible to the antibiotic prescribed, as she did not have access to lab results. She stated she would just alert the physician if there was no improvement in symptoms with the current antibiotic. The IP stated she had not reviewed R53's use of doxycycline to determine if the infection met criteria and whether the antibiotic was appropriate. She stated she had not seen the chest x-ray results from 5/7/2025.

Based on observations, interviews, and review of the facility's policies titled Storage of Medications F 761 and 5.3 Storage and Expiration Dating of Medications and Biologicals, the facility failed to remove expired medications from one of two medication carts located on the Left Wing. This deficient practice had the potential to place the residents at risk of receiving medications with altered effectiveness. Findings include: Review of the facility's policy titled, Storage of Medications F 761, reviewed 3/2025, indicated, . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed per state regulation . Review of the facility's policy titled, 5.3 Storage and Expiration Dating of Medications and Biologicals, reviewed 8/1/2024, indicated, . Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has shortened expiration date once opened or opened . Observation on 6/11/2025 at 10:20 am with Licensed Practical Nurse (LPN) 4, (also Unit Manager) of the medication cart at the nurses' station on Left Wing revealed one open bottle of Pro-Stat Nutricia 30 fluid ounces with an expiration date of 5/16/2025 and one unopened box of blood glucose control solution with the expiration date of 12/7/2024 in the first drawer of medication cart. LPN4 confirmed that both items were expired. There was also an open bottle of extra-strength antacids, with an expiration date of 3/2025. LPN4 confirmed all findings. During an interview on 6/11/2025 at 10:30 am, LPN4 stated, All the nursing staff are supposed to go through the medication carts and check expiration dates. We don't really have a system because someone is always checking them. During an interview on 6/12/2025 2:55 pm, the Administrator stated, I'm aware there were some expired medications found in the medication cart that shouldn't have occurred. Staff will need to be reeducated, so this doesn't happen again in the future.

2. Review of R8's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility with diagnoses that included seizures, aphasia, and deaf non-speaking. Review of R8's quarterly MDS, with an ARD of 3/13/2025 and located under the MDS tab of the EMR for Section C (Cognitive Patterns) revealed, he scored zero out of 15 on the BIMS, indicating severely impaired cognition; Section D (Mood) revealed, R8 did not exhibit any mood or behavioral symptoms, and Section N (Medications) revealed, he used antianxiety medication. Review of R8's Care Plan, dated 4/27/2025 and located under the Care Plan tab of the EMR, revealed, [R8] uses anti-anxiety medications r/t [related to] anxiety disorder. The approaches included Give anti-anxiety medications ordered by physician. Review of R8's Medication Administration Record (MAR), located under the Orders tab of the EMR and dated May 202025, revealed a physician's order, which originated on 4/17/2025, for lorazepam (an antianxiety medication), 0.5 milligrams (mg) three times daily for anxiety. Further review of the MAR revealed that the lorazepam was not administered on: -5/16/2025, 6:00 am - The comment code indicated supply reordered. -5/17/2025, 6:00 am and 2:00 pm - The comment code indicated supply reordered. -5/18/2025, 6:00 am, 2:00 pm, and 10:00 pm: - The comment code indicated supply reordered; and -5/19/2025, 6:00 am and 2:00 pm - The comment code indicated supply reordered. Review of R8's EMR under the Notes tab revealed corresponding notes regarding the missing doses of lorazepam: -5/15/2025, 11:30 pm: Reordered. -5/17/2025, 5:44 am: Waiting on pharmacy. -5/18/2025, 5:58 am: Waiting on pharmacy. -5/18/2025, 10:49 pm: Waiting for pharmacy. -5/19/2025, 5:25 am: Waiting on pharmacy. Review of R8's MAR, dated June 2025 and located under the Orders tab of the EMR, revealed that the lorazepam was not administered on: -6/6/2025, 6:00 am - The comment code indicated supply reordered. -6/6/2025, 10:00 pm - The comment code indicated, Other. -6/7/2025, 6:00 am - There was no documentation, and -6/7/2025, 2:00 pm - The comment code indicated, supply reordered. Review of R8's EMR under the Notes tab revealed corresponding notes regarding the missing doses of lorazepam: -6/6/2025, 6:13 am: Waiting for pharmacy. -6/6/2025, 11:49 pm: Medication not on cart, need new Rx [prescription]. There were no notes on 6/7/2025. In an interview on 6/12/2025 at 8:39 am, Licensed Practical Nurse (LPN) 3 stated R8 did not refuse medications and should receive medications as ordered. She stated that when a new order for a controlled medication was sent to the pharmacy, the nurse also had to call the doctor to authorize and sign the prescription. She stated most likely, the above instances where the medication was not administered was because there was a delay in getting the order signed by the physician. LPN3 did not know why the medication was not taken from the facility's emergency medication supply to ensure R8 did not miss doses. In an interview on 6/12/2025 at 8:59 am, LPN4, who served as the left side unit manager, stated she was not aware of the above instances of lorazepam not being available for R8. She stated she relied on the nurses to reorder medications when necessary and follow up when medications are not delivered timely. LPN4 added that lorazepam was available in the facility's emergency medication supply, so there was no reason for the dose not to be given. LPN4 stated there were no issues with getting orders signed by the physician, and the process typically went very smoothly and quickly. Based on observation, interview, record review, and review of the facility's policy titled 5.1 Delivery and Receipt of Routine Deliveries, the facility failed to provide controlled medications for two of three residents (R) (R76 and R8) reviewed for medications out of a total sample of 34. This failure had the potential to place R76 and R8 at risk of uncontrolled pain and anxiety. Findings include: Review of the facility's policy titled, 5.1 Delivery and Receipt of Routine Deliveries, revised 8/1/2024, revealed, . if any item ordered by the facility is not received in the delivery, facility staff should check for a pharmacy communication slip indicating: 2.1.1 medications that are back ordered. 2.1.3 medications that are too soon to be refilled. 2.1.5. other communications explaining the reason a medication or item was not delivered . Facility should contact pharmacy if facility requires an explanation for the missing items of medications . 1. Review of R76's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R76 was admitted to the facility with diagnoses that included dislocation of unspecified internal joint prosthesis, aftercare following joint replacement surgery, left hip joint osteoarthritis, and hypertension. Review of R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 3/25/2025 and located under the MDS tab of the EMR for Section C (Cognitive Patterns) revealed, R76 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R76 was cognitively intact. Review of R76's Order Summary, located under the Orders tab of the EMR, revealed R76 had physician orders, dated 5/19/2025, for tramadol, a narcotic pain medication, fifty (50) milligrams (MG), one tablet every eight hours for pain. During an observation on 6/11/2025 at 8:16 am, R76 asked Licensed Practical Nurse (LPN) 3 about his tramadol pain medicine and stated that it should have come in last night. LPN3 lets R76 know that it was not delivered, but she double-checks the narcotic box to be sure, and if not, she would call the pharmacy on it today. During an interview on 6/11/2025 at 8:18 am, R76 stated, I've been out of my pain med since Monday night at 10:00 pm. They haven't given me anything for two and a half days. During an interview on 6/11/2025 at 8:31 am, the Assistant Director of Nursing (ADON) stated, The nurses are supposed to reorder meds when the blister pack gets down to the last row. But if they run out of meds, then they're supposed to call the pharmacy and get a code and permission to access the Pyxis machine. The resident should not be out of their pain meds. The only time they wouldn't have a narcotic is if they were a new admission. At this point, we shouldn't ever run out. This is a valid concern, because I wasn't aware he was out. We can call the pharmacy and pull it from the Pyxis if needed. So, if he's asking for it, then we can call the doctor and get an order to change the med administration time also. During an interview on 6/11/2025 at 8:50 am, LPN4, also Unit Manager for this unit, stated, [R76]'s tramadol isn't in yet. But when it comes in, I will let him know. He can't have any until 2:00 pm, though, because that's when it's scheduled. LPN4 was asked what was being done to manage the resident's pain during this time he was without pain medication. LPN4 answered, Well, he hasn't complained of pain, so we'll give it at 2:00 PM if it comes in. During an interview on 6/11/2025 10:03 am, the Administrator stated, We have the Pyxis to take care of those emergent meds needing to be pulled. That's what it is there for. Nursing must call the pharmacy and have two nurses access it together. So, there is no reason his pain wasn't addressed and no reason his meds weren't here on time, if they were ordered on time. During an interview on 6/12/2025 at 2:55 pm, the Administrator stated, I investigated the pharmacy not delivering [R76]'s tramadol. The pharmacy said it was ordered, but there was an issue with the courier not delivering it. So, it should have been gotten out of the Pyxis and given to R76 for his pain.

Based on observations, staff interviews, and record review, the facility failed to ensure that one of three residents (R) (R27) reviewed for pressure ulcers out of a total sample of 34 sampled residents was provided with a pressure-relieving device to relieve pressure between bony prominences. This failure had the potential to place R27 at risk for pressure ulcer development. Findings include: Review of R27's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 2/7/2014 with diagnoses including dysphagia following an unspecified cerebrovascular disease, aphasia, hemiplegia, and hemiparesis following cerebral infarction affecting the left dominant side. Review of R27's most recent Annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 8/17/2024, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for all functional abilities, including bathing, dressing, personal hygiene, and mobility. R27 was also assessed as being incontinent of bowel and bladder and as having pressure ulcers. On 6/9/2025 at 3:10 pm, staff were observed in R27's room to provide care. During this observation, R27's legs were observed to be severely contracted and bent up to the lower torso. On 6/10/2025 at 12:33 pm, R27 was observed positioned on the left side. There was a foam wedge under the left knee. There were no devices between the resident's knees. On 6/11/2025 at 7:57 am, two staff were observed entering R27's room to provide care. The surveyor asked the staff to observe R27's position. The staff uncovered the resident. The resident was observed to have bilateral leg contractures with the legs drawn up tightly toward the buttocks. The resident's knees were together with no pressure-relieving device between the knees. On 6/11/2025 at 9:30 am, the surveyor entered R27's room with the Wound Care (WC) Nurse. R27 was positioned to the right side with a wedge underneath or below the right knee between the mattress and the resident's right outer leg. A folded flat sheet was observed between the resident's knees. When asked if there had been any pressure-relieving device used between the resident's knees, the WC Nurse said not that she was aware of.

3. Review of the R29's Face Sheet, located in the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. Review of R29's most recent annual MDS with an ARD of 7/17/2024, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R29 was cognitively intact for decision-making. This MDS assessment further indicated R29's vision was severely impaired and had no impairment in range of motion in the upper or lower extremities. Review of the MDS section titled Preferences for Customary Routine and Activities lists a series of questions about Activity Preferences. R29 provided the answer of Very Important for the following questions: How important is it to you to listen to music you like? How important is it to you to keep up with the news? How important is it to you to do things with groups of people? How important is it to you to go outside to get fresh air when the weather is good? Review of the most recent quarterly MDS with an ARD of 3/21/2025 revealed R29's Cognition was a score of 14, identifying this resident remained cognitively intact. Review of R29's current Care Plan under the Care Plan tab in the EMR revealed a 2/20/2024 initiation date. The Focus column on this care plan stated that R29 had little or no activity involvement. The goal initiated on 2/20/2024 was that R29 would express satisfaction with the type of activities and level of activity involvement when asked through the review date. The interventions included: Invite R29 to scheduled activities (Date initiated06/12/2025); R29 needs assistance/escort activity functions; and monitor/document for the impact of medical problems on activity level. The Care Plan included a revision date on 5/21/2025; however, the only intervention dated 6/12/2025 was to invite (R29) to scheduled activities. An interview was conducted with R29 on 6/10/2025 at 12:20 pm. When asked what types of activities R29 liked to do, R29 expressed that she could not see and that she just sits there and listens to the TV. During all four days of the survey, 6/09/2025 to 6/12/2025, R29 was observed in her room sitting on the side of her bed. An interview was conducted with the Activities Director (AD) on 6/10/2025 at 1:00 pm. The Activities Director was asked if she could provide activity participation records for R29. The AD reviewed her records, both for group activities and one-to-one participation records, from April to June 2025. The AD stated she has tried to invite R29, but she won't come. When asked if she could show me where it is documented that the resident has been invited, the AD verified that there are no activity participation records or documentation where R29 has attended or has been invited to activities. Based on observation, resident interview, resident family interview, staff interviews, record review, and policy review, the facility failed to ensure three of four residents (R) (R8, R52, and R29) reviewed for activities, out of a total sample of 34 sampled residents, received sufficient activity engagement to meet their needs. Findings include: Review of the facility's policy titled, Activities and Social Events, dated October 2024, revealed, When developing the resident's activity and social care plan, the resident should be given an opportunity to choose when, where, and how he or she will participate in activities and social events . The staff will evaluate a resident's physical and mental capacity to participate in various levels of activities. They will note any significant physical and cognitive limitations or behavior issues that would influence the level of a resident's participation or type of activities that are relevant to that individual. They will also note in the medical record any restrictions or needs that might be relevant to participation in activities. 1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms and was dependent on staff with mobility and all activities of daily living. Review of R8's annual MDS, with an ARD of 8/12/2024 and located under the MDS tab of the EMR, revealed it was very important for him to participate in reading, music, current events, group activities, favorite activities, outside activities, and religious services. It was somewhat important for him to be around pets. Review of R8's Recreation (Activities: Admission/Annual/COC [change of condition] Assessment, dated 8/11/2024 and located under the Assessment tab of the EMR, revealed it was very important for R8 to attend religious services. He also enjoyed pets, arts and crafts, Bingo, games, outings, cooking, writing, cultural activities, current events, gardening, movies, music, resident council, socials, and sports. R8 was interested in activity participation and was cooperative. Review of R8's Care Plan, dated 2/27/2025 and located under the Care Plan tab of the EMR, revealed it did not address R8's activity needs or participation. Review of R8's Activity for the Day participation records for May 2025 and June 2025, provided by the facility on paper, revealed R8 participated in: -5/27/2025: Bingo -6/9/2025: Bingo -6/10/2025: Outside and Popsicles During an observation on 6/9/2025 beginning at 10:03 am, R8 was seated in a geriatric chair in the left side day room with the TV on. R8 was unable to understand or respond to questions. He remained in the geriatric chair without any activity or staff engagement until 12:18 pm, when R8 was wheeled to a table in the left side day room for lunch. He remained in the geriatric chair at the dining table until 1:15 pm, when he was wheeled away from the table but left in the left side day room. R8 was observed yelling out periodically during this time. At 1:45 pm, R8 was taken to the Bingo activity in the main dining room in his geriatric chair by the Activity Director (AD). During the activity, R8 did not participate or receive assistance to engage in the activity. The AD sat at a different table playing his Bingo card. R8 remained in Bingo until 2:22 pm, when he was brought back to the left side day room. R8 remained in his geriatric chair in the day room, exhibiting periodic yelling out at staff and squirming in his chair, without any activity or staff engagement until 3:25 pm. During an observation on 6/10/2025 beginning at 1:02 pm, R8 was observed seated in his geriatric chair in the left side day room without any activity or engagement. At 2:08 pm, the AD was observed inviting residents to participate in a Bean Bag Toss activity. However, R8 was not invited to attend. R8 remained seated in the day room until 2:27 pm, when he was taken to his room to prepare for his wound treatment. During an observation on 6/11/2025 beginning at 7:27 am, R8 was observed seated in his geriatric chair in the left side day room with the TV on. He remained seated without any activity or engagement until 10:31 am, when he was taken to his room During a telephone interview on 6/11/2025 at 1:43 pm with R8's family member (F)1, she stated she believed R8 could use more engagement in activities. F1 stated, I just see him sitting there in the common area. F1 stated R8 was very social and was very involved in his community and his favorite activities, especially arts and crafts. F1 stated that the hardest thing for R8 has been the loss of freedom that came with his leg amputation, and he was now not getting exposure to social events or activities. F1 stated she felt R8 could benefit from more activity engagement, particularly in hands-on sensory stimulation types of activities. In an interview on 6/12/2025 at 12:10 pm, the AD stated R8 was deaf but communicated with sign language and gestures, and he could also read lips. She stated R8 enjoyed Bingo, though he typically needed the staff to play his board for him. The AD stated he also went out to smoke periodically or attended outside activities. The AD stated R8 was not provided with one-to-one visits, and his only programming was occasional attendance at group activities like Bingo. She stated that based on a review of R8's attendance records, he should be receiving one-to-one visits for additional engagement and interaction, but she had not yet implemented this. 2. Review of R52's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE]with diagnoses including depression, stroke with hemiplegia, encephalopathy, dementia, and blindness in one eye. Review of R52's annual MDS, with an ARD of 3/19/2025, revealed he scored 15 out of 15 on the BIMS, indicating intact cognition. He did not exhibit mood or behavioral symptoms. R52 was dependent on staff for transfers from bed to wheelchair and for wheelchair mobility. He felt it was very important to participate in reading and outdoor activities, and somewhat important to participate in music, current events, group activities, favorite activities, and religious services. Review of R52's Care Plan, dated 5/21/2025 and located under the Care Plan tab of the EMR, revealed, The resident is dependent on staff for activities, cognitive stimulation, social interaction r/t cognitive deficits. The approaches included: The resident . needs 1 to 1 bedside/in-room visits and activities if unable to attend out of room events . Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility . [and] Provide with activities calendar. Notify resident of any changes to the calendar of activities. Review of R52's Recreation (Activities: Admission/Annual/COC Assessment, dated 1/15/2025 and located under the Assessment tab of the EMR, revealed he enjoyed arts and crafts, pets, Bingo, games, outings, cooking, cultural activities, current events, movies, music, religious services, resident council, socials, and sports. He was very interested in participating in activities and was cooperative and motivated. Review of R52's Activity for the Day participation records for May 2025 and June 2025, provided by the facility on paper, revealed R52 participated in: -5/12/2025: Bowling There were no records of participation for June 2025. In an observation in R52's on 6/9/2025 at 10:04 am, he was lying in bed with the TV on. R52 stated he did not attend a lot of activities and spent most of his time lying in bed. R52 stated he especially liked to play Bingo, but added he only attended Bingo every now and then because the staff did not always let him know when it was going on or get him out of bed in time to attend. R52 stated he would like to attend Bingo more often. During observations on 6/9/2025 from 12:28 pm to 2:00 pm, R52 was lying in bed. At 1:45 pm, the AD was observed inviting and escorting residents to play Bingo. However, R52 was not invited to get out of bed to attend Bingo. The Bingo activity took place in the dining room. In an interview on 6/9/2025 at 2:00 pm, R52 stated he did not know Bingo was taking place but would have liked to attend. He stated he needed help getting cleaned up and getting out of bed before he could attend the activity. During observations on 6/10/2025 from 8:23 am to 9:28 am and from 1:02 pm to 2:08 pm, R52 was observed lying in bed with his TV on. At 2:08 pm, the AD was observed inviting residents to participate in a Bean Bag Toss activity. However, R52 was not invited to attend. R52 remained in bed. In an interview on 06/12/2025 at 12:05 PM, the AD stated R52 sometimes attended group activities and did not receive one-to-one visits. The AD stated his activity participation was low, but this was because the nursing staff did not always assist in getting R52 out of bed and to activities. The AD stated R52 was not specifically invited to activities, but groups were announced over the intercom, and that should alert the nursing staff to start helping get residents to the activity. The AD stated she had never done training with the nursing staff on preferred activities and times of day or strategies to help get residents to participate in activities. The AD stated she needed the nursing staff to help get R52 to activities because she could not get all the residents there by herself.

Based on observation, record review, and policy review, the facility failed to ensure one of six residents (R) (R8) reviewed for assistance with Activities of Daily Living (ADLs), out of a total of 34 sampled residents, received assistance with ADLs. This failure had the potential to cause skin breakdown, urinary tract infection, or discomfort for R8. Findings include: Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above the knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms and was dependent on staff with activities of daily living, including toilet hygiene. R8 did not use the toilet and was always incontinent of bladder and bowel. Review of R8's most recent Bladder Incontinence Evaluation, dated 11/9/2024 and located under the Assessments tab of the EMR, revealed he was incontinent and used incontinence briefs at all times. The assessment documented, Proceed with a check and change program. Review of R8's Care Plan, dated 2/27/2025 and located under the Care Plan tab of the EMR, revealed R8 required staff participation with activities of daily living such as personal hygiene, bathing, and oral care. The Care Plan did not address R8's incontinence and need for a check and change program. Review of R8's POC [Point of Care] Response History, dated 5/12/2025 through 6/10/2025 and located under the Tasks tab of the EMR, revealed he was always incontinent. Review of R8's Kardex, provided on paper by the facility and dated 6/12/2025, revealed, Bladder continence and Bowel movement/continence were documented with no further information included. During an observation on 6/9/2025 beginning at 10:03 am, R8 was seated in a geriatric chair in the left side day room. R8 was unable to understand or respond to questions. He remained in the geriatric chair in the day room without any incontinence checks by staff. At 12:18 pm, R8 was wheeled to a table in the left side day room, without an incontinence check, by Certified Nurse Aide (CNA) 2. He remained in the geriatric chair at the dining table until 1:15 pm, when he was wheeled away from the table but left in the left side day room, without an incontinence check, by CNA2. R8 was observed yelling out periodically during this time. At 1:45 pm, R8 was taken to the bingo activity in the main dining room in his geriatric chair by the Activity Director (AD). He remained in bingo until 2:22 pm, when he was brought back to the left side day room. R8 remained in his geriatric chair in the day room, exhibiting periodic yelling out at staff and squirming in his chair, without an incontinence check until he was taken to his room at 3:25 pm by CNA2.

2. Review of R27's admission Record located in the EMR under the Profile tab, revealed an admission date of 02/07/14 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left dominant side. Review of R27's most recent annual MDS located in the EMR under the MDS tab with an ARD of 8/17/24, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for all functional abilities. Review of the EMR under the Orders tab revealed that there was no current physician's order for the use of heel protectors. Review of the EMR under the Care Plan tab revealed a care plan initiated on 02/10/22 with a focus stating: [R27] has skin impairment/pressure injury r/t [related to] decreased mobility . One of the care plan interventions revealed R27 was to wear heel protectors while in bed. This intervention was initiated on 02/12/22. Observations of the R27 were made on 06/11/25 at 7:57 AM, 06/11/25 at 9:30 AM, 06/11/25 and at 4:30 PM while in bed. There were no heel protectors in place. During an interview with LPN 1 on 06/11/25 at 4:50 PM, LPN 1 was asked about the care plan intervention for heel protectors for R27. LPN 1 stated that she was not aware of an order for heel protectors for R27. R27's care plan was reviewed with LPN 1 that included the intervention to wear heel protectors with the date of initiation being 02/12/22. LPN 1 stated that the intervention would need to be reviewed to see if it is still what the wound care doctor wants. During an interview with the MDSC on 06/12/25 at 11:45 AM, the MDSC was asked about the resident's care plan for pressure injuries and the use of heel protectors. The MDSC stated she was made aware on the prior day of the heel protectors not being ordered and stated the heel protectors have been removed from the care plan. 3. Review of the EMR Face Sheet tab, indicated R4 was admitted to the facility on [DATE] with diagnosis including but not limited to dementia in other diseases classified elsewhere, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mild intellectual disabilities, other seizures. Review of R4's EMR, annual MDS with an ARD of 03/30/25, revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Review of R4'4 EMR Care Plan tab, indicated R4 care plan history dates were as follows: 12/20/24 and 03/24/25. In the Care Plan under Nursing, R4 was a long-term nursing home placement. The goal was for R4 to remain at this facility for long-term nursing home placement. Date initiated 03/36/24, revision on 05/21/25, and target date 09/19/25. During an interview on 06/11/25 at 1:54 PM, the Social Service Director (SSD) reviewed the Care Plan history which indicated R4 had been back in the facility since 03/26/24, and there were only two completed care plans showing. The SSD verified the information but was not able to explain. Based on interview, record review, and review of facility policy, the facility failed to ensure quarterly care plan conferences were being completed in order to assess, review, and revise the care plan as needed five of 34 sampled residents (Resident (R)8, R27, R29, and R4) reviewed for care plan conferences and care plan revisions. This had the potential for the residents to have unmet care needs. Findings include: 1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, lack of coordination, seizures, absence of right leg above knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/25 and located under the MDS tab of the EMR, revealed he was dependent on staff with activities of daily living including toilet hygiene and dependent on staff for bed mobility and transfers from bed to chair. R8 did not use the toilet and was always incontinent of bladder and bowel. a. Review of R8's Care Plan, dated 02/27/25 and located under the Care Plan tab of the EMR, revealed R8 required staff participation with activities of daily living such as personal hygiene, bathing, and oral care. The Care Plan did not address R8's incontinence and need for a check and change program. Review of R8's Kardex, provided on paper by the facility and dated 06/12/25, revealed, Bladder continence and Bowel movement/continence were documented with no further information included. In an interview on 06/12/25 at 8:39 AM, Licensed Practical Nurse (LPN)3 stated R8 was incontinent of bowel and bladder and used incontinence briefs. She stated he should be checked and changed if needed at least every two hours if not more often. In an interview on 06/12/25 at 9:06 AM, LPN4 (who served as the left side unit manager) stated R8 should be checked and changed if needed at least every two hours. She stated she was not aware he was going longer than two hours without incontinence care. In an interview on 06/12/25 at 12:31 PM, Certified Nursing Assistant (CNA)2 stated R8 was incontinent and used incontinence briefs. In an interview on 06/12/25 at 11:39 AM, the Minimum Data Set Coordinator (MDSC) stated R8's Care Plan did not address incontinence or a check and change program, but this information should have been included. Review of the facility policy titled, Quality of Life - Activities of Daily Living, dated April 2025, revealed, Residents are provided with appropriate care and services including . [assistance with] elimination . Update Care Plan appropriately and interventions as needed. b. Review of R8's Care Plan, dated 02/27/25 and located under the Care Plan tab of the EMR, revealed R8 required staff participation with transfers. The Care Plan did not address R8's specific assistance needs with transferring. In an interview on 06/11/25 at 10:35 AM, CNA11 stated he did a two-person transfer for R8, and added he would have used his gait belt if he was transferring R8 by himself, but since CNA12 was assisting, it was not needed. CNA11 stated he preferred to do R8's transfers with two CNAs assisting rather than alone. In an interview on 06/12/25 at 8:39 AM, CNA12 stated R8 transferred with the assistance of two staff and could pivot on his leg to assist. LPN 3 added during a two-person transfer, a gait belt should be used. In an interview on 06/12/25 at 11:39 AM, the MDSC stated R8's Care Plan did not address R8's specific needs regarding transfers, but this information should have been included. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated October 2024 revealed, Staff will document resident transferring and lifting needs in the care plan.

2. Review of the R29's Face Sheet, located in the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. Review of R29's most recent annual MDS with an ARD of 7/17/2024, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R29 was cognitively intact for decision-making. This MDS assessment further indicated R29's vision was severely impaired and had no impairment in range of motion in the upper or lower extremities. Review of the MDS section titled Preferences for Customary Routine and Activities lists a series of questions about Activity Preferences. R29 provided the answer of Very Important for the following questions: How important is it to you to listen to music you like? How important is it to you to keep up with the news? How important is it to you to do things with groups of people? How important is it to you to go outside to get fresh air when the weather is good? Review of the most recent quarterly MDS with an ARD of 3/21/2025 revealed R29's Cognition was a score of 14, identifying this resident remained cognitively intact. Review of R29's current Care Plan under the Care Plan tab in the EMR revealed a 2/20/2024 initiation date. The Focus column on this care plan stated that R29 had little or no activity involvement. The goal initiated on 2/20/2024 was that R29 would express satisfaction with the type of activities and level of activity involvement when asked through the review date. The interventions included: Invite R29 to scheduled activities (Date initiated 6/12/2025), R29 needs assistance/escort activity functions; and monitor/document for the impact of medical problems on activity level. The Care Plan included a revision date on 5/21/2025; however, the only intervention dated 6/12/2025 was to invite (R29) to scheduled activities. An interview was conducted with R29 on 6/10/2025 at 12:20 pm. When asked what types of activities R29 liked to do, R29 expressed that she could not see and that she just sits there and listens to the TV. During all four days of the survey, 6/9/2025 to 6/12/2025, R29 was observed in her room sitting on the side of her bed. During an interview on 6/12/2025 at 11:50 am with the Minimum Data Set Coordinator (MDSC), it was explained that the 7/17/2024 annual MDS included R29's activity preferences; however, the current Care Plan with a revision date of 5/21/2025 did not include those likes. When the MDSC was asked if she would expect those likes to be a part of the R29's Care Plan to be sure R29's is provided the type of activities in the assessment, the MDSC stated Yes. Review of R29's EMR in the Orders tab revealed an order dated 1/15/2024 for TED (Thrombo-Embolic Deterrent) Hose stockings, on in am, off in pm, one time a day for Edema BLE (bilateral lower extremities). This order was active as of 11/16/2024, and there had been no order to discontinue. Review of R29's EMR in the Assessments tab revealed Nursing Weekly Skin Evaluations dating back to 3/6/2025 of R29 having edema in the lower extremities. An interview was conducted with R29 on 6/11/2025 at 7:51 am. R29 was sitting on the side of the bed with his/her feet in a dependent position. When R29 was asked about the swelling in his feet and legs, and if he/she had ever worn any socks or hose for his/her swelling. R29 stated that he/she had worn them in the hospital but has not worn them at the facility. During an interview on 6/11/2025 at 4:15 pm, LPN 1, the right-wing Unit Manager, was asked about the physician's orders for TED hose for R29. LPN1 reviewed the order and stated that the order was written by a nurse practitioner who no longer worked at the facility. LPN1 stated she could reach out to R29's cardiologist to see if he would like the resident to wear the TED hose because that would require measurement. The surveyor followed up with LPN1 on 6/12/2025 at 1:00 pm and stated that the Medical Doctor came in today and the TED hoses were not necessary. LPN1 stated that the TED hose had been discontinued and removed from the orders. During an interview on 6/12/2025 1:49 pm, the MDS Coordinator (MDSC) was notified that there were orders for TED hose for R29's edema. The MDSC was notified that the edema has been mentioned in the weekly assessments since 3/20/2025. When asked if this were an issue that should have come up in meetings where she would be notified, the MDSC stated yes. The MDSC verified by looking at the most recent weekly assessment that edema was mentioned. When the MDSC was asked if the resident with edema should have had a care plan, she stated yes. 3. Review of R27's admission Record located in the EMR under the Profile tab, revealed an admission date of 2/7/2014 with diagnoses including dysphagia following an unspecified cerebrovascular disease, aphasia, hemiplegia, and hemiparesis following cerebral infarction affecting the left dominant side. Review of R27's most recent annual MDS located in the EMR under the MDS tab with an ARD of 8/17/2024, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for all functional abilities to include bathing, dressing, personal hygiene, and mobility. R27 was also assessed as being incontinent of bowel and bladder and as having pressure ulcers. On 6/10/2025 at 12:33 pm, R27 was observed positioned on the left side. There was a foam wedge under the left knee. There did not appear to be any devices between the residents' knees. On 6/11/2025 at 7:57 am, two staff were observed entering R27's room to provide care. The surveyor asked the staff to observe R27's position. The staff uncovered the resident. The resident was observed to have bilateral leg contractures with the legs drawn up tightly toward the buttocks. The residents' knees were together with no pressure-relieving device between the knees. On 6/11/2025 at 9:30 am, the surveyor entered R27's room with the Wound Care (WC) Nurse. R27 was positioned to the right side with a wedge underneath or below the right knee between the mattress and the resident's right outer leg. A folded flat sheet was observed between the resident's knees. When asked if there had been any pressure-relieving device used between the resident's knees, the WC said that she was not aware of one. During an interview with the MDSC on 6/12/2025 at 11:45 am, the MDSC was asked about the residents' contractures. The MDSC confirmed there was no care plan specifically addressing the contractures and pressure relief. When asked if there should be a care plan addressing the contractures and pressure relief, the MDSC stated yes. Cross-Reference F679 and F686 Based on record review, staff interview, and policy review, the facility failed to develop a comprehensive care plan for three of 34 sampled residents (R) (R8, R29, and R27). These failures placed R8, R29, and R27 at risk for unmet physical and psychosocial care needs and the inability to meet their maximum practicable level of functioning. Findings include: 1. Review of R8's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including muscle weakness, seizures, absence of right leg above knee, aphasia, and deaf nonspeaking. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/13/2025 and located under the MDS tab of the EMR, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R8 did not exhibit any behavioral symptoms and was dependent on staff with mobility and all activities of daily living. Review of R8's annual MDS, with an ARD of 8/12/2025 and located under the MDS tab of the EMR, revealed it was very important for him to participate in reading, music, current events, group activities, favorite activities, outside activities, and religious services. It was somewhat important for him to be around pets. Review of R8's Recreation (Activities: Admission/Annual/COC [change of condition]) Assessment, dated 8/11/2024 and located under the Assessment tab of the EMR, revealed it was very important for R8 to attend religious services. He also enjoyed pets, arts and crafts, bingo, games, outings, cooking, writing, cultural activities, current events, gardening, movies, music, resident council, socials, and sports. R8 was interested in activity participation and was cooperative. Review of R8's Care Plan, dated 2/27/2025 and located under the Care Plan tab of the EMR, revealed it did not address R8's activity needs or participation. In an interview on 6/12/2025 at 11:39 am, the MDS Coordinator (MDSC) stated she and the Activity Director (AD) worked together on developing activities Care Plans. She stated that if a resident had concerns with low participation, a Care Plan should be implemented. The MDSC stated she needed to check with the AD on the creation of an activity Care Plan for R52. In an interview on 6/12/2025 at 12:10 pm, the Activity Director (AD) stated the MDSC was responsible for creating activities Care Plans, and she would expect one to address activities for R8.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure one of five residents (R) (R64) reviewed for Advance Directives out of a total sample of 34 residents had the correct code status, which identified her wishes in the event of a medical emergency. The failure placed residents at risk of not having their end-of-life wishes honored. Findings include: A review of the facility policy titled Advance Directives, dated 5/2024, revealed, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Inquiries concerning advance directives should be referred to the Administrator, Director of Nursing Services [DON], and/or to the Social Services Director. Review of R64's electronic medical record (EMR) revealed R64 was readmitted to the facility on [DATE]. Review of the EMR banner revealed a code status of Full Code, all measures. Further review of the EMR under the Orders tab, which stated Full Code, all measures. Review of the Care Plan tab of the EMR revealed R64 had requested to be full code status initiated on [DATE] with a revision date of [DATE]. The goal was that staff would respect the wishes and rights of the resident regarding having CPR performed. Initiated on [DATE], revision on [DATE], and target date of [DATE]. Review of R64's Clinical Physician's Orders revealed an order dated [DATE] for Full Code, all measures. Further review revealed an order dated [DATE] for Hospice care. Review of the clinical record revealed a document titled Georgia Do Not Resuscitate Order dated [DATE] and completed with the resident's name and physician's signature. Interview on [DATE] at 10:57 am with Registered Nurse (RN) 1 (Hospice nurse) revealed that R64 was a Do Not Resuscitate (DNR), and that there were signed documents for the DNR that should be in the resident's chart. During an interview on [DATE] at 11:18 am, License Practical Nurse (LPN) 1, when asked about R64's code status, stated the resident was a full code and we would do everything possible to save her with compressions (CPR). LPN1 provided the code status book, which revealed R64's code status sheet was green, which meant she was a full code. During an interview on [DATE] at 11:39 am, LPN2 was asked what R64's code status was. LPN2 went to the EMR and stated R64 was a full code. LPN2 stated the resident's code status was on her profile page of the EMR and in the resident's physician orders, but she would also look in the code book. LPN2 stated she would start compressions on R64. During an interview on [DATE] at 11:41 am, the Staff Developer (SD) indicated that if a resident codes, staff would look in the code book and look in the EMR to determine a resident's code status to know what direction to take (whether to initiate CPR or not). The SD revealed that if the EMR and code book stated the resident was a full code, a code blue would be called, and chest compressions would be started. During an interview on [DATE] at 11:49 am, LPN3 stated that to determine a resident's code status, she would look at a resident's EMR and follow the physician's order. LPN 3 was asked to look at the EMR for R64's code status. LPN3 reviewed R64's EMR and stated the resident was a full code, so she would begin compressions. During an interview on [DATE] at 11:56 am, the MDS Coordinator stated that when assisting a resident who had coded, staff look in the EMR for the code status. Another nurse would check the code status book, and staff would follow the documented code status. In review of R64's EMR, the MDS Coordinator stated the resident was a full code, so compressions would begin. Interview on [DATE] at 12:42 pm, RN2 (Hospice nurse) revealed R64 was admitted to hospice while at home and was moved to the nursing facility. RN2 stated that since R64's admission to hospice on [DATE], the resident had always been DNR. During an interview on [DATE] at 12:02 pm, with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional Nurse, all reviewed R64's chart together, the DON indicated that R64 was full code with all measures. The process would be to go to the EMR, and the banner would reveal Advance Directive wishes. The DON stated that staff could also refer to the code status book that was kept at the nursing station.

Based on resident and staff interviews and record review, the facility failed to ensure one of 34 sampled residents (R) (R4) was invited to participate in care plan meetings. This had the potential to cause R4's wishes and goals for her stay at the facility to be unmet. Findings include: Review of R4's Face Sheet tab of the electronic medical record (EMR) indicated R4 was admitted to the facility on [DATE] with diagnoses including dementia in other diseases classified elsewhere, psychotic disturbance, mood disturbance, and anxiety. Review of R4's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/30/2025 and located under the MDS tab of the EMR, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R4's Care Plan, located under the Care Plan tab of the EMR and with a revision date of 5/21/2025, revealed no documented evidence that R4 had been invited to or participated in her care plan meetings. Review of the care plan revealed an initiation date of 3/26/2024 and revision dates including 12/20/2024, 3/24/2025, and 5/21/2025. During an interview on 6/9/2025 at 10:23 am, R4 indicated not knowing about any care meetings where staff from different departments, such as nursing, activities, dietary, and herself, talked about her care, plans, and goals. R4 stated she had not attended that type of meeting and indicated she had only been part of the resident council meeting. During an interview on 6/10/2025 at 3:10 pm, the Social Services (SSD) confirmed she was responsible for scheduling the care plan meetings. The SSD stated that she handed family members a letter when they came to the facility, notifying them of the care plan meeting times. She stated there was a sign-in sheet for each meeting, and the meetings were held quarterly. The SSD was asked to provide the sign-in sheets for R4's care plan meetings to show the residents' invitation and/or participation. The SSD stated she would look for them. During an interview on 6/11/2025 at 1:54 pm, the SSD was again asked to provide evidence that R4 had been invited to and/or participated in her care plan meetings. The SSD stated she was still looking for the information. No information had been provided by the end of the survey.

Based on interviews, record review, and policy review, the facility failed to ensure three of 34 sampled residents (R) (R59, R65, and R76) reviewed for residents' rights were able to exercise their right to vote in elections through absentee ballots or other authorized methods. Findings include: Review of the facility's policy titled, Exercise of Rights / Resident Rights F 550, dated 11/2024 revealed, . Our residents may exercise his or her rights as a resident of our community and as a citizen or resident of the United States . Residents will be encouraged to participate in activities of their choice, including community activities (e.g. voting, religious observances, etc.) . Transportation to community activities may be arranged through the Activity or Social Services Departments. 1. Review of R59's Profile Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed R59 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, rheumatoid arthritis, and hypertension. Review of R59's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed R59 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of a spreadsheet titled Residents That Want To Vote, collected on [DATE] by Activity Director (AD), revealed that R59 wanted to vote and had no valid identification (ID). During an interview on [DATE] at 12:26 pm, R59 stated, I wanted to vote, but no one asked me or told me how to. 2. Review of R65's Profile Face Sheet, located in the EMR under the Profile tab, revealed R65 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, metabolic encephalopathy, and memory deficit following cerebral infarction. Review of R65's quarterly MDS, with an ARD of [DATE] and located in the EMR under the MDS tab, revealed R65 was cognitively intact with a BIMS score of 14 out of 15. Review of a spreadsheet titled, Residents That Want To Vote, collected on [DATE] by the AD, revealed that R65 wanted to vote and had no valid ID, due to the ID being expired and from California (CA). During an interview on [DATE] at 12:24 pm, R65 stated, I wanted to vote, but they said I couldn't because I have a CA ID. 3. Review of R76's Profile Face Sheet, located in the EMR under the Profile tab, revealed R76 was admitted to the facility on [DATE] with diagnoses including dislocation of unspecified internal joint prosthesis, aftercare following joint replacement surgery, left hip joint osteoarthritis, and hypertension. Review of R76's quarterly MDS, with an ARD of [DATE] and located in the EMR under the MDS tab, revealed R76 was cognitively intact with a BIMS score of 15 out of 15. Review of R76's admission Inventory of Personal Effects, dated [DATE] and provided by the facility, revealed, R76 had a driver's license and social security card on his person. Review of R76's admission Recreation (Activities) admission Assessment, dated [DATE] and provided by the facility, revealed R76 was not a registered voter and was interested in voting. During an interview on [DATE] at 10:45 am, R76 stated, No one asked me [if I wanted to vote] when I got here in the beginning, and that was in [DATE]. I wanted to vote, though, because I think not voting has contributed to my depression, because they let that man in there. During an interview on [DATE] at 4:58 pm, the Social Services Director (SSD) stated, We went around to all the residents, I believe on [DATE], to ask who wanted to vote in the November election. We wrote all their names down on a list. Some residents did not have a valid Georgia (GA) ID or an ID at all. So, they can't vote. The families didn't come to take them to vote or to help the residents who needed to get an ID. We can't take residents to the Department of Motor Vehicles (DMV). Medical transport won't take them because it's not medically related. Our transport van wasn't working at the time, or needed to be registered. I don't know if the residents can use a ride-share to go vote. [R65] was on the list of wanting to vote, but she has a CA ID, not a GA one, so she can't vote. The daughter never came to help her get an ID so that she could vote. During an interview on [DATE] at 10:20 am, the SSD stated, I only address the voting if they come to me. No one came to me after we went through each resident who wanted to vote to see if they had a valid ID to vote. We had to register them by [DATE]th. When I talk to the residents about resident rights, I tell them voting is their right, but no one came to me about voting in November. If someone had come to me, then I would arrange for absentee ballot voting. During an interview on [DATE] at 12:16 pm, the Activities Director (AD) stated, On [DATE]th, I asked every resident who could talk and understand if they wanted to vote. Then I gave the list to the SSD because she is the one who asked me to go around and ask the residents. I don't know what happened after that. Asking them if they wanted to vote was the only part I was involved in. We couldn't take the residents who wanted to vote because our transportation van was getting fixed. [R76] wasn't a resident when I went around and asked everyone about voting. I didn't go back around and ask the new admissions between [DATE]th and [DATE]th if they wanted to vote because [SSD] didn't ask me to. I enter the information in the quarterly assessments. Anyone can see my assessments, but I don't think anyone pays attention to them to see if someone wants to vote. During an interview on [DATE] at 2:55 pm, the Administrator stated, There was a breakdown in communication regarding the voting. I always make sure everyone asks the resident because it is their right. I'm not sure why it happened, but there was a breakdown. We started a process where we upload all the IDs now because of the voting issue. We tried to ask all the residents the day prior to the registrations being due on [DATE], so we could arrange transport. Then the medical transport said they will only transport if medically related. We asked the county if they would come in, set up, and assist with voting, but they couldn't do that. Then we wanted to do absentee voting, and we couldn't make that happen in time.

Based on staff interviews, record review, and review of the facility's policy titled, Vaccination of Residents, Including Influenza, Pneumococcal, Respiratory Syncytial Virus (RSV), and COVID-19, Reporting of, the facility failed to offer or provide documentation of consent or refusal of vaccinations for five of five residents (R) (R7, R14, R53, R66, and R72) reviewed for vaccination consents. Findings include: Review of the facility's policy titled Vaccination of Residents, Including Influenza, Pneumococcal, RSV, and COVID-19, Reporting of last revised September 2023, revealed Guidelines, General Immunization: 3. Evaluate new residents vaccination status upon admission. 4. The resident or resident's legal representative may refuse vaccinations for any reason. 5. Residents have the right to refuse, be free of interference, coercion, discrimination, and reprisal of the community staff for refusing to take any vaccines. 6. If vaccinations are refused, the refusal shall be documented in the resident's medical record. Review of the medical record for R7 revealed the resident was admitted to the facility with diagnoses including but not limited to schizophrenia, and major depressive disorder. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim Director of Nursing (DON). Review of the medical record for R14 revealed the resident was admitted to the facility with diagnoses including but not limited to cerebral infarction and post traumatic seizures. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Review of the medical record for R53 revealed the resident was admitted to the facility with diagnoses including but not limited to dysphagia, hemiplegia and hemiparesis following cerebral infarction. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Review of the medical record for R66 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction and memory deficit. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Review of the medical record for R72 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to chronic renal failure, chronic obstructive pulmonary disease, and COVID-19. There was no indication in the record that a consent for vaccinations given or declined was signed by the resident or their representative. This omission was verified by the Interim (DON). Interview on 1/25/2024 at 4:15 pm the Interim DON confirmed the lack of consents for the five residents listed. She stated going forward she will get all requested information from the residents and offer RSV vaccines to all residents.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, F 656, F 657, F 658 Comprehensive Care Plan, the facility failed to develop and implement a care plan for activities of daily living (ADL) for one of 35 sampled residents (R) (R8). The deficient practice had the potential for decline in R8's functional abilities. Findings include: Review of the facility's policy titled F 656, F 657, F 658 Comprehensive Care Plan revised August 2022 documented under Policy: An individualized comprehensive resident centered care plan that includes measurables objectives and time frames to meet the residents medical, nursing, mental, cultural and psychological needs is developed for each resident. Procedure: 8. Each resident's comprehensive care plan is designed to: . f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. 1. Review of the electronic medical record (EMR) for R8 revealed diagnoses that included but not limited to syncope and collapse, repeated falls, presence of cardiac pacemaker, and hypertensive heart disease with heart failure. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R8 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Further review revealed R8 has no impairment with upper extremity/lower extremity and partial/moderate assistance with wheelchair, eating, toileting, shower/bathe-self. Review of the care plan revealed R8 had no care plan developed for ADLs. Observation on 1/24/2024 at 8:10 am, R8 was in bed resting. R8 was clean and odor free. R8 was asked if she received a shower. R8 stated that she could not say if she did or not. R8 stated she does not remember when she came to the facility. Interview on 1/25/2024 at 9:15 am with the Social Services Director (SSD), the SSD acknowledged that an ADL care plan was not developed for R8. She stated that she created and developed care plans for residents as well as the MDS Coordinator, who was also a participant in the care plan meetings. Interview on 1/25/2024 at 9:30 am with the MDS Coordinator, she acknowledged that R8 does not have a care plan for ADLs. She stated that she could not answer why R8 did not have a care plan for ADLs. Interview on 1/25/2024 at 2:21 pm with the Director of Nursing (DON) revealed her expectation of the SSD and the MDS Coordinator was for them to develop a base line care plan/comprehensive assessment that included ADL upon admission.

Based on staff interviews, record review, and review of the facility policy titled, F 625 Bed Hold, the facility failed to ensure a bed-hold policy upon transfer to the hospital for one of 35 sampled residents (R) (R79). Findings include: Review of the facility policy titled F 625 Bed Hold revised May 2023 indicated the following: 1. Upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office will provide information concerning our bed-hold policy. 2. When emergency transfers are necessary, the facility will provide the resident and the resident representative with information concerning our bed-hold policy per state law as applicable. R79 was admitted to the facility with diagnosis including but not limited to encounter for surgical aftercare following surgery on the digestive system, diabetes mellitus, cocaine dependence with intoxication delirium, major depressive disorder, and insomnia. Review of R79's Physician orders revealed an order of buspirone hydrochloride (HCL) 7.5 milligrams (mg), duloxetine HCL 40 mg, and apixaban 5 mg. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented R79 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. Interview on 1/25/2024 at 9:30 am with Regional Director of Clinical Services AA indicated they did not do a bed hold on resident when he went to the hospital. Interview on 1/25/2024 at 9:49 am with Social Services Director (SSD) revealed they did not do a bed hold on the resident when he went to the hospital due to the resident's behaviors. The SSD indicated they 1013'd (the purpose of this certificate (1013) is to authorize transportation to an emergency receiving facility) the resident and the police were called and the nurse who the resident touched inappropriately pressed charges against the resident. The SSD mentioned R79 was discharged to a personal care facility after leaving the hospital. The SSD indicated they did not give him 30 days' notice but would not take him back.

Based on record review, staff interview, and review of facility policies titled Care Plans last revised 11/2017 and 'Wandering-Unsafe Resident last revised 11/2017, the facility failed to follow the care plan for one of seven residents (R#1) by not checking the wander guard for proper function. On 4/22/2021, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/22/2021 at 12:41 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/10/2021 when R#1 eloped from the facility undetected through an exit door and remains missing. The Immediate Jeopardy is outlined as follows: 1. On 4/10/2021 at 11:00 p.m. R#1 was noted to be missing, who was an elopement risk, and wearing a Wander guard bracelet. Staff searched the facility inside and out but were unable to locate the resident. The police were notified and issued a Mattie's Call for the resident. The facility is uncertain how or when the resident eloped from the facility. As of 4/29/2021, R#1's whereabouts were still unknown. 2. On 1/17/2021, R#2 eloped through a window, after removing a screw that prevented the window from opening fully. Staff were able to locate the resident quickly at a nearby business and was returned to the facility, without injury. As part of the subsequent Quality Assurance (QA) interventions included: Check wander guards and windows daily, educate staff on elopement policy and procedures and drills will be completed. The facility identified seven residents at risk for elopement. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: K) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) CFR 483.70 Administration (F835 Scope and Severity: K) CFR 483.75(g)(2)(ii) Qapi/qaa Improvement Activities (F0867 Scope and Severity: K) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) On 4/27/2021 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/27/2021. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/27/2021. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). Findings include: Review of policy titled 'Wandering, Unsafe Resident' states: 4. Interventions to try to maintain safety will be included in the resident's care plan 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk for elopement or other unsafe behavior. Review or policy titled 'Care Plans-Comprehensive' last revised 11/2017 revealed: 8. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems, 15. The IDT (interdisciplinary team) will outline services in the comprehensive care plan that meet professional standards of quality or accepted standards of clinical practice. Review of electronic health record (EHR) revealed R#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview of Mental Status (BIMS) score of five out of 15 indicating severe cognitive decline and no behaviors and no wandering. The resident was assessed for transfer, walk in and out of room and corridor, locomotion on and off the unit with supervision only. The resident had no impairment of extremities. Record review for R#1 revealed an elopement assessment dated [DATE] with a score of eight indicating low risk for elopement, however, it is documented that a Wander Guard was placed on R#1 upon admission. Review of the elopement assessment dated [DATE] revealed a score of 13 indicating moderate risk for elopement. Review of care plan for R#1 dated 1/20/21 revealed that R#1 is Moderate risk for elopement and wandering based upon risk evaluation. Goal: R#1 will not have any complications through review period. Interventions included to check Wander Guard for proper functioning, Wander Guard in place to left ankle. Review of EHR Nurse's Note dated 4/10/2021 at 11:10 p.m. revealed R#1 was not in her room and could not be located in the facility. Staff searched in and around facility although the resident could not be located. An interview on 4/14/21 at 3:34 p.m. with Certified Nursing Assistant (CNA) AA revealed the last time she saw the resident on 4/10/2021 was at approximately 5:45 p.m. when picking up meal trays after dinner. CNA AA revealed that the resident was in her room in bed. An interview on 4/14/21 at 3:49 p.m. with CNA BB revealed the last time she saw the resident was at approximately 8:30 p.m. on 4/10/21 when passing out bedtime snacks. She further revealed that around 11:00 p.m. while making her last round for shift change, she did not see the resident in her room and notified the nurse. After staff searched the building, they could not locate R#1. An interview on 4/14/21 at 4:12 p.m. with Licensed Practical Nurse (LPN) CC revealed that last time she saw R#1 was at approximately 8:20 p.m. on 4/10/21. She further revealed that at approximately 8:30 p.m. the resident came to the nursing station wanting a snack. LPN CC revealed that on 4/10/2021 at 10:30 p.m. she was assisting CNAs with rounds and at 10:45 p.m. R#1 was not in her room. She further revealed that staff checked the bathroom, and she was not there. LPN CC revealed that no alarms had gone off and she then notified management, and 911 was called at approximately 11:05 p.m. An interview on 4/15/21 at 8:11 a.m. with Registered Nurse (RN) DD revealed that R#1 came to the nursing station around 8:30 p.m. asking for snacks, juice and some ice then returned to her room. RN DD further revealed that she was taking care of other residents and did not realize that R#1 was missing. She further revealed she left her shift early and LPN CC took over her assignment. RN DD confirmed that the resident's Wander Guard was on her left ankle. RN DD stated that LPN CC called her later, on her cell phone, to say that R#1 was missing. An interview on 4/19/21 at 1:43 p.m. with LPN GG revealed that the Wander Guard bracelets is checked for placement when arriving at work and departing from work. Further states that the maintenance department is responsible for checking functioning of the Wander Guards. An interview on 4/19/21 at 1:47 p.m. with LPN HH revealed that nurses check for proper placement of the Wander Guards but that the Maintenance Department is responsible for checking the functioning of the device. An interview on 4/19/21 at 1:51 p.m. with LPN II revealed the Wander Guard bracelet is visibly checked at the start of her shift and at the end of her shift but that the Maintenance Department is responsible for checking the functioning of the device. An interview on 4/19/21 at 2:04 p.m. with Director of Nursing (DON) revealed that the Maintenance Department was responsible for checking the functioning of the Wander Guards and that the nursing staff was only responsible for making sure that the bracelet was attached to the resident and not damaged. An interview on 4/19/21 at 2:07 p.m. with Maintenance Assistant revealed that the Maintenance Department is responsible to ensure the alarms on the doors are functioning properly to alert staff if a resident with a Wander Guard bracelet is attempting to exit. The Maintenance Assistant revealed that the nursing staff are responsible to ensure the Wander Guard bracelet are functioning. An interview on 4/19/21 at 2:11 p.m. with the Administrator revealed that the Maintenance Department is responsible for checking the functioning of the Wander Guard bracelet. An interview on 4/19/21 at 2:17 p.m. with the Maintenance Director revealed the Maintenance Department was only responsible to check the doors for proper function and does not check to ensure the device on the resident is working. He further revealed that the nursing staff are responsible to make sure the device is functioning properly. An interview on 4/19/21 at 2:49 p.m. with the Administrator and DON confirms there is no evidence that staff have been checking the functioning of the Wander Guard bracelets for proper functioning, per the care plan. Further interview revealed that they are not sure if R#1's Wander Guard bracelet was functioning prior to her elopement on 4/10/2021. Cross refer to F689 The facility implemented the following actions to remove the Immediate Jeopardy: Resident R#1 was admitted to Arrowhead Health and Rehab on 11/02/2020. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#1 is [AGE] years old with a birthdate of 12/05/1962. Resident R#1 exited the facility on 04/10/2021. It is unknown how she left the building or if she was still wearing her Wander Guard Bracelet. Prior to previous admissions to [NAME] Hospital, resident R#1 resided at the Red Shield Homeless Shelter and was indigent. This resident is alert and oriented and is ambulatory without any assistive devices. She is independent with her Activities of Daily Living and she makes independent decisions. Resident R#1 scored a 5 on her BIMs assessment on 03/23/2021 on a quarterly MDS. 1. The Wander Guard bracelets for five current residents wearing Wander Guards were checked for proper function on 4/19/2021 by the Director of Nursing using a Roam Alert Pocket Tag Reader. The Tag Reader was held a minimum of 12 inches away from each Wander Guard bracelet or placed adjacent to the bracelet and the reader detected the signal indicating the bracelet was functioning properly. The results of the checks were documented in the Wander Guard Function Binder Tool by the DON. 2. The care plans of five residents triggering for moderate or high elopement risk were. reviewed on 4/11/2021 by the Interdisciplinary Care Plan Team. One additional resident received a Wander Guard bracelet on 04/13/2021 based on this review. 3. New Wandering I Elopement assessments were completed for 74 in-house residents of the facility on 04/22/2021 by the ADON, 2 LPN Unit Managers, Staff Development Coordinator, and the Restorative Nurse. One additional resident was assessed as a moderate elopement risk. This resident's care plan was updated, and a Wander Guard bracelet was tested for proper function, applied to this resident, and updated in the Wander Guard Function binder by the DON. New admissions will be assessed for wandering and elopement and care plans will be developed at that time. 4. From 04/22/2021 to 04/25/2021, employees were educated on the following topics: a. Wander Guard Tag Testing, Placement and Function Policies and Procedures. Employees educated were: 1 of 1 Activity Director, 1 of 1 Administrator, 1 of 1 Admissions Staff, 1 of 1 Clinical Reimbursement Coordinator, 9 of 9 Dietary Staff, 7 of 8 Housekeepers, 1of 1DON, 1of 1 Marketing Director, 1of 1 Medical Records Staff, 36 of 37 CNAs, 24 of 24 LPNs, 6 of 6 RNs, 2 of 2 Plant Ops Staff, 6 of 7 Rehab Staff and 1of 1 Social Service Director. b. Recognizing and Reporting Exit-Seeking Behavior so Assessments can be Completed and Care Plans Updated, as Necessary. Employees educated were: 1 of 1 Activity Director, 1 of 1 Administrator, 1 of 1 Admissions Staff, 1 of 1 Clinical Reimbursement Coordinator, 8 of 9 Dietary Staff, 1 of 1 DON, 7 of 8 Housekeepers, 1 of 1 Marketing Director, 1 of 1 Medical Records Staff, 35 of 37 CNAs, 24 of 24 LPNs, 6 of 6 RNs, 2 of 2 Plant Ops Staff, 7 of 7 Rehab Staff and 1 of 1 Social Service Director. c. Wander Guard Device Check Policies & Procedures. Employees educated were: 1of 1 Activity Director, 1 of 1 Administrator, 1of 1 Admissions Staff, 1 of 1 Clinical Reimbursement Coordinator, 9 of 9 Dietary Staff, 6 of 7 Housekeepers, 1 of 1 Marketing Director, 1of 1 Medical Records Staff, 35 of 37 CNAs, 24 of 24 LPNs, 6 of 6 RNs, 2 of 2 Plant Ops Staff, 7 of 7 Rehab Staff and 1 of 1 Social Service Director. d. Wander Guard Tag Testing for Proper Functioning. Nursing Staff Only. Employees educated were: 37 of 37 CNAs, 24 of 24 LPNs and 6 of 6 RNs. 5. The Interdisciplinary Care Plan Team will review and update care plans for elopement and wandering risk monthly for three months then quarterly thereafter. Documentation of these updates will be tracked using our Care Plan Audit tool. 6. Results of the care plan reviews and updates will be reviewed during monthly QAPI meetings using the QAPI Agenda form tool with notes. Modifications to this system will be made and implemented, as necessary. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Review of the Wander Guard Functioning tool revealed that R#3, R#4, R#5, R#6, R#7 and R#8 had their Wander Guard bracelets checked daily (4/19/2021 through 4/27/2021) for function, utilizing the Pocket Tag Reader, which is signed by the DON. Observation on 4/19/2021 at 2:50 p.m. with the DON checking the Wander Guard bracelets, using Name Alert Pocket Tag Reader five residents with a Wander Guard bracelet to ensure functioning. The results were entered into the Wander Guard Function Binder Tool. 2. Review of the Care Plans for R#3, R#4, R#5, R#6, R#7 and R#8 revealed updates on 4/22/2021 to include: Wandering risk: Interventions to check for function daily, monitor placement of Wander Guard every shift, wandering/elopement risk assessment Quarterly and PRN (as needed). R#8 was identified as a new wandering risk with a Wander Guard added for safety on 4/22/2021. 3. Review of the facility Census list dated 4/22/2021 revealed that all residents, in house (74) had a been assessed for wandering/elopement and documented on the Wandering and Elopement Evaluation form. R#8 was identified as a wandering/elopement risk with a Wander Guard placement, updated care plan, and was added to the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Review of the In-service sign-in sheets between 4/22/2021 and 4/26/2021 for the following training revealed: Wander Guard Tag Testing, Placement and Function Policies and Procedures. Recognizing and Reporting Exit-Seeking behavior-which will prompt a new Assessment and care plans to be updated as necessary. Wander Guard Device Check Policies and Procedures. Wander Guard Tag Testing for Proper Functioning-Nursing Staff only. Review of the sign-in sheets for the education listed above dated 4/22/2021 through 4/23/2021 revealed that 1 Activity Director, 1 Administrator, 1 Admission staff, 1 Clinical Reimbursement Coordinator, 9 Dietary Staff, 7 Housekeeping staff, 1 Medical Records staff, 36 CNAs, 24 LPNs, 6 RNs, 2 Maintenance (Plant operations), 6 Therapy staff, 1 Social Services Director, 1 DON and 1 Administrator had received education. 5. Review of the IDT care plan audit completed 4/22/2021 revealed that Wandering/Elopement assessment were completed, and care plans were updated for seven residents (R#3, R#4, R#5, R#6, R#7 and R#8) with R#8 being identified as a new wandering/elopement risk. An interview on 4/28/2021 at 10:05 a.m. with the Administrator and the DON revealed that new Wandering/Elopement Assessment were completed for all residents (74) on 4/22/2021 which identified seven residents at risk. The resident's care plans were updated on 4/22/2021. All residents will have a Wandering/Elopement risk assessment completed Quarterly, and as needed, thereafter. New admissions will have an assessment completed and care plans developed to reflect the findings. The results will be tracked utilizing the Care Plan Audit Tool. 6. Review of the QAPI Agenda Form dated 4/19/2021 and 4/22/2021 outline that Care Plan Audit Tool to be reviewed at monthly meetings to ensure that IJ Removal Plan is being followed. In attendance, per sign-in sheets, were the Administrator, DON, Medical Director, ADON, Maintenance Director and Social Services Director. Interviews with the following LPNs revealed they were educated on the revised Wandering/Elopement Policy and Procedure, Responsibilities in checking placement and that the DON or ADON will check the function of the Wander Guard bracelets daily, Wandering/Elopement Assessments to be conducted Quarterly and more often if needed, care plans must be updated to match the resident's risk, ensuring all documentation is completed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .m An interview with the Social Services Director on 4/28/2021 at 11:10 a.m., Registered Nurse (RN) the ADON on 4/28/2021 at 10:49 a.m., the DON at 10:59 a.m. explained the education that they had received concerning their role on elopement, care planning, checking the function of the Wander Guards, notifying the nurse of wandering behavior and completing and documenting Wandering/Elopement assessments.

Based on observation, interviews, record review, staff interviews, and review of facility policies 'Wandering, Unsafe Resident', ' Routine Resident Checks, Use of Wanderguard System', and 'Routine Resident Checks', the facility failed to provide supervision and monitoring to prevent the elopement of two (2) residents (R) from a sample of seven (7) residents identified by the facility for being at risk for elopement (R#1 and R#2). Facility failed to ensure the wander-guard tag was functioning properly. R#1 eloped from the facility and has not been located. R#2 eloped from the facility and was located approximately two blocks from the facility. On 4/22/2021, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/22/2021 at 12:41 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/10/2021 when R#1 eloped from the facility undetected through an exit door and remains missing. The Immediate Jeopardy is outlined as follows: 1. On 4/10/2021 at 11:00 p.m. R#1 was noted to be missing, who was an elopement risk, and wearing a Wander guard bracelet. Staff searched the facility inside and out but were unable to locate the resident. The police were notified and issued a [NAME]'s Call for the resident. The facility is uncertain how or when the resident eloped from the facility. As of 4/29/2021, R#1's whereabouts were still unknown. 2. On 1/17/2021, R#2 eloped through a window, after removing a screw that prevented the window from opening fully. Staff were able to locate the resident quickly at a nearby business and was returned to the facility, without injury. As part of the subsequent Quality Assurance (QA) interventions included: Check wander guards and windows daily, educate staff on elopement policy and procedures and drills will be completed. The facility identified seven residents at risk for elopement. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: K) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) CFR 483.70 Administration (F835 Scope and Severity: K) CFR 483.75(g)(2)(ii) Qapi/qaa Improvement Activities (F0867 Scope and Severity: K) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) On 4/27/2021 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/27/2021. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/27/2021. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). Findings include: Review of policy titled Routine resident checks, use of Wander Guard system last revised 07/2020 states: Policy Statement: Staff shall make routine resident checks of those using a Wander Guard to help maintain resident safety and well-being; Policy interpretation and implementation: 1. Refer to policy, 'Routine Resident Checks' 2. Utilize the wander-guard per manufacturer guidelines; Procedure: 3. Test and replace per manufacturer guidelines. Review of policy titled Wandering, unsafe resident last revised 11/2017 revealed: Policy Statement- The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Wandering-random or repetitive locomotion. This movement may be goal directed (e.g. appears to be searching for an exit) or non-goal directed or aimless. Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) during the evaluation completed upon admission, quarterly, and as needed. 2. The staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. Interventions to try to maintain safety will be included in the resident's care plan. 5. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. 7. 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. 1. Review of electronic health record (EHR) revealed R#1 was admitted to the facility on [DATE] with diagnoses including but not limited to [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and hypertension. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview of Mental Status (BIMS) score of five out of 15 indicating severe cognitive decline and no behaviors and no wandering. The resident was assessed for transfer, walk in and out of room and corridor, locomotion on and off the unit with supervision only. The resident had no impairment of extremities. Record review for R#1 revealed an elopement assessment dated [DATE] with a score of eight indicating low risk for elopement, however, it is documented that a wander-guard was placed on R#1 upon admission. An elopement assessment dated [DATE] revealed a score of 13 indicating moderate risk for elopement. Review of care plan for R#1 dated 1/20/21 revealed that R#1 is Moderate risk for elopement and wandering based upon risk evaluation. Goal: R#1 will not have any complications through review period. Interventions included to check Wander Guard for proper functioning, Wander Guard in place to left ankle. Resident is assessed for refusing medications, showers, meals and care. Review of the resident's Admission Record dated 11/20/2020 revealed the resident had an appointed State Guardian as the Responsible Party (RP). Review of Nursing progress notes dated 11/2/2020 revealed that R#1 was admitted to the facility from another Long-Term Care Facility. The resident is alert with confusion, ambulates without difficulty and has a history of delusions. The resident stated that I need to leave and go to Georgia Tech to apply for school to be a lawyer. Review of the Psychiatric Diagnosis Evaluation dated 11/12/2020 revealed the resident (R#1) presents with delusions, flight of ideas-wants to find her own place and live alone. The resident states she has belongings at a shelter and wants someone from the White House to come visit her. Resident's current medications: [MEDICATION(S)] ER 250 milligrams (mg) daily, [MEDICATION(S)] 5 mg at bedtime, and [MEDICATION(S)] 1 milliliter every 30 days. Continue to monitor mood and behavior. Follow up in 1-3 months. Review of the Psychiatric Diagnosis Evaluation dated 12/10/2020 revealed the resident is seen today for follow up for increased delusions/paranoia. Current medications: [MEDICATION(S)] ER 250 mg at bedtime, [MEDICATION(S)] 4 mg tablet, [MEDICATION(S)] 5 mg at bedtime and [MEDICATION(S)] 100 mg intramuscular (IM) every 30 days. Summary: Resident states I want to go home, I have an interview (sic). Recommendations: Increase [MEDICATION(S)] to 10 mg by mouth at bedtime, [MEDICATION(S)] 0.5 mg by mouth every morning and continue [MEDICATION(S)] 4 mg at bedtime. Closely monitor for side effects. Continue to monitor mood and behaviors. Review of the Interdisciplinary Team (IDT) notes in the EMR dated 1/21/2021 at 12:05 p.m. revealed R#1 will continue to be on wandering precautions. R#1 is ambulatory with dementia and unspecified [CONDITION(S)]. Resident thinks she always have a place to go and at times says she needs to leave. Plan: Will continue to monitor functioning and placement of wanderguard (sic) as needed. Review of the Communication to the RP note dated 2/2/2021 revealed that the resident has a new Guardian appointed to her. Review of the Social Services note dated 3/29/2021 revealed assessment completed on 3/23/2021, resident is alert with confusion, she continues to state that she works for the Federal Bureau of Investigation (FBI) and a doughnut manufacture. Resident continues to write grievances 6-7 pages that do not make sense (delusional thinking). Resident is planning to get her own apartment that guardian will help with placement. Resident often refuses showers and medications; she is followed by psych services. Review of a nursing progress note, Late entry, dated 4/10/2021 at 17:57 (5:57 p.m.) revealed during medication administration observed resident in room, sitting on bed, vital signs taken including pulse oximetry, no complaints of pain or discomfort voiced. Review of a nursing progress note dated 4/10/2021 at 20:05 (8:05 p.m.) revealed resident observed walking toward Nurses Station with multi-layers of clothing, bilateral pants leg cuffed position with left ankle Wander Guard bracelet visible. Resident stated, Can I have a cup of juice with ice and some graham crackers?. Nurse provided snacks, resident stated, Thank you and walked back to her room. Review of Nursing progress notes, late entry, dated 4/10/2021 at 23:10 (11:10 p.m.) revealed that during last rounds, writer did not see the resident in the room, staff was notified and an immediate search, by all staff, was conducted. Management was notified, police called, and guardian notified via voicemail. Guardian returned call, known information was provided to her. Review of the police report dated 4/10/2021 at 2340 (12:40 p.m.) narrative report: On 4/10/2021 at 2344 hrs (hours), I was dispatched to the facility (address) in regards (sic) to a missing person. Upon my arrival, I made contact with the complainant. I was advised the resident (name) was last seen when she came to the Nurse's Station asking for a snack at roughly 2030 hrs. A search of the rooms and the surrounding area was conducted. Officers furthered the search to the surrounding areas, with no luck finding the resident (name). The complainant advised the resident was last seen wearing a red wool jacket and green hat. A description of the resident was given. The resident walks with a bow to her left leg and has a partial amputation of the left hand, possibly her ring finger. The complainant advised that the resident is diagnosed with [CONDITION(S)], hypertension and [CONDITION(S)]. The resident is on medications for her mental illness but does not take it due to refusal. A copy of the report was sent to the Georgia Criminal Investigation Center (GCIC) to have the resident listed as missing and a [NAME]'s Call was made for the resident. Nothing further at this time. Review of the Timeline for Elopement of R#1 from the Administrator revealed the following: 1. 8:30 p.m. resident at Nurses Station asking Registered Nurse (RN) DD for snacks. Resident was observed at this time with a red hoodie, sweatpants and layers of clothing. 2. 11:00 p.m., Certified Nursing Assistant (CNA) BB went to R#1's room to offer more snacks but could not find the resident. Licensed Practical Nurse (LPN) CC and LPN TTT were notified. 3. 11:00 p.m., Charge Nurses and staff went to rooms and known areas that resident likes to sit (lobby, dining room, etc.) 4. 11:15 p.m., Code Amber (missing person) was initiated, and the search started. 5. 11:30 p.m., staff went to search in their cars to the nearby stores, gas stations, shopping areas (to include specific stores that the resident spoke about) 6. 11:39 p.m., The Administrator was notified and directed staff to call the police immediately. 7. 11:45 p.m., The police, RP and the Medical Director were notified. 4/11/2021 8. 12:15 a.m., The Assistant Director of Nursing (ADON) began education of staff. 9. 12:20 p.m., Staff went to nearby Homeless shelters. 10. 12:30 p.m., Maintenance checked doors, Wander Guards and windows and assisted in the search. 11. 1:30 a.m., The Administrator, Director of Nursing (DON) and ADON searched the last known address and bus stations in Atlanta area. 12. 4:15 a.m., The Administrator notified management to come to the facility to assist with search. 13. 4:55 p.m., Social Services assisted with search; she went to places the resident had identified that she owns throughout Atlanta. 14. 8:00 a.m., Administrator, DON and ADON visited downtown and other homeless shelters, and Bus Stations. 15. 11:00 a.m. through 3:00 p.m. Management staff contacted the [NAME] County Police and all area hospitals. 16. 3:24 p.m., The DON contacted the Level I trauma hospital emergency room and was informed the resident had been admitted but was unable to give any additional information due to confidential file code. The State Survey Agency was notified on 4/11/2021 timely which included steps to be taken to prevent further incidents. Windows and doors secured, door codes changed and made sure all Wander Guards were working. As a result of Maintenance conducting daily door checks, it was determined that one door was not functioning properly on 4/14/2021. The Safety and Security Company was notified and arrived to evaluate the door. Record review revealed that the Administrator had posted someone at the door to ensure that there was no further elopement once the non-functioning door was identified. Review of the Administrator's documentation, the door closer was replaced, by the Maintenance Department, on 4/18/2021 at 1:00 p.m. Review of the door checks and sign off sheets by staff, revealed that staff signed off every 15 minutes beginning on 4/14/2021 at 1:30 p.m. through 4/18/2021 at 1:15 a.m. Review of a Field Service Order Report (Safety and Security Company) dated 4/14/2021 revealed that customer reporting right-wing Mag-Lock inoperative. Troubleshooting revealed right wing exit door Maglock is operational. Door closure (exterior) has failed and needs to be replaced. Personnel MUST pull door closed. Two doors in left wing tested : satisfactory, recommend upgrading locks from 600 FP to 1200 FP (at 12 VDC). Review of a Field Service Order Report (Safety and Security Company) dated 4/16/2021 revealed that three Maglocks were replaced and tested . Review of the Wander Guard manufacturer recommendations revealed that monthly testing and maintenance of the product is essential to verify the system is operation correctly and to ensure that the probability to detecting an alarm and/or locating the transmitter are maximized. An interview on 4/14/21 at 3:34 p.m. with CNA AA revealed that she was working on 4/10/2021 and that she last saw the R#1 was at approximately 5:45 p.m., in her room in bed, when picking up meal trays after dinner. An interview on 4/14/21 at 3:49 p.m. with CNA BB revealed the last time she saw R#1, on 4/10/2021, was at approximately 8:30 p.m. when passing out bedtime snacks. CNA BB further revealed that when making her last rounds for the shift, at around 11:00 p.m., she did not see the resident in her room and reported it to the nurses during their walking report. She revealed that staff then began searching the building and could not locate the resident. An interview on 4/14/21 at 4:12 p.m. with Licensed Practical Nurse (LPN) CC revealed that last time she saw R#1 was at approximately 8:20 p.m. on 4/10/21. She further revealed that at approximately 8:30 p.m. the resident came to the nursing station wanting a snack. LPN CC revealed that on 4/10/2021 at 10:30 p.m. she was assisting CNAs with rounds and at 10:45 p.m. R#1 was not in her room. She further revealed that staff checked the bathroom, and she was not there. LPN CC revealed that no alarms had gone off and she then notified management, and 911 was called at approximately 11:05 p.m. A telephone interview with the Guardian on 4/14/2021 at 2:49 p.m. revealed that the Guardian program had been notified on 4/10/2021 that the resident was missing. He revealed that the hospital would not give his program any information on the resident. An interview on 4/15/21 at 8:11 a.m. with Registered Nurse (RN) DD revealed that the resident came to the Nurse's Station around 8:30 p.m. asking for snacks, juice and some ice then returned to her room. RN DD further revealed that she was taking care of other residents and did not realize that R#1 was missing. She further revealed she left her shift early and LPN CC took over her assignment. RN DD confirmed that the resident's Wander Guard was on her left ankle. RN DD stated that LPN CC called her later, on her cell phone, to say that R#1 was missing. An interview on 4/15/21 at 8:29 a.m. with the DON revealed that LPN CC sent her a text at 11:32 p.m. on 4/10/21 and informed her that R#1 was missing, followed by a phone call. The DON had asked how long the resident had been missing with LPN CC informing her that some staff were outside searching for the resident. The DON instructed LPN CC to check closets, bathroom, freezer and call the police and that she was on the way to the facility. The DON was informed that the roommate of R#1's was asleep. The DON further revealed that upon her arrival at the facility then police were onsite. The DON supplied a description of the resident and a photograph. The DON revealed that the resident was not located after searches of the surrounding area, local hospitals, and shelters. An interview with the Administrator on 4/15/21 at 10:46 a.m. revealed she was notified on 4/10/2021 at approximately 11:30 p.m. that R#1 was missing and immediately came to the facility. The Administrator revealed that the police were onsite when she arrived at the facility. The Administrator revealed that the facility and the guardian were having difficulty getting information on R#1 from the Level 1 trauma hospital which had told the DON on 4/11/2021 that the resident had been admitted . The State Survey Agency contacted the Level 1 trauma hospital and was informed the resident was not and had not been at the hospital since 11/2020. This information was shared with the Administrator. An interview on 4/19/21 at 1:43 p.m. with LPN GG revealed that the Wander Guard bracelet is checked for placement when arriving at work and departing from work. She further revealed that the maintenance department is responsible for checking functioning. An interview on 4/19/21 at 1:47 p.m. with LPN HH revealed the Wander Guard bracelet is visibly checked every shift for proper placement and the Maintenance Department is responsible for checking the functioning of the device. An interview on 4/19/21 at 1:51 p.m. with LPN II revealed the Wander Guard bracelet is visibly checked at the start of her shift and at the end of her shift. She further revealed that the Maintenance Department is responsible for checking the functioning of the device. An interview on 4/19/21 at 2:04 p.m. with Director of Nursing revealed the Maintenance Department was responsible for checking the functioning of the Wander Guard. She further revealed that the nursing staff was only responsible for making sure that the bracelet was attached to the resident and not damaged. An interview on 4/19/21 at 2:07 p.m. with Maintenance Assistant revealed that the Maintenance Department is responsible to ensure the alarms on the doors are functioning properly to alert staff if a resident with a Wander Guard bracelet is attempting to exit. He further revealed that the nursing staff are responsible to ensure the Wander Guard bracelet are functioning. An interview on 4/19/21 at 2:11 p.m. with the Administrator revealed the Maintenance Department is responsible for checking the functioning of the Wander Guard bracelet. An interview on 4/19/21 at 2:17 p.m. with Maintenance Director revealed the Maintenance Department was only responsible to check the doors for proper function. He further revealed that he does not check to ensure the device on the residents are working and that the nursing staff are responsible to make sure the device is functioning properly. An interview on 4/19/21 at 2:49 p.m. with the Administrator and Director of Nursing confirms there is no evidence that staff have been checking the functioning of the Wander Guard bracelets for proper functioning. They further revealed they are not sure if R#1's bracelet was functioning prior to her elopement. On 4/20/2021 at 10:00 a.m. a voicemail was left for the [NAME] County Police investigator to return a call to the surveyor. The investigator did not return the call. An interview with the Administrator on 4/24/2020 at 3:00 p.m. revealed that the police would not return her calls regarding the resident. An investigator came to the facility and reported that there were no new updates. He further stated that the police felt the resident had returned to her former life and they would not be able to locate her. 2. Record review revealed that R#2 was admitted to the facility on [DATE] with the following diagnoses: diffuse traumatic brain injury, dysphagia, [CONDITION(S)] disease, lack of coordination, seizures, [CONDITION(S)], and [CONDITION(S)]. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was not interviewed for a BIMS assessment due to rarely/never understood. Was independent for ambulation. Review of the resident's care plan revealed he was at high risk for elopement/wandering based upon risk evaluation. Interventions included: resident is looking or trying to go somewhere, intervene as appropriate. Provide structural activities: reorientation strategies, Wander Guard in place. Review of the facility incident summary revealed the resident eloped through his bedroom window on 1/17/2021 at around 4:00 p.m. The resident's window had a screw in place to prevent the window from opening fully which he was able to remove. The resident was found about 4:24 p.m. at a pharmacy about two blocks from the facility. A complete assessment was done with no injuries noted. The resident was found before the police were called. The resident revealed to the staff that it looked good outside and he wanted a soft drink. When asked why he went out the window, the resident replied that it looked good, and I wanted to go out for a while. Maintenance came in immediately to repair the window that had a security screw in place but had been removed. The window was secured, other windows were checked, and the resident was placed on every 15-minute checks for 24 hours. Current Wander Guards will be checked daily, and windows and Wander Guard system will be checked daily. Staff was re-educated on Elopement policy and procedures and drills were completed. The resident was seen by the Psychiatric services on 1/21/2021. An Ad-Hoc QAPI meeting was held. Review of the QAPI minutes dated 1/19/2021 revealed the Aim: no further attempts to elope, Measure: We will assess all wanders or elopement risk residents, Change: Educate all staff, walking rounds by nurses, moved closer to Nurses Station, Why: wanted to go outside, wanted to smoke, pandemic precaution has not smoked since 12/29/2020, all windows have been checked and will be checked daily. The resident was discharged to another facility on 3/24/2021. The facility failed to ensure that Wander Guards were checked for proper function rather than placement only which put all Wander Guard residents at risk of elopement. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On April 10, 2021at 8:30 pm, resident R#1 was at the desk asking the nurse for crackers. The nurse MW, RN, gave the resident a package of crackers. The nurse observed the resident R#1 had on a red hoodie, sweatpants, and layers of clothing. 2. At 11:00 pm, CNA DW went into room to offer more snacks and to check on resident R#1. She reports that she did not see the resident. She notified charge nurse PT, LPN and GH, LPN. 3. At 11:00 p.m., the charge nurses and staff went to rooms and known areas that resident R#1 liked to sit (lobby, dining room, etc). 4. At 11:15 pm Code Amber was initiated, and the search started. 5. At 11:30 pm, staff drove to nearby stores, gas stations and shopping areas to try to locate resident R#1. 6. At 11:39 pm, the Administrator received a call from the Director of Nursing. Administrator told the Director of Nursing to have the charge nurse called the police immediately. 7. At 11:45 pm, [NAME] County Police were notified and arrived at 11:55pm. They searched the immediate area and were unable to locate R#1. An officer stated that an Amber Alert would get sent out on 04/11/2021. R#1 is a Ward of the State and has a State Appointed Guardian. The Guardian was called, a message was left, and the Medical Director was notified. 8. On 04/11/2021at 12:00 am, the Administrator notified our Regional VP and our corporate reporting group. 9. At 12:15 am, the Assistant Director of Nursing began staff education on our Elopement Policies and Procedures. 10. At 12:20 am, an LPN and a CNA went to nearby Homeless shelters to search for R#1. 11. At 12:30 am, Maintenance staff checked the doors, wander guard system and windows and assisted with search. 12. At 1:30 am, the Administrator, Director and Assistant Director of Nursing searched R#1's last known address, The Red Shield Homeless Shelter, and bus stations in the Atlanta area. 13. At 4:15 am, the Administrator notified Department Managers to come into the facility to regroup and to provide updates. 14. At 4:55 am, Social Services staff assisted with the search. R#1 had previously told staff that she owns a Donut store in the Mid-town area. 15. At 6:00 am, the Administrator went to the gas station nearest to the facility. The gas station staff said they had not seen R#1 and could only release camera footage to the police. 16. At 7:00 am, the Activities Director and Business Office Manager arrived at the facility to assist with the search. 17. At 8:00 am, the DON, ADON and Social Services went back downtown to known shelters. Red Shield would not release any information. Atlanta Mission did not have her. My Sister Mission did not have her. East Point areas were searched. The Grey Hound bus station was also included in the search along with known areas of downtown where homeless people reside. 18. At 10:00 am, the Administrator and Activities Director went to the [NAME] Bus station in College Park to provide a missing person flyer to the [NAME] Police. The officer said he was sending it throughout their system. Area business were also searched. 19. Between 11:00 am and 3:00 pm, the Administrator, DON, ADON and Social Services made calls to the [NAME] County Police as well as hospitals including [NAME] Midtown, Atlanta Medical Center (main and south campus), Southern Regional and [NAME]. 20. At 3:24 pm, the DON called [NAME] Hospital. A staff member at [NAME] informed the DON, ADON and the Administrator that R#1 was admitted to [NAME] but due to confidential files they could not release any information. 21. On 04/11/2021, an Ad Hoc QAPI meeting was conducted to discuss our elopement policies and to try to determine how this resident eloped. A 5 Whys assessment was inconclusive. We believed resident R#1 was at [NAME] Hospital and we planned to ask her how she got out of the building. The facility has a camera at the front door and at the employee time clock but neither have the ability to record or playback. Meeting attendees were the Medical Director, Administrator, Director of Nursing, Assistant DON, Maintenance Director, and the Social Services Director. 22. On April 11, 2021, the elopement books were reviewed by the Social Services Director to be sure they contained the face sheets and pictures of residents who have been assessed as being a potential elopement risk. 23. On 04/12/2021 at 9:00 am, the Administrator called [NAME] County Police to let them know we were told that R#1 was at [NAME] Hospital. 24. At 10:00 am, our Social Worker spoke with the State Appointed Guardian for R#1. The Guardian was told that R#1 was at [NAME] Hospital under an [NAME]. The Guardian said that her supervisor was also given that information by [NAME]. 25. 0n 04/13/2021 at 9:30am, A Detective W, from [NAME] County Police, came to Arrowhead and informed the Administrator that he was assigned this case and he would give it to an investigator. Detective W said he would not take the [NAME] alert down until the investigator actually sees R#1 at [NAME]. He stated he would let the Administrator know in a few days if this was still in effect. He also said the police report would be ready this week. There has been no follow-up with us from the [NAME] County Police Department. 26. On 04/14/2021 at 10:00 am, the Administrator called the [NAME] County non- emergency number to find out who the investigator is for this case. We are receiving no feedback from the [NAME] County Police Department. 27. At 10:45 am, the Administrator spoke with the [NAME] County operator and left message to have Detective W please return the call. 28. We continued to believe that R#1 was at [NAME] Hospital. 29. On 04/14/2021 at 12:00 pm, a state surveyor arrived at the facility. We told her about all of the search efforts that had been made up to that point. We told her we were having difficulty getting information from [NAME] Hospital. 30. From 04/14/2021 at 1:30 pm until 04/18/2021 at 1:45am, on duty nursing staff were making Q (every) 15 minute checks to be sure exterior doors were closed and locked. We found 3 doors that closed slowly. We called a vendor on 04/14/2021 to assess these doors. 31. On 04/14/2021, the door vendor assessed the doors and ordered the required parts. 32. On 04/15/2021 at 2:00 pm, the Administrator was informed by the Regional Director at the State Survey Agency that R#1 had not been at [NAME] Hospital. This information was reported to our Regional VP. 33. At 2:30 pm, the Administrator called [NAME] County Police and left another message with the Operator regarding the new information and asked for Detective W to return the call. 34. At 2:40 pm, the Administrator called the State Appointed Guardian of R#1 and informed her that we were told resident R#1 had not been at [NAME] Hospital. The Guardian requested and was sent another face sheet with the picture of R#1 because she had only recently been appointed as this resident's Guardian and had not yet met this resident. I was provided with the Guardian's supervisor's name and phone number. 35. At 3:00 pm, the Administrator called the [NAME] County Police and asked for the investigator who was assigned to this case. Officer B told me they will have the investigator call me. I asked for the investigator's name and was told they had no way to find that out so I again left a message for Detective W to call me so I could find out the investigator's name. 36. At 3:15 pm, the Administrator called the State Guardian Supervisor to see if she could assist in any way to find out who the investigator is or if there was anyone who could get information from the shelters as we were not given information there either. The Guardian Supervisor said she had also just found out that R#1 was not at [NAME] and that she had contacted her legal department again to try to get some information. She said she had spoken to the same people at [NAME] that we had. [TRUNCATED]

Based on record review, staff interview and review of the 'Administrator Job Description', and 'Position Description Director of Nursing', and review of 'Quality Assurance Performance Improvement (QAPI)' meeting held on 1/19/2021, the facility failed to be administered in a manner to ensure there was an effective elopement prevention program that consistently monitored residents at risk for elopement and determine the root cause of resident elopements, and failed to ensure that all staff were knowledgeable regarding how to check the wander guard bracelet for proper functioning, and prevent resident elopement. On 4/22/2021, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/22/2021 at 12:41 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/10/2021 when R#1 eloped from the facility undetected through an exit door and remains missing. The Immediate Jeopardy is outlined as follows: 1. On 4/10/2021 at 11:00 p.m. R#1 was noted to be missing, who was an elopement risk, and wearing a Wander guard bracelet. Staff searched the facility inside and out but were unable to locate the resident. The police were notified and issued a Mattie's Call for the resident. The facility is uncertain how or when the resident eloped from the facility. As of 4/29/2021, R#1's whereabouts were still unknown. 2. On 1/17/2021, R#2 eloped through a window, after removing a screw that prevented the window from opening fully. Staff were able to locate the resident quickly at a nearby business and was returned to the facility, without injury. As part of the subsequent Quality Assurance (QA) interventions included: Check wander guards and windows daily, educate staff on elopement policy and procedures and drills will be completed. The facility identified seven residents at risk for elopement. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: K) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) CFR 483.70 Administration (F835 Scope and Severity: K) CFR 483.75(g)(2)(ii) Qapi/qaa Improvement Activities (F0867 Scope and Severity: K) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) On 4/27/2021 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/27/2021. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/27/2021. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). Findings include: Review of document titled 'Administrator Job Description' revealed 'Purpose of your job position: The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times.' Review of document titled 'Position Description Director of Nursing' revealed 'Basic Function: Administrative authority regarding the operation of the Community. Coordinates all departments relating to nursing. Accountable for all functions, activities, training, and education of all nursing employees. Shares responsibility with Medical Director for execution of resident care policies, federal and state regulations. Exercise's initiative and independent judgement. Review of electronic health record (EHR) revealed R#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview of Mental Status (BIMS) score of five out of 15 indicating severe cognitive decline and no behaviors and no wandering. The resident was assessed for transfer, walk in and out of room and corridor, locomotion on and off the unit with supervision only. The resident had no impairment of extremities. Review of EHR Nurse's Note dated 4/10/2021 at 11:10 p.m. revealed R#1 was not in her room and could not be located in the facility. Staff searched in and around facility although the resident could not be located. Record review for R#1 revealed an elopement assessment dated [DATE] with a score of eight indicating low risk for elopement, however, it is documented that a Wander Guard was placed on R#1 upon admission. Review of the elopement assessment dated [DATE] revealed a score of 13 indicating moderate risk for elopement. Review of QAPI meeting held on 1/19/21 after R#2 had eloped from the facility on 1/17/2021 revealed: Aim (what are we trying to accomplish) No further elopements; Measure (how we will know if a change is and improvement) We will assess all wanders or elopement risk residents; Change (what changes can we make that will result in improvement) Educate all staff, walking rounds by nurses. An interview on 4/19/21 at 2:04 p.m. with Director of Nursing (DON) revealed the Maintenance Department was responsible for checking the functioning of the Wander Guard bracelets. The Administrator further stated that the nursing staff was only responsible for making sure that the bracelet was attached to the resident and not damaged. An interview on 4/19/21 at 2:07 p.m. with Maintenance Assistant revealed that the Maintenance Department is responsible to ensure the alarms on the doors are functioning proper to alert staff if a resident with a Wander Guard bracelet is attempting to exit. He further revealed that the nursing staff are responsible to ensure the Wander Guard bracelet are functioning. An interview on 4/19/21 at 2:11 p.m. with the Administrator revealed that the Maintenance Department is responsible for checking the functioning of the Wander Guard bracelet. An interview on 4/19/21 at 2:17 p.m. with Maintenance Director revealed the Maintenance Department was only responsible to check the doors for proper function. Further interview revealed that he does not check to ensure the device on the resident is working and that the nursing staff are responsible to make sure the device is functioning properly. An interview on 4/19/21 at 2:49 p.m. with the Administrator and DON confirmed there is no evidence that staff have been checking the functioning of the Wander Guard bracelets for proper functioning. They further revealed that they are not sure if R#1's bracelet was functioning prior to her elopement on 4/10/2021. Cross Refer to F689 The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Administrator is documenting ongoing daily efforts to locate missing resident R#1 by calling and following up with contacts listed on the Elopement Contact Listing Tool. These contacts include Hospitals, Morgues, Jails, Homeless Shelters, Sheriffs Office, Police Office, GBI, and the Guardian's Office. These will be contacted Monday through Friday by the Administrator and I or the Social Services Director. Physical searches will continue within a one-mile radius of the facility, hospitals, homeless shelters, and known areas where homeless people congregate. 2. The Administrator or the Weekend Manager on Duty will review Wander Guard placement and functionality documentation daily (7 days per week) for 30 days and the Administrator will review and sign the Wander Guard Function binder tool weekly. The Wander Guard Function binder tool will be reviewed during monthly QAPI meetings using the QAPI Agenda Tool with notes. Daily Wander Guard Placement documentation is located on the appropriate residents' Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The Administrator will review Overall Wander Guard functionality and door code changes documentation from the Plant Ops Director monthly during QAPI meetings by reviewing printed Tels reports and the Door Code Tracking Worksheet Tool. 4. The Administrator received additional training on her Job Description and administrative duties during an elopement event and from the Regional Vice President of Operations on 04/23/2021. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. An interview with the Administrator on 4/28/2021 at 10:05 a.m. revealed that as an ongoing effort to locate R#1 the facility has implemented an Elopement Contact Listing Tool to contact hospitals, morgues, jails, homeless shelter, Sheriff's office, Police Department, GBI, and the State Guardian's office. Contacts are made Monday through Friday by the Administrator or the Social Services Director and documented on the tool. Searches will continue within a one-mile radius of the facility, hospitals, homeless shelters, and known areas where homeless people are known to congregate. Review of the Elopement Contact Listing Tool revealed what contacts have been made or searches of specific areas beginning 4/10/2021 through 4/27/2021 and continue. 2 and 3. An interview with the Administrator on 4/28/2021 at 10:05 a.m. revealed that the results of the Wander Guard Function test, the overall Wander Guard monitoring and the Door Code Changes will be reviewed and documented during the monthly QAPI meetings using the QAPI Agenda Form Tool. Modifications to the policies and procedures will be made and implemented as needed. 4. Review of the in-service and signature sheet for the Administrator dated 4/24/2021 revealed the Regional Vice President of Operations reviewed the Administrator's role in the QAPI Committee responsibilities, tracking and communication of door alarm changes, QAPI policy statement, QAPI implementation process, goals of the QAPI committee, committee authority, committee members, required meeting times, QAPI reports, actions, confidentiality, the QAPI audit process and the annual review.

Based on record review, staff interviews, and review of policy titled Quality Assessment and Performance Improvement Plan and Program (QA/QAPI) the facility failed to have an effective Quality Assurance (QA) process that identified concerns related to care and management of residents at risk for elopement (seven residents), including failure to ensure the Wander Guard system functions properly, after an elopement on 1/17/2021 by R#2, to prevent the elopement of R#1 on 4/10/2021. On 4/22/2021, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. On 4/22/2021 at 12:41 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/10/2021 when R#1 eloped from the facility undetected through an exit door and remains missing. The Immediate Jeopardy is outlined as follows: 1. On 4/10/2021 at 11:00 p.m. R#1 was noted to be missing, who was an elopement risk, and wearing a Wander guard bracelet. Staff searched the facility inside and out but were unable to locate the resident. The police were notified and issued a Mattie's Call for the resident. The facility is uncertain how or when the resident eloped from the facility. As of 4/29/2021, R#1's whereabouts were still unknown. 2. On 1/17/2021, R#2 eloped through a window, after removing a screw that prevented the window from opening fully. Staff were able to locate the resident quickly at a nearby business and was returned to the facility, without injury. As part of the subsequent Quality Assurance (QA) interventions included: Check wander guards and windows daily, educate staff on elopement policy and procedures and drills will be completed. The facility identified seven residents at risk for elopement. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: K) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) CFR 483.70 Administration (F835 Scope and Severity: K) CFR 483.75(g)(2)(ii) Qapi/qaa Improvement Activities (F0867 Scope and Severity: K) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: K) On 4/27/2021 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/27/2021. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/27/2021. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). Findings include: Review of facility policy titled 'Quality Assessment and Performance Improvement Plan and Program' revealed Policy Statement: This facility shall develop, implement, and maintain an effective, comprehensive, data driven Quality Assessment and Performance Improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life. The community will maintain documentation of the plan that demonstrates evidence of the ongoing QAPI program, including but not limited to: Reports demonstrating systemic identification, reporting, investigation, analysis and prevention of adverse events which lead to development, implementation, and evaluation of corrective actions or; Defined annual Performance Improvement activities. Policy Interpretation and Implementation: 1. Components of the plan: A. ongoing, comprehensive and address the full range of care and services provided by the facility. B. Include clinical care, quality of life and resident choice. C. Utilize existing best evidence of outcomes to measure quality, for example Quality measures as defined by CMS. D. Reflect the complexities and unique care that the community offers, for example, peritoneal [CONDITION(S)], ventilator care, etc. 3. Components of the program include: a. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety; b. To reinforce and build upon effective systems of services and positive care measures; c. To provide structure and process to correct identified quality deficiencies; d. To establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome. 1. Record review revealed that R#2 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed the resident was not interviewed for a BIMS assessment due to rarely/never understood. Was independent for ambulation. Review of the resident's care plan revealed he was at high risk for elopement/wandering based upon risk evaluation. Interventions included: resident is looking or trying to go somewhere, intervene as appropriate. Provide structural activities: reorientation strategies, Wander Guard in place. Review of the facility incident summary revealed the resident eloped through his bedroom window on 1/17/2021 at around 4:00 p.m. The resident's window had a screw in place to prevent the window from opening fully which he was able to remove. The resident was found about 4:24 p.m. at a pharmacy about two blocks from the facility. A complete assessment was done with no injuries noted. The resident was found before the police were called. The resident revealed to the staff that it looked good outside and he wanted a soft drink. When asked why he went out the window, the resident replied that it looked good, and I wanted to go out for a while. Maintenance came in immediately to repair the window that had a security screw in place but had been removed. The window was secured, other windows were checked, and the resident was placed on every 15-minute checks for 24 hours. Current Wander Guards will be checked daily, and windows and Wander Guard system will be checked daily. Staff was re-educated on Elopement policy and procedures and drills were completed. The resident was seen by the Psychiatric services on 1/21/2021. An Ad-Hoc QAPI meeting was held. Review of QA/QAPI meeting minutes held 1/19/2021 revealed Aim (what are we trying to accomplish) No further elopements; Measure (how we will know if a change is and improvement) We will assess all wanders or elopement risk residents; Change (what changes can we make that will result in improvement) Educate all staff, walking rounds by nurses. Attendees: Administrator, Medical Director, and Director of Nursing. The resident was discharged to another facility on 3/24/2021. 2. Review of electronic health record (EHR) revealed R#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had a Brief Interview of Mental Status (BIMS) score of five out of 15 indicating severe cognitive decline and no behaviors and no wandering. The resident was assessed for transfer, walk in and out of room and corridor, locomotion on and off the unit with supervision only. The resident had no impairment of extremities. Record review for R#1 revealed an elopement assessment dated [DATE] with a score of eight indicating low risk for elopement, however, it is documented that a wander-guard was placed on R#1 upon admission. An elopement assessment dated [DATE] revealed a score of 13 indicating moderate risk for elopement. Review of care plan for R#1 dated 1/20/21 revealed that R#1 is Moderate risk for elopement and wandering based upon risk evaluation. Goal: R#1 will not have any complications through review period. Interventions included to check Wander Guard for proper functioning, Wander Guard in place to left ankle. Resident is assessed for refusing medications, showers, meals and care. Record review revealed the resident was under Psychiatric Care for mental illness and delusions. Review of a nursing progress note dated 4/10/2021 at 20:05 (8:05 p.m.) revealed resident observed walking toward Nurses Station with multi-layers of clothing, bilateral pants leg cuffed position with left ankle Wander Guard bracelet visible. Resident stated, Can I have a cup of juice with ice and some graham crackers?. Nurse provided snacks, resident stated, Thank you and walked back to her room. Review of Nursing progress notes, late entry, dated 4/10/2021 at 23:10 (11:10 p.m.) revealed that during last rounds, writer did not see the resident in the room, staff was notified and an immediate search, by all staff, was conducted. Management was notified, police called, and guardian notified via voicemail. Guardian returned call, known information was provided to her. Review of the police report dated 4/10/2021 at 2340 (12:40 p.m.) narrative report: On 4/10/2021 at 2344 hrs (hours), I was dispatched to the facility (address) in regards (sic) to a missing person. Upon my arrival, I made contact with the complainant. I was advised the resident (name) was last seen when she came to the Nurse's Station asking for a snack at roughly 2030 hrs. A search of the rooms and the surrounding area was conducted. Officers furthered the search to the surrounding areas, with no luck finding the resident (name). The complainant advised the resident was last seen wearing a red wool jacket and green hat. A description of the resident was given. The resident walks with a bow to her left leg and has a partial amputation of the left hand, possibly her ring finger. The complainant advised that the resident is diagnosed with [CONDITION(S)], hypertension and [CONDITION(S)]. The resident is on medications for her mental illness but does not take it due to refusal. A copy of the report was sent to the Georgia Criminal Investigation Center (GCIC) to have the resident listed as missing and a Mattie's Call was made for the resident. Nothing further at this time. Review of document titled Ad Hoc for Elopement meeting revealed a meeting held on 4/11/2021 to discuss finding and strategies to prevent and/or decrease the chance of residents eloping or wandering away from the facility. (Search continued for missing resident). Education and Elopement drills discussed and conducted. Head counts done by charge nurses immediately. Department heads and Corporate management notified. All windows and doors checked by staff. All windows and doors rechecked by Maintenance. The TELS system (a computer-based system for maintenance) was updated by maintenance. Interview of staff conducted. Hospitals, jails, and shelters called. Metro Atlanta searched, Jonesboro, Riverdale, and other nearby areas searched. Attendees: Director of Nursing, Administrator, Assistant Director of Nursing, Social Services Director, Medical Director, and Maintenance Director. Review of document titled Elopement dated 4/19/21 revealed: IDT (interdisciplinary team) meeting to discuss elopement residents and risks. Identify solution. Wandering resident will be place, if possible, in the same area so that staff will be able to identify residents. Nursing continues to monitor for placement. Department Manager or designee will check for functioning of tag, maintenance will also check as need and monitor Wander Guard systems daily and implement TELS. Attendees: Director of Nursing, Assistant Director of Nursing, Unit Manager, and Charge Nurse. Review of Performance Improvement Plan (PIP) with a start date of 4/13/21 and a target date of 7/13/21 revealed an Elopement Assessment was created after R#1 eloped. Root cause analysis revealed: 1. Scores were not reflecting at risk resident. 2. Lack of knowledge of finding due to incorrect scoring of system. 3. Noticeable changes but not identified due to incorrect scoring of system. 4. Unable to properly identify at risk residents due to inadequate scoring. 5. At risk resident not identified. Interview on 4/15/21 at 10:46 a.m. with the Administrator revealed she was notified R#1 was missing on 4/10/21 at approximately 11:30 p.m. and came immediately to the facility and assisted in searching for R#1. Interview on 4/21/21 at 1:50 p.m. with Administrator revealed the QAPI committee meets once monthly on the last Thursday of the month per facility policy and that the QAPI committee had not completely identified all elopement causes. Cross refer to F689 The facility implemented the following actions to remove the Immediate Jeopardy: 1. During the second AD Hoc QAPI meeting on April 19, 2021, the updated Wander Guard bracelet facility policy was reviewed to include documentation of bracelet placement every shift and functionality will be documented daily (7 days per week) by either the Director of Nursing or another Licensed Nurse, using the Wander Guard Function binder tool. The participants in this meeting were the Medical Director, Administrator, Director of Nursing, and the Assistant DON. 2. From 04/22/2021 to 04/26/2021, employees were educated on the following topics: a. Recognizing and Reporting Exit-Seeking Behavior so Assessments can be Completed and Care Plans Updated, as Necessary. Employees educated were: 1 of 1 Activity Director, 1 of 1 Administrator, 1 of 1Admissions Staff, 1 of 1 Clinical Reimbursement Coordinator, 8 of 9 Dietary Staff, 1 of 1 DON, 7 of 8 Housekeepers, 1 of 1 Marketing Director, 1 of 1 Medical Records Staff, 35 of 37 CNAs, 24 of 24 LPNs, 6 of 6 RNs, 2 of 2 Plant Ops Staff, 7 of 7 Rehab Staff and 1 of 1Social Service Director. b. As of 04/26/2021, the following staff have been educated on QAPI Committee Members, QAPI Purpose, Communication and Meeting Schedule. Staff receiving this education were: 1of 1Activity Director, 1 of 1Administrator, 1of 1Admissions Staff, 1 of 1 Business Office Manager, 1 of 1 Clinical Reimbursement Coordinator, 8 of 8 Dietary Staff, 1 of 1 DON, 7 of 8 Housekeepers, 1 of 1 Marketing Director, 1 of 1 Medical Records Staff, 33 of 37 CNAs, 23 of 24 LPNs, 6 of 6 RNs, 2 of 2 Plant Ops Staff, 7 of 7 Rehab Staff and 1 of 1 Social Service Director. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Review of the QAPI minutes and agenda dated 4/19/2021 revealed that Wander Guard Placement on each resident not checked for function. All resident's Wander Guards will be checking daily for placement and function and recorded on the logbook. This will be checked daily on the 7:00 a.m. to 3:00 p.m. shift. Education started immediately with Nursing for checking on Function of Wander Guard. In attendance: Medical Director, Administrator, DON, ADON and Staff Development. An interview with the Administrator on 4/28/2021 at 10:05 a.m. revealed that the results of the Wander Guard Function test, the overall Wander Guard monitoring and the Door Code Changes will be reviewed and documented during the monthly QAPI meetings using the QAPI Agenda Form Tool. Modifications to the policies and procedures will be made and implemented as needed. 2. a. Review of the In-service sign-in sheets between 4/22/2021 and 4/26/2021 for the following training revealed: Wander Guard Tag Testing, Placement and Function Policies and Procedures. Recognizing and Reporting Exit-Seeking behavior-which will prompt a new Assessment and care plans to be updated as necessary. Review of the sign-in sheets for the education listed above dated 4/22/2021 through 4/23/2021 revealed that 1 Activity Director, 1 Administrator, 1 Admission staff, 1 Clinical Reimbursement Coordinator, 9 Dietary Staff, 7 Housekeeping staff, 1 Medical Records staff, 36 CNAs, 24 LPNs, 6 RNs, 2 Maintenance (Plant operations), 6 Therapy staff, 1 Social Services Director, 1 DON and 1 Administrator had received education. b. Review of the QAPI education for the QAPI committee, dated 4/22/2021, revealed that the objectives were to ensure that the QAPI committee thoroughly and effectively identified concerns related to the management of the Wander Guard System. Included in this in-service were the DON, Social Services Director, Admissions Director, Housekeeping Manager, LPN MDS Coordinator, Medical Records Director, Rehab Director and a member of the Rehab team. All staff were in-serviced on Wander Guard Tag Testing, Placement and Function Policies and Procedures, Recognizing and Reporting Exit-Seeking behavior, which will prompt a new Assessment to determine Elopement risk and that care plans will be updated to reflect the resident's risk and interventions. Review of the sign-in sheets for the education listed above dated 4/22/2021 through 4/23/2021 revealed that 1 Activity Director, 1 Administrator, 1 Admission staff, 1 Clinical Reimbursement Coordinator, 9 Dietary Staff, 7 Housekeeping staff, 1 Medical Records staff, 36 CNAs, 24 LPNs, 6 RNs, 2 Maintenance (Plant operations), 6 Therapy staff, 1 Social Services Director, 1 DON and 1 Administrator had received education. Interviews on 4/28/2021 with the DON at 10:59 a.m. and ADON at 10:49 a.m. revealed they have participated in the QAPI meetings, review of the Policies and Procedures related to preventing elopement and have conducted the in-services. They are aware of the procedures for checking the Wander Guard function testing and documenting the findings. Interviews with the following LPN's revealed they were aware of the new Policies and Procedures for the QAPI meetings, how to recognize wandering/exit seeking behaviors and how to report and document: 4/28/2021-LPN II, at 10:36 a.m., LPN QQ at 10:42 a.m., LPN MM at 11:18 a.m., LPN VV at 11:22 a.m., LPN JJ at 12:06 a.m., LPN GG at 12:22 p.m., LPN JJJ at 1:20 p.m., LPN HH at 1:24 p.m., 4/29/2021-LPN TT at 7:57 a.m., LPN OOO at 9:54 a.m., LPN PPP at 9:58 a.m., and LPN CC at 11:14 a.m. CNA's 4/28/2021: CNA XX at 11:31 a.m., CNA YY at 11:33 a.m., CNA AA at 11:42 a.m., CNA AAA at 11:45 a.m., CNA OO at 11:50 a.m., CNA BBB at 11:56 a.m., CNA CCC at 12:00 p.m., CNA DDD at 12:03 p.m., CNA LLL at 1:33 a.m., CNA MMM at 1:37 a.m., 4/29/2021-CNA EE at 6:12 a.m., CNA PP at 6:49 a.m., CNA SSS at 11:25 a.m. and CNA LL at 11:27 a.m. Dietary Aides (DA): 4/28/2021-DA GGG at 1:16 p.m., DA HHH at 1:17 p.m., DA III at 1:18 p.m., and DA NNN on 4/29/2021 at 9:51 a.m. Housekeeping Department: 4/28/2021-Housekeeper (HK) EEE at 12:05 p.m., Housekeeping Manager NN at 12:35 p.m. and Floor Tech QQQ on 4/29/2021 at 10:03 a.m. An interview with the Social Services Director on 4/28/2021 at 11:10 a.m., Maintenance Assistant FF on 4/28/2021 at 10:56 a.m., Maintenance Director (Plant Operation Manager) on 4/28/2021 at 11:02 a.m., Admissions Coordinator on 4/28/2021 at 11:06 a.m., Medical Records/Central Supply on 4/28/2021 at 11:13 a.m., and the Business Office Manager on 4/28/2021 at 1:28 a.m.

Based on record review, resident and staff interviews the facility failed to ensure that one (1) resident ("Q") was free of abuse from a sample of thirty (30) residents. This failure resulted in harm for this resident. Findings include: Interview on 3/10/2011 at 8:30 a.m. with resident "Q" revealed that the staff turned the resident roughly and during the turning process, the indwelling urinary catheter was pulled out. Continued interview revealed that blood was on the inside and outside of the incontinence brief. Review of a report, "Resident Report of Abuse" dated 2/16/2011 for resident "Q" revealed that on 2/14/2011, a Certified Nursing Assistant (CNA) "II" threatened the resident, and while turning the indwelling urinary catheter was pulled out which resulted in a meatal tear with bleeding. Continued review revealed that Licensed Practical Nurse (LPN) "JJ" heard the altercation and went into the room to diffuse the situation. Review of nurses note dated 2/14/2011 revealed, LPN "JJ" was in the resident's room and the resident complained that CNA "II" removed the indwelling urinary catheter which caused bleeding. Review of nurses note dated 2/15/2011 at 6:30 a.m. revealed an assessment of bloody drainage of the indwelling urinary catheter which required medication for pain. Review of nurses note dated 2/16/2011 at 10:15 a.m. revealed blood at urethral meatus. Review of the skin assessment sheet dated 2/17/11 revealed that the meatus had a partial thickness wound with no exudate, no odor and pink tissue. Skin assessment date 2/23/11 revealed that the assessment remained the same and on 3/01/11 the wound was resolved.

Based on clinical record review, review of the facility abuse policy and resident and staff interviews, the facility failed to ensure that their abuse policy was followed for one (1) resident ("Q") of the sampled thirty (30) residents. This failure resulted in actual harm for this resident. Findings include: Review of a Resident Report of Abuse dated 2/16/2011 for resident "Q", revealed that on 2/14/2011, a Certified Nursing Assistant (CNA) "II" threatened the resident, and while turning the resident the indwelling urinary catheter was pulled out which resulted in a meatal tear with bleeding. Continued review revealed that Licensed Practical Nurse (LPN) "JJ" heard the altercation and went into the room to diffuse the situation. There is no evidence that the LPN reported the incident to the Director of Nurses, Administrator or nurse supervisor. Continued review of the Resident Report of Abuse revealed that CNA "II" returned to work on the evening of 2/15/2011, and was assigned to resident "Q" again. The resident complained to a nurse that he was afraid of CNA "II" who then changed CNA "II" assignment. Review of the facility work schedule revealed that the CNA "II" was on the schedule for 2/14/2011 and 2/15/2011. Interview on 3/14/2011 at 12:30 p.m. with Administrator revealed that CNA "II" did return to work on 2/15/2011, which is against the facility abuse policy. Review of the facility policy for abuse revealed that any allegation of abuse should be reported to the Administrator immediately and that employee involved in any allegation of abuse will be suspended pending investigation.