Every finding on record at Bayonet Point Health Center by Harborview

Based on observations, staff interviews and record review, the facility failed to maintain the kitchen and kitchen equipment in a sanitary and functional manner during two of four days observed (8/12/2024, 8/13/2024), related to; 1. Kitchen dish washing machine not operating per the machine's maintenance service specifications/recommendations; 2. Not maintaining ceiling vents above food preparation stations in a dust/debris free environment; and 3. Not maintaining the walk in freezer free from heavy ice build up on various boxes of food items. Findings included: 1. On 08/12/2023 at 9:10 a.m. the kitchen was toured with Dietary Manager. He provided a general kitchen tour of the kitchen and other kitchen spaces. The Dietary Manager was asked if he or his staff were utilizing the dish washing machine and he confirmed that a Dietary Aide Staff K was running the machine and has been doing so for about twenty minutes. The Dietary Manager revealed they are running a High Temperature dish washing machine and was being maintained by an outside dish washing machine maintenance service. The Dietary Manager and Staff K both revealed that the maintenance service technician had not been out recently as there had not been any problems with the dish washing machine. Staff K revealed the High Temperature Wash cycle should reach 150 degrees F (Fahrenheit)., and the Rinse cycle should reach 180 degrees F. This was confirmed through interview with the Dietary Manager and review of the machine's specification plate. Staff K was asked to provide a demonstration of the wash and rinse cycle. He noted he has already been washing dishes and has ran crates of dishes and other eating utensils through the machine with no concerns. Staff K revealed he did not have to prime the machine to make temperatures, as the machine has a heating booster, which supplies hot water on demand. The following were dishwashing machine wash and rinse cycles, as demonstrated by Staff K; 1. Demonstration on 8/12/2024 at 9:15 a.m.; Wash -150 +degrees F., Rinse - 160 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. 2. Demonstration on 8/12/2024 at 9:16 a.m.; Wash - 150 + degrees F., Rinse - 165 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. 3. Demonstration on 8/12/2024 at 9:18 a.m.; Wash - 150 + degrees F. ; Rinse - 169 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. 4. Demonstration 8/12/2024 at 9:26 a.m.; Wash - 150 + degrees F., Rinse - 170 degrees F. Both Staff K and the Dietary Manager confirmed the Rinse temperature and revealed it should reach 180 degrees F.+, but it did not. The Dietary Manager provided the dish washing machine temperature logs for the past two months (8/2024 and 7/2024), for review. The dish washing machine temperature logs revealed staff were documenting the following: - July, 2024, 1st through 29th; Wash and Rinse temperatures documented 200 degrees F. for all three meals for both wash and rinse cycles. The chemical sanitizer was documented at 150 parts per million (ppm). NOTE: The machine was not operating as a Low Temp machine, therefore, there was no actual chemical sanitizer delivery system. Staff had documented 150 ppm when there was no sanitizer. Further, days 7/6/24 - 7/30/24 for the dinner cycle, staff did not initial completion. Photographic evidence of the log was taken. - August, 2024, 1st though 12th; Wash and Rinse temperatures documented 200 degrees F. for all three meal services, with a chemical sanitizer = 150 ppm. NOTE: The machine was not operating as a Low Temp machine, therefore, there was no actual chemical sanitizer delivery system. Staff had documented 150 ppm when there was no sanitizer. Photographic evidence obtained. The Dietary Manager confirmed the logs did not appear to be correct and filled out appropriately. He revealed he has only been employed at the facility for a few weeks and was not able to speak on why the logs were wrong. An interview was conducted at that time with dietary staff K and J, who operate the dish washing machine routinely, both revealed they were not sure why the dish machine logs were reading PPM at 150 as the machine was not operating with a chemical sanitizer delivery system. They were also not able to explain why the logs had 200 degrees F. for both wash and rinse for every day and every meal service. A continued interview with Staff K revealed the dish washing machine maintenance technician was out at the facility about a week maybe two ago an did some adjustments but did not remember what was adjusted. However, in a later interview with the Dietary Manager, he revealed he did not believe the Maintenance technician was out recently to do any work on the dish washing machine. Both Staff K and the Dietary Manager confirmed the dish washing machine was not working appropriately and the dish washing machine service technician will be called to come out for service. At this time he will use the three compartment sink to wash and rinse dishes until the machine is repaired and working appropriately. On 8/13/2024 at 8:05 a.m. The Dietary Manager revealed the dish machine maintenance service technician made it out this a.m. to change the dish machine from a High Temperature machine to a Low Temperature machine. The Dietary Manager revealed the technician said the machine should reach 120 + Wash, and 120 + Rinse with a chemical sanitizer to reach 50-100 ppm. He revealed the [name of company] technician changed the machine and tested it several times before he left. The Dietary Manager revealed the Wash cycle reached 120 + and the Rinse reached 120 + and the PPM was between 50 - 100 ppm. On 8/14/2024 at approximately 12:10 p.m. The Kitchen was toured and the dish machine service technician was at the dish washing machine making adjustments to the chemical solution delivery system. The technician revealed he was earlier able to switch the machine from a High temp, to a Low temp machine as the machine could no longer get to high temperature wash and rinse cycle. 2. On 8/12/2024 at 9:10 a.m., the kitchen was toured with the Dietary Manager. During the tour, three ceiling vents and the surrounding ceiling area was observed with heavy black dust/debris. The debris was hanging off the ceiling and vents in a manner that was or was at risk for falling directly downward towards and on food preparation tables and food serving areas. The Dietary Manager revealed it was the maintenance department's responsibility for cleaning and maintaining the ceiling vents. The Dietary Manager revealed he had only been working at the facility for a short time and was not sure when the last time the ceiling vents and ceiling were cleaned from debris. Photographic evidence was obtained. On 8/15/2024 at 10:00 a.m., an interview with the Maintenance Director revealed he and the maintenance department staff are responsible for cleaning the ceiling vents in the kitchen and other kitchen area spaces. He revealed the ceiling vents are on an electronic cleaning program schedule. The Maintenance Director believed the system schedules cleaning of the vents at least once a quarter. He was not able to say how long ago the vents were cleaned and confirmed the vents and ceiling areas in the kitchen would need to be cleaned more frequently. 3. On 8/12/2024 at 9:10 a.m. the kitchen was toured with the Dietary Manager. During the tour, the walk in freezer was entered and observed. During that time, the left rear inside of the freezer was observed with a top shelf of packaged food. The top of the packaged food was observed with heavy ice frosting and ice build up. The top shelf of the same area was also observed with heaving ice frosting and ice build up. Directly above the area in question was observed with the electric fan motors and insulated tubing. The entire tubing area was observed heavily iced around and with ice cycles approximately five to seven inches long. Photographic evidence obtained. An interview with the Dietary Manager confirmed the ice build up on the shelves and packaged food and revealed he does clean the ice machine and defrosts it when it is needed. He also confirmed that ice does build up quickly and was not sure if the mechanics has a leak or not. He revealed he would need to put in a work order with the Maintenance department. He did not believe Maintenance was aware of the leak in the back as of yet. On 8/15/2024 at 10:00 a.m. an interview with the Maintenance Director revealed he was not aware of the ice build up in the ice machine and he would look into it and ensure if there is a leak, he would fix it, or if the seals on the door needed to be replaced, he would replace them. He further revealed it is up to the Dietary staff/manager to get with him if there is anything wrong with the mechanics of the walk in refrigerator or walk in freezer. On 8/15/2024 at 10:00 a.m. the Nursing Home Administrator provided the Dishwasher Temperature policy and procedure with a revision date 6/2024, for review. The policy stated; It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwater temperatures. The Policy Explanation and Compliance Guidelines revealed; 1. All the items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitizing. 3. For High Temperature dishwashers (heat sanitation); a. The wash temperature shall be 150 - 165 degrees F. b. The final rinse temperature shall be 180 degrees F. or above but not to exceed 194 degrees F. (165 degrees F for stationary rack, single temperature machine). Corrective actions shall be taken for final temperatures below the required final rinse temperatures. 4. For low temperature dishwashers (chemical sanitation): a. The wash temperature shall be 120 degrees F. b. The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine_ on dish surface in final rinse. 5. Chemical solutions shall be maintained at the corrected concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of the concentration checks shall be recorded. 6. Waster temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. On 8/15/2024 at 10:00 a.m. the Nursing Home Administrator provided the Preventative Maintenance Program policy with a 6/1/2024 revision date for review. The policy stated; A preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The guideline revealed; 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventive maintenance (PM) is required. Required PM may be determined from the manufacture's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be competed and how often to complete them. 4. Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years.

Based on record review and interview, the facility failed to ensure two residents (#21 and #216) out of two residents with history of trauma had triggers identified to prevent re-traumatization. Findings included: Review of the Admission Record showed Resident #216 was admitted to the facility on [DATE] with diagnoses that included but not limited to Post-Traumatic Stress Disorder (PTSD) Chronic, Schizoaffective Disorder, Bipolar Disorder, Generalized Anxiety Disorder and Major Depressive Disorder, Recurrent. Review of the baseline care plan showed no social service goals related to the diagnosis of PTSD or identified triggers. Review of the Informed Trauma Questionnaire dated 08/06/24 showed I. Assessment 1. Have you ever had an experience that was so upsetting to you that is changed you emotionally, spiritually, physically and behaviorally? Answer No. Review of the of Admission Minimum Data Set (MDS) dated [DATE] Section C-Cognitive Patterns showed Resident #216 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact). During an interview on 08/13/24 at 5:11 p.m., Resident #216 stated that she was a Veteran and was diagnosed with PTSD. Resident # 216 stated that since being admitted to the facility no one had discussed the diagnosis of PTSD or any triggers that would cause her re-traumatization. During an interview on 08/14/24 at 9:41 a.m., Staff C Registered Nurse (RN) stated she was not aware of any Residents in the facility with the diagnosis of PTSD or with a history of trauma. During an interview on 08/14/24 at 9:43 a.m., Staff D Certified Nursing Assistant (CNA) stated she was not aware of any Residents, including Resident #216, with a diagnosis of PTSD or a history of trauma in the facility. Staff D, CNA stated that if there was a resident diagnosed with PTSD, she would have received that information in report. During an interview on 08/14/24 at 9:45 a.m., Resident #216 stated that she received her diagnosis of PTSD from her military experience. Resident #216 stated her identified trigger for PTSD was being startled for example, being woke up fast. During an interview on 08/14/24 at 9:55 a.m., Staff E Social Services Director (SSD) stated that a diagnoses of PTSD or history of trauma has to go on the baseline care plan. Staff E, SSD stated that she would expect the trauma assessment questionnaire to reflect a diagnosis of PTSD in some manner especially if residents are veterans. Staff E, SSD stated Staff F, Social Service Assistant (SSA) was a new assistant who worked part time and was completing assessments on residents. During an additional interview on 08/14/24 at 10:15 a.m., Staff E, SSD identified Residents #216 and #21 as the two residents in the facility with a diagnosis of PTSD. Staff E, SSD stated she would have expected Resident #216's Trauma Assessment Questionnaire dated 08/06/24 to accurately depict the diagnosis of PTSD so triggers could have been identified. Staff E, SSD stated she would compete an accurate assessment of Resident #216's history of trauma so triggers can be identified to prevent re-traumatization. 48223 Review of Resident #21's Admission Record revealed resident was readmitted on [DATE] with the following diagnosis: Parkinson's Disease, Post Traumatic Stress Disorder (PTSD), Mood Disorder due to known physiological condition, delusional disorder, Major depressive disorder, unspecified psychosis, anxiety and other co-morbidities. Review of Resident #21's care plan revealed the following Focus Areas: - Resident #21 has impaired cognitive function or impaired thought process related to impaired mobility delusion, PTSD, date initiated 3/20/2024 revised on 8/21/2023. Under interventions/Tasks no mention of the triggers for the resident's PTSD. - The resident has moments of anxiousness, PTSD, date initiated: 6/16/2023 revised on: 7/4/2023. No interventions/tasks of any triggers for resident's PTSD. - The resident has a psychosocial well-being problem related to trauma as a child-triggers PTSD screen. Becomes delusional at times mania, date imitated 4/1/2023 and revised on 6/21/2023. Under interventions/Tasks no mention of the triggers for the resident's PTSD. During an interview on 8/14/24 at 9:36 a.m., Staff A, Certified Nursing Assistant (CNA) stated there was no Resident that she knew of with a history of trauma or a diagnosis of Post Traumatic Stress Disorder (PTSD). Staff, CNA stated that Resident #21 talked to her past family history but she is demented. CNA stated, No one had discussed in report that Resident #21 had PTSD or had a history of trauma. During an interview on 8/14/24 at 9:38 a.m., Staff B, Licensed Practical Nurse (LPN) stated she was not aware of any Residents with a diagnosis of PTSD and had not heard anything in report about any residents with a diagnosis of PTSD. Staff B, LPN stated that she did know that Resident #21 had a diagnosis of schizophrenia though. Review of the facility's policy Quality of Care- Trauma-informed care dated 06/01/24 showed, Policy: The facility shall provide adequate care and services that residents attain and maintain the highest practical physical, mental and psychological well-being. Procedure: The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with profession standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Based on interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to ensure two residents (Resident #98 and #260) of the five residents sampled for baseline care plans. The findings include: Review of Resident #98's admission record revealed an admitted [DATE] with diagnoses of coronary artery bypass graft(s) with complications, urinary retention, Percutaneous endoscopic gastrostomy (PEG) tube, and other co-morbidities Review of Resident #98's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 6/25/2024 revealed resident at risk for falls, resident has a foley catheter, a PEG tube, and diet order of NPO (nothing by mouth). Review of Resident #98's Interim Care Plan dated 6/25/2024 and completed 7/8/2024 revealed no care plan for a urinary catheter, nor dietary instructions for PEG tube. Review of Resident #260's admission record revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease with exacerbation (COPD), Pulmonary fibrosis, atrial fibrillation (A-Fib), and other co-morbidities Review of Resident #260's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 7/21/2024 revealed resident at risk for falls, pressure ulcers, oxygen at 4 liters a minute, primary diagnosis of bilateral lower extremity weakness, pulmonary fibrosis, A-Fib and COPD. Review of Resident #260's Interim Care Plan dated 7/24/2024 and completed 8/6/2024 revealed no evidence completed and given to resident within the 48-72 hours of admission. During an interview on 8/12/2024 at 10:45 AM with Resident #260 and spouse. Resident #260 stated not being given any treatment plan or plan of care. During an interview on 8/14/2020 at 10:20 AM, the Minimum Data Set Coordinator (MDS) Coordinator, stated the baseline care plans are started on admission and updated until the full comprehensive care plan is completed. Review of Resident #98's interim care plan was started on 6/25/2024 but not completed until 7/8/2024. Review of Resident #260's interim care plan was started on 7/24/2024 but not completed until 8/6/2024. The MDS Coordinator stated In hindsight, the interim care plan is completed outside of the required time frame of 48 to 72 hours. During an interview on 08/14/24 at 10:55 AM, the Director of Nursing (DON) stated the expectation for the baseline care plans to be completed within 48-72 hours of admission, reviewed with the resident and resident representative and a copy provided. Review of the facility's policy titled Baseline Care Plan dated 3/1/2023, revealed The facility will develop and implement a baseline care plan for each resident that includes that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of of a resident's admission. B. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social services. vi. PASSR recommendation, if applicable. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. A. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. interventions shall be initiated that address the resident's current needs including i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. Iii. Any special needs such as IV therapy, dialysis, or wound care. c. Once established, goals and interventions shall be documented in the designated format. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan. 6. The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided. b. Make a copy of the summary for the medical record. 7. If the summary was provided via telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident/representative. 8. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. This will be provided by the MDS nurse/designee by the comprehensive care plan.

Based on observations, interviews and record review, the facility failed to ensure a quiet and homelike environment on one of four units (GNR 300), during three of four days observed (8/12/2024, 8/13/2024, 8/14/2024). It was observed and overheard a resident was yelling and causing loud noises for long periods of time and affecting Residents on the entire GNR 300 hallway to include Residents #32, #49, #15, #1, and 14. Findings included: On 8/12/2024 and 8/13/2024 during the 7-3 shift (over four observations from 9:55 a.m. - 10:45 a.m.), Resident #69 was observed in her room and lying flat in bed. She was observed all four times not presenting with any behaviors, pain or discomfort. Upon visiting the room she did present with confusion and cognitive deficits. Resident #69 was not able to answer specific questions related to her medical care and services. On 8/12/2024 at 11:00 a.m. while seated at the GNR 300 Nurses' Station, a resident could be overheard from the GNR 300 hall yelling out loud. The yelling was intermittent and could not at first be determined who the resident was. After walking out from the nurse station and approximately thirty-five feet down the GNR 300 hall, it was determined Resident #69 was observed in her bed and yelling. It appeared she was yelling out words intermittently. An interview conducted at that time revealed she talked at a normal level and revealed she was ok and having a good day. She was asked if she needed anyone and she revealed that she did not. Resident #69 said she was fine. There were no identifiable concerns during the observation and interview that would indicate the resident was neglected, in pain or in discomfort. Interview with several unidentified staff who walked by Resident #69's room and room area, said, she does that, she yells out all the time, but just does that for no reason and that is her normal behavior. The staff continued to say that once they go in the room to visit with her and talk with her, she calms down and talks at a lower volume. However, when they leave the room Resident #69 starts to be loud again very shortly after they leave. It was measured Resident #69's room was thirty-five feet up the GNR 300 hall, from the nurse station. Resident #69's room was in the middle of the hallway. It was overheard of one resident from an unknown room saying aloud; please stop her, who is that? On 8/12/2024 at 1:45 p.m. Resident #69 was overheard yelling out and could be heard throughout the GNR 300 hallway, and past the unit station. Staff were observed to go in and out from the room but after they left the resident would keep calling out unrecognizable words and phrases intermittently. On 8/13/2024 at 9:20 a.m. through 10:00 a.m. Resident #69 was overheard from her room yelling out loud and was doing this intermittently for about twenty minutes until 10:20 a.m. Some residents could be overheard in other rooms shouting out, shut up, please stop her from yelling. Staff would go in the resident's room and intervene, but as soon as they left the room the resident would begin to yell out loud again. On 8/14/2024 at 8:15 a.m. Resident #69 was noted in room. A Nurse was in her room passing medication to her, and she accepted with no observable concerns. On 8/14/2024 from 10:00 a.m. through to 11:00 a.m. Resident #69 could be overheard calling out loudly and talking to herself, but was speaking in a very loud manner and she could be overheard throughout the GNR 300 hall and at the unit station. Staff did intervene, but as soon as staff left, she would speak loudly to herself too. There were times the room mate would also call out very loudly. Some residents in other nearby rooms could be overheard saying , please be quiet. On 8/15/2024 at 8:03 a.m. while walking down the GNR 300 hall, Resident #69's room door was closed all the way. At 8:20 a.m. the room door was still observed closed. Another tour on the GNR 300 hall at 8:32 a.m. revealed the resident's room door was now wide open and she was noted in her low bed and lying on her side watching television. She was not presenting with any behaviors, pain, discomfort, and was not yelling or calling out. On 8/15/2024 during the 7-3 shift the following random residents, who reside in the GNR 300 hall, were interviewed with relation to the noise coming from the resident's room: 1. Resident #32, who's room was thirty feet from Resident #69's room, revealed she hears some resident yelling all the time. She has mentioned this to staff before, but the resident has not stopped. She would rather the resident stop yelling, but feels there is no use of complaining anymore. Review of Resident #32's medical record revealed she was admitted at the facility on 9/6/2018. Review of the advance directives revealed Resident #32 was her own decision maker. Review of the current Minimum Data Set (MDS) assessment (Quarterly), dated 5/28/2024, revealed: Cognition/Brief Interview Mental Status BIMS (Brief Interview for Mental Status) score 15 of 15, which revealed the resident was able to speak related to her day and medical care. 2. Resident #49, who's room was ten feet from Resident #69's room, revealed she hears Resident #69 yelling out all the time, especially the past week or two. Hears her at night as well. She has complained and was told by staff that the resident could not help yelling out at times. She would like for her to stop. Review of Resident #49's medical record revealed she was admitted at the facility on 5/24/2019. Review of the advance directives revealed Resident #49 was her own decision maker. Review of the current MDS assessment (Annual), dated 5/17/2024, revealed: Cognition/BIMS score 13 of 15, which indicated the resident was able to speak about the day and her medical care. 3. Resident #15, who's room was fifteen feet from Resident #69's room, revealed he has overheard the resident yell out. He did not think she was in pain, she just yells out words and yells out to herself. He has spoken to staff about it before, but things have not changed. Review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #15 was his own decision maker. Review of the current MDS assessment (Annual), dated 6/14/2024, revealed: Cognition/BIMS score 15 of 15, which indicated the resident was able to speak related to his day and medical care. 4. Resident #1, who's room was eight feet from Resident #69's room revealed, she not care for the resident yelling out and knows she can't help it, but would like for the hallway to be more quiet. She believed she has spoken to staff about it before. Resident #1 revealed she has been a nurse for over [AGE] years and she knows that residents can sometimes yell out. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed the resident was her own decision maker. Review of the current MDS assessment (Quarterly), dated 7/18/2024, revealed: Cognition/BIMS score 15 of 15, which indicated the resident was able to speak related to her day and medical care. 5. Resident #14, who's room is seven feet from Resident #69's room, revealed; He is not really ok with all the yelling from the resident. He is normally out from his room during the day. Has overheard her yelling at night and that is problematic. He has spoken to staff before, but no real changes. Review of Resident #14's medical record revealed he was admitted at the facility on 5/2/2022. Review of the advance directives revealed the resident was his own decision maker. Review of the current MDS assessment (Modified Annual), dated 5/7/2024), revealed: Cognition/BIMS score 15 of 15, which indicated the resident was able to speak related to his day and medical care). On 8/12/2024 at 10:50 a.m., an interview with Staff H, Licensed Practical Nurse (LPN), who was a nurse on the GNR 300 unit, and knew Resident #69, revealed; she has heard her yell out at times and usually other staff will report to the room an intervene. She knows that Resident #69 is easily redirected, but it seems the resident will at times continue with her behaviors after the staff leave. On 8/14/2024 at 2:40 p.m. an interview with the Director of Nursing (DON) revealed she did know of Resident #69 and her yelling out behaviors. She revealed the resident is care planned with interventions for staff to help reduce the behaviors, and that the resident is being seen by psychology services. The DON was not sure of the exact interventions. The DON revealed she knows the resident yells out loud at times during the main 7-3 shift and that staff will respond and she will then subside with the yelling. The DON did confirm that once staff leave the room, she will at times begin to call out loud again. The DON revealed she did know that Resident #69 is not yelling out in pain or discomfort. On 8/15/2024 at 8:05 a.m. an interview with Staff G, LPN, who had Resident #69 on her schedule, and has had the resident on her routine schedule, revealed; she is well aware of the resident's calling out and yelling behaviors. She revealed the resident has been known to call out very loudly for awhile now and they have developed care planning measures with interventions to try and subside it. Staff G revealed she, along with any other staff will intervene when she starts to yell out and as soon as the resident is visited, she calms and talks normally, but is very confused and has cognition deficits. Staff G further revealed she has heard other residents in other rooms call out, shut up, who is yelling, at times. Staff G revealed she and other staff try to keep the hallway comfortable and explain to the other residents in the hall that the resident doesn't know what she is doing and she doesn't mean to yell out loud. Staff G also confirmed the resident is being seen by Psychology services routinely and there has been medication adjustments, but with no changes. Staff G feels they have put in so many different interventions to have the resident subside with the yelling out, but she just keeps yelling out at times for no reason. Staff G again revealed she will speak with the resident and will tell her everything is fine, but then will speak in unknown subject matter and will see the resident will ask and answer her own questions like she is talking with someone else. Staff G revealed they try to keep the hallway and room quiet for all the residents who reside on the unit to enjoy. She revealed she monitors staff/resident and resident/resident interactions as well as monitors residents behaviors through her shift. She revealed that aides are to report to her if there are any problems or behaviors with any of the residents. Then she will report to the supervisor and DON as well. On 8/15/2024 at 8:40 a.m. an interview with Staff D, Certified Nursing Assistant (CNA), who had resident on her assignment revealed; she knows the resident well and she is usually pleasant to speak with. She confirmed that as of late, the resident has been yelling out and screaming during the day. She revealed that when she reports to the yelling out, the resident will then stop and become very nice and talkative. Staff D also revealed as soon as she leaves the room, the resident will again start to yell for periods of time. Some of the things they try to do to reduce her from those behaviors are: Routine monitoring of the resident, offer the resident out from bed to group activities, talk with her about the day, turn the television on in the room to what she wants to watch. On 8/15/2024 at 9:00 a.m. an interview with Staff I, Restorative Aide, who has had the resident on her assignments at times, revealed; Resident #69 does yell out at times and if she hears her, she will report to the room and intervene. Review of Resident #69's medical record revealed she was admitted at the facility on 9/30/2021. Review of the advance directives revealed the resident had a guardian who was her responsible party. Review of the Diagnosis sheet revealed diagnoses to include but not limited to: Dementia, Anxiety. Review of the current MDS assessment (Quarterly), dated 7/11/2024, revealed; (Cognition/BIMS score - No score; Checked for Short Term Memory Problem, Long Term Memory Problem, Severely Impaired Decision Making Skills); (Behaviors - Part C Other behaviors symptoms not directed towards others e.g. verbal/vocal symptoms like screaming, disruptive sounds was checked 0 - Behavior not exhibited). Review of the current care plans with a next review date 10/13/2024 revealed the following but not limited to areas: 1. Resident has an alteration in sleep/wake cycles r/t [related to] insomnia, with interventions in place 2. Resident has cognitive deficits and mood disorder with episodes of unprovoked agitation, indifference, and poor decision making, leading to undesired behaviors. Behaviors include episodes of declination of needed personal care, medications and yelling out, with interventions in place as reviewed and observed. 3. Has impaired cognitive function related to dementia with interventions in place as reviewed and observed 4. Resident requires 24 hour care/supervision and wishes to stay in this facility under long term care, with interventions in place as reviewed 5. Resident uses anti-anxiety medication r/t Anxiety, with interventions in place as per review On 8/15/2024 at 11:00 a.m. the Nursing Home Administrator provided the Quality of Live - Homelike Environment Policy and Procedure, with a revision date of May, 2017, for review. The policy statement indicated; Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The Policy Interpretation and Implementation section revealed; 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include but no limited to: i. Comfortable noise levels.

Based on observation, interviews, and record review, the facility failed to follow their policy to 1. store medications appropriately in three of five (100-400 Hall) medication carts, failed to ensure controlled substances were appropriately stored in a locked drawer in one of two medications storage rooms (SSU Hall), and did not ensure expired [MEDICATION(S)] testing syringes were disposed of in one of two medication storage room refrigerators (100-300 Hall); 2. Failed to appropriately secure medications for two Residents (#67 and #334) of four residents. Findings included: A facility provided policy titled, Medication Storage, with no date, Page 01 of 01, was reviewed and read Policy: Medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Access to medications is limited to only authorized personnel. Procedure: 1. Storage areas may include, but are not limited to, drawers, cabinet, medication rooms, refrigerators, and carts. 3. Schedule II-IV medications must be maintained in a separately locked, permanently affixed compartments or cabinets. 6. Prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. 1. On 07/20/2022 at 3:10 p.m., an observation of the 400 Hall medication cart included in the second drawer from the top of the medication cart, two white round tablets, one half square white tablet, one quarter white tablet, and one round red tablet. Staff D, Registered Nurse (RN), confirmed the presence of the unsecured tablets. (Photographic Evidence Obtained.) On 07/27/2022 at 3:25 p.m., an observation of the medication the cart for 100-300 Halls included Twenty- and one-half loose pills in the second drawer from the top of the medication cart, two loose tablets in the fourth drawer from the top of the medication cart, and in the third drawer from the top of the medication cart, three loose pills. Staff C, (RN), confirmed the presence of the unsecured medications. On 07/27/2022 at 3:48 p.m., an observation of the medication cart located on the 200-300 Odd Hall included one loose pink tablet in the second drawer from the top of the medication cart. Staff E, (RN) confirmed the presence of the unsecured tablet. An observation was conducted on 07/27/2022 of the medication storage room for 100-300 Halls. During the observation with Staff C, (RN) she confirmed the presence of fifteen packets of [MEDICATION(S)] Injection 5/0.1 ML [MEDICATION(S)] purified protein derivative (PPD) injections, that had various expiration dates in the refrigerator as follows: (4) 7/19/2022 (1) 7/22/2022 (1) 7/16/2022 (1) 7/15/2022 (1) 7/14/2022 (1) 7/15/2022 (6) 7/24/2022 During an observation on 07/27/22 at 04:30 p.m., of medication room (SSU Hall) with Staff F, (LPN), the lockbox, that was affixed to the refrigerator, was seen to be open and not locked. Staff F, (LPN) confirmed the presence of a small white box containing two vials of Schedule IV Narcotic medication of [MEDICATION(S)] ([MEDICATION(S)]) 2MG/ML in it. Staff F, (LPN) further revealed that the lockbox drawer should be closed for all controlled substances, and that he was not aware the lockbox was open. According to The United States Drug Enforcement Administration (DEA) drug scheduling alphabetical listing, dated July 25, 2022- List of Scheduling Actions, Controlled Substances and Regulated Chemicals (usdoj.gov), with URL link: https://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdf Page 11 of 19, [MEDICATION(S)] ([MEDICATION(S)]) DEA number 2885, is a Benzodiazepine, a Schedule IV medication and a considered a controlled substance. On 07/27/2022 at 4:54 p.m., an interview was conducted with the Director of Nursing (DON). During the interview the DON was informed of the fifteen expired (PPD) medications in one of two medication storage rooms and was shown the picture of it. He was also informed of observations of unsecured medications found in the three medication carts. The DON revealed that his staff had notified him of the loose medications prior to the interview. The DON stated, My expectation is that the refrigerator permanently affixed lockbox will be locked appropriately, all unsecured medications, and expired medications should be checked for daily by all staff. On 07/27/2022 at 5:15 p.m., an interview with the DON and Assistant Director of Nursing (ADON) was conducted. The DON revealed he removed the Scheduled IV narcotic medication from the refrigerator and placed it in a double locked drawer for disposal. He was replacing the medication and reordered from the pharmacy. The ADON stated We did not know about the issue of the drawer being broken in the lock box, and we will fix it. 2. An observation was made on 07/26/22 at 9:25 a.m. of a [MEDICATION(S)] Powder bottle in a basket on Resident #67's bedside table. Photographic evidence was obtained. An observation was made on 07/27/22 at 9:07 a.m. of a [MEDICATION(S)] Powder bottle in a basket on the bedside table of Resident #67. Photographic evidenced was obtained. An observation was made of Staff A, Licensed Practical Nurse (LPN), on 07/28/22 at 9:13 a.m. looking into the basket on Resident #67's bedside table and pull the [MEDICATION(S)] Powder bottle out of it. Staff A stated the bottle of medication should not be in the basket. She said there was a [MEDICATION(S)] Powder bottle on the cart for Resident #67. Staff A stated Resident #67 did not have an order to self-administer the medication. Review of Resident #67's Admission Record revealed an admitted [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's orders revealed an order dated 06/22/22 for [MEDICATION(S)] Powder UNIT/GM to apply to abdominal folds topically every shift for abdominal fold redness. No documentation was found related to self-administering the medication. Review of the Minimum Date Set (MDS) dated [DATE] revealed in Section C. Resident #67 had a Brief Interview for Mental status (BIMS) score of 01, which indicated severe cognitive impairment. Review of the MDS dated [DATE] revealed in Section D. Resident #67 was rarely or never understood and a mood interview should not be conducted. Review of the Admission Data Collection dated 09/30/21 revealed in Section O. Medication Review Resident #67 does not self-administer medications. 3. On 7/25/22 at 10:15 am, an observation was made of Resident #334 sitting in her room. During this time, a bottle of unsecured medication was observed on the bedside table. The medication was labeled [name brand], Natural [MEDICATION(S)] with an expiration date of 12/2021. (Photographic Evidence was taken). On 7/27/22 at 9:15 a.m., Resident #334 was observed relaxing in bed. The bottle of medication was still on the bedside table. She was asked if she used the medication. She stated her son brought it, but she never used it. On 7/27/22 at 9:40 a.m., an interview was conducted with Staff G, LPN. He explained that on admission, it is explained to the residents that outside medications are not allowed due to possible reactions with medications that the nursing home is giving or wandering residents that may take the medication. Staff G removed the medication and discussed the above procedure with Resident #334. (3)

Based on observations, resident record, and interviews, the facility failed to develop care plan problem areas with interventions related to behaviors and the development of a potential rash for one (Resident #29) of thirty-eight sampled residents. Findings included: On 7/25/2022 at 10:00 a.m. and 12:40 p.m., Resident #29 was observed in her room and lying in bed. Both her left and right forearms and shoulder areas revealed multiple small scabbed areas. She was asked about her arms and she revealed staff had told her to stop scratching. She said she had tried to control her scratching and indicated the scabbed areas were from a rash that she could not explain. On 7/26/2022 at 11:40 a.m., Resident #29 was noted in her room with three staff members. The staff were about to transfer her from her wheelchair back to bed after she just returned from receiving a shower. The resident was observed with all the same scabbed areas on both her forearms and shoulders. The staff in the room could not explain the scabbed areas and did not know much about the resident. A review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #29 was her own responsible party. Review of the admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the current Quarterly Minimum Data Set (MDS) assessment, dated 5/9/2022 revealed: Cognition/Brief Interview Mental Status or BIMS score 13 of 15, which indicated the resident was able to answer questions related to her medical health and care; Activities of Daily Living or ADL - Bed Mobility = Resident requires Limited Assist with one person physical, Personal Hygiene = Resident requires Limited Assist with one person physical assist, Bathing = Is Self performance. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Apply skin prep to Right heel x shift for wound care. - Cleanse area to Right forearm with NS (normal saline), pat dry, apply xeroform cover with DCD (dry clean dressing) for abrasion (order date 6/23/2022). - [MEDICATION(S)] 25 mg 1 PO x 8 hours PRN for itching. (6/23/2022). Review of the progress notes dated from 4/8/2022 through 7/27/2022 revealed one note with documentation related to resident's forearms and read as follows. Nurse notes on 6/5/202, Pt has rashes on both arms which are not new. She scratched some areas on bilateral forearms. Cleaned with water and [MEDICATION(S)]. Bandages and a gauze wrap was applied supplied and labeled on both arms. The skin assessment dated [DATE] indicated multiple closed scratch marks to BUE (bilateral upper extremities) and BLE (bilateral lower extremities). Receiving medication with good effect. Areas showing signs of improvement. No open spots at this time. There were no other skin assessments with documentation related to the scratches or scabs. On 7/27/2022 at 9:30 a.m., an interview with the Licensed Practical Nurse (LPN) Staff T revealed he was aware of Resident #29's upper arms scabbing and that things had been getting better. He also stated her arms were much worse in the past but did not give a specific timeframe. He indicated the resident she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff T said the order was not clarified for [MEDICATION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no nurse progress notes or care plans that indicated the resident picks at her arms, and no care planning problem area to support that behavior. On 7/27/2022 at 11:45 a.m., an interview with Resident #29's Nurse Practitioner revealed he had been treating her arms for what he believed to be Pruritis. He said there might be a neurological condition related to her picking at the areas and he would now order a psych consult to address it. Review of Resident #29's current care plans with a next review date of 8/7/2022, revealed the following areas: - ADL self care deficit r/t (related to) impaired balance, ROM (range of motion), history of fracture right ankle with interventions in place and as per observation - Does not cooperate with care r/t refusing meds at times with interventions in place as reviewed and observed There were no care plan problem areas related to either behaviors of picking, or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/28/2022 at 7:45 a.m., an interview with both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed they were aware Resident #29 had scabbing on her arms and the physician was treating the areas with ointment. They were not aware of the reason for the ointment until today (7/28/2022). After review of the electronic record they confirmed the resident has had this scabbing/itching since 6/5/2022. They confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and ADON did not know why the care plans were not developed, but confirmed that there should have been a care plan developed for either behaviors of picking or for skin conditions specific to rash/pruritis. On 7/27/2022 the Director of Nursing provided the Comprehensive Resident Centered Care Plans policy and procedure, not dated, for review. The Intent of the policy revealed: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharged for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. It will be consistent with the medical plan of care and those disciplines that have direct involvement with the resident's care. The care plan will contain information about the physical, emotional, psychosocial, spiritual educational and environmental needs as appropriate. It is our (facility) purpose to ensure that each resident is provided with individualized, goal directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care. Procedure: (2.) The facility must develop and implement a comprehensive person centered care plan for each resident , consistent with the resident rights set forth at 483.10( c )(2) and 483.10( c )(3), that includes measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (a) The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well being as required under 483.24, 483.25 or 483.40. Developing the Care Plan: (3) Each discipline will check and / or add interventions/approaches to include but not limited to: (a) The intervention statements describe those measures performed by the staff to help the resident achieve the expected outcomes. (b) [MEDICATION(S)] entries reflect activities that incorporate observations, assessments, management and teaching components that will restore, maintain and /or promote the resident's well-being. Updating Care Plans: (1) Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. (3.) The care plans will be updated and/ or revised for the following reasons: a. Significant change in the resident's condition b. A change in planned interventions c. Goals are obtained and new goals established to meet current resident needs and/or goals d. New diagnosis, new medications, or abnormalities (4.) Any revision, additions, or deletion to the care plan will be dated and initiated.

Based on interviews and record review, the facility failed to ensure behavior monitoring was in place for one (Resident #67) of three sampled residents on [CONDITION(S)] medications. Findings Included: A review of admission records indicated Resident #67 was admitted on [DATE] with diagnoses including [CONDITION(S)], unspecified dementia without behavioral disturbances, and [CONDITION(S)]. A review of orders revealed an order for [MEDICATION(S)] Tablet 25 milligrams (mg). Give 25 mg by mouth at bedtime related to Unspecified .Dementia without Behavioral Disturbances. Start date: 01/04/22. Review of the electronic Medication Adminsitration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for the months of May, June, and July of 2022 did not include any behavior or side effects monitoring for [CONDITION(S)] medications. Resident #67's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C. (Cognitive Patterns) revealed Resident #67 had a BIMS (Brief Interview for Mental Status) score of 1, which indicated severe cognitive impairment. Resident #67's MDS dated [DATE] was reviewed. Section N. (Medications) of the MDS indicated Yes-Antipsychotics were received on a routine basis only. Review of the care plan with a focus area dated 10/28/21 and revised on 07/27/22, revealed Resident #67 has cognitive deficits and mood disorder with episodes of unprovoked agitation, indifference, and poor decision making, leading to undesired behaviors .The goal dated 10/28/21 and revised on 07/27/22, revealed Resident #67 will be free from negative outcome related to (r/t) declination of medication .The interventions include .observe/report any change in condition (07/27/22) .A focus area dated 11/16/21 and revised on 07/27/22, revealed Resident #67 has impaired cognitive function/dementia and impaired thought processes r/t Dementia. The goal dated 11/16/21 and revised on 07/27/22, revealed Resident #67 will be able to communicate basic needs on a daily basis .No care plans were currently in place for behavioral monitoring or use of [CONDITION(S)] medication. An interview was conducted on 07/27/22 at 9:24 a.m. with Staff B, Certified Nursing Assistant (CNA). She stated Resident #67 hollers out a lot and answers herself a lot. She noted Resident #67 has conversations with herself. Staff B said she usually reports changes in moods to the nurse. In an interview with the Director of Nursing (DON) conducted on 07/27/22 at 9:42 a.m., he stated the expectation for residents with Dementia taking antipsychotic medications was to have behavioral monitoring in place. Observed the DON look through Resident #67 orders to find an order for behavioral monitoring. The DON confirmed there was not an order in place for behavioral monitoring. Review of the Behavior and Psychoactive Management Problem under Facility's Behavior Management Program will consist of: 3. Monitoring the resident's behavior(s) to establish patterns, determine intensity and behavior frequency, and identifying the specific (targeted) behavior(s) that are distressing to the resident which are decreasing the resident's quality of life. Under Behavior Management Team Care Process: 1 .The behavior Management Team will effectively manage the psychoactive medication process for the residents by: d. Monitoring on a regular basis, and with change in the approaches implemented for effectiveness

Based on record review and interviews, the facility failed to ensure a safe and orderly discharge for one resident (#1) of three sampled residents. Resident #1, a [AGE] year old male, was discharged home where he lived alone, with no running water inside of the home, holes in the walls, floors, and ceiling, an inadequate food supply, and no means for communication outside of the home due to no telephone or computer. Findings included: Review of Resident #1's Admission Record revealed an original admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a 5 day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/11/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition, inattention, and disorganized thinking continuously. The resident required limited assistance with one-person physical assistance for walking in room and corridor, and locomotion on the unit. The resident required supervision with one person physical assistance for personal hygiene and needed physical help with transferring by one person during bathing. The assessment indicated Resident #1 was not steady and was only able to stabilize with staff assistance for moving from seating to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfers. The MDS indicated active discharge planning was already occurring for the resident to return to the community. The MDS was signed as completed by the Registered Nurse (RN) on 5/17/22. A review of a Physical Therapy (PT) Evaluation Only with no additional treatment dated 5/12/22 revealed an assessment summary of: Communication Ability to Express Ideas and Wants = Usually understood; Ability to Understand Others = Usually understands; Follows 1-Step Directions = Independently with prompts/cues Cognition Decision Making Ability for Routine Activities = Moderately Impaired Reason for Therapy Clinical Impressions/Reason for Skilled Services: Pt [patient] is at PLOF [prior level of function]. Indep[endent] with bed mobility, transfers with supervision and amb [ambulation] with WW [wheeled walker] > [greater than] 300 with CGA [contact guard assistance]. Pt would be appropriate for ALF [Assisted Living Facility]. Pt does requires [sic] supervision secondary to poor safety awareness/impulsive Complexities Barriers likely to Impact Discharge to Next Level = Multiple medications/management required Patient Characteristics that may Impact Treatment = Addiction/alcohol. Lacks insight into condition and risk factors Intervention Modes Can interventions be provided using treatment modes other than individual? = No A review of a 5/17/22 Psychiatric Assessment completed by Staff D, a Psychiatric Advanced Practitioner Registered Nurse (APRN) revealed the reason for the visit was primary care physician request to establish patient with multiple psych issues and [CONDITION(S)]. History of present illness: [CONDITION(S)], forgetfulness, [CONDITION(S)], [CONDITION(S)], hypertension, muscle spasm, and shortness of breath. The mental status exam revealed Resident #1's behavioral mood was anxious, flat, sad, and friendly. His speech was normal; his motor behavior was calm; he was alert and oriented times 3; his thought process, memory, judgement, and insight were intact; and he exhibited no evidence of harm to self/others. A review of a 5/18/22 note by the APRN (Staff C), who works with Resident #1's attending physician, revealed the reason for the appointment was a follow-up and patient is status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Now here for close management of these acute illnesses in the postacute rehabilitation setting. The APRN noted an interim history to include: The patient may be considered unstable due to recent hospitalization and therefore would require complex medical decision making to keep him from returning to the hospital, reduce morbidity, and reduce mortality. 24-hour nursing care was required to implement the medical plan. Subsequent follow up visits would be needed to maintain stability in this complex patient. Travel outside of the facility may contribute to further decompensation and therefore all efforts will be made to provide services in house when available and appropriate by our team. The treatment notes revealed We will continue to follow and monitor the patient's current medical conditions .Procedures: .We will continue with 24 hour nursing care. Will follow . The note was electronically signed by the APRN on 5/23/22. A review of the discharge MDS assessment - return not anticipated with an ARD of 5/26/22 and signed as completed by the RN on 6/1/22 revealed the resident's BIMS score had slightly improved to a 13 out of 15 indicating intact cognition. The functional status section of the MDS indicated the resident required supervision with transfers, walking in the room and corridor, locomotion off the unit, dressing, toilet use, and personal hygiene. The resident was totally dependent for bathing. A review of the functional abilities and goals for discharge section of the MDS revealed the resident was independent with oral hygiene, toilet hygiene, bathing, and dressing. The MDS also indicated that the resident was independent with no additional concerns with balance. A review of the progress notes for April, May, and June 2022 revealed no notes related to discharge planning and no entries or assessments by social services. A review of Resident #1's care plans revealed no care plan was present related to discharge, discharge planning, or long term care placement. On 06/09/22 at 12:30 p.m., the Assistant Director of Nursing confirmed that she did not observe any care plans related to discharge. Interview with the Social Services Director (SSD) on 6/9/22 at 3:54 p.m. revealed she has not been documenting in the clinical records for residents and has not been doing the care plans. She stated she spends a lot of face to face time with the residents and needed to get caught up with the documentation part of her position. A review of a form titled Discharge Request dated 05/24/22 with a discharge date of [DATE] revealed: 1. Patient to discharge home with home care for nursing, physical therapy and occupational therapy; 2. DME (Durable Medical Equipment) required: [NAME] and Wheelchair; 3. Home Health Company: [name of home health agency]; 5. Pharmacy: May discharge with medications and narcotics as indicated. The form was signed by Staff C, APRN and dated 5/24/22. A review of the Discharge Plan and Instructions with an effective date of 05/26/22 at 14:44 (2:44 p.m.) revealed Resident #1 was discharged home alone via car. Interview with the SSD on 6/9/22 at 11:54 a.m. revealed the resident left in a taxi, and she walked him out along with one of the nurses that day. A review of another State Agency's report dated 5/27/22 revealed: Resident #1 was a vulnerable adult suffering from depression, anxiety, [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), left eye vision loss, and [CONDITION(S)]. He shuffles when he walks and was unbalanced. Resident #1 wears glasses and was supposed to use a walker to assist with walking. He currently lives in a trailer with no running water and a caved in roof. Rodents have eaten some of his medications, there was an odor and the toilet will not flush because the sewer line needs replacing. Resident #1 was unclean, dirty, had not bathed, and had been drinking five to six drinks a day since he was discharged . There was a bottle of liquor on his counter. Resident #1 lives alone and does not have any family or friends available to provide assistance or caregiving support or services. He does not drive and does require assistance for transportation services including shopping/errands. His residence has hazardous living conditions, and he does not have an adequate amount of food in the home. There are verified findings of self neglect. The residence presented with poor sanitation and cleanliness. Resident verified his home does not have running water inside the home. He verified he does have a history of alcoholism and lives in deplorable conditions. He verified his home has holes in the walls and floors and ceiling. He verified he does not currently have any way to communicate outside of the home due to no telephone or a computer. He verified he is a high risk for falling and is aware of his residence needing corrective action to clean the home. The report also contained photographic evidence of the home. On 06/08/22 at 12:24 p.m., an interview was conducted with an Adult Protective Services Investigator who visited Resident #1's home post discharge from the facility on 5/27/22. He stated, this was definitely an inappropriate discharge and the term deplorable living conditions does not begin to describe the place Resident #1 was discharged to. The investigator described Resident #1's cognition as just north of the border of capacity. On 06/08/22 at 9:37 a.m. and 10:03 a.m., attempts were made to reach Resident #1 via the phone number listed on the facility's Admission Record. The phone did not ring, and voicemail came on immediately stating voicemail was not set up yet. On 06/08/22 at 9:58 a.m., a telephone interview was conducted with the family member listed on Resident #1's Admission Record. The family member reported he lived out of state and had not seen the resident's home, but the resident told him that his home was pretty bad. He reported to him that water pipes were broken and there were holes in the walls. Resident #1 told him that he was trying to find an Assisted Living Facility (ALF). The family member stated, You should ask the nursing home why they sent him there like that. On 06/08/22 at 10:55 a.m., the Social Service Director (SSD) reported she had been employed by the facility since December 2021. The SSD reported that if a resident was discharging home, she would speak to therapy to see how far they are walking and what equipment they are using. She would also speak with the doctor to ensure it was a safe discharge. She would then speak to the resident to see what equipment they would need, write out the discharge order, and fax the order to the doctor. If the resident had a home health agency they preferred she would set up services with that company otherwise, she usually recommends a home health care agency. She sends a fax to the home health agency indicating the resident was discharging and what services they would need. The SSD reported that about 2 weeks prior to Resident #1's discharge, she sent Resident #1 to the home with the facility's Unit Clerk, (Staff A) to get some of his belongings. On 06/08/22 at 11:02 a.m., Staff A, Unit Clerk/Certified Nursing Assistant (CNA), confirmed she went out to the home with Resident #1 (prior to Resident #1's discharge date ). She stated the resident lived in a trailer. When they arrived, the door was open, but a screen was nailed across the bottom of the door. The top portion of the door was wide open allowing anything to come in and out of the house. A neighbor came over and unnailed the screen at the bottom of the door so they could go in. Staff A stated, it was deplorable. Everything had paper overflowing. There was stuff everywhere and you could not see the floor in the home. There were holes in the wall in the bedroom. The lights were on but there was no running water. Staff A, said she told the resident, He can't live in here. Resident #1 stated that was how he lived and that was fine with him. He stated that was how he lived for [AGE] years. Staff A stated he became agitated because she kept telling him he couldn't live like that. The resident stated he didn't cook and all he used was the microwave. He kept stating it was fine. Staff A stated she reported the condition of the home to the SSD when she returned to the nursing home that day. Staff A was shown the photographic evidence attached to the other State Agency's report. Staff A confirmed that these pictures were from the same home she had visited with the resident weeks earlier. She reported picture #1 was the porch, pictures #2-6 were the kitchen, picture #7 was to the right of the kitchen, pictures #8-10 was the bedroom, picture #11 was the porch, picture #12 was the kitchen, pictures #13-15 was the porch, picture #16 was the bedroom, and picture #17 was the porch. She stated the home smelled unlived in and wet. On 06/08/22 at 11:12 a.m., the SSD reported Resident #1 was asking every day to go home. He said he had so many things to get. He continued to say he really wanted to go home. She tried to convince him to go to an ALF, showed him pictures, and told him they had a pool. The resident told her he was not high maintenance, and he didn't need all of that. She was getting worried and didn't want him to leave Against Medical Advice (AMA). The SSD stated she called the Psych APRN (Staff D) to do a psych evaluation because he was not understanding that no one should live in the condition of the house like that. Resident #1 stated he loved his home. He had so many things there and he was a writer. The psych APRN evaluated him and reported he was alert and oriented and had capacity. The SSD reported that the day after the resident discharged , she placed a call to an outside state agency related to the condition of the home. She felt he was a risk to himself, and the home was not livable. The SSD stated she can't force residents to stay if they are fully intact and want to go home. The outside agency accepted the report, and they called her the day after she submitted the report. The SSD reported she did not document the identification number of the person that accepted the report, and they had no contact with her after that. The case worker from the outside agency reported she talked to him, went out to the home, and the resident was now understanding that his home was not in a livable condition. The case worker spoke to the resident about going to an ALF, and he agreed. The SSD reported she was not sure if he had been admitted to the ALF. As of that time, the SSD was not sure where Resident #1 was. On 06/08/22 at 11:30 a.m., the SSD reported that she found out Resident #1 had moved into an ALF. (This was verified by another state agency's report on 6/10/22). The SSD stated she spoke with the Administrator of the trailer park where Resident #1 lived, and stated that she was told Resident #1's electricity was working. The water was turned off on the inside of the home, and the resident could turn the water on outside of the house to use the water. On 06/08/22 at 1:12 p.m., the SSD reported that Staff C, APRN for the attending physician had signed the discharge order but she also consulted with another Medical Doctor, Staff B, about the condition of the home and the resident's wish to discharge. She told this other Medical Doctor/Staff B that she would have Staff D, the Psych APRN evaluate the resident. The SSD stated that Staff B, Medical Doctor, said if Resident #1 wants to go, they couldn't keep him in the facility. On 06/08/22 at 1:50 p.m., Staff B, Medical Doctor, was interviewed and reported that he thought Resident #1 was discharging to an ALF. Staff B reported that he probably would not send a resident to a home in deplorable conditions. The condition of Resident #1's home was described to Staff B, Medical Doctor. The Medical Doctor stated, he was not aware of the condition of the home. On 06/08/22 at 1:22 p.m., a telephone interview with the sales representative from the home health agency revealed they never went out to Resident #1's home because they did not accept his insurance. On 06/08/22 at 1:32 p.m., the SSD was asked if Resident #1 was discharged with physical therapy, occupational therapy, nursing and a walker per the discharge orders. She stated he finished PT/OT in the facility. He was able to walk out of the facility. The SSD said she had found out that the home health agency didn't accept the insurance for Resident #1 after the resident was already discharged from the facility. She stated that she should have made sure they accepted his insurance before he left the facility, but he did not need any services or equipment. She stated from a social service standpoint, he had his rights, and the doctor was ok with them discharging him home. She stated the resident told her he had a walker at home. She stated that the lack of home health also helped to prompt her to call in the report to the other state agency the day after discharge because it was weighing on her mind. On 06/08/22 at 2:11 p.m., the Nursing Home Administrator (NHA) was informed of the concerns related to Resident #1's discharge from the facility. The NHA stated, It is a safe discharge. After showing the NHA the photos from the home, he stated he had seen houses a lot worse than that, and some people choose to live like hoarders every day. The NHA stated the resident had lived at this place for [AGE] years and that's where he wanted to be. He stated Resident #1 had a right to go home because they received an order from the doctor, and he was evaluated by psych and social services and found to have capacity. The NHA continued on to state they can't make a resident stay if they don't want to stay in the facility. On 06/09/22 at 10:55 a.m., Staff E, Physical Therapist, stated she treated Resident #1 in the past and had last evaluated him on 5/12/22. He was reassessed to see where his functional status was to see if it was ok for him to discharge. Her evaluation found that he was independent with bed mobility. He needed supervision with transfers, was walking more than 300 feet with a two wheeled walker with supervision, and independent with a wheelchair. His strength was within normal limits and he had no range of motion concerns. Because of his decreased safety awareness and impulsiveness, he would need supervision so the plan was for him to go to an ALF. He was ok with it at first and for some reason, he changed his mind. Her recommendation was to go to an ALF. She was never told he was going home. She would have said it would be unsafe to discharge him home because of his history with alcoholism, and she would not have made the recommendation to send him home. She stated he had capacity and could make his own decisions. If a resident wants to go home, you can't stop them, but because he was no longer on therapy case load, she didn't know he was going home. She had not done home evaluations since the pandemic started. The Physical Therapist stated Resident #1 originally came to the facility because he was an alcoholic, and they found him on the ground. On 06/09/22 at 12:38 p.m., Staff C, the APRN who had been seeing Resident #1 routinely during his stay at the facility and wrote the discharge order dated 5/24/22 was interviewed by telephone. Staff C stated cognitively, Resident #1 was good to go, and he just wanted to go home. He found out about the home situation after he was discharged . Staff did not tell him about that prior to the discharge. When they discharge a resident, they must make sure the residents are safe. He would not have sent him home if he would have known about the condition of the home. Clinically, he was safe and stable. We want them to be safe. If he had known about this, he would have wanted those things (like the water) to be resolved before discharging the resident. He stated he was not privy to that information related to the condition of the home when he signed the order for discharge. On 06/09/22 at 2:10 p.m., the Psych APRN, Staff D was interviewed. She reported that she had only seen Resident #1 one time because she was asked to assess his capacity. She did not recall staff telling her that this was needed to assess to see if it was safe for him to go home. That does not ring a bell. She only completed a random admission assessment. When she went to see him in his room, he was nasty, not cooperative, didn't want to talk, said he was busy, and didn't have time for her, but she did find him to be alert and oriented x 3 and he did appear to have capacity. Staff D was informed that Resident #1 was discharged to a home with no running water and a roof that was caving in. She stated I would not send someone home without running water. She stated they must be able to take a shower and groom themselves. That's a basic human necessity. On 06/09/22 at 4:40 p.m., the Administrator again stated he didn't understand how this was an unsafe discharge if the resident wanted to go home and had the capacity to make this decision. He stated the resident lived like this for [AGE] years and that he had seen worse living conditions than this. A review of the undated facility policy and procedure titled Discharge Planning/Implementation revealed the following: Policy: It is the policy of the facility that the Social Work Department, along with the Interdisciplinary Team, begin discharge planning for each resident upon admission to the facility . Procedure: . 6. The Social Worker will maintain contact with the Interdisciplinary Team to facilitate an appropriate discharge for the resident and ample time to coordinate plans with the resident's designated representative and applicable community agencies. 7. The Social Worker, with the Interdisciplinary Team will examine and document the following: a. Medical condition/prognosis of the resident; b. Support from family/designated representative; . d. Housing situation of the resident; e. Home care needs of the resident; j. The physician's determination of the appropriateness of discharge of the resident; k. Barriers to the discharge and plans to overcome them; i. Identification of community referrals; m. Description of future living arrangements; n. Assessment of the environment the resident is entering, with a focus on safety and ability to maneuver and live in these surroundings (i.e. wheelchair accessibility, elevators, etc.) o. In cases where the resident is independent in activities of daily living, factors such as mental status, ability to take medication, potential for return to drug use (if this is a risk factor), ability to protect him/herself from infection, ability to maintain weight, as well as the adjustment to the home setting, are some of the issues to be considered .

Based on record reviews and interviews, the facility failed to develop a discharge care plan for three residents (#1, #2, #3) of three sampled residents. Findings included: 1. Review of Resident #1's Admission Record revealed an original admitted [DATE], and a discharge date of [DATE] to private home with home health services. A review of a 5 day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/11/22 revealed active discharge planning was already occurring for the resident to return to the community. The MDS was signed as completed by the Registered Nurse (RN) on 5/17/22. A review of the progress notes for April, May, and June 2022 revealed no information related to discharge planning by social services, the interdisciplinary team, or any other departments/staff. A review of Resident #1's care plans revealed no care plan was present related to discharge, discharge planning, or long term care placement. On 06/09/22 at 12:30 p.m., the Assistant Director of Nursing confirmed that she did not observe any care plans related to discharge. Interview with the Social Services Director (SSD) on 6/9/22 at 3:54 p.m. revealed she has not been documenting in the clinical records for residents and has not been doing the discharge care plans. She stated she spends a lot of face to face time with the residents and needed to get caught up with the documentation part of her position. 2. Review of Resident #2's Admission Record revealed an original admitted [DATE] and a discharge date of [DATE] to private home with home health services. A review of a 5 day MDS assessment with an ARD of 5/25/22 revealed the resident participated in the assessment and expects to be discharged to the community. The MDS indicated that no active discharge planning was already occurring for the resident to return to the community. The MDS was signed as completed by the Registered Nurse (RN) on 5/30/22. A review of Resident #2's progress notes revealed no notes related to discharge planning by social services, the interdisciplinary team, or any other departments/staff. A review of Resident #2's baseline care plan and other care plans on file revealed no care plans related to discharge or discharge planning. Interview with the SSD on 6/9/22 at 12:01 p.m. revealed Resident #2 wanted to go home or he was going to leave Against Medical Advice (AMA). The resident was discharged back to home where he lives with his sister and home health was set up. Follow-up interview with the SSD on 6/9/22 at 3:54 p.m. confirmed that she did not document on Resident #2 and no discharge care plan was developed. 3. Review of Resident #3's Admission Record revealed an original admitted [DATE], and a discharge date of [DATE] to private home with home health services. A review of an admission MDS assessment with an ARD of 05/6/22 revealed the resident and a family or significant other participated in the assessment and the resident expects to be discharged to the community. However, no active discharge planning was occurring for the resident to return to the community. The MDS was signed as completed by the Registered Nurse (RN) on 5/12/22. A review of Resident #3's Care Area Assessment (CAA) Summary dated 5/12/22 revealed the resident did not trigger for the care area of return to community referral, and no care plan was developed for discharge/discharge planning. A review of Resident #3's baseline care plan dated 4/29/22, prior to the admission MDS and development of a comprehensive care plan, did include a care plan for discharge with a goal of returning to community. Review of this baseline care plan revealed no interventions were check marked to assist the resident in returning to the community. A review of the progress notes for April and May 2022 revealed no information related to discharge planning by social services, the interdisciplinary team, or any other departments/staff. On 6/9/22 beginning at 12:01 p.m., an interview was conducted with the SSD. She stated Resident #3 had a caretaker/close friend at the home and was alert and oriented x 3. She was another resident who was going to leave AMA if we didn't let her go, so the physician wrote the order to discharge home with home health services of physical and occupational therapy, and nursing with a walker. Follow-up interview with the SSD on 6/9/22 at 3:54 p.m. confirmed that she did not document on Resident #3 and no discharge care plan was developed. Review of the undated policy and procedure provided titled Discharge Planning/Implementation revealed: Policy: It is the policy of the facility that the Social Work Department, along with the Interdisciplinary Team, begin discharge planning for each resident upon admission to the facility. Discharge potential and review of available discharge planning options are also reviewed during Quarterly and Annual Comprehensive Care Plan Meetings. Procedure: 6. The Social Worker will maintain contact with the Interdisciplinary Team to facilitate an appropriate discharge for the resident and ample time to coordinate plans with the resident's designated representative and applicable community agencies. 7. The Social Worker, with the Interdisciplinary Team will examine and document the following: b. Support from family/designated representative d. Housing situation of the resident e. Home care needs of the resident m. Description of future living arrangements n. Assessment of the environment the resident is entering, with a focus on safety and ability to maneuver and live in these surroundings (i.e. wheelchair accessibility, elevators, etc.) p. When discharge is the appropriate plan of action, the Social Worker will contact the agencies providing concrete and supportive services, in order to achieve a transition with minimal upheaval and to ensure continuity of care. The Social Worker will complete all required forms and referrals or arrange to have them completed t. If the Interdisciplinary Team determines that the resident's return to home with family is appropriate, the Social Worker will make all arrangements for home care services, equipment, etc. w. The Social Worker will document all aspects of the discharge plan on the discharge planning care plan and social work progress notes.

Based on record reviews and interviews, the facility failed to complete a discharge summary for two residents (#1 and #3) of three sampled residents. Findings included: 1. Review of Resident #1's Admission Record revealed an original admitted [DATE], diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes for April, May, and June 2022 did not reflect any notes related to discharge planning or the discharge that occurred for Resident #1 by any disciplines. A review of the Discharge Plan and Instructions with an effective date of 05/26/22 at 14:44 (2:44 p.m.) revealed the following: Resident #1 was discharged home alone via car. Section 2 Physician Information a. The Physician and/or physician extenders who will follow you once you are discharged was blank. Section 3 Summary of Stay C. Additional information pertinent to discharge and skin evaluation prior to discharge or leave of absence must be completed on all discharges was blank and was not signed. Section 4 Functional Mobility/Self Care Skills This section was blank and was not signed. Section 5 Nutrition This section was blank and was not signed. Section 6 Discharge Summaries A. Discharge Summaries B. Medication Summary C. Treatment Summary E. Equipment All sections were blank and not signed. Section 7 Managing Your Future This section was blank and not signed. Section 8 Acknowledgements This section was blank and not signed. Section 9 Discharge Body Audit This section was blank and not signed. On 06/09/22 at 11:54 a.m., the Social Services Director (SSD) stated she didn't give Resident #1 any papers upon discharge. He had a bag with medications, so she knows he left with medication although this portion was not completed on the discharge form. They called him a taxi and she walked him out with one of the nurses. She does not know if any discharge planning notes were documented, but they went in the room to talk to him. On 06/09/22 at 12:30 p.m., the Assistant Director of Nursing confirmed the discharge plan and instructions were incomplete. 2. Review of Resident #3's Admission Record revealed an original admitted [DATE], and a discharge date of [DATE]. A review of the progress notes for April and May 2022 revealed no information related to discharge planning or the discharge that occurred for Resident #3 on 5/27/22 by any disciplines. A review of the Discharge Plan and Instructions for Resident #3 with an effective date of 5/27/22 at 9:36 a.m. revealed: 1. Summary of Discharge: Indicates resident was accompanied by family and discharged to home via car. discharged from (Center Name): BLANK Center Phone # (number): BLANK. 2. Pharmacy phone # was listed incorrectly and was the physician's phone #. d. Office Visits have been scheduled as follows: BLANK E. Home Health Services: Phone # and Contact Name: BLANK F. Medical Equipment Supplier: Phone # and Contact Name: BLANK. 3. Summary of Stay Admission Diagnosis(es): BLANK Reason for Discharge: BLANK. A. Services provided during stay: 1. Services provided Included checkmarks under: fluids/nutrition, antibiotics, Physical Therapy and Occupational Therapy. Review of the 5/6/22 Minimum Data Set Assessment and progress notes revealed the resident also received Speech Therapy, Wound care, and IV (intravenous) therapy but these items were not checkmarked on the Discharge Instructions 2. Discharge Diagnosis (es): BLANK 4. Skin Conditions: BLANK 5: Pain: BLANK 6. Other: BLANK Signature and Date for entire section of 3. Summary of Stay: BLANK. 4. Functional Mobility/Self Care Skills - all areas were completed but the area for signature and date was BLANK. 5. Nutrition: Dietary recommendation was completed but the area for signature and date was BLANK. 6. Discharge Summaries: 1. Activity Discharge Summary: BLANK 2. Social Services Discharge Summary: BLANK 4. Nutrition Discharge Summary: BLANK 5. Therapy Discharge Summary: BLANK B. Medication Summary - NO CHECKMARKS FOR : provided and reviewed pharmacy medication profile, prescriptions sent with resident, medications sent with resident C. Treatment Summary: Treatments/therapy needed UNCHECKED E. Equipment Needed: UNCHECKED Signature and Date for Discharge Summaries: BLANK. 7. Managing Your Future Please do not hesitate to reach out to us if you have questions in the meantime. Listed below are the staff members who will be glad to assist you with this. Entire section is BLANK to include a post discharge phone call; admissions name and telephone #; nursing name and phone #; social services name and phone number. 8. Acknowledgements: 2. This booklet has been reviewed with me and I understand the information. My questions have been answered and I have been given a copy of the booklet. An additional copy has been placed in my medical record. 2a. A copy of this plan was given to : BLANK 3. Personal belongings have been released and signed for on the inventory sheet: UNCHECKED with patient/responsible party signature/date and time - BLANK; Health Coach signature date and time BLANK; Nurses Signature date and time BLANK 9. Discharge Body Audit: Skin intact - YES or NO both UNCHECKED; check and describe all applicable current skin conditions with no sites or descriptions marked. On 06/09/22 at 12:30 p.m., the Assistant Director of Nursing confirmed that the discharge plan and instructions were incomplete. On 06/09/22 at 3:54 p.m., the SSD reported she documents notes but a lot of times she writes in her own notebook and uses check off list. She spends most of her time in the residents' rooms and doing FaceTime calls with families. She was aware that she needed to get caught up with documentation and confirmed the lack of social services/discharge planning notes in the residents' records. Review of the undated policy and procedure titled Discharge Planning/Implementation revealed: Policy: It is the policy of the facility that the Social Work Department, along with the Interdisciplinary Team, begin discharge planning for each resident upon admission to the facility. Procedure: 6. The Social Worker will maintain contact with the Interdisciplinary Team to facilitate an appropriate discharge for the resident and ample time to coordinate plans with the resident's designated representative and applicable community agencies. 7. The Social Worker, with the Interdisciplinary Team will examine and document the following: b. Support from family/designated representative d. Housing situation of the resident e. Home care needs of the resident m. Description of future living arrangements n. Assessment of the environment the resident is entering, with a focus on safety and ability to maneuver and live in these surroundings (i.e. wheelchair accessibility, elevators, etc.) p. When discharge is the appropriate plan of action, the Social Worker will contact the agencies providing concrete and supportive services, in order to achieve a transition with minimal upheaval and to ensure continuity of care. The Social Worker will complete all required forms and referrals or arrange to have them completed s. Prepare a Comprehensive Discharge Summary to be sent with the resident when she/he is discharged , place a copy in the resident's medical record and a copy in the resident's social work file t. If the Interdisciplinary Team determines that the resident's return to home with family is appropriate, the Social Worker will make all arrangements for home care services, equipment, etc. w. The Social Worker will document all aspects of the discharge plan on the discharge planning care plan and social work progress notes.

Based on observation, interview with Resident #1, interview with the family of Resident #1, facility staff interviews, medical record review, outside agency reports, and review of facility policies and procedures, it was determined that the facility failed to provide adequate supervision to one (Resident #1) of six residents who were identified as at risk for elopement. Resident #1 was assessed on admission as an elopement risk due to his known routine of visiting his wife in the facility prior to his admission. Based on the resident's cognitive impairment, independent mobility either ambulating or with the use of a wheelchair, poor decision making skills, wandering oblivious to safety needs, and his ability to exit the facility, the facility chose to place a wander monitoring bracelet (a device that will trigger an alarm to alert staff to the resident's location and may lock a door to prevent exiting) on the resident's right ankle. Within one week of his admission, he was observed pushing on an exit door and was able to step out of the building which resulted in initiating 15 minute checks of his location. One week later Resident #1 left the building through the front door. The alarm sounded; however, staff did not investigate the cause. Staff who were assigned to care for Resident #1 on 12/11/2021 during the 3 PM to 11 PM shift did not complete the 15 minute check documentation and four of the direct care providers reported they were unaware of the order to provide 15 minute observation checks of Resident #1. Resident #1 was found by the county sheriff 0.1 miles from the facility due to someone reporting they saw a person unsteady and stumbling walking along the curvy, two lane highway (speed limit 45 miles per hour) at dusk. Facility staff were not aware that Resident #1 had left the building until a sheriff's employee phoned the facility. The facility's failure to supervise and document the location of Resident #1 during the evening of 12/11/2021, failure to investigate the front door alarm, and failure to individualize Resident #1's care plan to maintain the resident's safety to ensure all staff were aware of the resident's past routine of walking to and from his nearby home to visit his wife in the same nursing home, resulted in the findings of Immediate Jeopardy. While the resident was out of the building, he could have fallen, been hit by a car, and/or gotten lost . The Immediate Jeopardy began on 12/11/2021 and was removed on 12/14/2021, with a Scope and Severity reduced to a D. Findings Included: Resident #1 was a [AGE] year old male admitted to the facility on [DATE], according to the resident's face sheet, which included the reasons for admission as [CONDITION(S)], history of falling, muscle weakness (generalized) and unspecified [CONDITION(S)]. In an interview conducted on 12/21/2021 beginning at 4:05 p.m., with the resident's family, it was confirmed that the resident was admitted to the facility for short term rehabilitation after multiple falls at home. The son reported they thought if Resident #1 had some physical therapy he would be stronger and more stable. The son added that they felt he needed to use a walker, but his dad was denying the need. They felt if he heard it from the therapist, maybe he would believe the therapist and use the walker. The son confirmed that before his admission, his dad visited his wife daily, walking the 0.6 miles from his home to the facility and walking back after the visit. The son said he never knew his dad to fall when he walked between the facility and home, but once his dad got home, you could see he was tired after the walk. A review of the resident's physician orders revealed medications ordered upon admission included [MEDICATION(S)] tablet 137 mcg, one tablet in the morning for [CONDITION(S)]; [MEDICATION(S)] Tablet 2.5 mg, one tablet by mouth two times a day, related to unspecified [CONDITION(S)]; and [MEDICATION(S)] mg, three tablets by mouth every eight hours as needed for pain. Additional orders dated 12/06/2021 were noted for a wander monitoring bracelet, placed on the RLE (right lower extremity), check for placement and function; and anticoagulants, check for bleeding and bruising every shift. The physician's orders included resident to be one on one for safety every shift with a start date of 12/11/2021. Review of the record revealed there was not an order, until 12/06/2021, for the placement of the wander monitoring bracelet, which was assessed and placed at admission, on 11/30/2021. Upon admission, on 11/30/2021 at 18:15 (6:15 p.m.), the Admission/Readmission Data Collection form was completed for Resident #1. The admitting diagnosis was listed as persistent ground level falls, unsteady gait. The resident's cognition was checked as alert, oriented to person, place, time with a memory problem. His hearing and vision were identified as adequate, and his speech was clear. He was able to make himself usually understood by others and his ability to understand others was assessed as sometimes understood. Resident #1's mood was assessed as pleasant with confusion; and he had the behavior of wandering. His physical functioning was assessed a needing supervision of one person to transfer and to walk or get around in a wheelchair. The Admission Assessment form included an Elopement Risk Evaluation under the Safety Section. The evaluation identified the resident as having cognitive impairment, independent mobility either ambulating or with the use of a wheelchair, poor decision making skills, exit seeking behavior, wandering oblivious to safety needs, and his ability to exit the facility. Because of the elopement risk evaluation, the facility placed a wander monitoring bracelet on the resident's right ankle. The admission nurse's note contained on the admission document, included wander guard placed on r (right) ankle and requested by family d/t (due to) resident confusion and living close by and frequently coming to visit his wife on (the long term unit.) An interview was conducted with CNA (Certified Nursing Assistant) G on 12/15/2021 at 10:40 a.m. who confirmed a resident had eloped over the weekend. She reported that she was familiar with the resident as he would come in to visit his wife on the other unit. She reported that he had been admitted to the facility and she was the one who put the wander guard on his right ankle. She said that she ensured the wander guard was working, then put it on him and took his photo. She said the photo with the (Elopement Risk Alert) page was put into the Elopement book. She confirmed there are Elopement books on both the units and at the front desk. She reported she could only guess as to what had happened that night but thinks that he was visiting his wife and when he left her room, he just walked out the front door saying goodbye to anyone around. She said that he could have been with a group of visitors or even if he was alone, as he approached the door, the receptionist hit the bypass button and the door opened without alarming (due to the wander guard) and he left. On 12/15/2021 at 10:20 a.m., Resident #1 was observed lying almost flat in his bed, with the head of the bed up slightly. The resident was covered with a sheet but as his right ankle was peeking out from under the sheet, a gray band could be observed on his right ankle. The resident's television was on and a staff member (Personal Care Attendant B) was sitting in a chair at the foot of the bed. The resident smiled pleasantly and confirmed he was told he left the building after visiting his wife the other day. He reported that he doesn't remember specifically leaving the building or being brought back by the sheriff. When asked if he forgot that he had a room here, he reported that he doesn't remember why he left. He confirmed that he visits his wife and thought she lived downstairs (facility is one level). When asked if he wanted to visit her now, he said with a big smile on his face: whatever, I am ready. The Admission Minimum Data Set (MDS) assessment, dated 12/07/2021 assessed the resident's BIMS (Brief Interview for Mental Status) score as 9 out of 15, indicating moderately impaired cognition. The resident's functional status was assessed as needing extensive assistance by one staff for transferring and walking in his room. The resident was able to move around in his room or to other locations in the facility with supervision and set up help. The resident's balance was assessed as not steady, but able to stabilize with the help from another person. The resident was identified as using a walker or a wheelchair. The assessment included the resident's history of falls, having sustained falls prior to the admission without resulting in a fracture. The assessment also included the use of the wander/elopement alarm on a daily basis. Care plans were developed based on the MDS assessment and were noted to include the Focus area for Impaired Cognition and the Focus area for Elopement risk/wanderer. The resident was identified on the care plan as having impaired cognitive function/dementia or impaired thought processes related to forgetful, impaired cognition, date initiated 12/12/2021. An intervention for the Focus area included cue, reorient, supervise as needed. The resident was identified on the care plan as an elopement risk/wanderer related to forgetful on 12/02/2021 with revisions made on 12/12/2021. Interventions included: electronic monitoring device (initiated and revised on 12/13/2021), assess for elopement risk (initiated on 12/02/21), monitor location every. (sic) Document wandering behavior and attempted diversional interventions in behavior log, (initiated and revised on 12/02/2021), and resident to be one on one for safety, initiated on 12/11/2021 and revised on 12/12/2021. A review of a nurse's note dated 12/05/2021 revealed at 1637 (4:37 p.m.) the resident was observed at the end of a residential hall pushing on the exit door. The resident was able to open the door and step outside of the building. The door alarmed, as it was attached to the wander monitoring bracelet system, and staff were able to redirect Resident #1 back inside the building. The resident was placed on 15 minute checks. (There was no order noted in the Physician's orders or the Treatment Administration Record for the 15 minute checks.) A review of a nurse's note dated 12/11/2021 revealed at 1810 (6:10 p.m.), the resident was found 0.1 miles from the facility by the county sheriff. The note documented that the resident was last seen visiting his wife prior to dinner. The note continued: during dinner hour patient refused dinner and continued to visit with spouse. Prior to visiting with spouse, patient was in assigned room on unit in bed throughout 0700 until approximately 1645 [4:45 p.m.]. Patient assisted to spouse's room via wheelchair and also had his cane across his lap. Wander guard to patient's right ankle present. Patient alert at baseline. Hard of hearing, vision impaired, has unsteady gait. Patient returned safely by county sheriff to facility, to patients assigned room and placed on close monitoring by nursing staff. Family notified and made aware of situation and had no words. Director of Nurses notified and immediately arrived to facility. Patient resting in bed at this time. At 1840 (6:40 p.m.) on 12/11/2021 the nurse's note documented: full head to toe assessment done. No wounds, injuries were identified. Patient denied having any pain. Reported assessment to patient's nurse. On 12/11/2021 according to https://www.timeanddate.com, the weather was clear, 64 degrees Fahrenheit at 5:30 p.m. and the sun set at 5:35 p.m. A review of the [NAME] County Sheriff's Report revealed a call came in to dispatch at 17:15 (5:15 p.m.) on 12/11/2021. The call was received by a sheriff in the vicinity at 17:18 (5:18 p.m.) and observations of the resident indicated a white male with a cane, stumbling, appeared to have walked away from the location. The sheriff's report included a call to the facility, who confirmed the resident belonged in the facility. A report written by another state agency investigating the resident's unsupervised departure from the facility revealed no one at the facility noticed the resident was not present until the sheriff called notifying them that he was outside with the sheriff. The report included unknown how he got out. The report included the facility's explanation of how the resident had left the building, which was to walk out with a visitor. In the interview that was conducted with Resident #1's family, on 12/21/2021 at 4:05 p.m., the family confirmed they had been notified that the resident had been found (about one week after his admission) pushing on an exit door but they didn't think he had actually gotten out of the building. They confirmed that they had been notified of the 15 minute checks of the resident and added that when they had recently visited a staff member came in during their visit to check on him. The family confirmed that they were notified immediately that the resident had been able, somehow, to leave the building (on 12/11/2021) and the sheriff had brought him back. They said they were told he wasn't away from the building for very long and were told there was no injury. The family confirmed they were aware that a wander monitoring bracelet was placed on Resident #1's right ankle upon admission and they were in agreement with its use. Neither the son nor the daughter in law could remember who first suggested its use. When asked if they understood how the wander monitoring bracelet worked, the daughter in law reported that it would alarm a door with an announcement indicating which door alarm the wander monitoring bracelet set off. The family reported that once Resident #1 became a resident at the facility, he continued to visit his wife daily in the afternoons. The family reported that his father was used to coming and going and his father's leaving the building was the Perfect Storm. The son suggested maybe Resident #1 walked out with a visitor who was leaving at that time, in explanation of how much of a routine the resident and facility had with visiting and then leaving to walk home. The son explained that he thought his dad just had a memory lapse. A nurse's note was reviewed, written on 12/12/2021 at 11:27 a.m., which documented a meeting that was held with the family who had visited Resident #1 the day after he had left the building unsupervised. The note included a discussion about possibly having Resident #1 room with his wife. The note indicated that the family felt Resident #1 would try to do too much to help his wife if they roomed together, and they were afraid that he might fall and really hurt himself. The facility's Medical Director was interviewed at 11:05 a.m. on 12/22/21. She confirmed that she had been notified of the elopement. She reported that she didn't know much about the resident but was aware that he had a routine of visiting his wife and then walking home. She confirmed she was involved in the QAPI (Quality Assurance/Process Improvement) meeting that occurred post elopement. She reported that the facility was putting in new alarms and other security measures and monitoring the residents and the doors. She confirmed there was education and elopement drills, which were continuing. She reported that she wasn't aware of any other similar incidents. The Medical Director had no other suggestions to make but added that it was unfortunate that Resident #1 had eloped, and at least he wasn't injured. She thought that he was just following his routine and got confused. An interview was conducted on 12/22/2021 beginning at 11:15 a.m. with the Nurse Practitioner who provided care to Resident #1. He reported that he began to care for the resident once he was admitted to the facility. He described the resident as confused and demented and confirmed he had been notified by phone the day the resident had left the building unsupervised. He confirmed he was not aware of any discussions about the resident's discharge home and the resident would need to be cleared by physical therapy and social services to ensure he was safe to discharge. The Nurse Practitioner reported that his concern would be the resident's safety if he would try to walk back and forth to the facility and home if he was discharged home. He stated it was an unfortunate incident that he was able to get out of the facility because they had all the precautions in place. A review was conducted of the facility's stated investigation into Resident #1's ability to leave the building unsupervised. In an interview with the Director of Nursing (DON) beginning at 12:20 p.m. on 12/15/2021, she confirmed that the resident was known to facility staff because he visited his wife daily, prior to becoming a resident. When asked if any additional approaches were used with this resident since he had the routine of leaving the facility after visiting with his wife, the DON reported that the wander guard was put on him at admission. She confirmed they all thought that would be enough. She reported that all staff that were working when the elopement occurred on the 3 PM to 11 PM shift on 12/11/2021 were asked to write a statement about the resident and if they had seen him. She confirmed very few staff were also interviewed about what happened that night. She reported that no staff came forward to admit they had gone to the front door to turn off the alarm. She confirmed she did not know why staff did not investigate why the alarm at the front door was going off. The DON reported she was not aware of visitors that might have left during the dinner meal on 12/11/2021 that could have let Resident #1 out when they left. She confirmed that only staff are to have the door codes, not visitors. A review was conducted of the Treatment Administration Record (TAR) for Resident #1 to ensure his wander monitoring bracelet was being checked for proper functioning and placement. The wander monitoring bracelet order on the TAR revealed: check for function each day every night shift for monitoring, start date 12/06/2021; Wander guard check q (every) shift for placement every shift for monitoring, start date 12/06/2021. There was no documentation of Resident #1's wander monitoring bracelet functionality or placement in the December TAR before 12/06/2021. During an interview conducted on 12/15/2021 beginning at 12:20 p.m., the DON explained due to the facility's new ownership, the electronic medical records systems were changed out the evening of 11/30/2021 and for some reason, all orders put in on 11/30/2021 didn't get incorporated into the new system. She reported that it wasn't until 12/06/2021 that the lack of the order and place to document on Resident #1's wander monitoring bracelet functionality and placement was noticed and corrected. A review was conducted of the forms used to document the fifteen minute checks which were implemented after the resident was able to push open an exit door and step outside of the building on 12/05/2021. Documentation that staff had observed the resident every 15 minutes had been made beginning at 4:45 p.m. on 12/05/2021 and continued through to 12/10/2021 at 10:45 p.m. The page provided by the Director of Nurses for 12/11/2021, the day the resident left the building unsupervised, documented fifteen minute checks beginning at 4:30 p.m. There were vertical lines drawn in on the document from 11:00 p.m. on 12/10/2021 until 4:15 p.m. on 12/11/2021, where the staff were to initial indicating they had observed the resident. The top of the columns with the vertical lines was titled initials. There were no initials indicating the resident was observed until 4:30 p.m. on 12/11/2021. There there were initials indicating observation at 4:45 p.m. and 5:00 p.m. on 12/22/2021. At 5:15 p.m. on 12/11/2021, instead of staff initials indicating the resident had been observed, a horizontal line was noted in the box. Initials were observed in the boxes beginning at 5:30 p.m. through 10:45 p.m., which was the final observation for the day on that document. When the DON and the Regional Nurse were asked, at 5:15 p.m. on 12/15/2021, the reason for the horizontal line at 5:15 p.m. on 12/11/2021, they said they would have to find out who had been assigned to the resident and what the horizontal line meant. On 12/16/2021 at 1:40 p.m. the DON phoned the surveyor to explain the horizontal line. She said that she had spoken with the aide that had been assigned to Resident #1 who confirmed that the nurse took the resident to see his wife at 4:30 p.m. The aide said she put a horizontal line as she didn't see him when she had his dinner tray and tried to serve him his dinner. The DON reported that the aide told her she didn't know what else to do and she was busy passing dinner trays and assisting residents with dinner. The aide reported, according to the DON, that by 5:30 p.m. when the aide was to observe the resident again, the nurse was on the phone with the sheriff who was explaining that he had Resident #1 with him. Interviews were conducted with the staff who cared for the residents on 12/11/2021 on Resident #1's side of the building, the rehabilitation wing. Of the six staff assigned to the rehab wing, on the 3-11 shift on 12/11/2021, four staff (Licensed Practical Nurse (LPN) F, LPN J, CNA E and CNA D) confirmed in interviews conducted on 12/21/21 and 12/22/2021 that they were not aware that Resident #1 was on 15 minute checks. They reported they were aware of the resident's usual routine, to visit his wife in the late afternoon who resided in the other wing of the building and return to his room at dinner. They reported he wore a wander monitoring bracelet as he was at risk for wandering. The nurse assigned to care for Resident #1, LPN J, was an agency nurse and the other nurse, LPN F, was a PRN (worked infrequently) facility nurse. The nurse's aide who was assigned to the resident, CNA E, was employed directly by the facility. An interview was conducted by phone on 12/22/21 at 10:40 a.m., with the nursing aide (CNA E) who was assigned to care for Resident #1 on 12/11/2021 when the elopement occurred. She confirmed she was familiar with Resident #1 and cared for him most weekends. She reported that on 12/11/2021 at about 4:30 p.m. Resident #1 asked if he could go see his wife. She reported LPN J took him over to see his wife. She said at about 5:00 p.m. the dinner trays came out and staff were busy passing the trays. She remembered that staff were asking if Resident #1 was back from visiting his wife and if anyone had seen him. She reported that she was not aware that Resident #1 was on 15 minute checks prior to his leaving the building on 12/11/2021. She confirmed she had not been documenting that she was observing him every 15 minutes prior to his leaving the building. She reported that when he returned from leaving the building she was assigned as a one on one with the resident. She confirmed that when staff are assigned to provide one on one with a resident, they are to initial a form that every 15 minutes the resident is observed. She indicated there was nothing in place until he left the building. CNA E reported that she wasn't aware of a process for him to go see his wife as she thought he would just say he wanted to go see her. She reported that when the dinner trays arrived on the unit, they started to look for him and then the sheriff's office called saying they had Resident #1. She confirmed she hadn't heard an alarm, but that was because of passing dinner trays and going in and out of resident rooms so much. She confirmed that it was hard to hear the alarm on the floor and usually there was a receptionist in the lobby. She confirmed that the nurse took the call that Resident #1 was with the sheriff. She confirmed when Resident #1 came back, he was taken back to his room, he ate his dinner, then laid down, and he was fine. She reported that he seemed a little confused when he first got back. She added that she thought he was confused about having a room here and leaving the facility. She confirmed she knew that before he was a resident he would walk from his home and then walk back home after visiting his wife. She confirmed that Maintenance had come in that night to check all the doors and staff checked the wander monitoring bracelets on residents' ankles. CNA E confirmed that she had taken care of him a few times before, but she wasn't doing every 15 minute checks on him. She reported that it was the nurse who initiated the 15 minute checks once he returned. She confirmed she had never completed 15 minute checks on Resident #1 before he eloped. She confirmed that there had been a lot of elopement drills and training since then and confirmed that she had been taught during orientation about the elopement drills. On 12/21/2021 at 2:00 p.m. a phone interview was conducted with a a CNA, (CNA D), who had been assigned to the side of the building where Resident #1 lived. The aide revealed that she was not the resident's aide but had been assigned to provide showers to those residents scheduled for that shift for their shower. She said there were two other aides and a PCA providing care to the residents. She reported that she knew Resident #1 because he would visit his wife on the 200 hall, which is where she usually worked. She reported that he was definitely confused but not disoriented because he could move on his own and he definitely had a routine. He would visit his wife daily, in the evening and then go home. She thought that the people that he lived with would drop him off and then he would walk home. She knew that at admission he was identified as a wander risk, which she thought was approved by the family. She thought that it was the family that wanted the wander monitoring bracelet because they knew it was a possibility that he may attempt to walk out of the building. She reported that the aides were not told much about the protocol for using a wander monitoring bracelet, but they were told if their residents had a wander monitoring bracelet. She could not identify the aide who was assigned to Resident #1 at the time of the elopement, as she usually worked the other side of the building on the 11 PM to 7 AM shift. She said since there was enough staff, they assigned her to just do showers. She said she was told by the female nurse (LPN J) that she had taken him to see his wife. Then the sheriff called, and she said they realized he hadn't come back to his unit. She said once Resident #1 returned and she was finished providing showers, she was assigned to Resident #1 to provide one on one observation. She was asked what she would do if she couldn't find a resident? She said she would tell the nurse. She said she rounds her residents every 30 minutes, if they aren't on 15 minute checks, to make sure they are okay. She said she was aware the male nurse (LPN F) received a call and he put the call on hold to tell everyone to check their residents. She said that she told the nurse that Resident #1 had gone to visit his wife and he hadn't returned. She said someone called the other unit and they reported that he had been seen leaving the unit about ten minutes before. She said she let the nurse know he wasn't over there any longer. She said she hadn't heard the alarm from the lobby, but she knew someone had turned it off. She said when she walked over to the 200 hall to bring Resident #1 back, it wasn't alarming any longer. She thought it had been up to 30 minutes that he had left his unit for his visit to his wife. She reported that if an alarm goes off, they are to step outside and look around to be sure there isn't a resident out there that left the building. She said the resident's nurse (LPN J) was nowhere around and she hadn't told anyone that she was leaving the floor when LPN F took the sheriff's call. When Resident #1 was returned to his room, she was finished with the showers and was assigned to sit with him one on one for the rest of her shift. She confirmed that she documented her 15 minute checks beginning when he returned. She confirmed that the sheet of paper that she documented her 15 minute checks began with her. She confirmed that the other columns had vertical lines through the columns where the initials would go, making her think that the 15 minute checks had just begun. She said she thought the facility could have done a better job of keeping track of the resident. She reported that they knew he had his routine of visiting his wife then walking home and how the elderly like to follow their routine. She felt he should have been on supervised walks between his room and his wife's. A phone interview was conducted with a facility PRN nurse, (LPN F) on 12/21/2021 beginning at 3:30 p.m. He confirmed he worked on the 3 PM to 11 PM shift on 12/11/2021 on the rehabilitation unit with another nurse, who was assigned to Resident #1. He confirmed he received a call from 911 dispatch, during dinner, between 5 and 6 p.m. He said 911 dispatch asked if they were missing a resident. He said he put the call on hold and asked his aides to do a head count and went to the other side and told them to do a head count. By the time he returned to the call on hold, staff realized Resident #1 was missing. He said he knew that the resident, before his admission, visited his wife on the other side every day, walking from home, maybe a ten minute walk. The sheriff confirmed he had Resident #1 and would bring him back. The nurse went to the front door to get the resident and had him sit down in the lobby. He asked the resident where he was going, and the resident said he was going home. The nurse said he must still have in his mind that he lived at home, and he wasn't used to living here. The resident admitted he was hungry. He said the sheriff told him that someone had seen him, noted he seemed unsteady, and called the police. The resident was not injured and had no marks on him. He said before he went to the front door, he notified the DON who asked him to do a head count. He said after that he called the family and the doctor. LPN F confirmed that he was unsure when the resident was admitted and wasn't aware he was a resident, until he was brought back to the facility by the sheriff. He reported he was told that Resident #1 had been admitted for strengthening as he had had falls at home. He said that he wasn't aware he had been assessed at admission as an elopement risk. He said he wasn't sure where Resident #1's nurse was either at the time of the sheriff' call and didn't know which aide was assigned to him. He said that he knew the other nurse was working a double shift and had been in the building since 6 a.m., so maybe she was on a dinner break, but he didn't know. He confirmed that he was not aware that the resident was on 15 minute checks. When LPN F was asked what should occur if a resident on 15 minute checks wasn't observed, he reported that the aide should tell the nurse immediately. Then the nurse would assign all staff to do a head count of all of their residents and start searching all areas for anyone not observed. He confirmed that there was a head count of residents but no searching as the sheriff reported he had the missing resident. He said the resident was returned to the facility by 6:00 p.m. as that is when his phone notes the time of his call to the DON. He said changes had been made to the doors, maintenance checked all door alarms, and the nurses checked the placement and functionality of all residents with wander monitoring bracelets. A phone interview was conducted with the nurse (LPN J) on 12/21/2021 beginning at 2:45 p.m. She confirmed she had been assigned to Resident #1 who had a wife in the facility that he would visit. She said he didn't live far from the facility and would walk over to visit his wife from his home. She was aware that Resident #1 was admitted for strengthening and then was going to be discharged back home. She was not sure the reason for his wearing a wander monitoring bracelet but felt it had to do with his safety. She confirmed she wasn't that familiar with Resident #1 and thought maybe she had ca [TRUNCATED]

Based on observation, interview, and record review, the facility failed to document narcotics in the electronic record for two (Residents #1 and #2) of three residents reviewed. Findings included: 1. A review of the Admission Record for Resident #1 revealed she was admitted on [DATE] from an acute care hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (evaluation) and treatment related to AMS (altered mental status). During a phone interview with Staff A, Unit Manager on 12/6/21 at 12:34 p.m., she stated, I am familiar with the patient. When she was transferred out to the hospital, she was lethargic, but she could answer questions like I asked her who her visitor was and she was able to say her son. She was not drooling or anything of that sort. The son said the day before she was up playing on her IPAD, and this was not like her. She was a little lethargic and given that she was just admitted the day before and the son saying that was not normal for her to be acting that way we sent her out. Further review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Controlled medication utilization record for Oxycodone 5 mg revealed the medication was administered on 11/25/21 at 7:00 p.m. and on 11/26/21 at 2:00 a.m 2. A review of Resident #2's admission record revealed he was initially admitted to the facility on [DATE] and his most recent admission was on 11/15/2017. The resident was admitted from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Muscle weakness and pain in unspecified joint. On 12/6/21 at 4:00 p.m., Resident #2 was observed in bed with his legs continuously moving back and forth. He stated he was not in pain but he was hungry and wanted a snack. A review of Resident #2's order summary report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Started on 11/15/2017. Review of Resident #2's December electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 12/1/21 administered at 9:10 a.m. 12/4/21 administered at 4:44 p.m. 12/5/21 administered at 8:08 a.m. Review of Resident #2's controlled medication utilization record revealed [MEDICATION(S)]-Acetaminophen 5-325 mg gen sub for: [MEDICATION(S)] 5-325 tablet was administered on 12/1/21 at 9:10 a.m. 12/1/21 at 5:16 p.m. 12/4/21 at 9:08 a.m. 12/4/21 at 4:47 p.m. 12/5/21 at 8:00 a.m. 12/5/21 at 2:00 p.m. There was no documentation in the electronic medical record for the administration of [MEDICATION(S)] 5-325 mg tablet on 12/1/21 at 5:16 p.m. 12/4/21 at 9:08 a.m. 12/5/21 at 2:00 p.m. An interview was conducted on 12/6/21 at 2:55 p.m. with Resident #2's nurse, Staff B, Agency Registered Nurse on the 7:00 a.m. to 3:00 p.m. shift. Staff B pulled up Resident #2's electronic medication record and confirmed the computer said the last time the resident had Oxycodone Acetaminophen was 12/5/21 at 8:08 a.m. He confirmed there was no documentation for the Oxycodone-Acetaminophen for the 2:00 p.m. dose given per the narcotic sheet. Staff B, RN stated, You should sign off the narcotic on the controlled medication utilization record and on the computer MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/6/21 at 2:45 p.m., the Director of Nursing (DON) and the Regional Clinical Director confirmed Resident #2 had missed documentation on his electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Clinical Director said they would start education, at that time, with the nurses. The DON also confirmed Resident #1 had nothing signed off on her electronic MAR for her Oxycodone 5 mg order but had two doses administered according to the controlled medication utilization record. Review of the facility's 6.0 General Dose Preparation and Medication Administration policy with a revision date of 1/1/13 revealed . This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. .5.5 Document the administration of controlled substances in accordance with applicable law . 6.1 document necessary medication administration information (e.g., when medications are opened, when medications are given .).

Based on observations and staff interviews, the facility failed to post the total number, and the actual hours worked of the direct care staff for the benefit of the facility residents and the public on 04/05/21 through 04/07/21 as evidenced by the position and location of the clipboard that was identified by the Staffing Coordinator as the posting location. Findings included Upon entry to the facility at approximately 09:00 am on Monday 04/05/21 surveyors did not observe the information required by statutes concerning the posting for the nurse staffing information. The nurse posting information was not available for viewing until the last day of the survey, 04/08/21, when the staffing coordinator stated that the information was on a clipboard at one of the nursing stations. The staffing coordinator identified the location as being on the wall to the right of the skilled step-down unit (SSU). The observed clipboard was not identified as holding the staffing information and hung in a manner that did not allow viewing for visitors or any other passerby unless they knew to take it off the wall and turn the clipboard over. This clipboard was observed in this position during the four days of the survey (photographic evidence was obtained). This clipboard was not accessible to visitors who did not come to this particular unit and the staffing coordinator stated that she had been posting the information in this way for months. The Nursing Home Administrator stated that she was not aware of the posting requirements prior to our interview on 04/08/21, but that the posting would be available for prominent viewing by all the residents and their visitors at the reception counter from now on.

Based on observations, interviews and record review the facility did not ensure that Controlled substances were locked and stored in a permanently affixed compartment in two of two medication storage rooms sampled. Findings included: On 04/07/21 at 10:28 a.m. during the performance of the medication storage and labeling task the locked medication room on the Skilled Subacute Unit (SSU) inspection of the refrigerator in the same medication room at 10:30 a.m. accessed by Staff A, LPN, revealed a locked box. The box was not secured or maintained in a permanently affixed compartment in the refrigerator. Staff A, LPN unlocked the box, which revealed two clear plastic cases. The clear plastic cases were sealed with a green tamper proof seal and the contents could be seen through the plastic. Each plastic case contained three, 2mg/ml vials of the controlled substance lorazepam (photographic evidence was obtained). An interview with Staff A, LPN. He stated that he was not aware that the box containing control substances lorazepam had to be secured in a permanently affixed compartment. At 10:35 a.m. in an Interview with the Regional Nurse providing Clinical Services, she confirmed that the box should have been secured to a permanently affixed compartment in the refrigerator, but she thought it did not apply to Schedule II controlled substances. An inspection of the medication room located on the Geriatric Nursing Restorative (GNR) unit at 10:48 a.m. with Staff B, LPN, revealed a locked box in the refrigerator. The locked box was not secured or maintained in a permanently affixed compartment in the refrigerator. The locked box was accessed and opened by Staff B, LPN, which revealed two individual bags of the controlled substance Lorazepam 2mg/ml labeled with residents' name. One bag contains 10 vials and the other bag contains 8 vials. In-addition there were two clear plastic cases sealed with a green tamper proof seal. The contents could be seen through the clear plastic. Each plastic case contained three, 2mg/ml vials of the controlled substance lorazepam (photographic evidence obtained). In an interview with Staff B, LPN, she stated that she was not aware that the box containing control substances lorazepam should have been maintained in a permanently affixed compartment. On 4/7/21 11:40 a.m. in an interview with the Nurse Home Administrator, she concurred that the medications should have been maintained in a separately locked, permanently affixed compartment. A review of the facility policy Titled Long Term Care (LTC) Facility's Pharmacy Services and Procedure Manual revised 10/28/2019, under the subheading General Storage Procedures 3.1.1 It reads: Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separate locked, permanently affixed compartments . Under the subheading Control Substances Storage13.3 it reads: Facility should ensure that all II-V controlled substances are only stored in a manner that maintains their integrity and security.

Based on observations, interviews and record reviews the facility failed to ensure respiratory equipment was stored in a safe and sanitary manner for residents immunocompromised and at risk for respiratory infections, as evidenced by: 1) Failed to ensure oxygen tubing and nasal cannula were clean and stored properly for three residents (#1, #2, #3) out of 23 residents receiving oxygen related services, 2) Failed to ensure respiratory equipment for inhalation therapy was stored in a sanitary manner for two residents (#6, #7) out of seven residents with orders for respiratory inhalation therapy, and 3) Failed to ensure a [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) respiratory face mask was stored in a sanitary manner when not in use for one resident (#5) out of one resident sampled. Findings included: 1. A review of the facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, with a revised date of November 2011 revealed: Purpose - The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. General Guidelines: 1. distilled water used in respiratory therapy must be dated and initialed when open, and discarded after twenty-four (24) hours. Infection Control Consideration Related to Medication Nebulizers/Continuous Aerosol. 6. wipe the mouthpiece with damp paper towel or gauze sponge. 7. Store the circuit in a plastic bag, marked with the date and resident's name, between uses . An observation was conducted on 9/22/2020 at 9:30 a.m., Resident #1 was out on the 100 hall in her wheelchair and on the back of her wheelchair was an oxygen E-tank with oxygen tubing hanging off the back of the tank dragging on the floor. The nose piece (nasal cannula) had a brown crusty residue on it. (Photographic Evidence Obtained) An interview was conducted on 9/22/2020 at 9:35 a.m., Staff A, Nurse confirmed the oxygen tubing was on the floor. Staff A said, I did not see the tubing. It looks like her oxygen tank is empty too. A second observation was conducted on 9/22/2020 at 9:40 a.m., during a tour of Resident #1's room, the oxygen tubing and nasal cannula were out on top of the oxygen concentrator and not covered. The nose piece (nasal cannula) had a brown crusty residue on it. There was not a plastic storage bag observed at the resident's bedside.(Photographic Evidence Obtained) An interview was conducted on 9/22/2020 at 9:43 a.m., Staff A, Nurse said, Ok, I will put new oxygen tubing on there for her and get a new plastic bag for it to go into. A review of Resident #1's Admission Record revealed a pertinent [DIAGNOSES REDACTED]. A review of Resident #1's Medication Administration Record [REDACTED]. An observation was conducted on 9/22/2020 at 9:36 a.m. Resident #2 was in her bed and her oxygen tubing and nasal cannula were in a drawer that was open on her nightside stand. The oxygen tubing and nasal cannula were not covered and in the drawer with other personal care items. (Photographic Evidence Obtained) An interview was conducted on 9/22/2020 at 9:37 a.m., Staff B, Certified Nursing Assistant (CNA) said, Respiratory equipment is supposed to be stored in a bag when it is not in use. An interview was conducted on 9/22/2020 at 9:39 a.m., Staff A, Nurse said, Oh ok. No, it should not be in her drawer. I will take care of it. A review of the Resident #2's Admission Record revealed pertinent [DIAGNOSES REDACTED]. A review of Resident #2's MAR for September 2020 revealed there was not a physician order for [REDACTED].>An observation was conducted on 9/22/2020 at 9:55 a.m. Resident #3 was in his room in bed. Resident #3, pointing to his oxygen tubing and nose piece on the floor next to his bed said, Can you get someone to help me get my oxygen on? A review of Resident #3's Admission Record revealed a pertinent [DIAGNOSES REDACTED]. A review of Resident #3's MAR for September 2020 revealed there was not a physicians order for oxygen administration. A current physician order with a start date of 1/31/2020 showed to change tubing, mask and/or nasal cannula weekly . 2. An observation was conducted on 9/22/2020 at 9:58 a.m., Resident #6 was in her bed and on the nightstand next to her bed was a nebulizer machine with oxygen tubing and the nasal cannula sitting on top of the respiratory machine was uncovered (Photographic Evidence Obtained). An interview was conducted on 9/22/2020 at 9:59 a.m., Staff E, CNA said, Yes, I see the oxygen tubing. No, it should not be sitting out like that. There should be a bag that when the breathing treatment is done, the nurses put it in that bag. I do not see a bag. A review of Resident #6's Admission Record revealed a pertinent [DIAGNOSES REDACTED]. A review of Resident #6's MAR for September 2020 revealed there was not a physician order for [REDACTED].>An observation was conducted on 9/22/2020 at 10:06 a.m. Resident #7 was in his bed and on the nightstand next to the bed was a nebulizer machine with oxygen tubing and a nasal cannula sitting on top of the respiratory machine, uncovered, and not on a barrier. (Photographic Evidence Obtained). An interview was conducted on 9/22/2020 at 10:06 a.m., Staff F, CNA confirmed Resident #7's nebulizer mask was out and uncovered and said, I see it. Yes, it is supposed to be in a bag when it is not in use. A review of Resident #7's Admission Record revealed pertinent [DIAGNOSES REDACTED]. A review of Resident #7's MAR for September 2020 revealed a physician order with a start date of 7/13/2020 for oxygen as needed at 2L/min <90% (less than). An additional physician order with a start date of 9/16/2020 showed [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3)MG/3ml (milligram/milliliter) 1 vial inhale orally three times a day related to [MEDICAL CONDITION]. An interview was conducted on 9/22/2020 at 11:45 a.m., Staff D, Registered Nurse (RN)/Staff Educator said, All respiratory equipment should be cleaned after use and stored in a plastic bag at the resident's bedside. If any tubing is in the floor, they are to throw it away and get new tubing. 3) An observation was conducted on 9/22/2020 at 9:56 a.m., Resident #5's [MEDICAL CONDITION] was sitting out on the dresser next to the resident's bed. An interview was conducted on 9/22/2020 at 9:56 a.m., Staff E, CNA said, The nurses, when they make their morning rounds and pass medications, are supposed to make sure all respiratory equipment at the bedside is in a plastic bag. The bag has the resident's name, room number and the date the tubing was changed. An interview was conducted on 9/22/2020 at 11:30 a.m., The Director of Nursing (DON) reviewed the photographic evidence and confirmed the findings. The DON said, All respiratory equipment after use is to be cleaned and put in a plastic bag at the bedside.

Based on observations, interviews and record reviews the facility failed to follow standard precautions, the Centers for Disease Control and Prevention (CDC) guidelines and facility policy to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment. The facility failed to ensure two staff members (I and C) performed hand hygiene when providing health care services and environmental services for three residents (#8, #9 and #4). Findings included: A review of the facility policy titled, Handwashing/Hand Hygiene, revised on August 2019 (2 pages) revealed: Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. 5. Employees must wash their hands for twenty (20) seconds using antimicrobial soap or non-antimicrobial soap and water under the following conditions: After handling soiled equipment; After removing gloves or aprons. 6. The alternate method of hand hygiene is with an alcohol-based hand hygiene rub (ABHR) . 7. Hand hygiene is the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace handwashing/hand hygiene. An observation was conducted on 9/22/2020 at 9:48 a.m., of Staff I, Nurse in Resident #8's room with a capped insulin syringe in her left hand and no gloves on. Staff I, Nurse confirmed the resident's call light (pressure pad) was draped across the IV (intravenous) pole and lifted the call light off the IV pole and placed it within the resident's reach. Staff I, Nurse then walked out of Resident #8's room with the capped insulin syringe without performing hand hygiene. Staff I walked across the hall and entered Resident #9's room. Staff I put the capped insulin syringe down on the top of a dresser and reached above the dresser and pulled out a pair of gloves. Staff I put on the gloves without performing hand hygiene, picked up the capped insulin syringe and walked over to Resident #9 and administered the insulin to the resident. An observation was conducted on 9/22/2020 at 9:50 a.m., Staff C, Housekeeping was in Resident #4's room cleaning up a large brown liquid puddle on the floor. Staff C, Housekeeping did not have on gloves while she was cleaning the floor. An interview was conducted on 9/22/2020 at 9:50 a.m., Staff C, Housekeeping said, Yes, I should have gloves on. Staff C then put on a pair of gloves without performing hand hygiene. Staff C said, I'm sorry I should have used hand sanitizer before I put the gloves on. An interview was conducted on 9/22/2020 at 10:00 a.m., at the nurses' station with Staff I, Nurse and Staff D, Registered Nurse (RN)/Staff Educator was present. Staff I, Nurse said, No, you are right I should have had on gloves when I entered (Resident #8's) room. I did not wash or use hand sanitizer when I walked out of the room and across the hall to (Resident #9's) room. No, I put on gloves in his room and did not wash or sanitize my hands. I should have had gloves on while I had the capped insulin syringe in my hand. Staff D, RN/Staff Educator said, Staff are to wash or use hand sanitizer before and after resident contact and before putting on gloves and after taking them off. An interview was conducted on 9/22/2020 at 11:00 a.m., Staff D, RN/Staff Educator said, Staff C, Housekeeping knows she should have had gloves on when she was cleaning that mess on the floor. The account manager for environmental services in-serviced Staff C again on this.

Based on observation, clinical record review, and interviews the facility failed to ensure three residents ( #2, #3, and #4) out of three sampled residents received the monitoring of behaviors and side effects associated with psychoactive medications. Findings included: The policy titled, Medication Management - Psychoactive Medications, effective 11/30/14 and revised 3/23/18, identified [MEDICAL CONDITION] medications as any medication that affects brain activities associated with mental processes and behavior. The policy indicated the [MEDICAL CONDITION] medications included, but were not limited to, anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. The procedure portion of the policy revealed staff should monitor behavior and side effects every shift utilizing the Behavior Monitoring Flow Record (BMFR) or the electronic equivalent. The procedure also identified staff should monitor the residents' response to medication and progress towards goals and include monitoring the effectiveness of non-pharmacological approaches. 1. Resident #2 was admitted on [DATE]. The Admission Record included diagnoses, not limited to, unspecified dementia without behavioral disturbance, other [MEDICAL CONDITION], unspecified mood (affective) disorder, and unspecified single episode major [MEDICAL CONDITION]. Resident #2 was observed, on 12/3/19 at 9:20 a.m., lying in bed with a breakfast tray on the over-the-bed table next to the bed. At 11:05 a.m. on 12/3/19, the resident was observed and interviewed while lying in bed. The resident was wearing a clean t-shirt and had not odor. Resident #2 confirmed refusing showers and baths at times. The active physician orders [REDACTED].#2 identified the following orders: - [MEDICATION NAME] tablet Delayed Release 250 milligram (mg) - give one (1) tablet by mouth every 12 hours related to unspecified mood (affective) disorder. - [MEDICATION NAME] tablet 20 mg - give one (1) tablet by mouth at bedtime related to unspecified single episode major [MEDICAL CONDITION]. The record did not indicate an electronic BMFR. The September, October, November, and (MONTH) 2019 Medication Administration Record [REDACTED]. The MAR's did not identify staff were monitoring for side effects associated with the psychoactive medications administered to Resident #2 or if any non-pharmacological approaches were attempted or if those approaches were effective. The MARs indicated Resident #2 frequently refused medications. The psychiatric Advanced Practice Registered Nurse's (APRN) note, dated 9/1/19, indicated the reason for the visit was to follow up with resident and per nursing request. The note did not indicate the reason for the nursing request. The plan was to continue current medication regiment and to monitor for increased behavioral changes. The APRN note, dated 9/12/19, indicated a visit was conducted with Resident #2 due to name calling, agitation and behaviors and directed staff to continue current medication regimen and to monitor for increased behavioral changes. The APRN notes, dated 10/3/19 and 11/7/19, did not indicate behavior issues and revealed staff were to continue the medication regiment and to monitor for increased behavioral changes. The APRN note, dated 10/31/19, indicated an increase in Resident #2's [MEDICATION NAME], and [MEDICATION NAME]. The progress notes from the physician, dated 10/27/19, indicated Resident #2 had baseline dementia and nursing reported the resident often forgets problems that were going on. The physician note did not indicate Resident #2 had ongoing behaviors. The (MONTH) and (MONTH) 2019 progress notes indicated Resident #2 refused medications, vital signs, blood draws, and skin sweeps. The progress note, dated 11/3/19 on 1:03 a.m., indicated Resident #2 behavioral problems were verbal, other socially inappropriate behaviors, and rejected care. The current care plan for Resident #2 identified the following: - Resident had a behavioral problem r/t (related to) disrespectful to staff with prejudice behaviors, initiated and revised on 9/6/19. The interventions revealed staff should discuss the resident's behavior and reinforce why the behavior was inappropriate. - Resident used anti-depressant medication related to (r/t) depression, initiated and revised 7/12/19. The interventions instructed staff to monitor/document/report as needed (prn) adverse reactions to anti-depressant therapy. 2. Resident #3 was admitted on [DATE] and 10/7/19. The Admission Record included [DIAGNOSES REDACTED]. The September, October, (MONTH) and (MONTH) 2019 MARs for Resident #3 included the following physician orders: - [MEDICATION NAME] 20 milligram (mg) - give one (1) tablet by mouth in the evening related to unspecified single episode major [MEDICAL CONDITION]. The MARs and Treatment Administration Records (TAR) did not include monitoring of behaviors, side effects or the effectiveness of non-pharmacological interventions. The electronic record did not include a Behavior Monitoring Flow Record (BMFR). The psychiatric APRN visit note, dated 11/1/19, indicated Resident #3 had anxiety, frustrated easily, agitation, [MEDICAL CONDITION] with racing thoughts, and difficulty to sleep at night. The note instructed staff to continue current medication regimen and monitor for changes in behaviors. The Psychoactive Drug and Behavioral Management Committee reviewed Resident #3's [MEDICATION NAME], on 11/21/19, indicating no Gradual Dose Reduction (GDR) was necessary at that time. The Advanced Registered Nurse Practitioner (ARNP) note, dated 10/9/19, did not indicate Resident #3 had exhibited any behaviors. The Interdisciplinary Progress note, dated 9/10/19 and 9/24/19, did not reveal behaviors associated with the anti-depressant, [MEDICATION NAME], were addressed. The progress notes for (MONTH) 2019 indicated the following: - a note, dated 10/31/19, the resident refused a dressing treatment. - a note, dated 10/28/19, indicated Resident #3 had refused medication. - dated 10/11/19, a skilled note revealed no behavioral problems were noted. The current care plan for Resident #3 identified the resident used an anti-depressant medication. The interventions included to monitor and document any adverse reactions. 3. Resident #4 was admitted on [DATE]. The Admission Record included [DIAGNOSES REDACTED]. An observation and interview were conducted, on 12/3/19 at 11:01 a.m., with Resident #4 and a visitor. The resident was observed being propelled in a wheelchair from outside by the visitor. Resident #4 was alert, oriented and voiced no complaints. The active physician orders [REDACTED]. - [MEDICATION NAME] tablet 7.5 milligram (mg) - give 1 tablet by mouth at bedtime related to essential (primary) hypertension. The (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. The electronic record did not include a Behavior Monitoring Flow Record. The Admission physician note, dated 11/19/19, did not indicate a [DIAGNOSES REDACTED]. The Director of Clinical Services confirmed on 12/3/19 at 2:58 p.m., that [MEDICATION NAME] was an anti-depressant and was not used to treat hypertension. During an interview, on 12/3/19 at 2:58 p.m., the Director of Clinical Services (DCS) stated that monitoring of behaviors was done for antipsychotics but not for anti-depressants. She stated in the electronic record when an order for [REDACTED].#2's clinical record with the DCS revealed no BMFR or documentation of monitoring for behaviors. On 12/3/19 at 3:32 p.m., the Consulting Pharmacist confirmed visiting the facility monthly and reviewed new admissions at that time. The Consultant stated he didn't know if there was any type of documentation that stated the facility had to document the monitoring of [MEDICAL CONDITION].

Based on interview and record review the facility failed to revise the comprehensive resident centered care plan for one resident (#2) of three sampled residents related to refusing care and services to include medications and showers. Findings included: Resident #2 was admitted on [DATE]. Review of the medical record showed [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). The MDS showed the resident had no behaviors and rejection of care was not exhibited. The resident required physical help in part for the bathing activity. Review of the active care plans did not show Resident #2 was resistive to care and services for medications and showers. Resident #2 had a care plan for impaired cognitive function/dementia or impaired thought processes related to dementia initiated on 6/24/19. Interventions included but were not limited to monitor/document/report as needed any changes in cognitive function, specifically changes in decision making ability. A care plan meeting on 10/03/19 showed the meeting was with activities, social services, and nursing. The resident and family were invited, but both declined to attend. The current care plan was reviewed by the interdisciplinary team to include the physician and accepted. Review of the active physician orders [REDACTED].#2 was on Donepezil HCL 5 mg (milligrams) at bedtime for Alzheimer's, Folic Acid 1 mg daily for vitamin deficiency, [MEDICATION NAME] Sodium 50 mcg (micrograms) in the morning for [MEDICAL CONDITION], [MEDICATION NAME] 20 mg at bedtime for depression, [MEDICATION NAME] 2.5 mg daily for hypertension, [MEDICATION NAME] 25 mg daily for hypertension, [MEDICATION NAME] delayed release 250 mg every 12 hours for mood disorder, [MEDICATION NAME] 500 mg twice a day for diabetes, Mucus Relief 400 mg every 12 hours for nasal congestion, and vital signs every shift. Record review of the progress notes and Medication Administration Record [REDACTED]. In (MONTH) 2019 Resident #2 refused the following: [MEDICATION NAME], 1 dose [MEDICATION NAME], 1 dose [MEDICATION NAME], 2 doses [MEDICATION NAME], 3 doses Mucus Relief, 1 dose Vital signs, 3 times In (MONTH) 2019 he refused the following: Donepezil, 6 doses [MEDICATION NAME], 13 doses [MEDICATION NAME], 5 doses [MEDICATION NAME], 6 doses [MEDICATION NAME], 4 doses [MEDICATION NAME], 9 doses [MEDICATION NAME], 2 doses Mucus Relief, 4 doses Vital signs, 44 times In (MONTH) 2019 he refused the following: Donepezil, 6 doses [MEDICATION NAME], 23 doses [MEDICATION NAME], 6 doses [MEDICATION NAME], 4 doses [MEDICATION NAME], 5 doses [MEDICATION NAME], 11 doses [MEDICATION NAME], 10 doses Mucus Relief, 4 doses Vital signs, 29 times Record review of the nursing progress notes for (MONTH) 2019 and (MONTH) 2019 did not show any communication with the physician or family related to the resident refusing care and services to include medications and showers. On 10/01/19, 10/02/19, 10/03/19 and 10/07/19 the physician was made aware the resident refused folic acid, Vitamin B-12, Vitamin D-3, and multivitamins. In addition, a record review of the resident's shower schedule showed he was to shower twice a week on Tuesday and Friday. The review included the last 30 days, 11/04/19 through 12/02/19 or 8 showers. Resident #2 received a shower a total of four times on the following days: 11/12, 11/15, 11/17 and 12/01. The documentation in the medical record showed he refused showers on 11/05, 11/08, 11/19, and 11/22. During an interview with Resident #2 at 11:05 a.m. on 12/3/19, Resident #2 stated that he received assistance with bathing and sometimes refuses. During an interview on 12/03/19 at 1:30 p.m. Staff A, Licensed Practical Nurse (LPN) Unit Manager reviewed the active care plan for Activities of Daily Living (ADLs) initiated on 6/23/19 and stated there was not documentation related to resident refusing care or showers. She stated that his refusing of showers had been an issue. During an interview on 12/03/19 at 1:15 p.m. the Director of Nursing (DON) and the Regional Nurse stated that the care plans should address Resident #2's refusal of care, i.e. showers and medications. Record review of the facility's policy, Plans of Care, revised 09/25/17, showed an individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA (Omnibus Budget Reconciliation Act) MDS assessment, and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan it oriented toward attaining or maintain the highest practicable physical, mental and psychosocial well-being.

Based on observation, interview and record review, the facility did not ensure that 15 (Resident #3, 7, 13, 15, 25, 26, 27, 28, 33, 44, 48, 62, 64, 66, and 81) out of 47 residents sampled were treated with dignity during dining services in a manner that promotes maintenance or enhancement of their quality of life. Findings included: 1. Observation on 3/26/19 at 11:42 am lunch trays were delivered to the Sunshine Room. Staff Q, CNA pulled the rack of trays into the room, and Staff Q and Staff B, CNA began passing meal trays to residents #48, 27, 66, 7, 28, 81, 33, 44, 25, and 13. Residents sitting in the same area were not served at the same time, and residents who required assistance were set up with their food sitting in front of them until one of the two staff members could feed them. While passing trays, both the CNAs had to move residents away from the table so they could deliver food to the residents next to them. Staff B set up three residents' food standing across the table from where they were sitting. At 11:45 am, Staff B pulled Resident #7 backwards away from the table, and stepped in front of her with Resident #48's tray. Resident #48 was sitting to the right of the resident sitting across from Resident #7. Staff B sat the lunch tray on the table, and began to take items off of it. As she pulled each item off the lunch tray, she leaned over the table and placed the items in front of the resident. At 11:55 am the surveyor asked Staff B and Staff Q what Resident #48's name was. Staff B said Oh, that's Resident #48, I'll get to her in a minute. Staff B was leaning over the table attempting to feed a resident across the table from her, while encouraging another resident to eat on their own. At 12:00 pm, Staff B pulled resident #48 away from the table, and began to feed her while she was standing up. Staff Q was feeding multiple people at the same time. Observation of the main dining room on 03/27/19 at 11:42 AM Staff N began asking residents if they would like a bib to cover their clothes during lunch. When lunch trays were being served, Staff C, M, and N were serving trays in the order they came out of the kitchen. Some of the residents being served were not sitting at the same table, so while some tables in the main dining room were being served at the same time, others were being served one tray while 2-3 residents waited for their meal to arrive. During an interview with the Director of Nurses (DON) on 03/29/19 at 05:35 pm she said it was her expectation that when her staff fed residents they sit down and get on the resident's level. It is also her expectation that her staff do not call clothing protectors bibs. 2. An observation was made, on 3/26/19 at 12:16p.m., of Staff Member C, Certified Nursing Assistant (CNA), standing over the Resident #64 lying in a window bed on the 300-hall. The CNA was observed with an eating utensil in hand moving it from plate to resident. No chair was observed on the side of bed between bed and privacy curtain where the CNA was standing. While Resident #48 was sitting in a wheelchair in the Sunshine day room with other residents, Staff Member O, Licensed Practical Nurse (LPN) was observed, on 3/26/19 at 12:31p.m., standing over the resident, lifting an eating utensil from plate to the mouth of the resident. After the LPN left the day room, at 12:33p.m., Staff Member B, Certified Nursing Assistant (CNA), while standing next to Resident #48, was observed assisting the resident with eating. Staff Member C, CNA, was observed, on 3/26/19 at 12:42p.m., standing over Resident #62, while the resident was lying in bed, assist the resident with eating. Bilateral floor mats were on the floor next to the bed, which the staff member was standing on one of the floor mats with the meal tray sitting on the over-the-bed table, which was positioned in between the floor mat and privacy curtain. An observation was made, on 3/26/19 at 12:45p.m., a CNA, dressed in Personal Protective Equipment, raise Resident #3's bed, and began assisting the resident with eating, while standing next to bed. On 3/27/18 at 8:10a.m., a staff member removed a tray from the meal cart and enter the room of Resident #48. At 8:19a.m., an observation was made of the staff member standing next to the raised bed, assisting the resident with eating. The staff member identified herself as the Social Worker (SW). The observation revealed no visitor chair in the resident's portion of the room. On 3/27/19 at 8:37a.m., Staff Member C, CNA, was observed standing next to Resident #62 assisting with the resident with eating. The staff member was standing on a floor mat next to the bed and the meal tray sitting on a over-the-bed table was positioned on the other side of the mat. An observation on 3/27/19 at 8:42a.m., revealed a CNA standing next to Resident #26 and use large-handled utensils to assist with eating. On 3/27/19 at 8:50a.m., an observation was made of Staff Member C, CNA, standing on a floor mat next to Resident #3's bed, the bed was raised to hip-high position. The staff member was observed assisting the resident with eating. The facility-provided competency titled, Eating Support, undated showed #12: Never make the resident feel that the meal must be hurried but the procedure is pleasant. Give him/her your complete attention. Sit so you are at the same level as the resident.

Based on observation, record review, interviews the facility failed to provide the resident/representative with a summary of the Baseline Care Plan for two residents (#56 and #144) of 47 sampled residents. Findings included: 1. During a medical record review conducted on 3/28/19 for Resident #56 revealed that the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #56's Minimum Data Set ((MDS) dated [DATE] indicated under section C for cognition, the resident has a score of (2) indicating severely impaired. A review of Resident #56's Baseline care Plan revealed that the resident and staff member completed the Baseline care plan signed off on it on 2/11/19. An interview was conducted with the Director of Nursing and the MDS coordinator on 3/28/19 at 3:00 p.m. The MDS coordinator was able to confirm that the facility did not provide the resident and their representative with a summary of the baseline care plan. The Director of Nursing was asked if Resident#56 with a cognition score of (2) would be able to fully participate and understand the development of a baseline care plan, she responded that the Resident would not be able to fully understand. 2. During an interview with Resident #144 on 03/26/19 at 2:37 p.m., the resident reported that he was admitted to the facility yesterday early evening of 3/25/19. A review of the electronic medical record and the hard chart revealed no indication of the resident's Baseline Care Plan. An additional interview with the resident was conducted on 3/28/19 at 11:05 a.m. and he reported that no one had provided him with a Baseline Plan of Care. He was still unaware of his plan of care. A medical record review revealed that the resident was admitted to the facility on [DATE] at 5:00 PM with multiple [DIAGNOSES REDACTED]. The resident was alert and oriented and he was his own responsible person. On 3/28/19 at 3:00 P.M. an interview was conducted with the MDS Coordinator staff member (A) who was able to locate the Resident #144's Baseline care plan in a binder located in her office. Staff member A reported that once the baseline care plan is completed by the nurse on admission, the comprehensive care plan is developed. The baseline care plan for Resident #144 was dated 3/25/19 at 1700. The MDS coordinator was able to confirm that the facility did not provide the resident and their representative with a summary of the baseline care plan. An additional interview was conducted with the Director of Nursing on 3/28/19 at 4:00 p.m. who reports that it would be impossible to have the residents physicians involved in the baseline care plan development. The Director of Nursing provided the following policy; Plan of Care effective date 11/30/2014 with a revision date of 9/25/17 which indicates under procedure: *Develop and implement and individualized Person-Centered baseline plan of care within 48 hours of admission that includes but is not limited to, initial goals based on the admission orders [REDACTED].