Every finding on record at Breckinridge Memorial Nursing Facility

Based on observation, interview, and policy review, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for contamination during meal service. These failures had the potential to affect 18 of 18 residents who received meals from the dietary department.Review of the facility policy, Nutritional Services Infection Prevention and Control, revised 08/29/2022, revealed food handlers were required to perform hand hygiene prior to contact with or preparation of food items and beverages. Further review revealed employees were required to have hair covered with a hair net and beards and mustaches were to be kept close-cropped; however, the policy did not specify the use of beard guards/beard restraints.Review of the facility policy titled, Hand Hygiene, revealed the policy identified examples of when to perform hand hygiene, including before donning (putting on) personal protective equipment (PPE), after doffing (removing) PPE, and after touching a contaminated area and before moving to a clean area.Review of the facility policy titled, Food Temperatures, revised 07/2019, revealed temperatures were to be taken using a clean, calibrated thermometer.On 03/04/2026 at 9:01 AM, the surveyor met with the Dietary Manager (DM) in the kitchen and observed the DM in the kitchen without a beard restraint.On 03/04/2026 at 11:26 AM, the surveyor entered the kitchen to observe the meal tray line, and the DM was again observed in the kitchen without a beard restraint.During tray line service on 03/04/2026, multiple breaks in sanitary technique were observed. At 11:45 AM, Dietary Aide (DA) 3 donned gloves, adjusted the wall A/C remote control, and was prompted by the DM to change gloves. DA3 changed gloves but did not perform hand hygiene prior to donning the new gloves.Continued observations revealed at 11:47 AM, DA2 left the tray line to retrieve a ladle elsewhere in the kitchen and returned to the tray line without performing hand hygiene and without changing gloves. At 11:50 AM, DA2 left the tray line to retrieve mashed potatoes from the oven and returned without performing hand hygiene and without changing gloves. At 11:52 AM, DA1 left the tray line to retrieve an item from the warmer located outside the kitchen in the bistro area and returned without performing hand hygiene and without changing gloves.Further observations revealed at 12:01 PM, DA1 was observed standing with gloved hands held at the waist and resting against clothing.Other observations revealed improper handling and storage of the food thermometer during tray line service. At 11:57 AM, DA2 wiped a food thermometer with an alcohol wipe; however, DA2 then closed the thermometer with a gloved hand, and the gloved hand contacted the probe area. At 12:00 PM, DA2 used the same thermometer to take the temperature of a bowl of mashed potatoes. At 12:02 PM, DA1 wiped the thermometer after use but left it open on top of a temperature log binder with the probe in contact with the binder. At 12:05 PM, DA2 picked up the thermometer and used it to take the temperature of pureed chicken without re-wiping/sanitizing the probe. At 12:07 PM, DA2 cleaned the thermometer and set it down, open on an oven mitt, with the probe in contact with the mitt. At 12:09 PM, DA2 used the thermometer to take the temperature of pureed green beans without re-wiping/sanitizing the probe.During interview on 03/05/2026 at 9:36 AM, DA1 stated that if gloved hands touched a non-food item (including clothes), the required next step was to remove gloves, wash hands, and don new gloves, and stated that if gloved hands rested on clothing, the food could become contaminated, and residents could get sick.DA1 further stated the thermometer should be placed back in the holding tray and should be closed between temperature checks.During interview on 03/05/2026 at 9:28 AM, DA2 stated that after leaving the tray line, staff should wash hands and change gloves and acknowledged failing to do so could spread bacteria/disease and make someone sick.During interview on 03/05/2026 at 9:45 AM, DA3 stated that if staff touched a non-food item while gloved, gloves should be removed and replaced, and handwashing would be expected because germs could contaminate gloves and make residents sick.During interview on 03/05/2026 at 2:24 PM, the DM stated that if staff had to leave the tray line, they should deglove, wash hands, and reglove, and stated failing to do so could result in cross contamination, exposure to an allergen, and exposure of pathogens to food.The DM stated thermometers should be sanitized with alcohol prep pads prior to use and after assessing temperatures of every individual item and stated the thermometer should be closed and placed in a container that held the prep pads between uses.The DM acknowledged that when supervising the tray line, the DM should have been wearing a beard guard.During interview on 03/05/2026 at 3:00 PM, the Assistant Director of Nursing (ADON) stated staff should wear hair and beard restraints in the food prep area and that when changing gloves, staff should wash hands between glove changes to prevent contamination of gloves and food, and stated that laying a thermometer probe on a binder or oven mitt was not sanitary practice.Neither the Director of Nursing nor the Administrator were available for interview.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) to ensure it met the residents' medical, nursing, mental, and psychosocial needs as identified on his/her comprehensive assessment and other assessments for one (1) of eighteen (18) sampled residents (Resident (R)1). On 04/27/2024, R1 exhibited exit seeking behaviors, however, staff failed to care plan the resident for these behaviors. On 04/28/2024, R1 eloped from the skilled nursing facility (SNF) unit, located in a hospital, via the elevator without staff's knowledge and was found in the lobby trying to exit through the doors. The facility's failure to have an effective system in place to ensure residents' care plans were developed to address the residents' exit-seeking behaviors is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 12/20/2024 and determined to exist on 04/28/2024 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656, at a Scope and Severity (S/S) of a J. The facility was notified of Immediate Jeopardy on 12/20/2024. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 12/31/2024, alleging removal of the IJ on 01/01/2025. The State Survey Agency (SSA) validated the IJ was removed on 01/01/2025, prior to the exit on 01/03/2025. Remaining non-compliance continued at a S/S of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F689 The findings include: Review of the facility's policy titled, Assessments created January 2014, revealed a comprehensive assessment was to be completed within 14 days of a resident's admission, quarterly, and when a significant change in the resident's physical or mental condition occurred that was not normally resolved without further intervention by staff. Per policy review, it included the care area of wandering; however, did not cover elopement. During interview on 12/19/2024 at 1:20 PM, the Assistant Director of Nursing (ADON) stated the facility did not have a policy for Elopement or Wandering Assessments. Review of the facility's policy titled, Care Planning, effective 07/09/2012, revealed the needs of the resident, goals, time frames, required services, and the service setting were critical considerations in determining the resident's plan of care. Continued review of the policy revealed regular reviewing and revising the care plan, treatment, and services was to occur at 90 day intervals or more frequently, based on the resident's clinical condition, care goals, and the plan of treatment, care, and services. Per policy review, revisions were to occur as needed to meet the needs of the resident's changing condition and were to be evaluated through monitoring the effectiveness of care planning and the provision of care, treatment, and services. Review further revealed residents and/or families could be involved in the care planning process. 1. Review of the electronic medical record (EMR) for R1 revealed the facility admitted her on 08/10/2022 with diabetes that included: aphasia (loss of ability to express or understand speech), hemiplegia/hemiparesis, type II diabetes, and depression. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/24/2024, revealed the facility assessed R1 with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated she had been unable to complete the assessment. Per review of the MDS, the facility assessed R1 as not exhibiting any behaviors of wandering. Review of the MDS revealed R1 had impairment to both her upper and lower extremities on one side of her body and she used a wheelchair for mobility. Further review revealed the facility also assessed R1 as needing assistance for transferring from the wheelchair to bed and for moving from sitting to standing. Review of R1's CCP dated 02/14/2024, revealed the facility had not care planned the resident for wandering or exit seeking behaviors. Per review of R1's CCP dated 04/28/2024, revealed the facility had care planned R1 for elopement risk and as a wanderer after she eloped from the facility. Review of the EMR revealed Wandering Risk Assessments for R1 dated 08/10/2022 (her admitted ), 05/04/2023, and on 04/13/2024. Review of the Wandering Risk assessment dated [DATE], revealed the facility assessed R1 as not being independently mobile; not exhibiting wandering behaviors; not having exit seeking behaviors; and not having the ability to exit the facility. Review of the Wandering Risk assessment dated [DATE] for R1, revealed the facility assessed the resident as the same as on her admission (08/10/2022). Review of the Elopement Risk assessment dated [DATE] (fifteen days prior to her elopement) revealed the facility assessed R1 as having no elopement attempts, no wandering behaviors, and as independently mobile. Review of the Nursing Narrative Note for R1 dated 04/28/2024, electronically signed by Registered Nurse (RN) 4 at 5:49 PM, revealed an unidentified Certified Nurse Aide (CNA) told the RN that R1 had been found by housekeeping staff in an elevator on the first floor. Review revealed the housekeeper brought R1 back up to the SNF unit, and Medical Director (MD) was notified, and an order received for a wander guard device which was placed on the resident's left ankle. Continued review revealed the MDS RN, (who was currently the ADON) had been covering for the DON, who was on vacation. Per review, the MDS RN (current ADON) notified R1's family, and the resident was educated on the purpose of the wander guard device. Observation on 12/16/2024 at 4:56 PM, of R1 revealed the resident seated in her wheelchair and rolling herself about the unit's hallway. The State Survey Agency (SSA) Surveyor attempted to interview R1 (who had a diagnosis of expressive aphasia), at the time of observation; however, the resident only responded with yes to the Surveyor's questioning of her name. All other questions were met with silence. In interview on 12/17/2024 at 3:58 PM, Registered Nurse (RN) 1 stated she worked in acute care for the hospital the SNF unit was located in and was the person who found R1 in the first-floor lobby (on 04/28/2024). She said R1 had been in a wheelchair and was pushing on the lobby door trying to get out the door which led to the parking lot. RN 1 stated R1 had a coke and some snacks with her and when she approached R1 to ask what she was doing, R1 told her she was trying to leave. She reported she had a cafeteria staff member call the SNF unit to let them know R1 was in the lobby. RN 1 said she stayed with R1 until a staff member from the SNF unit came to take her back to the unit. She explained she thought the elopement occurred around 4:00 PM to 5:00 PM, that day and there had been no one in the business office which was located near the lobby. RN 1 further stated she had never seen any other SNF unit residents in the lobby unless they were with staff or family, and had not seen R1 back in the lobby area since. In interview on 12/19/2024 at 10:56 AM, CNA 7 stated she had been going on break (on 04/28/2024) and was on her way to the elevator when she saw R1 rolling down the hallway towards the nurses' station. She said she had not thought anything about the resident rolling towards the nurses' station and also the elevators, so she left for lunch. CNA 7 stated she left to sit in her car during her break and when she returned she had not seen R1 in the hallway, and asked CNA 5 if the resident had gone to her room. She reported while looking for R1 in her room, housekeeping called the SNF unit and alerted CNA 5 that R1 was downstairs in the lobby. CNA 7 stated she had not seen R1 when she entered the facility's lobby after returning from her lunch break. She said she did not remember any issues occurring with R1 the day she eloped (04/28/2024); however, stated R1 had been having a tough week that week and had been hitting staff and having exit seeking behaviors. CNA 7 reported she had been told in report (on 04/28/2024) that R1 had tried to get out off the unit, the day before (on 04/27/2024). She stated she could not recall the CNA who gave her that information in report and did not know if that CNA notified the RN of R1's exit seeking behaviors. In interview on 12/19/2024 at 11:27 AM, CNA 8 stated she remembered R1 having a lot of exit seeking behaviors in the month prior to her elopement. CNA 8 stated she had been physically assaulted by R1 when she stopped R1 from trying to get on the elevator and leave the unit. She reported telling RN 4 and the former DON (RN 6) and said management (present ADON and the former DON) had been aware of R1's exit seeking behaviors prior to her elopement. The CNA said staff had been told they had to watch R1 closely to prevent her from leaving the unit. She stated in the month of April, R1 tried to get off the unit three to four times, but staff had been able to retrieve her most of the times. CNA 8 reported however, twice R1 had gotten in the elevator (one of which was the day she eloped). She said the day of the week or time of day when R1 attempted to get off the SNF unit was not a factor, as the resident had tried on different shifts and on different days. CNA 8 further stated if R1 thought she had an opportunity to get off the unit she would try and leave. In interview on 12/19/2024 at 1:20 PM, the ADON/MDS Coordinator, she stated she had been the MDS Coordinator at the time of R1's elopement (on 04/28/2024). She stated she had been notified of R1's elopement as she had been the manager on call, and was covering for the DON, who was on vocation at the time. The ADON said that when she arrived to the facility on the day of the elopement, staff had already brought R1 upstairs and talked to the Medical Director who ordered a wander guard device for the resident. Per the interview, the ADON stated she did not care plan the resident for her exit-seeking behavior prior to the resident's elopement because staff did not inform her of the resident's exit-seeking behaviors. In interview on 12/19/2024 at 1:41 PM, the DON stated she had been the DON since 06/30/2024. She said she expected her staff to keep residents safe by redirecting the resident when they were exhibiting exit seeking behaviors. She reported she also expected staff to notify the nurse, ADON, DON, Administrator, Medical Director, and resident's family of those behaviors. The DON explained if a resident got out of the facility, she expected staff to also alert the police, and implement constant supervision of the resident and place a wander guard monitor on him/her immediately. In interview on 12/19/2024 at 1:50 PM, the Administrator stated R1's elopement occurred on a weekend, and the ADON called her to let her know the resident had gone downstairs where she had been found by a staff member from another department. She stated she was unaware of R1's wandering and exit seeking behaviors prior to her elopement. The Administrator stated her expectations for staff, for residents exhibiting exit seeking behaviors, was for them to report up the facility's chain of command to the ADON. She said interventions she expected to be put in place to prevent further elopements, was to closely supervise the resident and place a wander guard on the resident after an elopement. The Administrator reported if R1 was out of her room staff should keep an eye on her regularly and should bring her to where they were providing other residents' care so they could observe her more often. She further stated R1's behaviors were never voiced to her by nursing staff. The Administrator stated R1 was care planned for elopement and exit seeking behaviors after R1's elopement. She stated staff did not make management aware of the resident's exit seeking behaviors. The facility provided an acceptable IJ Removal Plan on 12/31/2024: Resident affected by the IJ: The facility took immediate action on 4/28/2024, to remove the IJ. Immediately following the elopement of R1 that occurred on 4/28/2024, the resident was returned to the facility without any injury/harm sustained, as determined by an assessment performed by the RN on duty. Per MD order, a wander guard was placed on R1's person to ensure staff would be alerted if she tried to enter the elevator/exit the 2nd floor facility again. Her family was notified, and they agreed with the plan in place. R1 was able to continue to self-propel in her wheelchair throughout the facility while she worked on her crossword puzzles, as she normally did. Staff continued to complete a weekly elopement risk assessment, per the facility's assessments policy. As documentation shows, R1 was not previously identified as an elopement risk, with no documentation of wandering or exit-seeking behaviors. Policy was followed and continues to be followed. Additional policy has been created to ensure a consistent plan following an elopement. Other residents affected: All residents are assessed weekly per assessments policy. No other residents were considered to be an elopement risk. Training: Upon receiving the IJ, education on wandering and exit-seeking behavior was provided to all staff of the nursing facility by the ADON. Education began on 12/23/2024 and was completed on 12/30/2024 for all actively working staff. The education was added to the orientation check list for new hires of the facility as of 12/23/2024 by the ADON. The training was an in-person verbal educational format in which employees received a copy of the material presented. It described wandering and exit-seeking behaviors, and the steps that were to be taken should those behaviors occur within the facility. Monitoring: The MDS Coordinator completed audits to ensure the wander guard transmitter was in place for R1 and elopement assessments were completed on the resident as per policy. Audits were done 04/28/2024 through 06/29/2024, with 100% compliance. The ADON will conduct random interviews with staff to ensure understanding of the education provided. A minimum of 2 interviews will be conducted at least once weekly for six months. If staff give any indication they were unclear of education provided, they will be reeducated immediately. Interviews began on 12/30/2024 and will continue until 100% compliance is maintained for 90 days. The ADON will monitor resident charts weekly to ensure completion of elopement risk assessment. The audit began on 12/30/2024 and will continue until 100% compliance is maintained for 90 days. Information from all audits and interviews will be taken to quarterly QAPI meetings. Action: Assessments policy was revised to change the wording from wander risk assessment to Elopement Risk Assessment by ADON on 12/23/2024. Policy named assessments was already in place for assessing residents for elopement and wandering. A new policy titled, Elopement was created on 12/30/2024, to address steps to be completed upon an elopement occurring. Input for the policy was provided by QAPI members: CEO, DON, ADON, Safety Office, and Quality Officer. The new policy was provided to all Nurses on 12/30/2024. Per policy, care plans are updated immediately following a change in care by the nurse on duty. R1's care plan was updated on 4/28/2024, after her elopement by the RN on duty. It was not updated prior because the facility was not aware of any wandering/exit-seeking behaviors by the resident. All staff received education (see prior training section) on reporting behaviors. Care plans continue to be updated immediately by the nurse on duty and reviewed quarterly by the MDS Coordinator. IJ removal date: 01/01/2025 Attached you will find: 1. Education sign in sheet 2. Assessments Policy 3. Elopement Policy (The attachments referenced above are on file with the State Survey Agency.)

Based on interview, record review, and review of the facility's investigation documentation and policies, the facility failed to have an effective system in place to ensure resident safety for 1 of 18 sampled residents, (Resident (R)1). On 04/27/2024, R1 exhibited exit-seeking behaviors, however, the facility failed to ensure the resident was provided increased supervision. On 04/28/2024, R1 eloped from the facility (a skilled nursing facility [SNF] unit) without staff knowledge and was found on the first-floor lobby (of the acute care hospital the facility was located in) trying to exit the building [facility]. The facility's failure to have an effective system in place to ensure residents' safety is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 12/20/2024 and determined to exist on 04/28/2024 in the area of 42 CFR 483.25 Quality of Care, F689, and Substandard Quality of Care (SQC) at 42 CFR 483.25. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 12/31/2024, alleging removal of the IJ on 01/01/2025. The State Survey Agency (SSA) validated the IJ was removed on 01/01/2025, prior to exit on 01/03/2025. Remaining non-compliance continued at a S/S of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F656 The findings include: Review of the facility's policy titled, Assessments, created January 2014, revealed a comprehensive assessment was to be completed within 14 days of a resident's admission. Per review, the comprehensive assessment was also to be completed quarterly, and when there was a significant change in a resident's physical or mental condition that was not normally resolved without further intervention by staff or by starting standard disease related clinical interventions. Continued review revealed the policy addressed the care area of wandering; however, not elopement. In interview on 12/19/2024 at 1:20 PM, the Assistant Director of Nursing (ADON) stated the facility did not have a policy for Elopement or Wandering Assessments. Review of the facility's policy titled, Code [NAME] (Missing Patient/Resident), last revised 09/2023, revealed the policy described the procedure for staff to follow when a resident went missing from their department. Review of the facility's policy titled, Resident Rights and Responsibilities, with an effective date of 01/01/2000, revealed the resident had the right to a safe and secure environment safeguarded by clinical and non-clinical personnel. Review of the Adult Transmitter manual (for the resident monitoring devices) revealed it contained information regarding the use of the device, transmitter testing, and how to place the device on a resident. Review of the electronic medical record (EMR) for R1 revealed the facility admitted the resident on 08/10/2022 with diagnoses that included: diabetes type II, aphasia, hemiplegia/hemiparesis, hypertension, hyperlipidemia, and depression. Continued review of R1's EMR revealed Wandering Risk Assessments dated 08/10/2022 and 05/04/2023. Review of the Wandering Risk assessment dated [DATE], revealed the facility assessed R1 as not independently mobile, not having exit seeking behaviors, not exhibiting wandering behaviors, and not having the ability to exit the facility. Review of the Wandering Risk assessment dated [DATE], revealed the facility again assessed R1 as not being independently mobile, not demonstrating exit seeking behaviors, not having wandering behaviors, not having a history of elopement. Continued review of the 05/04/2023, Wandering Risk Assessment for R1 revealed the resident had the ability to exit the facility. Further review of R1's EMR revealed an additional Elopement Risk assessment dated [DATE], which noted R1 as having no elopement attempts, no wandering behaviors, and as being independently mobile. Review of the Activities of Daily Living (ADLs) documentation charted by the Certified Nurse Aides (CNA's) on 04/28/2024, revealed R1 had ADL care performed at 9:02 AM and 7:59 PM on 04/28/2024. In interview on 12/19/2024 at 1:20 PM, the ADON stated the CNAs did not have an area to chart resident checks on their flowsheets. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/24/2024, revealed the facility assessed R1 as having a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had been unable to complete the assessment. Per review of the MDS, the facility assessed R1 as not exhibiting any behaviors of wandering. Continued review revealed the facility assessed R1 as having impairment to both the upper and lower extremities on one side and to use a wheelchair. Further review revealed the facility also assessed R1 as needing assistance for chair to bed transfers, and for moving from sitting to standing. In addition, review revealed the facility assessed R1 as not having the ability to walk. Review of R1's Comprehensive Care Plan (CCP) dated 02/14/2024, revealed the facility had not care planned the resident for wandering or exit seeking behaviors. Continued review of R1's CCP revealed the facility care planned the resident on 04/28/2024 (the date of her elopement from the facility), for being an elopement risk and wanderer. Review of the Nursing Narrative Note for R1 dated 04/28/2024 at 5:49 PM, electronically signed by Registered Nurse (RN) 4, revealed the Certified Nurse Aide (CNA, no specific aide identified) came to get Registered Nurse (RN) 4 to tell her the resident had been found by housekeeping in an elevator on the first floor, of the hospital in which the SNF was located. Per review, the housekeeper brought R1 back up to the unit (facility). Continued review revealed the Medical Director was notified, and a wander guard (monitoring device) was placed on R1's left ankle, and the resident's family also notified. Further review revealed R1 was educated on the purpose of the wander guard. Review of the Facility's Incident Report dated 04/28/2924 at 4:22 PM, revealed RN 1, from the acute care on the first floor, found R1 in her wheelchair in the lobby of the building. Per review, CNA 5 went to the lobby and brought R1 back to the unit (facility). Review revealed the ADON, resident's Family Member (FM) 3, and Medical Director were notified and an order received for a wander guard (monitoring device) According to review of the Report, the investigation noted the facility's security cameras were reviewed, and showed R1 leaving the unit (facility) at 3:58 PM via the elevator. Continued review revealed R1 was observed on the video exiting the elevator at 3:59 PM where she propelled herself into the lobby and down the hallway toward Radiology. Continued review revealed at 4:22 PM a nurse (RN 1) from the acute care floor was seen with R1. Review revealed CNA 5 was notified and was seen on the video attending to R1 at 4:24 PM and returning her to the facility on the second floor. Per continued review, interviews with staff revealed R1 had been self-propelling in the hallway as she normally did, and a CNA (not identified by name) reported after she returned from her lunch break, she had not seen R1 in the hallway and checked the resident's room, but had not found R1 there either. Further review revealed the CNA also reported while she was walking to ask the other CNA where R1 was, they received the call notifying them that the resident was downstairs (in the lobby). Additionally, review revealed R1 was assessed and found to have no injuries, and had been assessed as not wandering aimlessly nor being considered an elopement risk. Review further revealed R1, was interviewed; however, due to her expressive aphasia, when asked about leaving the facility she shook her head back and forth as if to indicate no. Observation of R1 on 12/16/2024 at 4:56 PM, revealed the resident was seated in her wheelchair in the hallways and was rolling herself about the unit (facility). The State Survey Agency (SSA) Surveyor attempted to interview R1 on 12/16/2024 at 4:56 PM; however, the resident only answered yes to the Surveyor's question regarding her name. All the other questions the SSA Surveyor asked were met with silence. In interview with RN 1 on 12/17/2024 at 3:58 PM, she stated she worked in acute care in the hospital where the SNF unit was located. RN 1 stated she found R1 in the first-floor lobby, pushing on the exit door trying to get out the door which led to the parking lot. She said R1 was in a wheelchair when she found her, and had a coke and snacks with her. RN 1 reported she approached R1 and asked what the resident what she was doing and what unit she was from. She stated R1 told her she was trying to leave. RN 1 said she had a cafeteria staff member call the SNF unit (where R1 resided) to let them know R1 was in the lobby. She said she stayed with R1 until a staff member from the SNF unit came to take her back to the unit. RN 1 stated she thought the elopement occurred around 4:00 to 5:00 PM, and no one was in the business office located near the lobby. She further stated she had never seen any other residents in the lobby unless they were with staff or family and had never seen R1 back in the lobby since. In interview with FM 3 (R1's POA) on 12/17/2024 at 7:03 PM, she stated she had been notified the resident got off the unit; however, could not remember how long it took them to tell her after the incident occurred. She stated she did not think there was a lapse of time between when her mother (R1) got off the unit and when the facility notified her. FM 3 said R1 rolled up and down the hallways (of the facility) in her wheelchair, but she had never got off the unit before that incident. She reported R1 had been virtually non-verbal since her stroke [AGE] years prior. The Family Member stated family frequently took R1 outside for fresh air, so the resident knew the way out of the building prior to her elopement. She said since the incident however, they had not taken R1 out of the facility. FM 3 reported after R1 got off the unit, staff kept a close eye on her and the resident now had a wander guard in place to prevent her from getting off the unit again. In a follow up interview on 12/19/2024 at 11:54 AM with FM 3, she stated no one had been to visit R1 on 04/28/2024, the day the resident eloped. She stated she could not remember if anyone had taken R1 out of the facility (either outside, to eat or to shop) in the month preceding her elopement either. In interview with CNA 2 on 12/18/2024 at 9:18 AM, she stated she had worked part time at the facility for two to three years, and in that time had never seen R1 exhibit exit seeking behaviors. She stated however, in the past when R1's daughters or sister came for a visit the resident seemed like she wanted to leave with them because she would become more unsettled after their visits. In interview with CNA 8 on 12/19/2024 at 11:27 AM, she stated she remembered R1 having a lot of exit seeking behaviors in the month prior to her elopement. CNA 8 reported she had been physically assaulted by R1 when the resident was trying to get off the unit and she (the CNA) tried to stop R1 from getting on the elevator. She stated she told nursing staff, RN 4 and the former DON/RN 6, and management (the present ADON and former DON) had been aware of R1's exit seeking behaviors prior to her elopement. The CNA said staff were told they had to watch R1 closely to prevent her from leaving the unit. She reported in the month (April) R1 tried to get off the unit at least three to four times, but staff had been able to retrieve her most of the times. CNA 8 stated however, twice R1 had gotten on the elevator, one being the day she eloped. She explained the day of the week or time of day that R1 attempted to get out was not a factor because she had tried to leave on different shifts and on different days. CNA 8 further stated she thought if R1 had an opportunity to get off the unit she would try and leave now. In interview with CNA 7 on 12/19/2024 at 10:56 AM, she stated on the day of R1's elopement, she had been going on break when she saw R1 rolling down the hallway towards the nurses' station. CNA 7 said she had not thought anything about R1 rolling down the hallway towards the nurses' station and consequently the elevators, so she left for lunch. She reported when she returned from lunch she did not see R1 in the hallway and asked CNA 5 if R1 had gone to her room, then went to the resident's room to look for her. The CNA stated housekeeping called and spoke with CNA 5, and told her R1 was downstairs in the lobby. She reported she had not seen R1 when she exited the building for lunch or upon her return from lunch. CNA 7 said she did not recall what time she went to lunch but remembered CNA 6 (who was scheduled to work until 2:00 PM) had left already for the day. She stated her lunch break had lasted 30 minutes on the day R1 eloped. The CNA explained she did not recall any issues with R1 occurring on 04/28/2024; however, did remember the resident had been having a tough week that week. She said R1 had been hitting staff and having exit seeking behaviors. CNA 7 stated she had been told in report on 04/28/2024, that the resident had tried to get out of the unit, the day before (04/27/2024). She could not recall the CNA who gave her that report though and did not know whether that CNA notified the RN of R1's exit seeking behaviors (on 04/27/2024). CNA 7 further stated R1 was not able to walk and could only move about the unit/facility in her wheelchair. In interview with RN 5 on 12/19/2024 at 11:37 AM, she stated R1 had no exit seeking behaviors before the elopement that she had witnessed or had been told about. RN 5 stated R1 went up and down the hallway in her wheelchair, but did not try to get on the elevator. She said she and her CNAs watched R1 just like they did all the other residents, making sure they were safe and accounted for. RN 5 explained she did not recall anything occurring around the time R1 eloped which might have upset her. She reported R1 liked to exert control and would often throw a fit if she did not get her needs met in the way she wanted. RN 5 stated R1 had not tried to get out since the elopement, and she had never seen R1 hanging out by the elevators. In interview with the [NAME] Clerk (WC) on 12/18/2024 at 9:54 AM, she said she sat at the desk at the entrance to the unit and R1 would have had to have gone past her to get to the elevators (when she eloped). She stated she also took care of residents' laundry and so, was sometimes away from the desk. The WC explained she only worked Monday through Friday 7:00 AM to 3:00 PM, and had not been at work when R1 eloped, as the incident occurred on a Sunday afternoon. She said she was the only WC for the unit and there was not a WC on nights and weekends. She further stated after R1's elopement she had observed the resident at the elevator trying to get on it and then being removed from the elevator area by CNAs and taken back to her room. In an interview on 12/19/2024 at 10:42 AM, the Safety and Compliance Director (SCD) stated he had been the person viewing the camera video footage of R1's elopement with the ADON. He said however, the facility no longer had that video footage because it got taped over after about a month. The SCD stated on the video, R1 rolled down the hallway towards Radiology on the first floor of the building, but had not tried to access any doors along the way. Per the SCD in interview, R1 was then observed to turn around and roll back the way she came from, towards the exit doors. He stated he could not recall which door in the lobby R1 had been trying to exit through. The SDC stated all the doors on the left side of the building's main corridor and the right side of the main corridor, except the main cafeteria door were locked on nights and weekends. He reported the Radiology Department, which R1 passed by, had two doors located on the main hallway, one of which was always locked. The SCD said the other door to Radiology was always closed, but might not be locked if staff were working in Radiology. He stated radiology staff ensured both doors were locked if they had to go to the Emergency Department (ED). The SCD said he was not sure if staff had been in the Radiology Department at the time the event occurred (on 04/28/2024). In interview with the ADON on 12/19/2024 at 1:20 PM, she stated she had been the MDS Coordinator at the time of R1's elopement and the SNF unit had not had a ADON at the time of R1's elopement. The ADON stated R1 had not had exit seeking behaviors prior to that elopement. She said R1 wheeled up and down the hallway only, and never tried to get on the elevator. The ADON reported she had never been made aware of R1 exhibiting exit seeking behaviors by any staff member prior to the elopement. She stated nor had she been informed of anything that went on during that day (04/28/2024) that might have upset R1. Per the ADON in interview, she had been the on call for the former DON (RN 6), who was on vacation at the time of R1's elopement. She said the former DON now worked full time in the hospital's Medical Surgical Unit; however, still worked Pro Re Nata (PRN) for the SNF unit. The ADON stated when she arrived at the facility on the day of R1's elopement, staff had already brought R1 back upstairs and talked to the Medical Director, who ordered the wander guard device. In continued interview on 12/19/2024 at 1:20 PM, the ADON stated she observed the camera video footage of the elopement with the SCD, R1 had not tried to access any doors in the downstairs hallways. Per the ADON in interview, on the video R1 had rolled down the hallway towards Radiology, then turned around and came back to the lobby prior to where she pushed on the exit door, trying to get out. The ADON said the lobby had two exit doors, but she did not remember which door in the lobby R1 had been pushing on to try and exit the building. She stated R1 could read and did word puzzles, and it was thought she read signs and that was why she had not tried opening other doors in the hallways. The ADON reported R1 was the only resident who wandered and had tried to elope. In interview with the DON on 12/19/2024 at 1:41 PM, she stated she had only been the DON since 06/30/2024, and had worked in the acute care unit of the hospital prior to that. The DON stated her expectations of her staff regarding residents who wandered was for staff to keep those residents safe by redirecting the resident when they were exhibiting exit seeking behaviors. She said she also expected staff to notify the nurse, ADON, DON, Administrator, Medical Director, and resident's family of those types of behaviors. According to the DON in interview, if a resident got out of the facility, she expected staff to also alert the police. She reported interventions to prevent further elopement were expected to be implemented, providing constant supervision. The DON further stated she would want someone constantly with the individual one on one (1:1) for the first few days after the elopement. She additionally said she expected staff to make sure they knew where to find all residents on an hourly basis. In interview with the Administrator on 12/19/2024 at 1:50 PM, she stated the elopement of R1 occurred on a weekend. The ADON called her to let her know that R1 went downstairs where she was found by a staff member from another department and had not sustained any injuries. She said the ADON told her staff had brought R1 upstairs to the unit and assessed her and placed a wander guard device on her. Per the Administrator in interview, the ADON said she would make a report about the incident to the proper authorities and start the investigation. She stated her expectations of facility staff, regarding a resident exhibiting exit seeking behaviors, was that they would report such information up the chain of command to the ADON. The Administrator said she also expected staff to report the incident to the resident's family and the Medical Director. She said the ADON would alert her and the DON. The Administrator reported interventions staff should put in place to prevent further elopements were to put the resident on closer supervision, and it would depend on the resident's mobility and condition that would dictate how often the resident should have eyes laid on them. The Administrator stated staff should keep the at risk resident in line of sight at all times after an elopement, and place a wander guard device on resident. She stated immobile residents should be seen by staff hourly and mobile residents more frequently. The Administrator further stated if R1 was out of her room, staff should keep an eye on her regularly and should take her to where they were providing care for other residents care in order to observe her more often. The facility provided an acceptable IJ Removal Plan on 12/31/2024: Resident affected by the IJ: The facility took immediate action on 4/28/2024, to remove the IJ. Immediately following the elopement of R1 that occurred on 4/28/2024, the resident was returned to the facility without any injury/harm sustained, as determined by an assessment performed by the RN on duty. Per MD order, a wander guard was placed on R1's person to ensure staff would be alerted if she tried to enter the elevator/exit the 2nd floor facility again. Her family was notified, and they agreed with the plan in place. R1 was able to continue to self-propel in her wheelchair throughout the facility while she worked on her crossword puzzles, as she normally did. Staff continued to complete a weekly elopement risk assessment, per the facility's assessments policy. As documentation shows, R1 was not previously identified as an elopement risk, with no documentation of wandering or exit-seeking behaviors. Policy was followed and continues to be followed. Additional policy has been created to ensure a consistent plan following an elopement. Other residents affected: All residents are assessed weekly per assessments policy. No other residents were considered to be an elopement risk. Training: Upon receiving the IJ, education on wandering and exit-seeking behavior was provided to all staff of the nursing facility by the ADON. Education began on 12/23/2024 and was completed on 12/30/2024 for all actively working staff. The education was added to the orientation check list for new hires of the facility as of 12/23/2024 by the ADON. The training was an in-person verbal educational format in which employees received a copy of the material presented. It described wandering and exit-seeking behaviors, and the steps that were to be taken should those behaviors occur within the facility. Monitoring: The MDS Coordinator completed audits to ensure the wander guard transmitter was in place for R1 and elopement assessments were completed on the resident as per policy. Audits were done 04/28/2024 through 06/29/2024, with 100% compliance. The ADON will conduct random interviews with staff to ensure understanding of the education provided. A minimum of 2 interviews will be conducted at least once weekly for six months. If staff give any indication they were unclear of education provided, they will be reeducated immediately. Interviews began on 12/30/2024 and will continue until 100% compliance is maintained for 90 days. The ADON will monitor resident charts weekly to ensure completion of elopement risk assessment. The audit began on 12/30/2024 and will continue until 100% compliance is maintained for 90 days. Information from all audits and interviews will be taken to quarterly QAPI meetings. Action: Assessments policy was revised to change the wording from wander risk assessment to Elopement Risk Assessment by ADON on 12/23/2024. Policy named assessments was already in place for assessing residents for elopement and wandering. A new policy titled, Elopement was created on 12/30/2024, to address steps to be completed upon an elopement occurring. Input for the policy was provided by QAPI members: CEO, DON, ADON, Safety Office, and Quality Officer. The new policy was provided to all Nurses on 12/30/2024. Per policy, care plans are updated immediately following a change in care by the nurse on duty. R1's care plan was updated on 4/28/2024, after her elopement by the RN on duty. It was not updated prior because the facility was not aware of any wandering/exit-seeking behaviors by the resident. All staff received education (see prior training section) on reporting behaviors. Care plans continue to be updated immediately by the nurse on duty and reviewed quarterly by the MDS Coordinator. IJ removal date: 01/01/2025 Attached you will find: 1. Education sign in sheet 2. Assessments Policy 3. Elopement Policy (The attachments referenced above are on file with the State Survey Agency.)

Based on interviews and review of the facility's policies and procedures, it was determined the facility failed to protect and facilitate the residents' right to communicate with individuals and entities within and external to the facility, including the ability to send and receive mail, packages and other materials delivered to the facility for 3 of 18 sampled residents (Resident (R) 6, R8, and R14). The facility did not pick up, sort, and deliver mail to residents on weekend, more specifically on Saturday, to R6, R8, and R14, with the potential to affect 18 of 18 residents residing in the facility. The findings include: Review of the facility's policy titled, Resident Rights and Responsibilities last revised on 08/01/2001, on page 4, number 24 revealed, A resident shall be permitted to send and receive mail without hindrance, unless clinically contraindicated. In interview on 12/19/2024 at 9:50 AM with the Director of Nursing (DON); with the Administrator at 10:05 AM; and with the Assistant Director of Nursing (ADON) at 2:41 PM, they all stated the facility currently had no policy and/or procedure in place regarding residents' rights to send and/or receive mail on Saturdays. In interview with the Activities Director (AD) on 12/18/2024 at 1:30 PM, she stated residents did receive their mail on Monday through Friday in the facility. She further stated however, the Saturday mail was not picked up until Monday because the Business Office was not open on weekends. The AD additionally stated residents did not get their weekend mail until the following Monday. Review of the electronic medical record's (EMR's) for R6, R8, and R14 revealed all three residents had been assessed as having a Brief Interview for Mental Status (BIMS) score of 15, indicating they were all cognitively intact and interviewable. In interview with R6 and R8 on 12/18/2024 at 1:35 PM, both stated they were not aware they could send and/or receive mail on the weekend, specifically on Saturday, in the facility. Both R6 and R8 stated they did not receive any mail on Saturday, but said they were able to receive and send mail Monday through Friday. In interview with R14 on 12/18/2024 at 1:40 PM, she stated she was not aware if she had ever received mail on the weekends or if she had ever received mail at all. In interview with the Supervisor of Patient Accounts on 12/19/2024 at 9:12 AM, she stated the Emergency Department (ED) staff brought the mail to the business office during the week where it was sorted then sent to each department. She said Saturday's mail was dropped off in the Business Office; however, since there were no staff working on the weekends, it did not get taken to the appropriate department until the following Monday. In interview with the [NAME] Clerk (WC) of the skilled nursing facility (SNF) unit on 12/19/2024 at 9:25 AM, she stated she went downstairs to the Business Office every morning, Monday through Friday, to pick up the SNF unit mail. She stated the mail she picked up each day was the mail from the previous day. The WC further stated the mail from Friday and Saturday was picked up on the following Monday. In interview with the Admitting Clerk in the ED on 12/19/2024 at 9:40 AM, she stated she was unaware of how the mail was picked up; however, said she was willing to help figure how it was. The ED Admitting Clerk phoned a staff person in the Business office who was unsure of how the mail was handled, but gave a different Business Office staff person's name. She phoned the second Business Office staff person who said she actually picked the mail up from the facility's mailbox and brought it to the Business Office, Monday through Friday. In interview on 12/19/2024 at 9:42 AM, the Business Office staff person, who picked up the mail, stated no one got the mail on Saturday from the mailbox. She said when she came back in to work on the following Monday, she picked up the mail from the mailbox, which included the Saturday and Monday mail. She further stated both days (Saturday's and Monday's) mail was taken to the Business Office on Monday. In interview with the Assistant Director of Nursing (ADON) on 12/19/2024 at 2:41 PM, she stated the Business Office brought the mail up each day, which had been placed in the mailbox that same day. She clarified the [NAME] Clerk was referring to employees' mail being received from the facility she picked up every day. The ADON stated the mailbox was located outside the ED. She said each day when the United States Parcel Service (USPS) delivered the mail, the Business Office staff person picked up the mail from the mailbox and dropped it off at the Business Office, where it was sorted then delivered to the appropriate department. The ADON reported no one picked up the mail from the mailbox on Saturdays because the Business Office was closed over the weekend. She stated the Business Office staff person picked up the Saturday and following Monday mail that following Monday. Per the ADON in interview, the residents received their mail the day it was delivered by the USPS, Monday through Friday. She said however, the mail that was dropped off on Saturday by the USPS was not delivered to the residents until the following Monday. The ADON stated she had never even thought about that issue, until it was brought up during the State Survey Agency (SSA) Recertification Survey. She reported residents did have a right to receive their Saturday mail on Saturday, even if the Business Office was closed for the weekend. The ADON further stated they were going to have to establish a policy or a process for residents to send and/or receive their mail on the weekend. In interview with the Director of Nursing (DON) on 12/19/2024 at 9:50 AM, she stated there was not currently a policy or process for picking up residents' mail on weekends. The DON stated someone from the Business Office picked up the mail, Monday through Friday. She reported however, since the Business Office was only open Monday through Friday 8:00 AM to 4:00 PM, she did not know who took care of the mail on Saturdays. The DON said the ED staff possibly were who picked up the mail from the mailbox through the week and dropped it off to the Business Office. The DON further stated she believed the residents had a right to send and/or receive their mail on the weekends, as well as through the week, regardless of the Business Office being closed over the weekend. In interview with the Administrator on 12/19/2024 at 10:05 AM, she stated there was no process or policy or procedure in place regarding picking up the mail on the weekend. The Administrator stated she had not ever thought of that being an issue. She further stated however, she agreed residents had a right to send and/or receive their mail on Saturday, as well as, through the week, regardless of the fact the Business Office was closed on the weekend.

Based on interview, record review, and review of facility policies, the facility failed to ensure residents were free from abuse for one of 18 sampled residents (Resident (R)13). On 10/10/2024, staff witnessed R1 strike R13 three times on the leg with a rolled-up newspaper. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation in the Nursing Facility, effective date of 09/01/2011, and revised on 06/25/2013, revealed residents had the right to be free from mental, physical, sexual, and verbal abuse, neglect, and misappropriation of property. Per review, it was the policy of the facility to protect residents from real or perceived abuse, neglect, or misappropriation of property from anyone. Further review of the policy revealed it outlined the procedure for the management of suspected abuse/neglect and discussed the requirement for staff education. Review of the facility's policy titled, Resident Rights and Responsibilities, with an effective date of 01/01/2000, revealed the resident had the right to a safe and secure environment safeguarded by clinical and non-clinical personnel. Review of the facility's Incident Report dated 10/10/2024, revealed on that date at 3:14 PM, R1 was witnessed by Certified Nurse Aide (CNA) 3 self-propelling in her wheelchair over to R13 (her roommate, who was lying on the bed). Per review, CNA 3 observed R1 hit R13 three times across the legs with a rolled-up newspaper. Continued review revealed R13 was immediately moved from R1's room to a different room. Staff were made aware R1 was to be kept under constant supervision and not allowed to enter any other residents' rooms. Review revealed physical examination of R13 was conducted, with no injuries noted. Further review revealed R13 was unable to tell staff if she felt safe or not due to her mental status. Additional review revealed the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator (ADM), Medical Director, and families of both residents were notified. Review further revealed changes were made to the Comprehensive Care Plan (CCP) for R1 and changes in R1's medications were made. 1. Review of the electronic medical record (EMR) for R1 revealed the facility admitted the resident on 08/10/2022, with diabetes type II, aphasia, hemiplegia/hemiparesis, hypertension, hyperlipidemia, and depression. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/24/2024, revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident had been unable to complete the assessment. Per review of the MDS, the facility assessed R1 as not exhibiting any behaviors of wandering. Continued review revealed the facility also assessed R1 to have impairment to both upper and lower extremities on one side and as using a wheelchair. Further review revealed the facility additionally assessed R1 to require assistance to move from sitting to standing and for chair to bed transfers, and was not assessed for the ability to walk. Review of R1's Comprehensive Care Plan (CCP), dated 02/14/2024, revealed the facility care planned the resident for a behavior problem related to refusing medications, pocketing medications, throwing fits, and shaking her fist at staff. Per review, the goal was for R1 to have fewer episodes of those behaviors and have no evidence of those behavioral problems by the next review date. Continued review revealed the interventions included: anticipating and meeting R1's needs; assisting her to develop more appropriate methods of coping and interacting with others such as returning to her room when angry or encouraging her to express her feelings appropriately. Further review revealed the interventions also included: caregivers to provide the opportunity for positive interactions and attention by stopping to talk with R1 as they passed by; intervening as necessary to protect the rights and safety of others by approaching and speaking to R1 in a calm manner, diverting her attention, or removing the resident from the situation and taking her to an alternate location if needed. Additionally, review revealed other interventions included: minimizing the potential for R1's disruptive behaviors by offering talks which diverted her attention; monitoring her behavior episodes and attempting to determine the underlying cause by considering location, time of day, persons involved and situations and documenting the behaviors. Review further revealed an update to R1's CCP made on 10/10/2024, related to the behavior of slapping another resident on the leg with a newspaper, with an additional goal added noting the resident would not cause harm or injury to others, with no further interventions added. Review of the Progress Note from the Medical Director on 10/15/2024 revealed R1 had expressive aphasia from a stroke and was frustrated that she had issues communicating. Per review, since R1's sister passed away, she had been refusing to take medications or have her labs drawn. Continued review revealed R1 had became increasingly agitated and had even struck her roommate (R13), and he sent the resident to a Geriatric Psychiatry provider who almost immediately sent the resident to the medical floor due to her past atrial fibrillation. Further review revealed the Medical Director noted R1 returned to the facility in no better condition than she left and was still angry and acting out. Review revealed the Medical Director also noted, because R1 refused to take her medications orally, he decided to try Risperdal Consta injections (a long acting antipsychotic medication) for help with her mood issues. In addition, review revealed the Medical Director noted he was trying to find a geriatric psychiatric facility for consultation. Review of the Progress Note dated 10/26/2024 revealed the Medical Director was at the facility checking on R1. Observation of R1 on 12/16/2024 at 4:56 PM, revealed the resident sitting up in her wheelchair, rolling herself down the hallway. The State Survey Agency (SSA) Surveyor attempted to interview R1 on 12/16/2024 at 4:56 PM, with the resident only answering yes to one of the Surveyor's questions. During the rest of the Surveyor's questions R1 remained silent. In interview on 12/17/2024 at 7:08 PM, R1's Family Member (F)3 and POA, stated she had been told of the incident of R1 hitting R13 on the leg with her newspaper immediately after it occurred. F3 stated R1 had gone through emotional issues lately and had been refusing her medications. She stated she thought it might have been from not taking her medications that caused her to act out aggressively towards R13. The Family Member stated she was not sure why R1 had hit R13; however, thought it might be because the resident was not able to communicate well, since her stroke [AGE] years ago. She reported she thought her mother's frustration at not being able to communicate might have contributed to her hitting R13 with the newspaper. F3 said staff were sympathetic to R1 and understood she could not communicate well. She further stated if there were any issues with R1, the facility immediately contacted her or her sister. 2. Review of the EMR for R13 revealed the facility admitted the resident on 09/21/2021 with diagnoses of Alzheimer's Disease, dysphagia, depression, and gastroesophageal reflux disease (GERD). Review of R13's Quarterly MDS Assessment, with an ARD of 10/08/2024, revealed the facility had been unable to assess the resident and a BIMS score of 99 was noted. Further MDS review revealed R1 was not assessed as having any behaviors. Review of R13's CCP dated 10/10/2024, revealed the facility care planned the resident as at risk of abuse related to R1 hitting her with the newspaper. Per review, the goals were for R13 to be free from any and all harm from other residents or staff and for her not to show any emotional or behavioral changes from the act of abuse she incurred. Further review revealed the interventions included: removing R13 from danger immediately; monitor her behaviors and meal intake; and monitor for any other signs and symptoms that might occur post abuse. Review of the Nursing Narrative Note dated 10/10/2024 at 4:30 PM, revealed monitoring of R13 was being completed to ensure her safety and observe for any effects of the incident that occurred earlier that day (when the resident was hit with the newspaper by R13). Per review, there were no signs of emotional distress noted and there were no changes in eating habits or facial grimace noted. Further review All appears within normal limits (WNL). Review of the Nursing Narrative Note dated 10/12/2024 at 4:00 PM, revealed R13 was pleasantly confused and had slept on and off throughout the day, as was her usual habit. Further review revealed R13 ate well for breakfast and lunch, and had no signs or symptoms of distress. Review of the two Nursing Narrative Notes dated 10/14/2024 at 9:54 AM and at 10:53 PM, revealed R13 remained in a private room at that time, with no signs of distress and no changes in her sleeping or eating habits per the CNAs. Per review, of the second note (timed 10:52 PM) revealed R13 was in good spirits with no signs or symptoms of distress, her appetite remained normal and she slept intermittently as was her pattern. Review of the History and Physical (H&P) Report dated 11/09/2024, revealed the Medical Director noted R13 had chronic dementia and profoundly limited insight, and could only respond to simple phrases. Observation and an attempted interview with R13 on 12/16/2024 at 5:28 PM, revealed the resident answered the Surveyor's questions with nonsensical answers. In interview on 12/17/2024 at 12:04 PM, Family Member (FM) 1, (R13's daughter and POA) stated the resident had not experienced any further issues with R1 since the incident in October. She said the facility immediately changed R13 to another room, away from R1. FM 1 reported the only issue she had was with the resident's room change. She stated R13 was the one who had to be moved even though she had not incited the altercation. She stated she was told the reason for moving R13 to a new room was R1 was wheelchair bound and could move around in her wheelchair in her previous room. The Family Member stated she was also told that it was easier for R1 to access the bathroom in her previous room. She said she had been notified immediately about the incident. FM 1 further stated R13 had not exhibited signs of fear of R1 and there had been no other altercations between the two residents since the one in October. In interview on 12/17/2024 at 12:13 PM, FM 2 stated her mother had been notified of the incident between R1 and R13 immediately after it occurred and the facility moved R13 to another room. FM 2 stated she found out about the incident when she went to visit R13 and found that she was no longer in her old room. She said R13 had not voiced any fears of R1 since the incident occurred and was not able to remember the incident. In interview with CNA 3 on 12/18/2024 at 9:38 PM, she stated she had been coming out of the dirty supply room when she witnessed R1 roll over to R13's (her roommate's) bed and hit her three times on the leg with a rolled-up newspaper. She stated she separated the residents and placed them in different rooms and reported the incident to Registered Nurse (RN) 2. The CNA said RN 2 notified the ADON, and R13 was moved to a separate room to live. In interview with RN 2 on 12/18/2024 at 10:10 AM, she stated she had not seen the incident when R1 hit R13 with the newspaper. She stated CNA 3 witnessed the incident and came and told her about it immediately. RN 2 reported she called the ADON and asked CNA 3 to write down the details of the event she witnessed. She said R1 had been agitated that day and had displayed behaviors such as crying, yelling, and screaming in the hallway. RN 2 stated R1 had been angry because she wasn't getting what she wanted. She explained R1 would often take the blankets off her bed and throw them in the floor if the bed was not made the correct way. The RN reported R1 got angry if she was not the first one to be dressed. Per RN 2 in interview, after the incident she tried to talk with R1 and calm her down, but the resident was so agitated she would not calm down. She said she called R1's family and they came to the facility to calm the resident down. RN 2 stated initially staff moved R1 to another room and left R13 in their old room; however, eventually R13 was moved to a different room. The RN stated R1 had gone through a period where she pocketed the pills under her partial plate and then spit the medications out after the nurse left the room. She said she felt R1 not taking her medications had fueled the incident between her and R13. RN 2 reported after the incident, R1 was sent out to a behavioral health hospital, where they cut down on the medications the resident had been taking. She stated since returning to the facility R1 seemed to be doing better now, and the resident had not had aggressive behaviors after having her medications adjusted. The RN further stated prior to the incident involving R13, R1 had only displayed aggressive behaviors towards staff. In interview with CNA 4 on 12/18/2024 at 10:26 AM, she stated she had not been at work the day of the incident when R1 hit R13 with the newspaper. She stated R1 had been aggressive towards staff prior to the incident when she did not get what she wanted, but she had never seen the resident be abusive to any other resident before or after that incident. The CNA reported staff must earn R1's trust, meaning that they would come and do things for her when they were done helping another resident. She said if staff were busy, R1 would holler until they came to assist her, and there had been times that she had to walk out of the resident's room due to her aggressive behaviors. CNA 4 stated R1's behavior had been a lot better since her medications had been changed. She further stated R13 was not fearful of R1 after the altercation and her demeanor and behavior had not changed after the incident. In interview with the Medical Director on 12/18/2024 at 10:49 AM, he stated R1 had experienced a stroke and had expressive aphasia (difficulty in producing speech or forming words), and acted out because she could not express herself. He said R1 often got frustrated with not being able to communicate her wants and needs. The Medical Director explained R1's behaviors were not dementia related behaviors and he felt like they were frustrated malignant behaviors. He stated R1 had been acting out in the past year, and refusing her medications or pocketing the medications to spit out after the nurse left the room. Per the Medical Director interview, he had treated R1 for many years, even prior to her stroke, and over the years the resident had become angrier and angrier. He said when R1 finally got to the point she refused to take medications by mouth and her behaviors had escalated, he changed her psychiatric medications and ordered R1 Risperdal Consta via an injection. The Medical Director further stated since the medication change R1's behaviors had gotten better. He additionally stated R1 knew what she wanted and what she wanted to do; however, was unable to tell staff and that led to her getting frustrated. In interview with the Assistant Director of Nursing (ADON) on 12/19/2024 at 3:41 PM, she stated she had not been at the facility when R1 hit R13 with the newspaper, as she had already left for the day. The ADON stated RN 2 called her and told her CNA 3 witnessed R1 hit R13 on the leg three times with a rolled-up newspaper. She said a staff member was put with R1 to watch her to keep other residents safe after the incident. The ADON explained she was not sure if the staff member stayed with R1 in the room or removed the resident from the room after the incident. Per the ADON in interview, staff had moved R13 to a different room within thirty (30) minutes of the incident. In continued interview on 12/19/2024 at 3:41 PM, the ADON stated her expectations of staff witnessing a resident-to-resident altercation was to remove or stay with the residents and notify the nurse immediately. She reported the staffs' priority was to make sure no one was harmed and interventions were placed immediately after the incident. The ADON said one of the interventions put in place after the incident was for staff to keep close supervision of R1, and another intervention had been for R13 to be moved to another room. She reported they had interdisciplinary team (IDT) meetings the next day after any abuse incident and had met the next day after the incident between R1 and R13. The ADON said R1 was also sent out for psychiatric evaluation and medication adjustment following the incident, and R13 had not exhibited any changes in her behaviors after the incident. She stated R13 had been monitored and had not had changes in her eating or sleeping habits. The ADON reported currently R1 and R13 did not acknowledge one another if they passed in the hallway and there had been no other altercations between the residents since the newspaper incident. In interview with the Director of Nursing (DON) on 12/19/2024 at 5:12 PM, she stated R1 had not been care planned for potential abuse towards other residents because she had never exhibited that type of behavior before. The DON said they did not care plan for something until it occurred, even if there was a risk for it occurring. She said after the incident of R1 hitting R13 with the newspaper, R1 was removed from the area and staff checked R13 to make sure she had no injuries. Per the DON in interview, someone stayed in the hallway to keep R1 from going into the room where R13 was, or from doing anything to other residents. She reported interventions were placed to prevent further altercations between R1 and R13, which included R13 being moved out of her room to a different room. The DON reported her expectations of staff when they witnessed a resident-to-resident incident was to stop the incident and report via the chain of command immediately. She further stated the most important thing staff should do was make sure both residents were safe. In interview with the Administrator on 12/19/2024 at 5:27 PM, she stated she been made aware of the incident between R1 and R13 shortly after it occurred. She said the ADON came to her office and told her about the incident after she returned to the facility and started the investigation. The Administrator reported R13 was moved to a different room and staff were instructed to keep an eye on R1 to protect R13 and other residents. She said the ADON made sure no other residents were abused by R1 or anyone else as part of her investigation. The Administrator stated the ADON put a staff member with R1 to keep a close watch on the resident; however, she did not recall how long the staff member had been placed with the resident for the close supervision. In continued interview with the Administrator, on 12/19/2024 at 5:27 PM, she stated she expected staff to report any abuse incident immediately up the chain of command. The Administrator stated R1's mood had changed prior to the incident, and she had stopped taking her medications, with her behaviors worsening because of that. She said R1's aggression towards staff was because they were providing care or wanting her to do something. The Administrator stated R1 had not been aggressive towards other residents prior to that one event, and that was the reason her care plan had been directed to her behaviors toward staff and not to other residents. She further stated they moved R13 because the ADON felt that if they moved R1 she would become more aggressive.

Based on observation, interview, review of the facility's policy, the facility failed to have an effective system to label and store resident specific medications for 2 of 10 sampled Residents (Resident (R)10 and R12). On 12/17/2024 at 12:06 PM eight (8) vials of antibiotic were observed sitting in a plastic tub without a resident label and sixty (60) cups of valproic acid were observed in six (6) packs, also not labeled with a resident label. Both were stored in the medication room on the counter. The findings include: Review of the facility's policy titled, Medication Storage,reviewed 12/07/2022, revealed medications labeled for individual patients (residents) were stored separately from floor stock medications when not in the medication cart. Review of a written statement provided by the Pharmacy Director (PD) on 12/18/2024 at 1:25 PM, revealed he acknowledged medications brought to the Skilled Nursing Facility (SNF) should have been labeled and the medications found in the medication room on 12/17/2024 had been unlabeled, which was unacceptable. The PD noted the unlabeled medication situation had been corrected and it would not occur again. Per review, he did not disagree with the fact that unlabeled medications could increase the incidence of a medication (med) error. Continued review revealed the PD documented other instances would have to occur for a med error to occur, such as: a nurse giving the unlabeled medication without an eMAR (electronic Medication Administration Record) prompt; or if the medication was an intravenous (IV) medication like the antibiotics, and the nurse inserted an IV prior to administration. Further review revealed additionally, if the nurse omitted barcode scanning of the medication a med error could occur. In addition, the PD noted nurses would also have to omit the scanning of the resident's identification band; however, residents in the SNF did not have an identification band. 1. Review of R10's electronic medical record (EMR) revealed the facility admitted the resident on 09/27/2022, with diagnoses of chronic kidney disease, anxiety, peripheral vascular disease, and fistula of the stomach and duodenum resulting in a cutaneous abscess of the abdominal wall. 2. Review of R12's EMR revealed the facility admitted the resident on 03/27/2024, with diagnoses of Alzheimer's Disease, chronic kidney disease, hypertension, and seizures. Observation of the medication (med) room on 12/17/2024 at 1:28 PM, with Registered Nurse (RN) 3, revealed a plastic container that had IV eight vials of antibiotics in it. Per observation, there were no resident labels on any of the vials and none on the plastic container to identify who the antibiotics were for. Further observation of the med room revealed 6 flats (cardboard trays that had 10 cups of Valproic acid side by side in them with cellophane wrapped around them) which were also not labeled. In interview, at the time of observation (12/17/2024 at 1:28 PM), RN 3 stated, when asked why the antibiotics and Valproic Acid were unlabeled and sitting on the counter in the med room, she stated R10 was the only individual getting intravenous (IV) antibiotics on the unit, so staff knew they belonged to R10. She stated there was not enough room in the med cart for all of R12's Valproic Acid, as six cups were used for her per day. The RN said, therefore staff stored the extra Valproic Acid in the med room and re-stocked the med cart with it as needed. RN 3 further stated she realized this practice could have caused possible med errors. In interview with the Pharmacy Director (PD) on 12/17/2024 at 3:18 PM, he stated 99.9% of all medications delivered to the SNF from the Pharmacy were in a baggy labeled with resident information. He said the resident label contained the order/prescription number, dosage times, directions for administration, name of the medication and dose, the resident's name, lot number, and dose expiration date. The PD reported sometimes IV medications might not have a resident label on it, if it was on the weekend and/or the medication was needed quickly. He said if that was the case he would drop the medication off unlabeled. The PD reported he had done that with the intention of putting labels on the medications when he came in the following Monday. (Interview was conducted on a Tuesday). He further stated he would immediately place the resident labels on the antibiotics. In continued interview on 12/17/2024 at 3:18 PM, the PD stated the Valproic Acid was stored on the counter in the med room with no resident label due to space constraints in the med cart; however, the medication should have been labeled. He stated he would also label each flat of 10 cups of Valproic Acid, not each individual cup. When asked by the State Survey Agency (SSA) Surveyor asked the PD what would happen if the plastic covering the individual cups was removed and thrown away, he said he hoped nursing staff would not throw away the plastic containing the label. He said however, he had never thought of that possibly occurring. The PD reported medications not labeled could go to an incorrect resident creating a med error. The SSA Surveyor asked the PD if a new resident admitted with orders for Valproic Acid and the medication was not labeled, he stated the medication could be given to the wrong resident. When asked how often he or his staff sent unlabeled medications to the SNF unit he stated that occurred about once per month. In interview with RN 2 on 12/18/2024 at 7:35 AM, she stated medications from the Pharmacy always came with a resident label on them. She stated if the medication did not have a resident label, she would take the medication back to the Pharmacy and have them place a label on it prior to administering the medication to the resident. The RN said, in reference to the cartons of Valproic Acid and antibiotics, the cartons of Valproic Acid should have a resident label on the carton and each vial of antibiotics should have a resident label on it. She further stated the purpose of the resident label on a medication was to prevent med errors. In interview with the Assistant Director of Nursing (ADON) on 12/19/2024 at 3:41 PM, she stated it was okay to give a medication from the pharmacy that did not have a resident label on it. She said that was because nursing staff should be scanning off the medication using bar code administration. The ADON further stated nursing staff should be double checking the order with the medication and performing the five rights of medication administration. In interview with the Director of Nursing (DON) on 12/19/2024 at 5:12 PM, she stated she thought there should be a resident label on all the medications; however, if there was not a resident label, she would still administer the medication to a resident. She said the nursing staff scanned the bar code of the medication label as well as checked the medication against the resident's orders prior to administering the medication. The DON reported that process occurred for every medication administered, every time and it did not matter if the medication was from the medication cart, the medication room, or hand delivered from the Pharmacy. In interview with the Administrator on 12/19/2024 at 5:27 PM, she stated medications in the med storage room did not need to have a resident label on them to be administered. She stated a resident label was not the criteria that nurses used to identify the correct medication, dose, resident, etc. The Administrator stated all nurses should be performing the five rights of medication administration before giving any medication. She said the nurses also scanned the medication label's barcode to help with the five rights of medication administration. Further, the Administrator stated she did not think a medication error could happen just because the medication did not have a resident label on it.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure advance directives were completed, reviewed, or updated periodically for one (1) of eight (8) sampled residents (Resident #19). Closed record review revealed Resident #19's advanced directive information was not updated when the resident's code status changed from a full code to a Do Not Resuscitate (DNR) in 2018. The findings include: Review of the facility's policy, Advanced Directives, dated [DATE], revealed the nursing facility would inform a resident (and/or their designated representative), upon admission, of their right to formulate an Advanced Directive. An advanced directive expresses the wishes of the resident concerning their care in the event that the resident was not cognitive or cannot speak for their self upon admission. Follow-up for residents who were non-cognitive or unable to speak for themselves upon admission; if the resident was not cognitive or unable to speak for themselves about the right to formulate an advanced directive, then the facility would supply the information directly to the patient at an appropriate time. This follow up process must be clearly documented in the residents record along with who presented the information, the resident's response and date and time. An advanced directive speaks to a resident wishes on appointing a health care surrogate, life prolonging treatment, nourishment and/or fluids, and organ/tissue donation. A Kentucky Living will packet (also known as an Advanced Directive) may be printed online at www.ky.gov. Copies should also be kept at the nurse's station. Attached to the policy was the Kentucky Living Will Directive and Health Care Surrogate Designation which states for the appropriate boxes to be checked and initialed per the residents wishes. Closed record review revealed the facility admitted Resident #19 on [DATE] with diagnoses which included Unspecified Dementia, Urinary Tract Infection, and Epilepsy. Further review revealed no code status was documented in the admission History and Physical by the Medical Doctor (MD) dated [DATE]. Additional review of Resident #19's medical record revealed the resident was identified as a full code upon admission; however, the medical record did not reflect an advance directive was completed. The Advanced Directives Information/Physician order form signed by Resident #19's spouse, former Director of Nursing (DON), and Medical Doctor (MD); which stated yes to cardiopulmonary resuscitation (CPR) and Ventilator. Further review revealed the question about Do Not Resuscitate (DNR) was not answered. And the form indicated Resident #19 did not have a living will or durable power of attorney. Review of the clinical record revealed an order changing Resident #19's code status to Do Not Resuscitate (DNR) on [DATE]. However, further review revealed the advanced directive information/physicians order sheet was not updated to reflect these changes. There was not a care plan reflecting the resident code status. Review of Resident #19's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) indicating Resident #19 cognition was unable to be assessed. Phone interview with Resident #19's Representative, on [DATE] 10:47 AM, revealed Resident #19 had been a DNR since 2018. He further stated the resident's spouse had taken care of all of that before he/she passed. Interview with the Minimum Data Set (MDS) Nurse, on [DATE] at 11:00 AM, revealed Resident #19 was a full code and the Physician had changed the order in [DATE] to Do not resuscitate (DNR). The MDS Nurse stated they do not have a process for updating advanced directives. Interview with Certified Nurse Aide (CNA) #1, on [DATE] at 11:06 AM, revealed she knew resident code status's by a list displayed in the CNA charting room. She further stated resident code status's were listed on their name tag outside of the resident rooms. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] 11:10 AM, revealed she would check the code status on the Medication Administration Record (MAR) if she needed the information when providing care. She stated a resident's code status was also displayed on the outside of the resident's room. Interview with the Director of Nursing (DON), on [DATE] at 11:28 AM, revealed the employees should pass on resident's code status in report and resident code status was also displayed on the name tag outside the resident's door. She stated if there were any changes of code status, the medical record would be updated immediately. The DON revealed the advanced directives were not reviewed. She further revealed if the code status information was not accurate, care may not be provided per the resident's wishes. Interview with the Chief Executive Officer (CEO), on [DATE] at 11:50 PM, revealed she would expect the resident's medical record and care plan to be accurate to reflect the resident's code status wishes. She further stated she expected the nurse to communicate any new orders or changes to the MDS Nurse. The CEO revealed if this information was not updated care provided to resident may not be within the resident's wishes.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to follow the care plan for two (2) of ten (10) sampled residents (Resident #6 and Resident #1). Staff failed to follow the care plan for Resident #6 related to elopement; and, for Resident #1 related to falls. Resident #6 stated multiple times he/she wanted to leave the facility prior to the elopement, and the facility placed a Wanderguard (WG) on the resident. On 08/08/2020, Resident #6 exited three (3) doors utilized only by staff and not equipped with Wanderguard (WG) alarms to exit the second floor facility. Respiratory staff discovered Resident #6 at the bottom of the stairwell, without his/her walker, and near an exit door. The respiratory staff notified the Long Term Care facility staff who retrieved the resident. Facility staff returned the resident to the second floor unit. The WG alarm sounded when the resident exited the elevator when he/she returned to the second floor facility. The care plan for Resident #6 included interventions to distract from wandering with diversions, structured activities, food, conversation, television, or book. However interview with Registered Nurse (RN) #2 revealed she last saw the resident during the morning medication pass. RN #2 stated she was unaware the resident left the second floor facility, and was notified the resident was found off the unit around midday. The nurse did not monitor the resident and did not implement the wanderer care plan to prevent elopement. Immediate Jeopardy and Substandard Quality of Care were identified on 01/15/2021 and determined to exist on 08/08/2020. The facility was notified on 01/15/2021 of the Immediate Jeopardy with deficiencies cited at 42 CFR 483.25 Quality of Care (F689 at S/S of J) and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 at S/S of J) with Substandard Quality of Care identified at 42 CFR 483.25 (F689). An acceptable Allegation of Compliance (AOC) was received on 01/28/2021 alleging removal of the Immediate Jeopardy on 01/26/2021. The State Survey Agency verified Immediate Jeopardy was removed as alleged on 01/26/2021, prior to exit on 01/29/2021 which lowered the Scope and Severity to a G at 42 CFR 483.25 Quality of Care (F689) and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), while the facility develops and implements a Plan of Correction; and, the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Additionally, the facility failed to implement resident specific care plan interventions regarding falls prevention for Resident #1. The facility care planned Resident #1 for transfers with the assistance of two (2) staff; however, one (1) staff person attempted to transfer Resident #1, resulting in a fall. The findings include: 1. Review of the facility's policy Care Planning, effective 07/09/2012, revealed care, treatment, and services were planned to ensure they were appropriate to the resident's needs. The plan of care should be individualized, based on diagnoses, resident assessment, and personal goals of the resident. The facility did not provide a policy for the Wanderguard (WG) system. Review of the WG User Guide, titled Wanderer Monitoring System Adult Transmitter, released 06/22/2010, revealed not to rely exclusively on patient generated alarms for patient care and safety with regular patient surveillance recommended. In addition, the guide recommended the facility keep records of test completions. The guide further revealed the system assisted staff to monitor residents in the facility; however, the system could not prevent elopement of residents by itself. Transmitters in use must be tested at least weekly using the transmitter tester, and the facility must keep records of test and transmitter inspection completions. Review of the closed clinical record revealed the facility admitted Resident #6 on 05/27/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Summary Progress Note for Resident #6, dated 05/27/2020, revealed the resident was confused about his/her situation. The note revealed the resident thought he/she was on the way to take care of financial business. The note further revealed the resident used a walker and wore glasses. Record review revealed no documented evidence the facility completed a Wandering Risk Assessment for Resident #6. However, the facility got a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan (CP) for Resident #6 for wanderer risk, initiated on 05/29/2020, revealed the resident wandered related to disorientation to place and the resident had impaired safety awareness. Interventions included to offer pleasant diversion, structured activities, food, conversation, television, or book; distract from wandering; identify pattern of wandering, if purposeful, aimless, or escapist and intervene as appropriate; and WG in place, check daily. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #6 with a Brief Interview Mental Status (BIMS) examination score of thirteen (13) and determined the resident was interviewable. In addition, the facility assessed and documented physical behaviors toward others occurred one (1) to three (3) days. The Admission MDS also revealed the resident was not steady walking and utilized a walker and wheelchair (w/c). The MDS revealed the resident had a fall in the last month prior to admission to the facility. Review of a Progress Note revealed on 06/30/2020 Resident #6 wanted to leave the facility and walked around his/her room and the facility without assistance or his/her walker. Review of a Progress Note, dated 07/03/2020, revealed the resident kicked the elevator and stairwell doors earlier in the week. Further review revealed on 07/12/2020, the resident was agitated and wanted to get to the gate where his/her family waited. Review of a note, dated 07/18/2020, revealed the resident stated he/she had to get dressed and asked for help to get out of there. On 07/19/2020, a Progress Note revealed the resident's bed alarm sounded, the resident walked to the window, put on his/her jacket, opened the window, then closed the window and sat down. The resident demanded he/she be taken to the front gate and was going to leave and no one would stop him/her. Further review revealed on 07/25/2020, the resident requested staff take him/her to Louisville and tried to bribe staff with money. Review of a Progress Note, dated 08/08/2020 at 4:10 PM, revealed the Respiratory Therapist (RT) discovered Resident #6 sitting at an exit door downstairs and notified the Long Term Care (LTC) facility staff. The LTC RN returned the resident to the second floor facility and the Wanderguard alarm sounded when she and the resident exited the elevator. Review of the facility's Incident Report, dated 08/08/2020 at 6:10 PM, related to Resident #6's elopement, revealed the resident was oriented to person only, confused, with impaired memory and a predisposing factor of active exit seeking and wandering. Record review revealed Resident #6 no longer resided at the facility and was discharged [DATE]. Interview, on 01/08/2021 at 9:30 AM, with the Respiratory Therapist (RT) revealed he discovered Resident #6 outside the Respiratory Therapy Department (hospital) around 1:00 PM to 2:00 PM and notified the LTC facility staff. Interview with RN #2 on 01/08/2021 at 9:30 AM, who was assigned to provide care for Resident #6 revealed she last saw Resident #6 during the morning medication pass before the elopement. RN #2 stated she was unaware the resident left the second floor facility, and was notified the resident was found off the unit around midday. However, review of the resident's care plan revealed interventions that included staff; (to monitor the resident) to distract him/her from wandering; identify pattern of wandering, if purposeful, aimless, or escapist and intervene as appropriate; and WG in place, check daily. Per interview, the LTC staff were not aware the resident was off the unit. Interview on 01/07/2021 at 2:08 PM, with Certified Nurse Assistant (CNA) #1 revealed she had seen Resident #6 walk without his/her walker. She stated when the facility admitted the resident; he/she wanted to go home and was upset he/she could not leave. The CNA stated the resident wore a WG on his/her ankle and the nurse was responsible to place and check the WG. She revealed if the resident was at risk of elopement, she would report it to the nurse, keep an eye on the resident to keep him/her safe. She stated they could monitor a resident at risk of elopement more frequently. She stated if the facility did not check on a resident at risk of elopement, the resident was at risk of death or other negative things could happen. Interview, on 12/22/2020 at 11:34 AM, with Registered Nurse (RN) #2 revealed the facility care plan provided guidelines how to care for the residents and keep the residents on track to their goals and maintain functional level. On 12/22/2020 at 2:20 PM, interview with Certified Nurse Aide (CNA) #1 revealed the resident's care plan informed staff how to care for the resident. She stated if the care plan was not followed, the resident could be harmed or result in death. Interview with CNA #5, on 12/22/2020 at 2:26 PM, revealed the care plan guided how to care for a resident in the facility. The CNA revealed a resident could be injured if the care plan was not followed. Interview, on 12/22/2020 at 2:40 PM, with RN #1 revealed the care plan informed staff how to care for an individual resident. She stated for resident safety the care plan should be followed or the resident could potentially be injured. Interview with RN #3, on 01/06/2021 at 2:46 PM, revealed the resident care plan was important to guide the facility regarding what needed to be done for, and how to treat the resident. Interview with the MDS Coordinator, on 01/07/2021 at 2:55 PM, revealed Resident #6 did not always use his/her walker and had poor balance. She stated the resident was confused and disoriented. The MDS Coordinator stated the facility care plan provided how to plan the care for the resident for risk of wandering. She further stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed if the WG was not checked per the care plan, there was a potential for harm or injury to the resident if he/she eloped. On 12/22/2020 at 4:08 PM, interview with the Director of Nursing (DON) revealed the care plan provided information on how to care for an individual resident. She stated it could be detrimental or a danger to a resident if the care plan was not followed. Interview, on 01/08/2021 at 3:58 PM, with the DON revealed the purpose of the resident's care plan was for staff to know what to do for the resident. She stated the facility did not train staff on how to follow a resident care plan. The DON revealed she did not monitor staff in completing the WG checks per the care plan. On 01/11/2021 at 1:21 PM, interview with the Chief Nursing Officer (CNO) revealed the care plan for Resident #6 for wandering looked like it was created on 08/03/2020. She revealed without the documentation on the TAR, she was unsure if the WG was checked per the care plan. She further revealed the purpose of the care plan was to let staff know the interventions needed for the resident. Interview with the Administrator, on 01/11/2021 at 2:49 PM, revealed the care plan was driven by the facility's assessment of the resident. She stated the care plan was the resident's current status and included any new needs to direct the resident's care. The Administrator revealed the TAR was a visual reminder of what to do for the resident, and was driven by the care plan. She stated if the WG checks were not documented on the TAR or in the nurse's notes it was unknown if the WG checks were completed. Interview with the Administrator, on 12/22/2020 at 4:48 PM, revealed staff were expected to follow the treatment and precautions listed on the resident's care plan. She stated the care plan was important to keep a resident safe, get what they needed, and maintain the highest level of functioning. 2. Review of the facility's policy Care Planning dated 07/09/2012, revealed care, treatment and services were planned to ensure they were appropriate to the resident's needs. The plan of care was individualized, based on diagnosis, resident assessments and personal goals of the resident and his/her family. The needs of the resident, goals, time frames, required services and the service settings were critical considerations in determining the plan of care. Review of Resident #1's clinical records revealed the facility admitted the resident on 06/13/1207, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview of Mental Status (BIMS) exam score of eight (8) out of fifteen (15) and determined the resident had moderate cognitive impairment. The facility assessed Resident #1 as a two (2) person physical assist for bed mobility, transfers, to walk, to dress, to toilet and for personal hygiene. Continued review of the MDS revealed the resident was documented with prior falls which resulted in injuries. Review of Resident #1's Physical Therapy (PT) evaluation dated 06/14/2017, revealed the resident was assessed as a fall risk and had continued weakness. The evaluation noted Resident #1 had increased pain, decreased ambulation, transfer, bed mobility, balance, and safety awareness. Review of Resident #1's Occupational Therapy (OT) evaluation dated 06/14/2017, revealed the resident required precautions for falls risk and had bed/chair alarms in place at all times. Resident #1 was documented to have poor safety awareness due to decreased cognition. Further review revealed Resident #1 experienced freezing episodes which decreased mobility. Review of Resident #1's Care Plan revealed the focus: the resident had an activities of daily living (ADL) self-care performance deficit related to physical decline (initiated 06/27/2017) and listed the intervention for transfer as may use mechanical lift for transfers. The resident required extensive assist with two (2) staff assistance for transfers (created 07/26/2017, initiated 06/26/2017 and revised 06/24/2019). Review of the care plan revealed the focus of: limited mobility related to recent illness and weakness from illness (created 07/26/2017, initiated 06/26/2017, revised 12/07/2018). Interventions listed included: use of mechanical lift for transfers. Use shower bed for showers (created and initiated 03/17/2019 and revised 06/01/2020). Further review revealed Resident #1 required the extensive two (2) person assist for ambulation with walker and extensive one (1) person assist with use of wheelchair (created 07/26/2017, initiated 06/26/2017). Further review of the care plan revealed another focus area identified: resident with impaired cognitive function/dementia or impaired thought process related to dementia (created and initiated 12/12/2018). Interventions listed: cue, reorient and supervise resident as needed (created and initiated 12/12/2018). Interview with Registered Nurse (RN) #2, on 12/21/2020 at 2:52 PM, revealed she was employed at facility for about a month at the time of this incident; however, she was a nurse for about eleven (11) years. She reported when she was trained mainly trained on how to use Point Click Care and how to chart medication and other items in that system. She reported she was not really trained on care plans. The RN reported she had informed the DON she did not feel enough information was passed down at shift change and things were only discussed if there was a change to the resident in the prior shift. Continued interview with RN #2 12/21/2020 at 2:52 PM, revealed on 01/19/2020, Resident #1's call light was activated and when she entered the room, the resident's feet were off the edge of the bed. She stated she tried to readjust the resident up in the bed, but she was not able. RN #2 stated she asked the resident if he/she could stand up on the side of the bed and pivot and resident said he/she could do it. She stated as soon as the resident's feet hit the floor his/her knees gave out and she lowered the resident to the floor. RN #2 stated she assessed the resident and did not note any concerns at the time. Additionally RN #2 revealed a CNA was called to the room to help get the resident up in the wheelchair and the resident was sent to dinner. RN #2 stated approximately thirty-five (35) minutes later Resident #1 located the RN and complained about pain in his/her leg and it was swollen and discolored. The RN stated the doctor was contacted and an order was given to get an x-ray which revealed Resident #1 suffered a fractured right tibia and right fibula. Interview with RN #1 on 12/21/2020 at 12:53 PM, revealed she partially trained RN #2 as well as other RN's and it depended on who was on shift with RN #2. She revealed that RN #2 was taken around to each resident and introduced while she gave out medication. RN #1 reported that RN#2 was in fact shown the care plan book which was kept in the CNA room. RN #1 revealed most nurses do not read the care plan book every day because at shift change staff were informed of any changes. Interview with Certified Nursing Assistant (CNA) #6, on 12/21/2020 at 2:45 PM, revealed the care plan was focused on each resident and it informed staff how to care for the resident. All staff members had access to the care plan information which was found in the CNA room. She stated when a resident required two (2) staff assist, she would do as much as she could for the resident and then get assistance to move the resident. Interview with CNA #4, on 12/21/2020 at 3:00 PM, revealed there was always a care plan book available in the CNA room and all staff had access to it. She stated if she was unsure how to care for a resident she reviewed the book. CNA #4 stated when she provided care for a resident who needed a two (2) person assist, she would do all that she could for the resident and then go get staff to help. Interview with CNA #1, on 12/21/2020 at 1:00 PM, revealed in the event of a resident fall, she would turn on the call light and wait for a nurse to come and asses the resident. CNA #1 reported all staff were annually trained on many different subjects and staff were not retrained when a resident had a bad fall. She stated nurses were always responsible for the completion of the Incident Reports. Continued interview with CNA #1, on 12/22/2020 at 2:20 PM, revealed the care plan informed staff how to care for a resident and what needed to be done for them daily. CNA #1 stated there was always a care plan book in the CNA room and all staff could access it. She stated if the care plan was not followed it could cause harm to a resident. Interview with CNA #5, on 12/22/2020 at 2:26 PM, revealed it was always important to follow the resident's care plan and if staff did not, the resident could get hurt. CNA #5 stated all staff members had access to the care plan information as it was kept in the CNA room. Interview with Registered Nurse (RN) #1, on 12/22/2020 at 2:40 PM, revealed the care plan was the document used to tell staff how to care for each resident. The care plan book was kept in the CNA room and both nurses and aides always had access to it. She stated the book was updated any time a resident had a change in status. RN #1 reported it was always important to use the care plan and follow it especially for lifts and two (2) person assist. She stated if the care plan was not followed the resident could end up with serious injury. Interview with the MDS Coordinator, on 12/22/2020 at 2:30 PM, revealed she created the majority of the care plans and updated them at the next meeting unless it was urgent. She reported care plans were important to show staff how to care for the resident's individual needs. She also reported residents could be harmed if the plan was not updated, current and followed. Interview with the DON, on 12/22/2020 at 4:08 PM, revealed after she was notified that resident had a broken leg, she went to the facility and provided re-education for RN #2. The DON stated she verbally retrained the staff and continued to reiterate the importance of the care plan. Further interview with the DON revealed care plans were used to tell staff what the resident's treatment requirements. She stated care plans explained the resident' care needs and how to meet the individual resident's needs. She stated if staff did not follow the care plan it could be detrimental to the resident's health. The DON stated that it was a danger to staff and residents if they did not use the proper lift required. Continued interview revealed staff was to complete a fall assessment within a certain time frame. She stated the facility conducted care plan audits and Root Cause Analysis (RCA) were done. Staff were observed while they provided care; however, no documented evidence was provided . Interview with the Administrator, on 12/22/2020 at 4:48 PM, revealed it was her expectation staff followed the treatment and precautions listed in the care plan which were developed through the evaluation of the resident. Continued interview with the Administrator revealed the care plan was important to ensure residents functioned at their highest possible level. The facility took the following actions to remove the Immediate Jeopardy: 1. The DON reviewed and updated all resident care plans for wanderguard (WG) assessments, on 01/17/2021. 2. The care plan for Resident #6 was updated after the elopement on 08/10/2020. Then resident had a WG on 08/08/2020, and discharged on [DATE]. 3. The MDS Coordinator updated the WG assessment on 01/18/2021. 4. The MDS Coordinator completed WG assessments on all residents on 01/18/2021. 5. The Chief Nursing Officer (CNO) reviewed the care plan policy on 01/18/2021. 6. On 01/15/2021, the CNO revised the assessment policy to include WG assessments on admission, then weekly. 7. The CNO, on 01/15/2021, updated new employee orientation checklists to include elopement education and frequency of WG assessments. 8. A Survey Compliance Committee met on 01/18/2021 and weekly for eight (8) weeks to review compliance of monitoring and reported in the quarterly Quality Meetings. Members included the Director of Nursing (DON), CNO, Administrator, MDS Coordinator, Safety Officer (SO), and Quality Director (QD). 9. The Quality Committee met and accepted the Allegation of Compliance (AOC) on 01/22/2021. The committee consisted of the CNO, DON, Infection Control, Pharmacy, SO, Physical Therapy (PT), Dietary, Financial, Respiratory, and Activities Director. 10. The CNO updated the Medical Director, on 01/22/2021, on the findings and corrective actions. 11. On 01/25/2021, the Executive Committee of the board met and accepted the AOC. 12. The CNO trained 90% of staff, by 01/22/2021, on the Immediate Jeopardy (IJ). Staff will be trained prior to the next shift worked, with expected completion on 01/26/2021. Staff signed they received and understood information. Education included updated assessment policy requirement to complete a wander risk assessment on admission, then weekly, by the nurse; review of the care plan policy; and updated wander risk assessment. The CNO and DON asked questions to ensure staff retained information. 13. The CNO was trained prior to training staff. 14. The DON or MDS Coordinator will weekly monitor the completion of the wander risk assessments and report to the Survey Compliance Committee until 100% compliance for two (2) months, then to the quarterly Quality committee. 15. The DON or MDS Coordinator reviewed all resident care plans weekly to ensure they were updated and included any wander risk, if identified from the wander risk assessment. Compliance will be reported to the Survey Compliance Committee weekly until 100% compliance maintained for eight (8) weeks, and to quarterly Quality committee for six (6) months. The State Survey Agency (SSA) validated the Allegation of Compliance (AOC). 1. Interview with the Chief Nursing Officer (CNO), on 01/29/2021 at 2:05 PM, revealed the MDS Coordinator reviewed resident care plans on 01/17/2021. On 01/29/2021 at 3:33 PM, interview with the MDS Coordinator revealed she and the Director of Nursing (DON) reviewed resident care plans on 01/18/2021. Interview with the Administrator, on 01/29/2021 at 4:20 PM, revealed the MDS Coordinator reviewed and updated resident care plans the week of 01/18/2021. 2. Interview, on 01/29/2021 at 2:05 PM, with the CNO revealed the MDS Coordinator updated Resident #6's care plan on 08/10/2020. Interview with the MDS Coordinator, on 01/29/2021 at 3:33 PM, revealed she updated the care plan on 08/10/2020 for Resident #6 related to the wander risk. On 01/29/2021 at 4:20 PM, interview with the Administrator revealed the MDS Coordinator updated the care plan for Resident #6 related to the elopement. Review of the care plan for Resident #6 revealed wander risk interventions. 3. On 01/29/2021 at 2:05 PM, interview with the CNO revealed the MDS Coordinator updated the wander risk assessment on 01/18/2021. Interview with the MDS Coordinator, on 01/29/2021 at 3:33 PM, revealed she updated the wander risk assessment the week of 01/18/2021. Interview with the Administrator, on 01/29/2021 at 4:20 PM, revealed on 01/18/2021 the MDS Coordinator updated the wander risk assessment. Review of the Wander Risk Assessment- updated revealed new questions that identify a resident at risk. 4. Interviews with the CNO, 01/29/2021 at 2:05 PM, the MDS Coordinator, on 01/29/2021 at 3:33 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed the MDS Coordinator completed wander risk assessments on all residents on 01/18/2021. Review of the Wandering Risk Assessments, dated 01/18/2021, revealed thirteen (13) of thirteen (13) residents were assessed. 5. On 01/29/2021 at 2:05 PM, interview with the CNO, and on 01/29/2021 at 4:20 PM, interview with the Administrator revealed the CNO reviewed the care plan policy with no changes made. Review of the Care Planning policy revealed an effective date of 07/09/2012. 6. Interview with the CNO, on 01/29/2021 at 2:05 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed the CNO reviewed and updated the assessment policy, on 01/18/2021, to include wander risk assessments completed on admission and then weekly. Review of the Wander Risk Assessments policy, revised 01/2021, revealed wander risk assessments will be completed on admission and for all residents weekly. 7. Interview with the CNO, on 01/29/2021 at 2:05 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed the CNO updated the new employee checklists on 01/18/2021 to include elopement and wander risk. Review of the Nursing Department-Orientation Staff Nurse and Nurse Assistant checklists revealed Elopement and Wanderguards (WG) included. 8. Interview with the Quality Director (QD), on 01/29/2021 at 1:48 PM, the CNO, on 01/29/2021 at 2:05 PM, the SO, on 01/29/2021 at 2:57 PM, the MDS Coordinator, on 01/29/2021 at 3:33 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed they met as the survey compliance committee weekly for eight (8) weeks and reviewed compliance with monitoring and reported their findings to the Quality Meetings. Review of the Compliance Meeting Minutes, dated 01/19/2021 and 01/27/2021, revealed they meet weekly for eight (8) weeks and discussed compliance with monitoring activities The committee included the Director of Nursing (DON), Chief Nursing Officer (CNO), Administrator, MDS Coordinator, Safety Officer (SO), Quality Director (QD). 9. Interview with the Infection Preventionist (IP), on 01/29/2021 at 1:48 PM, the Dietician, on 01/29/2021 at 2:00 PM, the CNO, on 01/29/2021 at 2:05 PM, the Director of Pharmacy and Activities Director, on 01/29/2021 at 2:38 PM, the SO and Chief Financial Officer (CFO), on 01/29/2021 at 2:57 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed they participated in a Quality meeting sometime the week after 01/15/2021 to review the AOC. Review of the Quality Assurance (QA) Committee, dated 01/22/2021, revealed the Allegation of Compliance (AOC) was reviewed by the Medical Director, DON, CNO, SO, Physical Therapy (PT), Infection Control, Dietician, Chief Financial Officer (CFO), Activities Director (AD), Respiratory, and Administrator. 10. Interview with the CNO, on 01/29/2021 at 2:05 PM, revealed she updated the Medical Director the week of 01/18/2021. Interview with the Administrator, on 01/29/2021 at 4:20 PM, revealed the CNO updated the Medical Director. 11. On 01/29/2021 at 2:05 PM, interview with the CNO, and on 01/29/2021 at 4:20 PM, interview with the Administrator revealed they met with the Executive Committee of the Board and reviewed the AOC, on 01/25/2021. Review of the Executive Session Minutes, dated 01/25/2021, revealed the CNO and Administrator participated and the committee approved the AOC. 12. Interview with Registered Nurse (RN) #1, RN #3, Certified Nurse Aide (CNA) # 5, and CNA #9, on 01/29/2021 at 2:00 PM, the CNO, on 01/29/2021 at 2:05 PM, the Ward Clerk, on 01/29/2021 at 2:50 PM, RN #2, on 01/29/2021 at 3:19 PM, CNA #4, on 01/29/2021 at 3:27 PM, the MDS Coordinator, on 01/29/2021 at 3:33 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed staff were trained on the updated assessment policy, the care plan policy, and the new wander risk assessment, and were asked questions (test) by the CNO after training, the week of 01/18/2021. Review of the staff training materials and signatures, dated 01/18/2021, revealed fifteen (15) out of eighteen (18) staff were trained on the cause of the Immediate Jeopardy (IJ); assessment and care plan policies; and, the updated wander risk assessment. 13. Interview with the CNO, on 01/29/2021 at 2:05 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed the CNO reviewed the regulations prior to conducting staff training. 14. Interview with the CNO, on 01/29/2021 at 2:05 PM, the MDS Coordinator, on 01/29/2021 at 3:33 PM, and the Administrator, on 01/29/2021 at 4:20 PM, revealed the MDS Coordinator reviewed the wander risk assessments weekly and reported to the survey compliance committee for eight (8) weeks, then to the quarterly QA committee. Review of the Wanderguard Audit, dated 01/17/2021 through 01/23/2021, revealed 100% compliance was noted by the DON. Review of the Compliance Meeting Minutes, dated 01/27/2021, revealed the wander risk assessments were reviewed weekly for compliance. 15. On 01/29/2021 at 2:05 PM, interview with the CNO, on 01/29/2021 at 3:33 PM, the MDS Coordinator, and on 01/29/2021 at 4:20 PM, the Administrator revealed the MDS Coordinator reviewed resident care plans weekly and reported to the survey compliance committee for eight (8) weeks, then to the Quarterly QA committee for six (6) months. Review of the Care plan Audit, dated 01/17/2021 through 01/23/2021, revealed 100% compliance was noted by the DON. < [TRUNCATED]

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide an environment that was free from accident hazards as possible for six (6) of ten (10) sampled residents (Residents #1, #2, #3, #4, #5 and #6). Resident #6 was at risk for elopement and Residents #1, #2, #3, #4, and #5 related to falls. Resident #6 had a history of wandering and telling staff he/she was going to leave the facility. The facility obtained a Physician's Order to apply a Wanderguard (device to monitor the resident's whereabouts) device to the resident's person. However, the facility failed to increase the resident's supervision. On 08/08/2020, Resident #6 exited three (3) doors, utilized only by staff and not equipped with Wanderguard (WG) alarms, to exit the second floor facility, without staff knowledge. Around 1:00 PM, Respiratory staff (hospital staff) discovered Resident #6 at the bottom of the stairwell, without his/her walker, near an exit door. Respiratory staff notified the Long Term Care (LTC) facility staff who retrieved the resident. Interview with the Registered Nurse, who was responsible for the resident's care stated she had last seen the resident that morning during medication pass, around 9:00 AM. The LTC facility staff returned the resident to the second floor unit. The WG alarm sounded when the resident exited the elevator when he/she returned to the LTC facility. Immediate Jeopardy and Substandard Quality of Care were identified on 01/15/2021 and determined to exist on 08/08/2020. The facility was notified on 01/15/2021 of the Immediate Jeopardy with deficiencies cited at 42 CFR 483.25 Quality of Care (F689 at S/S of J) and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656 at S/S of J) with Substandard Quality of Care identified at 42 CFR 483.25 (F689). An acceptable Allegation of Compliance (AOC) was received on 01/28/2021 alleging removal of the Immediate Jeopardy on 01/26/2021. The State Survey Agency verified Immediate Jeopardy was removed as alleged on 01/26/2021, prior to exit on 01/29/2021 which lowered the Scope and Severity to a G at 42 CFR 483.25 Quality of Care (F689) and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), while the facility develops and implements a Plan of Correction; and, the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. In addition, the facility failed to provide an environment that was free of accident hazards as possible to prevent falls for five (5) of ten (10) sampled residents (Residents 1, 2, 3, 4, and 5). The facility failed to ensure Resident #5 was protected from skin tears during transfers, and an injury of unknown origin. Resident #1 experienced a fall with injury to his/her head and suffered a fracture to the right tibia and right fibula during an improper transfer by staff. The facility assessed Resident #1 to require the assistance of two (2) persons. However, Registered Nurse (RN) #2 attempted to lift the resident without staff assistance, which resulted in a fall with an injury. Resident #2 had a fall prior to admission. However, the facility failed to assess the resident's fall risk to determine and care plan appropriate interventions to prevent further falls. Resident #1 had falls on 07/27/2020, 10/23/2020, 12/15/2020, 12/23/2020, and 12/30/2020. Resident #3 experienced multiple falls with and without staff present, one resulted in a femur fracture. Resident #3 suffered twelve (12) falls since admittance to facility. The facility failed to provide supervision to ensure the resident did not continue to have falls. Resident #4 experienced falls, on 01/04/2020 and 08/13/2020. However, the facility failed to assess the resident's fall risk, to determine if interventions to prevent further falls were still appropriate. Resident #5 experienced unwitnessed falls. The facility failed to investigate the falls to ensure interventions were in place to prevent further falls and injuries. The findings include: 1. Review of the facility's policy Code Green Patient Elopement, revised 10/2012, revealed the facility considered patients who left the facility without informing a member of the healthcare staff as eloped. Nursing staff, security staff or Administration completed an incident report, documenting the facts of the elopement and subsequent staff actions. The facility did not provide a policy for the Wanderguard (WG) system (system to monitor the resident's location). Review of the WG User Guide, titled Wanderer Monitoring System Adult Transmitter, released 06/22/2010, revealed a warning to not rely exclusively on patient generated alarms for patient care and safety. Regular patient surveillance was recommended. Additional recommendations included for the facility to maintain records of test completions. The guide further revealed the system assisted staff to monitor residents in the facility. However, by itself the system could not prevent elopement of residents. Transmitters in use must be tested at least weekly using the transmitter tester, and the facility must keep records of test and transmitter inspection completions. Review of the closed clinical record revealed the facility admitted Resident #6 on 05/27/2020 with diagnoses of Dementia with Behavior Disturbances, [CONDITION(S)], and Altered Mental Status. Review of the Admission Summary Progress Note for Resident #6, dated 05/27/2020, revealed the resident was alert, but confused about situation and did not answer questions correctly in most instances. The note revealed the resident thought he/she was on the way to take care of financial interests. Further review of the Note revealed the resident used a walker and wore glasses. Record review revealed Resident #6 no longer resided in the facility and was discharged on [DATE]. Record review revealed no documented evidence the facility completed a Wandering Risk Assessment for Resident #6; nor, did the facility provide a Wandering Risk Assessment for Resident #6. Review of a Physician's Order, dated 05/29/2020, revealed to check the WG each evening to insure the device worked. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #6 with a Brief Interview for Mental Status (BIMS) examination score of thirteen (13). The Admission MDS also revealed the resident was not steady walking and utilized a walker and wheelchair (w/c). Additional review of the MDS revealed the resident had a fall in the last month prior to admission to the facility. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 05/27/2020 through 08/31/2020, revealed the records did not list the daily check of the Wanderguard device. Review of a Progress Note, dated 06/30/2020, revealed Resident #6 wanted to leave the facility and walked around his/her room and the facility without assistance or, his/her walker. Review of a Progress Note, dated 07/03/2020, revealed earlier in the week the resident kicked the elevator and stairwell doors. On 07/12/2020, a note revealed the resident was agitated and wanted to get to the gate where his/her family waited for him/her. Review of a note, dated 07/18/2020, revealed the resident stated he/she had to get dressed and asked for help to get out of there. On 07/19/2020, a Progress Note revealed the resident's bed alarm sounded, the resident walked to the window, put on his/her jacket, opened the window, then closed the window and sat down. Continued review revealed the resident demanded he/she be taken to the front gate and stated he/she was going to leave and no one would stop him/her. On 07/25/2020, the resident requested staff take him/her to Louisville and tried to bribe staff with money. However, there was no documented evidence the facility increased the resident's supervision. Review of Resident #6's Care Plan (CP), initiated on 05/29/2020, revealed the resident wandered related to disorientation to place and the resident's impaired safety awareness. Interventions included offer pleasant diversion, structured activities, food, conversation, television, books, to distract from wandering; identify pattern of wandering, purposeful, aimless, or escapist; and WG in place, check daily. Review of a Progress Note, dated 08/08/2020 at 4:10 PM, revealed Registered Nurse #2 (RN) received a call from the Respiratory Therapist (RT), inquiring if the facility had a resident missing. The RN checked Resident #6's bed and bathroom and did not locate the resident. The RN checked the activity room and found the door between the activity room and the employee break room was open and the resident's walker was in the break room. Further review revealed no alarms sounded. The note revealed the RN told the RT she would be down with a w/c to retrieve the resident. Continued review revealed the resident was sitting on a chair he/she had taken down with him/her from the break room, outside the fire exit door behind the RT office. Additional review revealed when the RN brought the resident up in the elevator, the WG device went off (sounded) when the elevator door opened on the second (2nd) floor. The resident's bed alarm was not sounding and the resident stated he/she had turned it off. Resident #1 stated he/she would be going back downstairs, and the RN made sure both doors to the break room were locked. Review of the facility's Incident Report, dated 08/08/2020 at 6:10 PM, revealed the RT called and reported a resident sat outside the RT Department in a chair. Further review revealed the resident's walker and a small kitchen chair missing from the staff break room were found. The door from the activity room to the staff break room was unlocked, and the door was ajar to the staircase that led to the RT Department. The resident was found at the RT Department located at the bottom of the flight of stairs, at an exit to the outside of the building. The resident kept saying he/she was going back downstairs. Additionally, the Incident Report revealed the resident was oriented to person only, confused, had impaired memory and a predisposing factor of an active exit seeker and was a wanderer. On 01/08/2021 at 9:30 AM, interview with the Respiratory Therapist (RT) revealed he was in the office next to the bottom of the stairwell, around 1:00 PM to 2:00 PM, but could not be certain of the time. He stated he heard three (3) thumps, followed by some time, then another three (3) thumps. He stated he then heard the door outside the office close. The RT stated when he checked on the noise, he found a chair placed to hold the outside door open and Resident #6 trying to get out. He stated he called the facility to let them know and facility staff took the resident back upstairs. The RT stated he spoke to the Safety Officer and submitted a written statement to him. Interview with RN #2, on 01/08/2021 at 9:30 AM, revealed she was passing medications and received a call from the RT, around midday the day of the incident, who asked if they were missing a resident. The RN stated she knew immediately who the RT was speaking about, and the nurse looked in Resident #6's room and bathroom but did not find Resident #6. She stated the activity room was two (2) doors down from the resident's room and she found the door open, the resident's walker there, and a chair missing. She stated when she returned the resident to the facility the WG alarm sounded. Additionally, the nurse revealed Resident #6 previously told her he/she would escape and would get out. However, record review revealed no documented evidence the facility increased the resident's supervision. The nurse stated she last saw Resident #6 during the morning medication pass. The RN stated the CNA got too hot and propped the door open. RN #2 further revealed the door (to the stairwell) had an alarm, however the alarm was not loud enough to hear. The nurse stated she had spoken to the Safety Officer several times about her concerns. The RN also stated she requested the WG and placed it on the resident's ankle prior to the elopement (on admission). RN #2 stated if a resident eloped from the facility the resident was at risk of injury, getting lost, getting into the road, fall, or risk of death. Additional interview with RN #2, on 01/15/2021 at 11:31 AM, revealed she found the break room door open again the day after Resident #6 eloped from the facility. She stated she submitted her written statement to the DON and reported the elopement to the MDS Coordinator. The RN stated there were no WG alarms on the doors the resident passed through. RN #2 stated the first day Resident #6 was in the facility, he/she kept saying he/she had to go and she spoke with the DON, who directed her to put a WG on Resident #6. She also stated elopement risk was part of the admission assessment. However, she did not usually complete admission assessments as those were completed by the DON, MDS Coordinator, or another nurse. Observation, on 01/07/2021 at 10:05 AM, revealed the door from the hallway to the employee break room was not locked. This was the same room Resident #6 exited the unit. The break room had a refrigerator, microwave, toaster oven, sink, table and three (3) chairs. Further observation revealed a door from the break room to a locker room was open approximately two (2) to three (3) inches. And in the locker room, a door that led to a stairwell. On 01/08/2021 at 8:36 AM, observation with the Director of Nursing (DON) revealed the door from the locker room to the stairwell alarmed when open, and silenced when closed. This was door the resident exited from the unit. The stairwell had a total of seventeen (17) steps with a landing approximately half way down. At the bottom of the stairwell was a door to the left, opening to an office, and a door straight ahead that led to an alcove of doors. In the alcove, a locked door to the left led to an office, a set of double doors straight ahead which were unlocked, led to the mechanical room, and a door to the right led to the outside of the building. The door to return to the stairwell locked once closed. Straight ahead, out of the exit door, was a parking lot. A sidewalk to the right of the exit door led to the end of the building to a parking lot and loading dock toward the right, and a small building and parking toward the left. Observation, on 01/08/2021 at 11:25 PM, revealed the door from the locker room to the stairwell was opened by the DON. The alarm from the stairwell door could not be heard past the water fountain in the hallway, near resident rooms 204 and 211, while the fountain refrigeration was running. Observation of the door from the hallway to the break room, on 01/11/2021 at 9:50 AM, revealed the door was unlocked. The door from the break room to the locker room was opened approximately three (3) to four (4) feet. Observation from the hallway door to the break room down the hall to the nurse's station revealed the Ward Clerk was not visible while sitting at the desk. Interview, on 01/07/2021 at 2:08 PM, with Certified Nurse Assistant (CNA) #1 revealed when the facility admitted the resident, he/she wanted to go home and was upset he/she could not leave. The CNA stated the resident wore a WG on his/her ankle. Further interview revealed the nurse was responsible to place and check the WG. CNA #1 was unsure if the locker room exit door was alarmed. She further revealed a resident at risk of elopement should have more frequent monitoring or be checked on more often by staff. The CNA stated if a resident eloped from the facility there was a risk of all kinds of bad things that could happen to the resident, including death. On 01/07/2021 at 2:33 PM, interview with Registered Nurse (RN) #3 revealed Resident #6 used a walker at times and would need to sit down due to shortness of air. She stated the resident did not know where he/she was at times. RN #3 stated she had heard the resident say he/she would leave the facility and he/she was not supposed to be there. The RN stated the resident wore a WG on his/her ankle and the nurse was responsible to check and ensure the WG was in place and worked. Further interview with RN #3 revealed the elopement risk was part of the MDS assessment and, the risk of elopement determined if the WG was needed. RN #3 stated she was unsure if the elopement risk assessment was part of the admission assessment, as she did not usually complete resident admissions, or a quarterly assessment. Continued interview revealed the resident's WG was checked daily for placement and function. weekly. The RN stated she was not trained by the facility to assess for elopement or wander risk. She also stated the Safety Officer (SO) checked the WG alarms. Interview with the MDS Coordinator, on 01/07/2021 at 2:55 PM, revealed Resident #6 was unsteady without his/her walker, however he/she did not always use it. She stated the resident was confused and disoriented, and had poor balance. The MDS Coordinator stated RN #2 contacted her after the resident eloped from the facility, and she instructed the RN to write down what happened and turn it in to the DON. She stated the resident did not have a WG at the time of the elopement, however interviews and review of the clinical record revealed the resident wore a WG at the time he/she eloped. The MDS Coordinator stated there was no assessment for use of the WG which was used based on nursing judgement. She further revealed she was unsure if there was an elopement risk assessment. She stated the nurse checked the WG for placement daily on the TAR, and the Safety Officer (SO) checked the door alarms. She stated the Physician's Order for the WG should be listed on the TAR and the Care Plan (CP). The MDS Coordinator stated if a resident eloped from the facility the resident could be injured. On 01/08/2021 at 9:54 AM, interview with the Safety Officer (SO) revealed he was first made aware Resident #6 eloped from the facility the following Monday, 08/10/2020. He stated the alarm on the door from the break room locker room to the stairwell was an added measure as the stairwell was isolated and least used. Additionally, the SO stated he checked the alarm weekly. He also stated the alarm silenced when the door closed. The SO revealed the alarm on the door from the locker room to the stairwell was not part of the WG management system. He stated he did not remember RN #2 say she could not hear the alarm on the locker room stairwell door. The SO stated the bottom of the stairwell had a locked door to an office and a door that led to an alcove of doors. He further revealed the doors to the mechanical room should be locked and the exit door was locked from the outside. Continued interview with the SO, on 01/08/2021 at 10:37 AM, revealed he monitored doors. However he did not keep a log of doors found unlocked. Continued interview with the Safety Officer (SO), on 01/11/2021 at 11:28 AM, revealed no one checked the door alarms or WG system on the weekends. Review of the June 2020, July 2020, and August 2020 Thirty-Day Safety Officer Summary revealed, door alarms were checked Monday through Friday. However there were no initials of checks on the weekend. The Wander Control System section of the Thirty-Day Safety Officer Summary revealed if no residents used transmitters(Wanderguard devices) to write N/A (not applicable). Further review revealed N/A was documented Monday through Friday beginning 06/01/2020 through 06/24/2020. However, Resident #6 used the Wanderguard system. The May 2020 Summary, revealed the door alarms were not documented as checked ten (10) out of thirty-one (31) days. Review of the June and July 2020 Summaries revealed, the door alarms were not documented checked for eight (8) days each month. The Summery, dated August 2020, revealed door alarm checks were not documented for nine (9) out of thirty-one (31) days Interview with the Ward Clerk, on 01/15/2021 at 2:12 PM, revealed prior to Resident #6's elopement he checked to ensure the doors were locked whenever he could. He stated doors were kept locked for resident safety and peace of mind for staff. He further revealed if the doors were unlocked, a resident could fall or get into a hazardous room, which was neglectful, and mistreatment. Interview with the Director of Nursing (DON), on 01/08/2021 at 3:58 PM, revealed she was notified Resident #6 eloped from the facility the weekend the elopement occurred. She stated the resident went through the break room, downstairs, and was found outside by the RT. She stated the resident's WG sounded the alarm when the resident exited the elevator when he/she was brought back to the facility. The DON stated the WG needed a Physician's Order and should be checked every day to insure it functioned properly, and documented on the TAR. She revealed if the order did not carry over to the TAR, the order could be missed and she was not able to determine if the WG was checked. Continued interview, on 01/08/2021 at 3:58 PM, with the DON revealed the nurses completed a wander assessment if a resident was up and walked around or wanted to leave. She stated she was unsure if the wander assessment included use of a WG. Additionally, the DON reported the doors into the break room did not lock automatically and must be physically locked. Interview with the Chief Nursing Officer (CNO), on 01/11/2021 at 1:21 PM, revealed she was first made aware Resident #6 eloped from the facility the Monday following the weekend elopement, and thought the DON reported the elopement to her. The CNO stated she did not believe Resident #6 had a WG at the time of the elopement. She stated the door from the locker room to the stairs did not have a WG alarm. Additionally, the CNO stated the purpose of the WG was to keep the resident in the facility and let staff know when a resident left the building. She stated with the door unlocked, any resident could be in the stairwell. The CNO stated she did not know if the first floor doors were alarmed. Further interview revealed if a resident eloped from the facility, the resident could be harmed. Continued interview with the CNO, on 01/11/2021 at 1:21 PM, revealed Physician's Orders carried over to the TAR. She stated she was unsure who was responsible to ensure the Physician's Order, to check the WG was working for Resident #6, was carried over to the TAR. The CNO also stated she was unaware of where staff documented the WG was checked if it was not listed on the TAR. She stated she did not know if the WG checks were completed per the Physician's Order. The CNO stated the WG should be checked to ensure it worked, and not checking the WG, the resident could have a non-working device that could lead to a resident leaving the building. The CNO stated she was unaware if staff were trained how to check and document the WG, however the DON would know. She further stated she did not know if the facility conducted an elopement risk or WG assessment, and was unsure if any other residents were at risk of elopement. The CNO stated the Safety Officer checked the door alarms, however on the weekends no one checked the door alarms. She stated if the alarms were not checked the alarms might not work and a resident could elope. On 01/11/2021 at 2:49 PM, interview with the Administrator revealed the CNO notified her Resident #6 eloped from the facility. She stated the resident exited an unlocked door to the staff break room and went down the back stairwell. The Administrator stated she was informed Resident #6 did not have a WG at the time of the elopement and a WG was placed after the elopement occurred. However, interview and record review revealed the resident wore a WG when he/she eloped from the facility. The Administrator stated that based on the Physician's Order, the resident should have had a WG when he/she eloped. The Administrator further revealed the door Resident #6 passed through did not have a WG alarm. She stated the purpose of the WG was to keep a resident from leaving the unit, and if a resident left the unit there could be a wide array of outcomes. Further interview with the Administrator revealed the TAR was a visual reminder what to do for the resident's care. She stated if the WG checks were not documented on the TAR or in the Progress Notes, she would not know if the WG checks were done. Continued interview with the Administrator, on 01/11/2021 at 2:49 PM, revealed the door alarm checks were conducted by the Safety Officer (SO) weekly. She further stated when a resident had a WG, the SO checked the door alarms daily when he was at the facility, and no one was assigned to check the door alarms when the SO was not there. She revealed the purpose of checking the door alarms was to ensure the batteries worked. The Administrator stated she relied on the CNO, DON, and MDS Coordinator to ensure care was provided to residents as ordered and as needed. She stated negative harmful things could occur if a resident got downstairs, such as get into the boiler room or outside. 2. Review of facility's policy Fall Preventions revised 12/2020, revealed, All patients will be assessed upon admission and throughout stay using the Assessment of Adult Patient at Risk for Falls Form. Fall assessment will include cognitive impairment, impaired balance, impaired mobility, Neurological problems, musculoskeletal problems, chronic disease and Nutritional problems. The findings from this assessment shall be incorporated into a fall reduction program. Further review revealed patients will be reassessed as needed, as their condition warrants, when new medications are administered, dosage changes, patient under goes an invasive procedure and after falls. Review of facility's policy, Fall Reporting Instructions for Nursing Facility, revised 09/05/2018, revealed electronic Incident Report and Fall Assessments were to be conducted as soon as possible. One (1) hour after fall a reassessment would be done and neuro checks are completed with any head injury or an unwitnessed fall. This policy makes the following suggestions to staff, they should place a fall risk sign and/or use gripper socks, use one or more of the following: side rails, restraints and bed/chair alerts. Policy also states, Restraints should only be used only after other options have been determined to be ineffective or insufficient. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 05/19/2017 with diagnoses including Repeated Falls and [CONDITION(S)]. Additional diagnoses included [CONDITION(S)], Weakness, and Tremor. Review of a Fall Assessment, dated 05/19/2017, revealed the facility assessed Resident #4 at risk for falls. The facility did not provide any other Fall Assessments for Resident #4 after admission. Review of Resident #4's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) and was cognitively intact. Review of the resident's care plan for limited physical mobility, revised 05/2019, revealed the resident required assistance of two (2) staff for ambulation using a walker, or wheelchair (w/c). Review of the care plan for risk of falls, dated 05/26/2017, revealed interventions included call light in reach, prompt response to requests for assistance, appropriate footwear when ambulating, and physical therapy (PT) as ordered. Additionally, the care plan revealed the resident was at risk of falls due to diuretic use and pain medication side effects. Review of the Physical Therapy (PT) Evaluation, dated 05/20/2019, revealed Resident #4 had generalized weakness and immobility. PT would address the decreased strength, balance, transfers, and fall risk. Review of a PT Note, dated 06/06/2019, revealed the resident was discharged from PT and continued with Restorative Nursing. Review of a Quarterly PT screen completed 01/01/2020, dated 01/09/2020, revealed the resident was at baseline for mobility. Review of Resident #4's Progress Note, dated 01/04/2020 at 3:45 AM, revealed the resident was found lying on the floor next to the bed. The call light was in reach. The resident stated he/she tried to get up. Review of an Incident Report dated 01/04/2020 at 3:45 AM, revealed the resident was found lying on the floor beside the bed and stated he/she tried to get up. The facility assessed the resident with a bruise and skin tear. The Incident Report identified the resident ambulated without assistance and was weak. Review of the Skin Observation Tool, dated 01/07/2020 at 10:52 AM, revealed Resident #4 had a bruise to his/her forehead and a skin tear to the right shoulder from the fall. The facility did not provide a fall risk assessment after the fall to review if care plan interventions were still appropriate. Review of the Annual MDS, dated [DATE], revealed the facility assessed Resident #4 with a BIMS' score of thirteen (13) and determined the resident was interviewable. Continued review revealed Reisdent #4 had one (1) fall since the prior assessment. Review of a Progress Note dated 01/23/2020 at 11:40 AM, revealed the restorative care plan was reviewed for walking with a shuffling gait and active range of motion (AROM). Review of an Incident Report for Resident #4, dated 08/13/2020 at 7:09 AM, revealed the resident sat on the edge of the w/c and scooted off the w/c to the floor. The facility assessed the resident with a skin tear to his/her left elbow, and was caused by weakness during a transfer. Review of the care plan revealed the facility did not update the care plan for Resident #4 after the fall on 08/13/2020 to prevent another fall. The facility did not provide a fall risk assessment after the fall to review if care plan interventions were still appropriate. Observation, on 01/14/2021 at 8:36 AM, revealed the door to Resident #4's room was opened approximately two (2) inches,and a fall risk sign was at the resident's door. On 01/14/2021 at 8:53 AM and 9:37 AM, observations revealed the resident's door was closed. Observation of Resident #4, on 01/14/2021 at 11:47 AM, revealed the resident sat in a recliner in his/her room, call light in reach. Additional observation of Resident #4, on 01/14/2021 at 1:02 PM, 01/15/2021 at 8:47 AM and 11:15 AM, revealed the door was closed to the resident's room. Interview, on 12/21/2020 at 2:52 PM, with Registered Nurse (RN) #2 revealed she could not hear a resident's call light when she was in a another resident room. Continued interview with RN #2, on 12/22/2020 at 11:34 AM, revealed she also had difficulty hearing call lights in the hallway due to the sound of televisions. She stated the call lights only sounded at the nurse's station. On 12/21/2020 at 02:45 PM, interview with Certified Nurse Aide (CNA) #6 revealed if the double doors to the unit were open she could hear the call lights ding at the nurse's station. She stated she could not hear the call light sound when the facility closed the double doors during meal times. Interview with RN #1, on 01/06/2021 at 12:38 PM, revealed the facility did not have a fall program. She stated the facility assessed a resident's fall risk when admitted to the facility, when the resident changed in capabilities, or changed in cognitive abilities. She revealed she had never completed a fall risk assessment on a resident other than part of the admission assessment. The RN further revealed the MDS Coordinator completed fall risk assessments. Additionally, the nurse stated the MDS Coordinator, who worked three (3) days a week, was responsible to update the resident care plan after a fall. On 01/06/2021 at 1:49 PM, interview with the MDS Coordinator revealed the nurse on duty assessed a resident's fall risk on admission or if there were any changes to the resident. The MDS Coordinator stated interventions could include bed and chair alarms, low bed, fall mats, or more frequent safety checks. The MDS Coordinator revealed falls should be reported to the DON and an incident report completed. Interview with RN #3, on 01/06/2021 at 2:46 PM, revea [TRUNCATED]

Based on observation, interview, record review and review of facility's policy, it was determined the facility failed to ensure residents were free from physical restraints imposed for convenience and not required to treat the resident's medical symptoms. Observation of all facility beds revealed eighteen (18) of eighteen (18) beds had side rails attached. Record review revealed no documented evidence that assessments were completed for the use of side rails. Observation revealed three (3) out of ten (10) sampled residents (Residents #1,#3 and #5) had bed/chair alarms in place with no documented evidence to determine that the devices were used for safety versus used as restraints. The findings include: Review of the facility's policy, Restraints For Nursing Facility, dated [DATE] and revised [DATE], revealed a restraint is defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient (resident) to move his/her legs, body or head freely. The policy also revealed use of restraints was for the safety of patients from self-injury or injury of others. Restraints used by this facility are listed as soft belt, soft wrist/ankle restraints, Geri-chair, mittens and side rails. Continued review of the policy revealed an initial evaluation must be conducted face-to-face within one (1) hour after initiation of intervention. The physician or licensed independent practitioner who is responsible for care of the patient must be notified as soon as possible. Alternatives with the least restrictive measures must always be attempted prior to the use of restraints. Further review of the Restraint Policy revealed an order must be present from the physician, it must include the type of restraint to be used, the purpose and the amount of time to be used. When a restraint is ordered the Registered Nurse (RN) shall evaluate the resident's condition for the least restrictive restraint and shall be followed by a Physical Therapy (PT) evaluation and documentation of the least restrictive restraint to be used. The use of restraints must be documented as a modification to the resident's Plan of Care/Care Plan (CP). Continued review revealed the documentation should include a plan and a schedule or plan of rehabilitation to ensure the progressive removal of restraints or the progressive use of the less restrictive means. As needed and standing orders for restraints are not allowed. Per facility policy the attending physician must see and assess the resident before writing a new order for restraints. The charge nurse is responsible to ensure this happens at the end of 24 hours. Further review of the Restraint policy, revealed staff are to be trained and demonstrate competency in application of restraints, how to monitor and assess for restraints. Staff shall also be trained on factors that may trigger the need for restraints, use of non-physical intervention skills, how to determine least restrictive restraints through assessments and safety. Staff shall be trained how to recognize signs of distress due to restraints, and how to recognize changes that no longer require restraints. The Nursing Facility Director (DON) shall be responsible to ensure all staff are trained or shall designate a competent trainer in their place. Review of the facility's policy, Fall Reporting Instructions for Nursing Facility, dated [DATE] and revised [DATE], revealed suggestions for staff action after a fall was to use one or more of the following items: side rails, restraints, bed/chair alerts. It also stated orders must be written for the use of restraints and a restraint packet must be completed. The family must be notified before restraints are applied. Restraints are for the safety of the resident only and cannot be used for staffing issues. Restraints should be used only after other options have been determined to be ineffective or insufficient. Review of the facility's Care Planning policy dated [DATE] revealed care, treatment and services are planned to ensure that they are appropriate to meet the resident's needs. Care Plans will address the resident's needs, strengths, limitations and goals. Care Plans will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable. Further review revealed the plan of care shall be individualized, based on the diagnoses, resident assessment and personal goals of the resident and his/her family. The plan of care, treatment and services will include regular review and revision of each. It will be monitored for effectiveness and will be reevaluated and revised as needed to meet the needs of the resident's change of condition. Further review revealed Skilled Care will review the plan every two (2) weeks for the first quarter, every month for the second quarter and quarterly thereafter. Care Plans will also be reviewed when indicated by changes in the resident's condition. 1. Record review revealed the facility admitted Resident #5 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS completed, with no score. Further review revealed the MDS documented the resident's use of bed alarms daily, but not for bed rails. Review of the MDS dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was not interviewable. Continued review revealed the resident was listed for bed/chair alarms daily but not for bed rails. Review of the MDS dated [DATE] revealed the resident was listed again as a BIMS of 99, and was documented for bed/chair alarms as well as bed rails, both used daily. Review of the facility's document, Nursing Facility Level of Care, Request for admitted d [DATE], revealed Uses ½ side rails as enablers listed under additional safety/health information pertinent to admission. However, the facility did not provide an assessment for the use of side rails. Continued review of the document revealed under Activities of Daily Living (ADL's) it was noted the resident was independent for bed mobility. However, there was a hand written note stating the use of side rails for assistance and, transfers independent and a hand written note for the use of side rails or furniture. According to the facility's restraint policy bed rails were listed as a restraint and required an initial evaluation to be completed by the physician or a registered nurse and the resident must be seen by the physician within one (1) hour from intervention use. However, there was no documented evidence the facility conducted these evaluations, as required by policy. Review of the facility's document, Nursing Admission History and Assessment form dated [DATE], revealed the facility marked Resident #5 to use both side rails for safety and to promote independence for bed mobility. However, the consent for bilateral side rails was not checked. Continued closed record review revealed no documented evidence the facility conducted a siderails assessment, nor did the facility provide an assessment for the use of bed rails. Review of Resident #5's Physical Therapy (PT) evaluation dated, [DATE] revealed no documented evidence that assessments for bed rails or bed/chair alarms use was completed, as required by the facility's policy. Review of Resident #5's Occupational Therapy (OT) evaluation dated [DATE], revealed restraints were listed as a special need and described as bed/chair alarms. Record review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the facility's policy stated restraints must be used with a specific order which must include the type of restraint, purpose and time used. Per the facility's policy, as needed and standing orders for restraints were not allowed. Review of Resident #5's Care Plan (CP) revealed a focus area of resident high risk for falls related to confusion, gait and balance problems. Further review revealed the intervention listed was side rails. In addition, the care plan also listed a focus area as resident had an actual fall with minor injury related to impaired memory. The intervention was for the use of bed alarms, created [DATE] and initiated [DATE]. Review of Resident #5's closed medical records [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Incident Report #135 revealed on [DATE] staff responded to bed alarms. 2. Review of Resident #3's clinical records revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS, dated [DATE], revealed the resident had a BIMS' score of twelve (12) out of fifteen (15) which indicated moderately impaired cognition. Further review revealed the facility assessed the resident to require a one (1) person physical assist. However, the assessment did not list the use of bed rails and did not list the use of bed/chair alarms. Review of Resident #3's MDS, dated [DATE], revealed the resident had a BIMS score of six (6) out of fifteen (15) which indicated severe cognitive impairment. Further review revealed the resident was assessed to require one (1) person assist. Further review revealed the assessment did not list the use of bed rails and/or bed/chair alarms. However, SOURCE revealed bed rails and/or the use of bed/chair alarms were used throughout the resident's stay at the facility. Review of Resident #3's PT evaluation dated [DATE], revealed the resident was a fall precaution. However, there was no documented evidence that PT assessed the resident for the use of bed rails and/or bed/chair alarms, to ensure they were the least restrictive device, as required by the facility's policy. Review of Resident #3's OT evaluation dated [DATE], revealed the resident was a high risk for falls and did not have the use of restraints in place. Record review revealed the resident was listed to have bed/chair alarms in place for fall precautions. Continued review of Resident #3's medical records, revealed a Doctor's Order for bed/chair alarms dated [DATE], with an indefinite end date. Further review revealed the bed/chair alarms were to be used every shift, every day for safety awareness impairment and previous falls. However, the facility's policy stated an initial assessment must be done within one hour of restraint activation and an order cannot be listed as needed or opened ended for restraints. Review of Resident #3's CP revealed the facility used bed/chair alarms and to ensure they were in place as needed. Record review revealed the care plan was created and initiated on [DATE]; and, reviewed on [DATE] with no change. Review of the care plan revealed Resident #3 was not care planned for the use of bed rails. Per the facility's policy, the bed rails should have been care planned and monitored to ensure the effectiveness and determine if revisions were needed. Review of Resident #3's medical record revealed no documented evidence the facility completed an initial assessment for the use of bed rails and/or an assessment for the use of a bed/chair alarm. Further review revealed there was no documented evidence of medical symptoms that required the use of bed rails and bed/chair alarms. Review of Resident #3's Progress Notes, revealed on [DATE], the resident had turned off his/her bed/chair alarms. Registered Nurse (RN) #2 documented in the Progress Notes that the resident's bed/chair alarms had to be moved around often as the resident would hide them or disconnect them. Review of Progress Notes revealed on [DATE] at 7:30 AM, Registered Nurse (RN) #2 documented Resident #3 was up in the hallway and the bed alarm had sounded. On the same day at 10:00 AM, RN #2 documented she reeducated the resident about the use of the call light and bed/chair alarms. Further review revealed at 11:14 AM, RN #2 observed as the resident attempted to pull the bed alarm out from under the sheet to stop the beeping. RN #2 stated Resident #3 asked her, Do I have to sit here all day and wait for someone to help me? Review of facility Incident Report dated [DATE] at 11:14 AM, RN #2 entered Resident #3's room because a bed alarm sounded, resident was out of the bed on his/her knees and attempted to pull the bed alarm out from under the sheet. RN #2 assisted resident back into bed and left the room. Review of Incident Report #147, dated [DATE] at 5:50 AM, revealed Resident #3's bed alarm had sounded and RN #3 and Certified Nurse Aide (CNA) #1 went to check on the resident. Resident #3 was seated on the bed with his/her feet over the edge. There was no documented evidence of any actions taken by staff. Further review revealed the bed alarm ceased and RN #3 returned to the nurse's station. The bed alarm sounded again and CNA #1 returned to the room. RN #3 heard a loud noise and a holler and returned to room. Resident #3 was found on the floor between the bed and chair. Resident #3 was noted to be bleeding from his/her hand. Record review revealed no documented evidence the facility assessed the use of the bed alarms to determine if they were effective, or the least restrictive. Review of the Progress Note dated [DATE] at 11:15 AM, revealed the resident had a hematoma to back of his/her head, bruising to the right hip, reddened area to the mid lower back and fifth finger. Further review revealed RN #1 requested CT (computerized tomography) scan and an x-ray. Unsuccessful attempts to interview RN #3 were made. Interview with CNA #1 revealed she could not recall this incident. Review of Incident Report #187 dated [DATE] at 1:08 PM, revealed Resident #3's bed alarm sounded and staff responded to the room. Further review revealed Resident #3 was found on the floor. The resident stated he/she had gotten up to try and get a soda. Record review revealed no documented evidence the facility assessed the use of the bed alarm to determine if it was effective. Review of Incident Report #167 dated [DATE] at 1:30 AM, revealed staff responded to the call light bell; the resident was found on the floor with the call light in his/her hand. Further review revealed the resident's bed/chair alarm had not sounded; the resident had unhooked it and hid it under his/her pillow. Continued review of the Progress Notes revealed RN #1 reported on [DATE], the resident's bed/chair alarm sounded frequently because the resident continued to ambulate without assistance. Review of the care plan revealed no documented evidence it was updated and/or new interventions were tried. Continued review revealed no documented evidence the facility assessed the use of the alarm, after the resident. who has a BIMS' score of six (6) continued to remove the alarm. Observation of Resident #3 on [DATE] at 1:45 PM, revealed the resident was dressed and seated up on the edge of his/her bed. The resident appeared to be alert and held a small conversation with staff. Further observation revealed the resident appeared to be in good spirits, he/she smiled and engaged with staff. 3. Closed record review revealed the facility admitted Resident #1 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued closed record review revealed on [DATE] Resident #1 was noted to be deceased . Review of Resident #1's MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of eight (8) out of fifteen (15) which indicated moderate cognitive impairment. Further review revealed the MDS documented bed rails and bed/chair alarms were not in use. Review of Resident #1's Nursing Admission History and Assessment Form, dated [DATE], revealed the resident used the right bed rails for safety and to promote independence for bed mobility. However, review of the care plan revealed no documented evidence the use of the side rail was care planned. Review of Resident #1's OT evaluation, dated [DATE], revealed bed alarms were listed for use at all times for fall precautions. The evaluation also listed bed/chair alarms to be used at all times under the restraint section. However, review of the facility's restraint policy revealed PT would evaluate restraints to ensure the least restrictive device was used. Per facility policy, the use of restraints would be time limited and reassessed. Review of Resident #1's Nursing Assistant Care Plan, Side Rails section, dated [DATE] revealed the resident used side rails to reposition in bed for bed mobility. Further review revealed the care plan was created and initiated on [DATE], and revised on [DATE]. Review of Resident #1's closed record revealed no documented evidence of initial assessments for the use of bed rails or bed/chair alarms. Continued review revealed no documented evidence of the medical need for such restraints and no documented evidence that the less restrictive actions were taken. Further review revealed Resident #1's record did not include a consent form signed by the resident or resident representative to allow for use of bed rails and/or bed/chair alarms. Record review revealed bed rails and/or bed/chair alarms were used throughout resident's stay in the facility. Observations of each room and bed along with measurements of all bed rails was conducted with the Maintenance Director on [DATE] at 10:00 AM. Observation was conducted on eighteen (18) beds; each bed had a left and right rail at the head of the bed and ranged from 21 to 32 inches in length. Bed rails differed in shape, material and adjustment ability. Nine (9) beds had the ability to raise the bed up or to lower it to the floor, while other beds remain stationary. Five (5) beds had side rails that had three (3) adjustment levels, up and back behind pillow area, middle (next to pillow area) and lower which was flush to the mattress. Additionally, four (4) beds had rails at the bottom of the bed, left and right side rails (28 inches) in the lowered position. During the observations with the Maintenance Director, on [DATE] at 10:00 AM, he identified a red button on the outside of the bed rail which was used to lower and raise the bed rail. The buttons were located out of reach of a person lying in bed, making it unable for the person to move the bed rails up and down. Review of the Operation and Maintenance Manual for Elite Riser bed, 2008 revealed close supervision was necessary when the product was used near people with disabilities. Further review revealed no bed rail information was addressed in the manual. Interview with the Maintenance Director, on [DATE] at 10:00 AM, revealed the beds were hospital beds and the side rails were fixed and could not be removed. Interview with RN #2 on [DATE] at 11:30 AM, revealed no assessments were completed for bed rails. RN #2 stated an assessment should include if a resident could pull up, how a resident moved around and if the resident was able to get out of bed. She stated each resident's assessment would be different. The RN stated reassessments should be completed if a change in condition occurred, to reevalaute safety and mobility. Continued interview with RN #2, on [DATE] at 11:30 AM revealed bed/chair alarms should be listed on the resident's Treatment Administration Record (TAR). She stated the order from the doctor should generate a trigger on the care plan. RN #2 stated Resident #3 should not have had bed rails he/she would just climb over them. Interview with RN #1 [DATE] at 12:52 PM, revealed bed rail assessment should be done at admission. However, RN #1 stated it was not really an assessment, She stated the resident and or family member was just asked if the resident would like to have bed rails. RN #1 also revealed there were many concerns related to bed rails usage. She stated the resident could get their arm caught; face could be caught in the rail or it could be used to pull oneself out of bed. Further interview revealed when a resident was admitted to facility most of them said they did not care if they have bed rails or not. Continued interview with RN #1 revealed she did not know what the regulations stated in regard to bed rails. She stated she had not read the regulations and had not been trained on them. RN #1 stated she did not know what references were used to create the facility's policy. Interview with RN #3 on [DATE] at 2:50 AM, revealed the admission staff completed the bed rail assessments and adjusted the care plan. She also stated she didn't update care plans only the MDS Coordinator and DON do that. RN #3 stated bed rail assessments might be completed when there was a change of status. She stated bed rails were used when a resident needed assistance to turn or pull themselves up, but not to keep them in bed. Interview with the Director of Nursing (DON) on [DATE] at 9:30 AM, revealed residents were not assessed for bed rails at admission. The DON stated the family members or residents were just asked if they would like bed rails or not. Further interview revealed bed rails were classified as restraints. The DON stated the Charge Nurse would be responsible for admission assessments. (The facility defined the Charge Nurses as the nurse on duty, RNs #1, #2 and #3.) Additionally, the DON stated if a resident did not like bed alarms staff tried to use other interventions. She stated staff would try regularly scheduled toilet times, activities and asked the resident if he/she was hungry. The DON stated staff had tried to do 1:1 staff assistance, but COVID-19 made that a challenge. Continued interview with the DON on [DATE] at 9:30 AM, revealed she has not personally read the bed rail regulations, but she had always been told they could be used as a stabilizer. The DON stated residents or their family would be asked at admission if they wanted to use bed rails. Continued interview revealed there were several dangers related to the use of bed rails. She stated the resident could get stuck; resident could choke; skin tears could occur and the resident could be hurt during a transfer or reposition. Interview with the Chief Nursing Officer (CNO) [DATE] at 12:00 PM, revealed she has been in this role for six (6) years and she did not have any other Long Term Care (LTC) experience. She stated she had not read the LTC regulations, but she had scanned them. The CNO stated she believed the regulation only required permission from the resident in order to have bed rails on the bed. She stated the beds in the facility were hospital beds and the bed rails could not be removed. The CNO stated she did not recall the need for an assessment to have bed rails. Interview with Administrator (ADM) on [DATE] at 1:23 PM, revealed she had been in that position for ten (10) years and had not worked at any other LTC. She stated the regulations for bed rails reflected they could be used at LTC to assist residents based on their medical needs or to help them with movement in the bed and that an assessment was needed to determine use. The Administrator stated the family of the resident was to be educated about the use of bed rails. Continued interview with the Administrator revealed the assessment was listed in the admission packet and she did not understand it to be an actual bed rail assessment. She stated she believed the admissions packet covered everything an assessment would need. The Administrator also stated she did not expect a separate assessment needed to be done for bed alarms. Interview with the Administrator on [DATE] at 1:23 PM, revealed an order must be given from the doctor for bed alarms, the order could not be open ended and could not be as needed. She revealed documentation to support the use of bed alarms was required and reassessments should be done but did not know a timeframe. The Administrator reported she believed her staff met these requirement.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to update/revise resident comprehensive care plans for five (5) of ten (10) sampled residents (Residents #1, 2, 3, 4, 5). Resident #1 had a fall on 10/31/2019. Resident #1 had a change to his/her wheelchair with bilateral supports. The resident sat in his/her wheelchair at a dinner table and pushed himself/herself away from the table in a quick motion, which caused the chair to spin around, and the resident fell and landed on his/her head. The resident received stitches to the forehead. The facility did not review/revise the care plan for the fall or the bilateral supports added to the resident's wheelchair. Resident #2 had a fall on 07/27/2020, 10/23/2020, 12/15/2020, and 12/23/2020. The facility failed to review/revise the resident's care plan after the falls with interventions to prevent further falls. Resident #3 had a fall on 04/16/2020, 06/27/2020, 08/22/2020 (x 3), 10/16/2020, 11/13/2020, 12/14/2020, 12/16/2020, and 12/24/2020. The resident's fall on 12/24/2020 resulted in a major injury. The facility did not review the resident's care plan to determine if the resident's care plan required revision, after each fall with interventions to prevent further falls. Resident #4 had a fall on 01/04/2020 and 08/13/2020, however the facility did not review/revise the resident's care plan after either fall to prevent additional falls. Resident #5 had a fall on 05/01/2020, which resulted in a bruised, swollen face with a laceration. The care plan was not revised until 09/03/2020 with an intervention put in place to prevent continued falls. The findings include: Review of the facility's Care Planning policy, dated 07/09/2012, revealed care, treatment and services were planned to ensure they were appropriate to the resident's needs. Care planning would be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that were reasonable and measurable. The care plan would include the needs of the resident, goals, time frames, required services and the service settings were all critical to the resident's care. Resident's would be monitored to ensure the effectiveness of the care plan and would be reviewed and revised regularly. The facility would review care plans every two (2) weeks the first quarter, every month the second quarter, and quarterly thereafter. Care plans would also be reviewed when indicated by changes in the resident's condition. Review of the Minimum Data Set Coordinator's (MDSC) job description, undated, revealed the MDSC would attend/conduct the interdisciplinary team (IDT) care plan meeting to ensure optimal quality of care in respect to the resident's needs and abilities. She would update the IDT care plan, nursing plan, and certified nursing assistant plan as needed to reflect a current individualized plan of care. Review of the Registered Nurse's (RN) job description, undated, revealed the facility RN was responsible for development, implementation and evaluation of formal care plans and updated the plan of care as needed. Review of the Director's of Nursing (DON) job description, undated, revealed the DON was responsible for coordination of the interdisciplinary care plan process. 1. Review of the clinical record revealed the facility admitted Resident #4 on 05/19/2017 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Fall Assessment, dated 05/19/2017, revealed the facility assessed the resident to be at at risk for falls and implemented falls precautions. Review of Resident #4's care plan for falls, dated 05/19/2017, revealed interventions that included: up with two (2) assist, ambulate with assist of two (2); use a walker or wheelchair (w/c); and gait belt. The facility implemented additional interventions for risk of falls, dated 05/26/2017 to ensure the call light was in reach, and the resident wore appropriate footwear or non-skid socks. Further review revealed the facility revised the care plan, on 01/17/2019, and included a restorative walking program to keep the resident's foot from turning outward. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) examination score of fifteen (15) which determined the resident was interviewable. Record review revealed no documented evidence the facility completed any other Fall Assessments for Resident #4. Review of the Quarterly Physical Therapy (PT) screen, dated 01/01/2020 and documented on 01/09/2020, revealed PT assessed Resident #4 at baseline with mobility. Review of a facility Incident Report, and a Progress Note, both dated 01/04/2020, revealed staff found Resident #4 lying on the floor next to the bed. The resident stated he/she tried to get up. The facility assessed the resident as alert and oriented, with weakness, and the resident fell during a transfer and ambulated without assistance. Additional review revealed staff assessed the resident with a bruise over the right eyebrow and skin tear to the right shoulder. The call light was noted to be within reach. However, after this fall, the facility did not conduct a root cause analysis of the fall to determine if the care plan required revision to implement additional interventions. Per the facility's policy, the resident's would be monitored to ensure the effectiveness of the care plan and would be reviewed and revised regularly. Review of a Skin Observation Tool, dated 01/07/2020, revealed the resident also had bruising over both eyebrows from the 01/04/2020 fall. Record review revealed the facility did not review/revise the care plan related to the fall and did not revise interventions until 01/23/2020. Review of a Progress Note, dated 01/23/2020, revealed the facility reviewed the restorative care plan and continued the current restorative program for Resident #4 related to walking. The note revealed the restorative program included walking the resident with a walker and assistance for any distance, and the resident required many verbal cues for his/her shuffling gait. Review of the Annual MDS, dated [DATE], revealed the facility assessed Resident #4 with a BIMS score of thirteen (13). The facility assessed the resident required the extensive two (2) person physical assistance with transfers and walking in the room. Additionally, the facility assessed the resident with one (1) fall since the prior assessment. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #4 with a BIMS' score of fifteen (15) and required extensive assistance of two (2) for transfers and walk in room. Review of a facility Incident Report, dated 08/13/2020, revealed Resident #4 sat on the edge of his/her w/c and staff witnessed him/her scoot off onto the floor. The facility assessed the resident with a skin tear to his/her left elbow. The facility assessed the resident as alert and oriented with weakness. Review of the Progress Notes, revealed no documentation indicating the fall occurred. Review of Resident #4's care plan revealed the facility revised the care plan on 10/22/2020, related to restorative walking program for falls. On 01/14/2021 at 11:47 AM, observation of Resident #4 revealed the resident in a recliner in his/her room, with the call light in reach, and the resident's walker on the other side of the room. Observation, on 01/06/2021 at 12:05 PM, revealed Resident #4's door was closed. Observation, on 01/14/2021 at 8:31 AM, revealed the resident's door was open around two (2) inches. Observations, on 01/14/2021 at 8:53 AM and 9:37 AM, revealed the resident's door was closed. Continued interview with RN #1, on 01/14/2021 at 9:44 AM, revealed she did not update the care plan after Resident #4's fall in August 2020. Continued interview revealed she notified the MDS Coordinator, when she was at the facility, and the MDS Coordinator was responsible to make changes to the care plan. The RN further revealed nurses were told to make changes to the care plan immediately, however she was not trained to make changes on the care plan. On 01/14/21 at 01:22 PM, interview with Licensed Practical Nurse (LPN) #1 revealed she walked in on Resident #4 when he/she fell in January 2020. She could not recall if she put new interventions in place or updated the care plan, per the facility's policy staff was to monitor the effectiveness of the care plan and review and revise the care plan regularly. Interview, on 01/14/2021 at 03:05 PM, with the DON revealed she did not recall Resident #4's fall in January or August 2020. She stated the MDS Coordinator updated care plans. The DON revealed if there was a delay in updating the care plan, there could be no continuation of care for the resident. On 01/06/2021 at 12:38 PM, interview with RN #1 revealed the MDS Coordinator updated resident care plans. However she was unsure how often. She stated the MDS Coordinator worked three (3) days a week at the facility. RN #1 stated she had never updated a resident's care plan. Interview with the MDS Coordinator, on 01/06/2021 at 1:49 PM, revealed the care plan was updated within twenty-four (24) hours to add interventions when there was a change to the resident, such as a fall. She stated if she was at the facility, she updated the care plan, otherwise the nurse or the Director of Nursing (DON) updated the care plan. Interview with RN #3, on 01/06/2021 at 2:46 PM, revealed she did not update residents' care plans. RN #3 stated care plan revisions and updates were handled by the MDS Coordinator. Continued interview revealed when the MDS Coordinator was out, the DON completed the care plan updates. On 01/08/2021 at 3:58 PM, interview with the DON revealed the MDS Coordinator was responsible to make any changes to the residents' care plans. She stated she filled in for the MDS Coordinator when the MDS Coordinator was on leave, otherwise the MDS Coordinator was solely responsible to make care plan updates. Further interview with the DON revealed her expectation was the care plan was updated as soon as possible so staff would know what was going on with the resident. She stated the facility relied on pass down information to ensure residents received the right care. The DON stated staff were not trained how to update care plans as the nurse's should know how. Interview, on 01/11/2021 at 2:49 PM, with the Administrator, revealed the resident's care plan was driven by the facility's assessment of the resident, the resident's status, and new needs to direct the resident's care. She stated she relied on the DON and Chief Nursing Officer (CNO) to ensure resident care was provided as needed. 2. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 06/22/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) score of five (5). The facility also assessed the resident to require the limited assistance of one (1) person for transfers and to walk in the room. Additionally, the MDS noted the resident had one (1) fall in the last month prior to admission to the facility. Review of Resident #2's care plan, dated 07/06/2020, revealed the resident had limited physical mobility and weakness related to fracture. Interventions included: bed against the wall per resident preference, up with assistance, and ambulate with assist of one (1) and a walker. The care plan also included an intervention for precautions to avoid falls related to medication use, however the care plan did not specify what precautions to use. Review of a Progress Note, dated 07/27/2020, revealed the resident was assisted with one (1) staff and his/her walker, walked toward a chair, and lost his/her balance and fell into the wall. The resident wore a long arm cast (related to a fall before admission) on his/her left upper extremity which caused the resident to be off balance. The facility did not provide a fall risk assessment for Resident #2 prior to the fall on 07/27/2020. Review of the Incident Report, dated 07/27/2020, revealed the Certified Nurse Aide (CNA) assisted Resident #2 from the bathroom with his/her walker and the resident lost his/her balance. The report noted the resident fell sideways against the wall gently as the CNA held onto the resident as he/she fell . The resident stated he/she got tripped up and lost his/her balance. The report further noted the resident was alert and oriented, had a gait imbalance, and ambulated with assistance and a walker. The facility did not provide a fall assessment after the fall to determine if the care plan required revisions. Review of a Quarterly MDS, dated [DATE], revealed the facility assessed Resident #2 with a BIMS' score of eight (8) and required extensive two (2) person assistance for transfers and walking. However the care plan was not updated to reflect the resident required two (2) person assistance. Review of a Progress Note and the Incident Report, both dated 10/23/2020, revealed staff found the resident sitting on the floor in front of the recliner. The resident stated he/she slid out of the chair. The report noted the resident was alert and oriented and had weakness. Review of the Fall Assessment for Resident #2, dated 10/23/2020, revealed the facility assessed the resident at risk of falls and implemented falls precautions. However, the facility failed to document the interventions on the resident's care plan. Review of an Incident Report, dated 12/15/2020, for Resident #2 revealed staff found the resident sitting on three (3) blankets and his/her robe, on the floor. The resident stated he/she slipped to the floor. The report noted the resident was alert and oriented with impaired memory, and had gait imbalance. However, there was no documented evidence the facility revised the resident's care plan, after the fall, to include fall precaution interventions. Review of a Progress Note, dated 12/23/2020, revealed staff found Resident #2 laying on his/her back on the floor. An Incident Reported, dated 12/23/2020, revealed the resident was found laying beside the low bed. The resident stated he/she rolled to the floor. The report noted the resident was confused and incontinent. Review of the care plan revealed the facility failed to review or revise the care plan to include fall precaution interventions after the fall. Review of a Progress Note, dated 12/30/2020, revealed staff found Resident #2 laying on his/her right side on the floor and complained of right shoulder pain. Review of the Incident Report, dated 12/30/2020, revealed, the CNA found the resident laying on the floor beside the recliner, the walker in front of the overbed table next to the recliner, and the call light on the arm of the recliner. The resident stated he/she tried to get his/her walker to get up and fell . The report noted the resident was alert and oriented, had right shoulder pain, weakness, gait imbalance, and ambulated without assistance. However, the facility failed to follow it's policy, to regularly review and revise residents' care plans to ensure the effectiveness of the care plan. Review of the care plan revealed the facility updated Resident #2's care plan for an actual fall, on 12/31/2020. The care plan included to continue interventions of the at risk plan, and provide activities that promoted exercise and strength building where possible. Observation of Resident #2, on 01/14/2021 at 8:39 AM, revealed the resident laying in bed on his/her back, knees bent with one (1) leg crossed over the other. The bed was against the wall, the over bed table was next to the bed, and a bed alarm on the bed rail. Observation revealed a walker and bedside commode against the opposite wall. Interview with Resident #2, on 01/14/2021 at 8:39 AM, revealed he/she fell a while ago, but he/she did not remember a lot about it. Interview, on 01/14/2021 at 9:44 AM, with Registered Nurse (RN) #1 revealed she did not update Resident #2's care plan after the resident's fall on 07/27/2020. She stated she could make verbal changes to the care plan. She stated the CNAs follow the printed care plan. However, she had never written updates on the care plan. RN #1 stated Resident #2 was forgetful, but he/she could carry on a conversation. The nurse stated the MDS Coordinator was responsible to update resident care plans. However, the MDS Coordinator was only at the facility three (3) days a week. Interview with Licensed Practical Nurse (LPN) #2, on 01/14/2021 at 1:38 PM, revealed she did not think Resident #2 had precautions in place prior to his/her fall on 12/23/2020. She stated she did not put any new interventions in place after the fall and she did not update the care plan. LPN #2 stated the MDS Coordinator updated care plans. 3. Review of Resident #1's closed record revealed the facility admitted the resident on 06/13/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimal Data Set (MDS) dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview of Mental Status score of eight (8) out of fifteen (15), which indicated the resident had moderate cognitive impairment. Further review revealed the facility assessed the resident to be at risk for falls. Review of Resident #1's closed records revealed the resident experienced a fall on 10/31/2019 in which he/she was seated in his/her wheelchair at a dinner table and pushed away from the table in a quick motion, which caused the chair to spin around. Resident #1 fell out of the chair and landed on his/her head; the resident required stitches to his/her forehead. Further review of the Incident Report revealed the resident had recently had a change to his/her wheelchair with bilateral supports and that a reassessment would be done. However, the facility did not present any documented evidence that a reassessment was conducted. Review of Resident #1's care plan reveled no documented evidence that any new focus, goals or interventions were added to address the above incident. In addition, there was no documented evidence that any interventions for the bilateral supports to the resident's wheelchair were added. Review of Resident #1's Occupational Therapy (OT) evaluation, dated 06/14/2017, listed the resident was to have restraints of bed/chair alarm at all times. However, the care plan did not reflect any focus, goal or intervention for the use/evaluation of such restraints. 4. Review of the clinical record revealed the facility admitted Resident #3 on 04/07/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS dated [DATE], revealed the facility assessed Resident #3 to have a BIMS' score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility assessed the resident to require a one (1) person assist for bed mobility, transfers, walking, dressing, toilet and personal hygiene. The resident was also assessed as not steady, but able to stabilize without staff assistance when he/she moved from seated to standing position; to walk with assisted device; to turn around; to move on and off toilet and for surface-to-surface transfers. Review of the resident's care plan revealed it was not revised to reflect the 10/06/2020 assessment. Review of Resident #3's Progress Notes and the facility's Incident Reports revealed Resident #3 had a fall on 04/16/2020, 06/27/2020, 08/22/2020 (x 3), 10/16/2020, 11/13/2020, 12/14/2020, 12/16/2020 and 12/24/2020, which resulted in major injury. Review of the care pan revealed all interventions for this focus (falls) and goal area were created and initiated on 04/07/2020. Further review revealed a revision date of 06/01/2020. However, continued review revealed no revisions were documented on the care plan. In addition, further review revealed a focus area listed as resident has had actual fall without injury due to poor balance (documented as created 05/04/2020, initiated 04/16/2020 and revised 05/05/2020). Review revealed no documented evidence revisions were made to the care plan. 5. Review of Resident #5 clinical records revealed the facility admitted the resident on 03/20/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's MDS Assessments dated 02/08/2020 and 11/10/2020, revealed the facility assessed the resident to have a BIMS's score of 99. The facility assessed the resident as not interviewable. Review of Resident #5's OT evaluation dated 11/19/2020, revealed the facility assessed that the resident had declined in self-feeding. Further review revealed the facility assessed the resident required maximum assistance/dependent. In addition, the resident was noted with lack of cognition/response to environment with poor rehabilitation potential and at risk for malnutrition. Review of Resident #5's care plan revealed a focus of ADL self-care performance deficit related to Dementia/[CONDITION(S)] (created and initiated 04/14/2017 with revision date of 10/11/2018). However, there was no documented evidence that the care plan was revised to reflect the 11/19/2020 OT evaluation interventions. In addition, no revisions were made to eating interventions. Review of Resident #5's care plan revealed focus areas as nutritional problem or potential nutritional problem decreased appetite related to Dementia, Anorexia (documented as created, initiated and revised 10/17/2018). However, there was no documented evidence that revisions were made to care plan that addressed the OT 11/19/2020 evaluation. Review of the facility's Incident Report #135 revealed Resident #5 had a fall on 05/01/2020, which resulted in a bruised, swollen face with a laceration. Further review revealed the care plan was not revised until 09/03/2020 at which time a perimeter mattress was put in place to prevent continued falls. Interview with RN #1 on 01/06/2021 at 12:52 PM, revealed the MCSC was responsible to make changes to the care plan when there was a change of condition in a resident. She also revealed the care plans should be updated as soon as possible. She reported the care plan was not an order but any new information was passed down at shift change. She reported not all information was written in the care plan, but that did not mean the work was not done. Continued interview with RN #1 revealed the facility really counted on word of mouth pass down information and expected that orders would be entered in properly. RN #1 stated, We are a small enough unit, we can count on that. She also stated a small unit such as theirs did not require everything to be written down and to have a signature for every change made. Interview with RN #3, on 01/06/20/21 at 2:46 PM, revealed she did not update resident care plans. RN #3 stated care plans were updated by the MDS Coordinator. She stated when the MDS Coordinator was out, the DON completed care plan updates. Interview with MDS Coordinator on 12/22/2020 at 3:00 PM, revealed she was responsible for care plan revision and that nurses usually passed information on to her when there was a change in resident care. She stated if it was not urgent she would update the care plan at the next interdisciplinary team meeting (IDT). Further interview with the MDS Coordinator, on 01/06/2021 at 1:49 PM, revealed the care plan was updated within twenty-four (24) hours to add interventions when there was a change to the resident, such as a fall. She stated if she was at the facility, she updated the care plan, otherwise the nurse or the DON updated the care plan. On 01/08/2021 at 3:58 PM, interview with the DON revealed the MDS Coordinator was responsible to make any changes to the residents' care plans. She stated she filled in for the MDS Coordinator when she was on leave. However, otherwise the MDS Coordinator was solely responsible to make care plan updates. Continued interview with the DON revealed her expectation was that the care plans were updated as soon as possible so staff would be aware of what was going on with the resident. She stated the facility relied on pass down information to ensure residents received the right care. The DON stated staff were not trained how to update care plans. Interview, on 01/11/2021 at 02:49 PM, with the Administrator revealed the resident's care plan was driven by the facility's assessment of the resident, the resident's status, and any new needs to direct the resident's care. She stated she relied on the DON and CNO to ensure resident care was provided as needed.

Based on observation, interview, review of the Administrator's Job Descriptions, and review of the facility's policies and procedures it was determined the facility's administration failed to ensure the facility was administered in a manner that enabled effective use of its resources to attain and maintain the highest practical physical, mental, and psycho-social wellbeing of each resident. The facility administration failed to ensure its policies and procedures were followed to elopement risks. The failed to have an effective system to ensure residents were assessed and provided supervision to prevent elopements; failed to ensure residents were assessed for side rails use and that beds with side rails were assessed to be safe; and failed to ensure residents were assessed after falls to determine if additional interventions were needed to prevent further falls. Resident #6 eloped from the facility without staff knowledge. Residents #1, #2, #3, #4 and #5 had numerous falls. The finding include: 1. Review of the facility's policy Administration, dated 04/24/2020, revealed the facility operated and provided services in compliance with all applicable federal, state and local laws, regulations and codes and accepted professional standards and principles applied to professionals providing services in a long-term care facility. Review of the facility's policy Care Planning, dated 07/09/2012, revealed care planning was based on data collected from resident assessments with integration of those assessment findings in the care planning process. In Skilled Care, care plans were reviewed every two (2) weeks for the first quarter, every month for the second quarter and quarterly. Thereafter, they would be updated based on the resident's clinical condition, care goals, plan of treatment, care and services and revised as needed to meet the needs of the resident's changing condition. Review of the facility's policy Resident Safety Plan, revised 01/20/2015, revealed the Resident Safety Plan was used to recognize and acknowledge the risks to residents' safety and medical/health care errors, initiate actions to reduce the risk, internal and external reports to show what actions were taken. Review of the facility's policy Fall Reporting Instructions for Nursing Facility, revised 09/05/2018, revealed the electronic Incident Report and Fall Assessments were conducted as soon as possible. One (1) hour after a resident's fall, a reassessment was done and neuro checks were completed with any head injury or an unwitnessed fall. This policy made the following suggestions to staff: place a fall risk sign and/or use gripper socks, use one or more of the following: side rails, restraints, and bed/chair alerts. The policy further revealed restraints should only be used after other options were determined ineffective or insufficient. Review of the facility's policy Fall Prevention, revised December 2020, revealed the facility assessed and managed the patient's risk for falls. The policy revealed every patient care area would be evaluated for potential patient falls. The evaluation was completed by the department manager and/or Environment of Care Committee and findings included in the fall reduction program. All patients were assessed upon admission and throughout their stay with the Assessment of Adult Patient at Risk for Falls form. Additionally, prior falls were documented in the care plan. Patients were reassessed as needed, if their condition changed, new medications ordered or dosing changed, following a procedure, and following a fall. Bed alarms could be used when the patient was in bed or sat in a chair. The policy also revealed the facility trained staff in falls prevention to include, fall assessments, techniques to prevent falls, and transfer protocol. Review of the facility's policy Alarm Management, Patient Equipment, dated 06/22/2016, revealed alarms were only turned off by staff who were trained in Alarm Management Safety. The policy revealed an exception was a bed alarm may be turned off by a Certified Nursing Assistant (CNA) but the action must be documented in the Medical Record and the Charge Nurse notified. Documentation included the staff name, time alarm turned off, and the reason the alarm was turned off. Review of the facility's policy Resident Safety Plan, revised 01/20/2015, revealed the scope of the Resident Safety Plan included: ongoing proactive risk assessments, using internal and external knowledge and experience, to prevent error occurrences, and maintain and improve resident safety. The policy defined a Sentinel Event as an unexpected event or occurrence involving death or serious physical or psychological injury or risk thereof. It defined a near miss as any process variation which did not affect the outcome, but for which a recurrence carried a significant chance of serious adverse outcome. The policy also revealed all sentinel events and near miss occurrences would have a root cause analysis (RCA) conducted. An effective plan could not exist without optimal reporting. Staff were trained and educated during their initial orientation process and an ongoing basis. Review of the facility's policy New Employee Orientation and Annual Employee Training, revised 05/01/2014, revealed orientation was conducted in two (2) days for overview, however based on the department there may be ongoing/continued training. Annual training was conducted through on-line program Care Learning. Review of the facility's policy Bedside Shift Report, dated 10/17/2017, revealed shift report was done bedside for each resident. Shift report included resident status, any abnormal findings, safety checks for bed alarms proper placement and working order, call light within reach of resident, resident was dry and clean, room was stocked with supplies, room was clean, and path of egress was clear. Review of the facility's policy Restraints, revised 06/11/2013, revealed side rails were included as a type of restraint. Staff must be trained and demonstrate competency in monitoring and assessing for restraints. Training included how to assess the least restrictive options. Review of the facility's policy Abuse, Neglect and Misappropriation in the Nursing Facility, revised 06/25/13, revealed all allegations, observations or suspected cases of abuse to include injuries of unknown origin were investigated by the facility. Injuries of unknown origin included [CONDITION(S)], injury to head, scalp or face, hematomas, fractures, and falls. Review of the Chief Nursing Officer (CNO) Job Description, undated, revealed the CNO demonstrated knowledge and compliance of organization and department policies, regulations, and functioned as an administrative resource person on issues related to department and organization policy. The CNO ensured continued education of self and staff, took responsibility for regulatory compliance within the department, and stayed informed about compliancy changes. Review of the Administrator's Job Description, undated, revealed the Administrator ensured that nursing services, medical services, therapeutic and rehabilitation programs were planned, implemented and evaluated to maximize a resident's quality of life and quality of care. The Administrator ensured the health information management program for residents' care was planned, implemented, and evaluated to meet documentation requirements. The Administrator was also responsible to ensure development, implementation and review of resident care policies and procedures, and to ensure the facility complied with applicable federal, state, and local standards and regulations. Additionally, the Administrator was responsible to facilitate the process of communication between management and staff (for example, coaching and counseling). The Administrator also ensured environment safety and emergency safety programs were planned, implemented and evaluated to maintain the health and wellness of residents, staff and visitors. Furthermore, the Administrator was responsible to ensure policies and procedures were developed, implemented, and monitored to maintain compliance with federal, state, and local rules and regulations. Other duties included to observe, monitor, and evaluate the outcome of all the facility's programs, policies and procedures, and ensure the effectiveness. Additionally, the Administrator was responsible to educate staff/residents/families/responsible parties and other key groups in regard to interpretation of, and compliance with, regulatory requirements. Further, the Administrator was responsible to ensure potential liabilities to the facility were identified and an administrative intervention or risk management program was established to minimize or eliminate exposer, as well as develop leadership skills of management team and key staff and ensure an information management system was in place to support facility operations. Interview with the Administrator, on 12/22/2020 at 4:48 PM, revealed it was her expectation that staff followed the treatment and precautions listed on the care plan which were devised through evaluation of the resident. She stated It is important to conduct services by the care plan to keep residents safe and to maintain their highest level of functioning so they get everything they need. Continued interview with the Administrator, on 01/04/2021 at 1:50 PM, revealed she had been at the facility for ten (10) years and did not have any other Long Term Care Nursing experience. She revealed she was familiar with the federal regulations and knowledgeable of the requirements for bedrails and bed/chair alarms. She reported investigations in the facility started with the Director of Nursing (DON), and information then shared with the Chief Nursing Officer (CNO) and the Administrator. The Administrator stated if it was determined an incident could have been prevented and how, and if it was related to staff performance, the issue would be addressed and the staff would be retrained. If an incident was caused by faulty equipment, new equipment was obtained and staff retrained. The Administrator further stated root cause analyses (RCA) were done for all falls with injury, transfers with injury, medication errors and harm to patients. In addition, the Administrator stated significant or not, when a resident needed additional care or for a resident that had an injury of unknown origin. She stated the facility did not do an RCA for the incident involving Resident #2, dated 07/27/2020 because we already knew what happened and were working on correcting it. Continued interview revealed she received a real time alert for anything that negatively affected a resident. She stated she received a monthly report on falls and if fall rates increased it was discussed and a plan was put in place before they met with the board. Continued interview with the Administrator, 01/15/2021 at 1:23 PM, revealed she did not realize the facility should conduct a specific assessment for bed rails. She stated it would be her expectation that there would be enough information on the resident to derive the need for bed rails. and the same in reference to bed alarms. She stated staff should request a bed alarm, obtain an order from the doctor, and document to support the use of bed alarms. The Administrator stated reassessments were to be done but she was unsure of the timeframe, She stated a physician could not give an open ended order nor could an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If she became aware of a broken process through quality tracking, she was part of that process as well. Interview with CNO, on 01/15/21 at 1:23 PM, revealed she worked at the facility for six (6) years as the CNO. She revealed she did not have any other Long Term Care experience. She stated she could not recall what was required for use of bedrails other than permission must be given residents to use bedrails. She stated, Upon new admission to the facility, residents are asked if they want bedrails and she does not recall any residents saying they did not. Additionally she stated, Our bedrails are attached to the beds, they are hospital beds. The CNO revealed she had not read all of the Long Term Care federal regulations. 2. Review of a facility Incident Report, dated 08/08/2020, revealed a Respiratory Therapist (RT) called about a resident sitting outside the department. The nurse found the door from the activity room to the breakroom unlocked and Resident #6's walker in the breakroom. The RT noted the resident wore an ankle bracelet. Review of Registered Nurse (RN) #2's written statement, dated 08/08/2020, of the facility investigation revealed the door from the activity room to the breakroom was propped open. The resident went down the stairs with a chair from the breakroom and out the fire exit at the bottom of the stairs. The RN's statement revealed when she returned the resident to the second floor facility, the Wanderguard (WG) sounded when the resident exit the elevator. The nurse's written statement continued, on 08/09/2020, and revealed the RN found the door from the activity room to the breakroom propped open again. Interviews and record reviews revealed Resident #6 wore a WG device when he/she eloped from the facility through doors without a WG alarm. The facility implemented two (2) hour door checks for two (2) months (log documentation began 08/15/2020) to ensure the doors were locked, however multiple days of door check logs were missing, and multiple days had blank spaces. Interviews revealed the missing checks were not reported to management, and management did not follow up to ensure the logs were completed the doors were checked. Observation found the door unlocked twice during survey. Interview with the Director of Nursing (DON), on 01/08/21 at 03:58 PM, revealed she spoke with the Chief Nursing Officer (CNO) regarding Resident #6's elopement from the facility. She revealed the Safety Officer (SO) was responsible to check the door alarms worked and would have been completed on the following Monday after the elopement. She stated within a week of the elopement, the facility began to ensure doors were locked at certain times of the day. The DON stated the Ward Clerk, CNAs, and nurses were responsible to complete the door checks. She revealed she completed the facility investigation and the only statement obtained was from the nurse. She further revealed the facility did not conduct a root cause analysis of the elopement as they knew how the incident occurred that a door was left unlocked. The DON stated she did not monitor staff to ensure necessary care was provided to residents. She revealed she did not review orders to ensure they were entered correctly and carried over to the TAR. On 01/11/21 at 1:21 PM, interview with the CNO revealed the manager was responsible to complete the investigation and talk to who was involved. The CNO revealed the root cause analysis could be completed by the manager, herself or anyone involved and was required when there was severe harm to a resident. She stated she trained the DON the best she could, as the DON did not have the previous manager to train her when she, the DON, began in her role. The DON stated after the elopement, the facility began to check the doors were locked, however the CNO was unaware who was responsible to complete the door checks, and the door checks were not submitted to her for review. The CNO further revealed she was unaware Resident #6 had a WG at the time of the elopement and stated she was not aware of what occurred after the resident returned to the facility, usually the manager was notified. She revealed the SO checked the door alarms however no one checked the door alarms on the weekends. The CNO further revealed she was unsure if the facility continued to check the doors were locked, however after reviewing the investigation she stated the door checks were completed for two (2) months. The CNO revealed the DON reported directly to her and she trusted managers to follow up on everything needed. She further revealed the DON did not provide or submit any reports for review, and follow up was conducted in the QA meetings. Interview, on 01/11/21 at 02:49 PM, with the Administrator revealed the facility investigation should be completed by the DON, Safety Officer (SO), or CNO. She stated the CNO would report the findings to her. The Administrator revealed the elopement was discussed on Monday (08/10/2020) and thought she instructed to monitor the doors were locked. She further revealed she was unsure how long the doors were monitored, or if they were still monitored. She stated the door checks would we reviewed by the DON, and would not be submitted to her (the Administrator) for review. The Administrator stated she was not aware Resident #6 had a WG at the time of the elopement, and the door the resident went through did not have a WG alarm. She revealed the WG door alarms were checked weekly, and daily if a WG was in use, by the SO when he was there. She further stated there was not a process in place and no one was assigned to check the door alarms when the SO was not there. The Administrator revealed she relied on the DON and CNO to ensure care was given to residents as ordered and as needed. The Administrator stated she could not recall if Resident #6's elopement had been discussed in the last held QA meeting, and there was no ongoing discussion regarding problems with the doors. She further stated the facility did not conduct a root cause analysis on the elopement as they discussed what happened and was an isolated event. She revealed there was no discussion how the resident got through the door other than a staff inadvertently left a door unlocked. Additional interview with the CNO, on 01/15/21 at 02:33 PM, revealed she had not seen the nurse's written statement and was unaware the nurse found the door open again after Resident #6 eloped from the facility. She stated the manager was responsible to follow up with staff the door checks were completed as soon as possible. She also stated she was unaware doors were found unlocked during the door checks. Continued interview, on 01/15/21 at 03:03 PM, with the Administrator revealed she was not aware of the nurse's statement the door was found open again after the elopement. She stated the DON was responsible to follow up with staff immediately if the door checks were not documented as completed. She further stated there was no reason the Maintenance Director was not informed of the elopement when the incident occurred.

Based on interview, record review, and the Centers for Medicare and Medicaid Services Interim Final Rule, the facility did not provide COVID-19 testing twice weekly to eligible staff based on the county's positivity rate. The findings include: Review of the document titled, Center for Clinical Standards and Quality/Survey and Certification Group Ref: QSO-20-38-NH, dated 08/26/2020, revealed routine testing was based on the extent of [MEDICAL CONDITION] in the community, therefore facilities used their county positivity rate from the prior week as the trigger for staff testing frequency. The minimum testing frequency for a high county positivity rate (greater than 10%) was twice weekly. Interview with the Quality Director, on 12/21/2020 at 3:24 PM, revealed the facility mainly performed COVID-19 testing if there was a suspicion of [MEDICAL CONDITION] present. Continued interview revealed staff were being tested when they showed signs or symptoms of COVID-19. Interview with the Director of Nursing (DON), on 12/29/2020 at 3:41, revealed frequency of testing is determined by the Medical Director and Infection Control Nurse not by the county positivity rate. Interview with the Infection Control Nurse and Administrator, on 12/30/2020 at 11:51, revealed since the first positive COVID-19 test in the facility, each resident has been tested in different timeframes directed by each individual residents' physician. Also revealed the nursing facility does not follow CDC guidelines regarding testing due to being a nursing facility in a hospital.

Based on observation, interview and review of facility policy, it was determined the facility failed to recalibrate the digital thermometer in accordance with professional standards for foodservice safety in one (1) of one (1) kitchen. Record review of the Dietary kitchen logs, on 07/02/19, during lunch recalibration, revealed there was no documented evidence of recalibration temperatures. In addition, kitchen staff had not recalibrated the digital thermometer to determine accuracy for the months of (MONTH) 2019 through (MONTH) 2019. The findings include: Review of the facility Census and Condition, dated 07/01/19, revealed eighteen (18) of eighteen (18) residents received their meals from the kitchen. Review of facility Policy Equipment Condition and Safety, updated 04/19/19, revealed all appropriate staff were responsible for continuous assessment of the condition of all equipment in their use. The Operator's Manual should be on hand in the department utilizing equipment used. Electronic meters must respond to the appropriate control and operate properly. The meter should have free and full range of movement. When off, the meter will read zero (0) or the appropriate reading as specified by the manufacturer. Review of the Instruction Manual(NAME)Waterproof Digital Thermometer revealed the process to recalibrate the digital thermometer, are to place in a cup of ice-cold water for at least thirty seconds. The benchmark temperature are thirty-two (32) degrees Fahrenheit. Observation and interview, on 07/02/19 at 11:15 AM, revealed staff attempted to complete lunch temperatures without calibrating the digital thermometer. Interview with the Dietary Director reported she had been an employee for the facility for seven years in the kitchen and never recalibrated the digital thermometer. She revealed she had depended on the precision of the digital thermometer and the steam, which comes off the steam table to ensure the food temperatures are accurate. She reported she could not ensure the food had correct temperatures if the thermometer are not correct. The Dietary Director reported she did not remember how to recalibrate the thermometer so she had the Dietitian complete the task. Observation, on 07/02/19 at 11:15 AM, revealed Dietitian explained the process of recalibrating the thermometer to the Dietary Director. The Dietary Directory revealed the importance for food temperatures to be accurate for the welfare of the residents with compromised immune systems. The thermometer had to be correct in order to get the correct temperatures of the food to prevent food borne illness. Interview with Dietitian, on 07/02/19 at 03:33 PM, revealed she was not aware the kitchen staff had not been completing the recalibration process. The Dietitian reported education had been complete with the kitchen staff on how and when to recalibrate the thermometer. She explained the kitchen staff had taken trainings on Sevsafe, which covered recalibrations of the thermometers. The Dietitian stated if the thermometer had inaccurate food temperatures, the residents could become ill. Interview with Dietary Aide/Cook in the presence of the Dietary Director on, 07/02/19 at 03:40 PM, revealed she was trained on recalibrating non-digital thermometers however was told by the Dietary Director not to recalibrate the digital thermometer. The Dietary Aide/Cook reported the staff never kept any documentation or records of the recalibration readings. She stated the food temperatures should be at least 165 degrees Fahrenheit but liked food temperatures of 175 degrees Fahrenheit to be on the safe side. The Dietary Aide/Cook reported she just trusted the digital thermometer, however she would not know if the thermometer had been defective. The Dietary Aide/Cook stated if the foods had not been at the correct temperatures, the residents could get sick with their compromise immune systems. During the interview with the Dietary Aide/Cook, on 07/02/19 at 03:40 PM, the Dietary Director had interjected and revealed she thought the digital thermometer would be more accurate. She thought since the thermometer was digital, it did not need to be recalibrate. In addition, she reported the training on Servsafe did not state to recalibrate the thermometer. The Dietary Director reported the facility did not provide the kitchen staff an in-service on recalibrating a digital thermometer.

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for three (3) of eight (8) sampled residents, Resident #2, #4, and #17. Resident #2, #4, and #17 sustained falls on multiple occasions with no care plan revisions after the incidents to prevent further falls. The findings include: Review of the facility's policy, Care Planning, dated (MONTH) 2012, revealed care planning would be implemented through the integration of assessment findings, consideration of the prescribed treatment plan, and development of goals for the resident that were reasonable and measurable. The planning of care, treatment, and services would include regularly reviewing and revising the plan for care, treatment, and services and monitoring the effectiveness of the provision of care, treatment, and services. Care planning would be conducted every two (2) weeks for the first quarter, every month for the second quarter, and quarterly thereafter. It further revealed care plans would be reviewed when indicated by changes in the resident's condition. 1. Review of Resident #2's clinical record revealed the facility admitted the resident on 02/25/13. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required limited assistance of one (1) staff for transfers and walking in the room. The facility determined the resident had one (1) fall with minor injury since the last assessment. Review of the Care Plan for Resident #2 revealed the problem Falls, initiated 12/19/12, with a goal for the resident to remain free of serious injury from falls through 10/2012. The last review date listed on the plan was 04/13/16. The interventions included keeping the call light in reach at all times, reorient resident to physical limitation and current environment, report any falls, near misses, or other accidental self-injury to appropriate persons as needed for additional interventions. If the resident attempted to get out of bed, toilet, offer food or drink, and ask what he/she wanted, physical therapy to evaluate and treat for mobility issues, praise efforts and encourage increasing activity level as resident gains strength, assist to ambulate and encourage rest periods when resident appeared weak or unsteady. Review of an Incident Report, dated 02/27/18 at 2:00 AM, revealed Resident #2 got up to go to the restroom with his/her walker, stepped backward to sit on the bed to rest, and slid off the edge of the bed onto the floor. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) witnessed as they were walking down the hall. Review of an Incident Report, dated 03/06/18 at 1:50 PM, revealed Resident #2 got up to go to the restroom without calling for assistance. Resident #2 used his/her walker and had gripper socks on. Resident #2 stated he/she fell back and denied any pain or discomfort. Review of an Incident Report, dated 03/12/18, no time listed, revealed Resident #8 saw Resident #2 get up from his/her chair. Resident #2 slid off the bed and onto the floor. Resident #2 did not hit his/her head and vital signs were within normal limits. Review of an Incident Report, dated 05/02/18 at 2:30 PM, revealed Resident #2 was found on the floor with a folding white tray table bent and under his/her upper body. Resident #2 had a skin tear to the right upper arm. Resident #2 stated he/she was going to the bathroom to shave and he/she put their weight on the table and it gave away. Review of an Incident Report, dated 05/02/18 at 3:02 PM, revealed Resident #2 could not recall what had caused him/her to fall. Fall resulted in a left upper arm skin tear and a left knee skin tear. Further review of the resident's Care Plan revealed the facility did not update the plan with new interventions after the falls on 02/27/18, 03/06/18, 03/12/18, or after the two (2) falls on 05/02/18. 2. Review of Resident #4's clinical record revealed the facility admitted the resident on 01/05/18. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident required limited assistance of two (2) staff for transfers and extensive assistance of two (2) staff to walk in the room. The facility determined the resident had no falls since admission. Review of an Incident Report, dated 03/01/18 at 11:35 AM, revealed Resident #4 was lying on the floor in front of the toilet on his/her right side with pants down to the waist. Review of an Incident Report, dated 03/09/18 at 11:55 AM, revealed Resident #4 was found lying on his/her left side in the bathroom with a half dollar sized bruise to his/her right skull and a dime sized left elbow skin tear. Review of an Incident Report, dated 03/24/18 at 10:20 AM, revealed Resident #4 was found lying on the floor on his/her back. Resident #4 stated he/she was attempting to get his/her razor off the bedside table at the end of the bed. Review of an Incident Report, dated 04/12/18 at 5:30 PM, revealed Resident #4 was found lying on the floor on his/her right side with feet toward the closet. Resident #4 stated he/she was going to empty his/her urinal. Resident #4 had a one (1) centimeter skin tear to his/her right elbow and a skin tear to the base of the hand. Review of an Incident Report, dated 04/16/18 at 1:50 PM, revealed Resident #4 was found in front of his/her recliner with his/her feet tangled in oxygen tubing. Resident #4 had a left elbow skin tear Review of an Incident Report, dated 05/16/18 at 7:30 PM, revealed Resident #4 was lowered to the floor by a CNA when Resident #4 was unable to walk. Resident #4 had bilateral redness to his/her knees. However, review of the Care Plan for Resident #4 revealed the facility did not revise the plan to include the problem of Falls with interventions to prevent further falls until 05/22/18. Interventions included determining and addressing causative factors of the fall; and monitor, document, and report as needed for seventy-two (72) hours to the physician any signs and symptoms of pain, bruises, change in mental status, or new onset of confusion, sleepiness, inability to maintain posture, or agitation. Consult pharmacy to evaluate medications, provide activities to promote exercise and strength building where possible, and consult physical therapy for strength and mobility. 3. Review of Resident #17's clinical record revealed the facility admitted the resident on 01/08/18. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance of two (2) staff for transfers and walking in the room. The facility determined the resident had two (2) non-injury falls since admission. Review of an Incident Report, dated 01/13/18 at 4:00 AM, revealed Resident #17 was discovered up in his/her room by a nurse. When the nurse attempted to assist Resident #17, he/she backed up, got off balance, and fell on his/her buttocks. Review of an Incident Report, dated 01/24/18 at 11:30 AM, revealed Resident #17 was discovered sitting in front of his/her wheelchair with his/her buttocks on the floor. Review of an Incident Report, dated 02/09/18 at 4:52 PM, revealed Resident #17 attempted to go to the restroom without using the call light for help. Resident #17 put his/her recliner chair in the highest position and slid out. Review of an Incident Report, dated 02/14/18 at 9:00 PM, revealed Resident #17 was sitting in his/her recliner and pushed the remote on his/her recliner up causing him/her to slide into the floor. Review of an Incident Report, dated 02/27/18 at 1:30 PM, revealed Resident #17 was found by the therapy department in front of his/her recliner lying prone with his/her hands and face resting on the bottom of the bedside table. Review of the Care Plan for Resident #17 revealed the facility did not revise the plan with interventions to prevent further falls after each of falls listed on the incident reports. The problem Actual Fall with no injury, initiated 01/14/18, had a goal for the resident to resume usual activities without further incident through the next review date; however, the interventions listed were not initiated until 05/11/18. They included determining and addressing causative factors of the fall; and monitor, document, and report as needed for seventy-two (72) hours to the physician any signs and symptoms of pain, bruises, change in mental status, or new onset of confusion, sleepiness, inability to maintain posture, or agitation. Consult pharmacy to evaluate medications, provide activities to promote exercise and strength building where possible, and consult physical therapy for strength and mobility. Interview with CNA #1, on 05/23/18 at 4:41 PM, revealed the purpose of a care plan was to inform staff on how to take care of a resident. She stated if the care plan was not updated, then staff would not know how to care for the resident. Interview with RN #1, on 05/23/18 at 1:32 PM, revealed in order to know how to care for a resident, she would look at the physician orders [REDACTED]. She stated the care plan for residents was located at the nurses' station desk. She further stated care plan interventions should be updated regularly and should be clear to show what interventions were tried and whether or not they solved the problem. RN #1 stated if the care plan was not updated, then the resident could keep falling and could get hurt. Per interview, the MDS Coordinator was responsible for updating the care plans and nurses reviewed them as needed. The MDS Coordinator was not available for interview. Interview with the Director of Nursing (DON), on 05/23/18 at 2:12 PM, revealed she could not find any indication that the computer copies of the care plans, or the hard copies of the care plans, had been updated for Resident #2, #4, and #17 following each fall incident. The DON stated the care plan was a tool for all staff to know what was supposed to happen to ensure the resident received the appropriate care. The DON stated the MDS Coordinator was responsible for updating the nursing care plan for all residents. She further stated interventions had been implemented for Resident #2, #4, and #17 following each fall, but the interventions were not listed on the care plans. She stated if a staff member was new or unfamiliar with a resident, then they would receive orientation and/or a report from the off-going nurse, but all interventions should be on the care plan for reference.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision and assistive devices to prevent a fall for one (1) of four (4) sampled residents, Resident #1. Certified Nursing Assistant (CNA) #1 did not use appropriate technique to reposition Resident #1 in his/her wheelchair. In addition, the facility failed to provide the assistive equipment recommended by Occupational Therapy (OT) to improve his/her wheelchair, after Resident #1 sustained multiple falls. The findings include: Review of the facility's policy, Fall Prevention, revised April 2017, revealed staff received in-services on the fall prevention program, which included fall assessment and techniques to prevent falls. Review of the facility's policy, Resident Safety Plan, revised 01/20/15, revealed the policy's intent was to improve resident safety and reduce risk to residents with an environment that encouraged integration of safety priorities into all relevant organizational processes, functions, services, departments, and programs. Review of the facility's medical record for Resident #1 revealed the facility admitted the resident on 02/11/13, with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 was totally dependent upon two (2) staff for assistance with bed mobility and transfers. The resident had one (1) fall with no injury and one (1) fall with minor injury since the last assessment. Review of Resident #1's Comprehensive Care Plan, revised 06/26/16, revealed the facility assessed the resident was at risk for falls related to unsteady gait and poor balance. The goal was for Resident #1 to remain free of serious fall related injuries with the use of adaptive equipment and staff assistance with activities of daily living as needed. The care plan stated Resident #1 sustained falls on 04/03/17 and 04/13/17. An intervention, dated 04/14/17, was for Occupational (OT) and Physical Therapy (PT) to evaluate for positioning. An intervention, dated 06/25/17, was for the wheelchair to be changed due to poor positioning. Review of Resident #1's CNA Care Plan, dated 07/26/17, revealed Resident #1 required the assistance of two (2) staff for repositioning. Review of an incident report, undated, revealed Resident #1 sustained a fall on 06/25/17 at 5:15 PM. The report stated Resident #1 was slumped forward in his/her wheelchair outside the restorative dining room when CNA #1 tried to straighten him/her and the wheelchair fell backwards with Resident #1 hitting his/her head on the tile floor. Resident #1 sustained a knot to the back of his/her head, the physician was notified, Resident #1 received a Computed Tomography head scan in the Emergency Department and was cleared of any serious injury. In addition, the report stated the wheelchair brakes did not grab well, which caused the chair to move with Resident #1. The wheelchair was replaced and OT was ordered for positioning. Review of a facility investigation, dated 06/26/17, revealed on 06/25/17, Resident #1 was positioned incorrectly in his/her wheelchair and was leaning forward. CNA #1 attempted to reposition Resident #1 from the front and the wheelchair, and resident, fell backwards, causing Resident #1 to hit his/her head on the floor. The investigation stated CNA #1 did not follow Resident #1's care plan as he/she was a two (2) person assist for all repositioning. Review of Resident #1's Fall Assessment, dated 06/25/17, revealed the resident was assessed after sustaining a fall. Resident #1 was leaning forward in his/her wheelchair in the hallway, outside the restorative dining room before the evening meal. A faulty wheelchair was a factor listed as contributing to the fall and Resident #1 was moved to a new chair. The assessment went on to state Resident #1 sustained a small knot on the back of his/her head and neurological checks would be performed for twenty four (24) hours. Interview with CNA #1, on 07/25/17 at 2:39 PM, revealed he cared for Resident #1 frequently and he/she always leaned forward in his/her wheelchair. He stated he cared for Resident #1 on 06/25/17, and recalled the resident was waiting outside the dining room around 5:00 PM when he noticed the resident was leaning forward in the wheelchair as usual, but he/she looked crooked in the chair. Initially he pushed Resident #1's shoulders back against the chair but that did not correct his/her position. He then went to the front of the chair and attempted to cradle Resident #1, pick him/her up from underneath, and scoot him/her to a proper position. Resident #1's weight shifted and the wheelchair flipped backwards and his/her head hit the floor. CNA #1 stated he knew Resident #1 required two (2) staff for repositioning but had seen other staff reposition Resident #1 by pushing his/her shoulders back. He had never seen anyone reposition a resident by cradling, but he thought it might work. He also stated he could not recall receiving education on resident positioning in CNA training or education from the facility, except some resident specific tips from other CNAs via verbal shift report. Further interview with CNA #1 on 07/26/17 at 8:30 AM, revealed on 06/25/17, he thought Resident #1 just needed a boost; he was not trying to do a full reposition. He stated there was a wedge cushion in the wheelchair, but he could not recall the footwear Resident #1 was wearing or anything remarkable about the wheelchair. He went on to state that when he chose to reposition Resident #1 alone, using an improper technique, he and Resident #1 were both at risk for getting hurt. Observation of the facility's video, on 07/25/17 at 9:40 AM, revealed on 06/25/17 at 4:52 PM, Resident #1 was in a wheelchair in the hallway sitting with his/her back to the camera. CNA #1 approached Resident #1 from the front of the wheelchair, squatted in front of him/her and then the wheelchair tipped backwards and Resident #1's head hit the floor. Interview with Registered Nurse (RN) #1, on 07/25/17 at 4:00 PM, revealed Resident #1 had fallen multiple times and OT and PT had assessed Resident #1 and made recommendations. She stated a wedge cushion was one of the recommendations and she thought it was in the wheelchair because Resident #1 would come so close to the edge of the chair, he/she would fall out. The wedge was to counterbalance his/her constant forward lean. RN #1 stated Resident #1 required the assistance of two (2) staff for all repositioning. She stated when staff attempted to transfer or reposition a resident without the correct number of staff; they endangered the resident and themselves. RN #1 stated if OT determined through assessment that a resident needed different equipment, OT would write it up, order the equipment, and show staff how to use it. She went on to state Unsampled Resident B had often slid out of his/her wheelchair in the past, but new wheelchair assistive equipment that OT had added to his/her wheelchair prevented his/her sliding. Interview with OT #1, on 07/25/17 at 3:20 PM, revealed she had done a seating and positioning evaluation on Resident #1 following his/her April falls and recommended specific modifications to his/her wheelchair, which addressed Resident #1's leaning forward. She had forwarded a formal request for equipment for Resident #1 and Unsampled Resident B to the Director of Nursing (DON). She later met with the DON and Chief Executive Officer (CEO), who decided to order the equipment for Unsampled Resident B and not Resident #1. She stated administration told her it was a cost reduction measure and after the efficacy of Unsampled Resident B's equipment was determined, they might proceed with obtaining the equipment for Resident #1. There was no time period established for review nor was a follow up meeting scheduled. The OT also stated she was aware Resident #1's wheelchair was replaced and had assessed the new wheelchair to have similar brake issues and needed all the assistive equipment she had requested for the prior wheelchair. She stated Resident #1 was a moderate to severe fall risk each time he/she was placed in the wheelchair. Until his/her posture was improved with assistive equipment, he/she would likely fall again. Review of an OT assessment of Resident #1, dated 04/19/17, revealed Resident #1 slid out of the chair and required continuous repositioning, which placed the resident at an increased risk for falls and skin integrity breakdown. OT assessed Resident #1 with poor trunk control, a posterior pelvic tilt, and tendency to lean to his/her right side. Resident #1 was unable to independently right self, either forward, backward, or laterally, while sitting. The OT noted the fall on 04/13/17, and stated Resident #1 would benefit from a new customized wheelchair and seating system to reduce fall risk, increase safety, and maintain skin integrity. Review of a quote from an outside company, dated 05/10/17, revealed the company provided wheelchair assistive support and equipment and listed the assistive devices Resident #1 needed for a wheelchair. Interview with the DON, on 07/25/17 at 1:50 PM, revealed when Resident #1 first slid out of the wheelchair in April 2017, the resident broke a finger, and two (2) weeks later fell forward out of the wheelchair and sustained a facial laceration. She stated staff struggled creating a plan to keep Resident #1 safe in any chair because he/she leaned forward continuously. She stated she was relieved when OT devised a plan, but the interventions were delayed. She recounted her meeting with OT and stated the CEO only approved chair purchases for Unsampled Resident B, who had not fallen since the upgrades to his/her chair. She expressed regret that the facility did not order the equipment for Resident #1 in May 2017. Continued interview with the DON on 07/26/17, at 9:45 AM, revealed per her investigation, the root cause of Resident #1's 06/25/17 fall was CNA #1's poor repositioning technique and lack of assistive equipment, which may have prevented Resident #1 from leaning forward in his/her chair. Interview with the CEO, on 06/26/17, revealed she was responsible for the nursing care of all residents in the facility. Her expectation was for nurses to observe CNAs repositioning residents daily and to address any incorrect technique immediately. She went on to state all staff received appropriate resident positioning education, some seating based, in orientation. She also stated staff completed positioning, lift, and transfer competencies annually. She stated she was open to feedback from PT/OT regarding residents who were engaged in therapy. She also stated when the DON and OT brought the proposal to purchase equipment for Resident #1 and Unsampled Resident B, the quote was for fifteen hundred dollars ($1500.00). She recalled the OT stating the equipment would help the residents but did not recall the OT expressing to her that the equipment was a solution. She asked the team to determine which resident had the most difficulty with seating and order theirs first, and if that produced the outcome they desired, the facility would purchase more. The CEO stated when a resident did not get the seating equipment they needed, it could create a serious detriment to their health as the equipment was sometimes needed to prevent harm.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain a hazardous free environment as evidenced by three (3) unlocked areas containing various cleaning supplies, chemicals, and potentially harmful personal care items accessible to twelve (12) ambulatory residents out of a total of eighteen (18) residents. In addition, a medication cart was unlocked and unattended on the unit. The findings include 1. Review of the facility's Hazard Communication Program, dated 01/31/14, revealed the facility maintained a list of Safety Data Sheets (SDS) for all hazardous chemicals in the facility. The facility stored all chemicals at or below eye level and in an area that was out of public sight. Review of facility's policy, Resident Safety Plan, revised 01/20/15, revealed the facility improved resident safety and risks with an environment that encouraged safety priorities, recognition of risks to residents, and a reduction of process failures. Observation during the environmental tour, on 03/28/17 at 10:30 AM, revealed an unlocked activity supply room off of the main activity room accessible to residents. In a cabinet under the counter sat several chemicals including one (1) nineteen ounce (19 oz.) bottle of Envy foaming disinfectant cleaner, one (1) spray bottle of Fire Block Fire Retardant, one (1) fifty-one ounce (51 oz.) bottle Ultra Downy fabric softener, one (1) eight ounce (8 oz.) bottle of Miracle Gro Liquid African Violet Plant Food, and one (1) open twenty-one ounce (21 oz.) can of Scratch Free Comet with Bleach Disinfectant Cleanser. Additionally, in the activity supply room wardrobe cabinet was one (1) eight ounce (8 oz.) bottle of royal lemon scented nail polish remover. Continued observation during the environmental tour, on 3/28/17 at 10:30 AM, revealed a closet labeled Janitor accessible to residents that contained one (1) open two (2) liter bottle of Clean on the Go Damp Mop. Further observation during the environmental tour, on 3/28/17 at 10:30 AM, revealed an unlocked beauty salon with an unlocked locker labeled Beauty stuff. The beauty salon was accessible to residents. Inside the locker were one (1) eleven ounce (11 oz.) can of Suave Extreme Hold Hairspray and two (2) nine ounce (9 oz.) cans of Suave Extra Hold Shaping Mousse. Observations of the facility, on 03/29/17 at 8:45 AM, revealed the activity supply room off the main activity room and the locker in the beauty salon continued to remain unlocked and accessible to residents. Review of the SDS for Envy Foaming Disinfectant Cleaner, dated 08/08/14, revealed the chemical was extremely flammable. The toxicological information stated the chemical might be mildly irritating to the eyes. No information was available pertaining to ingestion and inhalation. Review of the SDS for Comet Cleaner with Bleach, dated August 2001, revealed the chemical caused mild transient gastrointestinal irritation with nausea, vomiting, and diarrhea. The chemical caused eye irritation, tearing, and stinging. It was also possible to be irritating to skin. Review of the SDS for Damp Mop, dated 07/28/15, revealed the chemical caused serious eye irritation. The chemical also caused nasal discomfort if inhaled and pain, nausea, vomiting, and diarrhea if ingested. Review of the SDS for Miracle Gro Liquid African Violet Plant Food, dated 07/29/05, revealed the chemical caused eye irritation and possible aggravation of asthma if inhaled. Review of the SDS for Suave Aerosol Hairspray Maximum Hold, dated 03/01/02, revealed the chemical was moderately toxic if ingested. Additionally, the chemical caused eye irritation upon exposure. Review of the SDS for Suave Mousse-Foam, dated 02/24/11, revealed the chemical was flammable until fully dry. The toxicology Information revealed the chemical caused redness and irritation with eye contact, skin reaction such as redness with overexposure, ingestion caused nausea, vomiting, and diarrhea, and inhaling the contents could be fatal or harmful. Interview with Certified Nursing Assistant (CNA) #2, on 03/30/17 at 10:15 AM, revealed she was unaware chemicals were stored in areas accessible to residents. She stated the facility stored some cleaning chemicals accessible to nursing staff in a locked area of the facility. However, she stated she had no knowledge of chemical hazards in the activities area and in the beauty salon. She stated it was a concern because residents could potentially get a hold of the chemicals and cause themselves harm. She stated she was aware the facility stored some hair products for residents in the beauty shop; however, she stated she did not know the locker where the facility placed those chemicals did not have a lock. Interview with the Registered Nurse (RN), on 03/30/17 at 10:43 AM, revealed she was unaware the facility stored beauty supply chemicals such as hairspray in an unlocked closet in the beauty shop. She stated it posed a risk to residents as they could access the chemicals and spray themselves or inhale the chemical and cause harm. She stated the facility had residents with dementia and residents with respiratory issues. Unlocked chemicals could pose a risk to those groups of residents. Interview with the Environmental Services, on 03/30/17 at 10:00 AM, revealed the facility stored all cleaning chemicals in a locked room on the first (1st) floor of the facility or on the housekeeping cleaning carts. He stated staff should not have stored a chemical in the Janitor closet and staff should have ensured the closet was locked. Interview with the Maintenance Director, on 03/30/17 at 1:49 PM, revealed he completed rounds three (3) times per day in the facility and made sure locked doors were locking correctly. He stated the Janitor closet had a lock on it that was operational. The Maintenance Director stated he did not know the door was unlocked on 03/28/17. The Maintenance Director stated he did not check cabinets during his rounds to ensure the facility had not stored chemicals inappropriately. Interview with the Activities Director, on 03/30/17 at 1:43 PM, revealed she was aware cleaning supplies were stored under the counter in the activity room. She stated she never considered the chemicals to be a potential hazard to residents. The Activity Director stated the facility had residents with dementia who could potentially access the chemicals and harm themselves. Interview with the Director of Nursing (DON), on 03/30/17 at 3:04 PM, revealed she was unaware the locker containing beauty shop chemicals remained unlocked. She stated the facility should have placed a lock on the locker to ensure residents did not have access to the chemicals. Additionally, she stated she was unaware chemicals were stored in the activities area under the counter. She stated staff was to ensure all chemicals were in a locked area. Interview with the Administrator, on 03/30/17 at 3:14 PM, revealed the facility had not previously identified issues with chemicals accessible to residents. She stated she was unaware of the hazardous items. 2. Review of facility's policy, Medication Security, revised 02/26/14, revealed all drugs and biologicals were stored in a secured and locked area and accessible only to authorized staff. Observation of the unit, on 02/28/17, at 3:17 PM, revealed the medication cart was unlocked and unattended at the door to resident room 210. The Licensed Practical Nurse (LPN) was inside the room with her back to the medication cart. Observation during medication pass, on 03/30/17 at 11:17 AM and 11:22 AM, revealed the RN walked away from the unlocked medication cart. Both observations revealed the RN entered adjacent resident rooms to administer medications to the residents, out of view of the unlocked medication cart. Interview with the RN, on 03/30/17 at 1:32 PM, revealed staff was to lock medication carts when unattended to keep both the residents and the medications safe. The RN stated she did not know why she left the cart unlocked and unattended. Interview with the LPN, on 03/30/17, at 1:53 PM, revealed medication carts were unlocked only when staff was retrieving medications and supplies. The LPN stated a locked medication cart kept the residents safe by preventing them from removing items. The LPN stated she thought she had locked the cart before leaving the area. Interview with the DON, on 03/30/17 at 2:04 PM, revealed staff was to lock medication carts when unattended to keep demented residents from gaining access to medications that may harm them. The DON stated she did not regularly audit for medication cart security and had not identified unlocked medication carts as an issue.

Based on observation, interview, and record review, it was determined the facility failed to secure medications as evidenced by observations of an unlocked medication cart on the unit accessible to twelve (12) ambulatory residents out of a total of eighteen (18) residents. Review of the facility's policy, Medication Security, revised 01/26/14, revealed all drugs and biologicals were to be kept in a locked and secure area accessible only to authorized staff. Medication carts were to be locked when unattended. Observation of the unit, on 02/28/17 at 3:17 PM, revealed the medication cart was unlocked and unattended at the door to resident room [ROOM NUMBER]. The Licensed Practical Nurse was inside the room with her back to the door and out of view of the medication cart. Observation during medication pass, on 03/30/17 at 11:17 AM and 11:22 AM, revealed the RN walked away from the unlocked medication cart. Both observations revealed the RN entered adjacent resident rooms to administer medications to the residents, out of view of the unlocked medication cart. Interview with the RN, on 03/30/17 at 1:32 PM, revealed staff was to lock medication carts when unattended to keep the residents safe. The RN stated she did not know why she left the cart unlocked and unattended. Interview with the LPN, on 03/30/17, at 1:53 PM, revealed medication carts were unlocked only when staff was retrieving medications and supplies and staff locked the medication cart anytime they moved away from the cart. The LPN stated a locked medication cart was a basic safety precaution. The LPN stated she thought she had locked the cart before leaving the area. Interview with the DON, on 03/30/17 at 2:04 PM, revealed staff should lock medication carts when unattended to keep demented residents from gaining access to medications that may harm them. The DON stated she did not regularly audit for medication cart security and had not identified unlocked medication carts as an issue.

Based on interview, record review and policy review, it was determined the facility failed to ensure two (2) of eight (8) sampled residents, Resident #1 and #3, and one (1) of two (2) unsampled residents, Unsampled Resident A had complete and accurate clinical records. Resident #1 and Unsampled Resident A had a Do Not Resuscitate (DNR) status on their red clinical charts and a Full Code status on their blue finance records. Both Resident #1 and Unsampled Resident A had Advanced Directives for a DNR. In addition, Resident #3's clinical record contained Unsampled Resident B's physician orders [REDACTED]. The findings include: Review of the Clinical Records Policy, revised [DATE], revealed the clinical records would be complete, accurate to documentation, readily assessable, and systematically organized. 1. Review of Resident #3's clinical record, revealed Resident #3's Physician order [REDACTED]. Resident #3's Physician order [REDACTED]. Review of Resident #3's, Medication Administration Record [REDACTED]. Thus, Resident #3 received the correct treatments and medications. Interview with the Ward Clerk, on [DATE] at 2:50 PM, revealed about a month and a half ago, the responsibility of placing the orders in the residents medical record was switched from the Ward Clerk to the nursing staff. The Ward Clerk stated anyone who placed the signed Physician order [REDACTED]. Review of Unsampled Resident B's Physician Orders, revealed no initial or date of the person who placed the orders into Resident #3's record. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:16 PM, revealed at the end of the month, two nurses would verify the orders were correct, then date and sign the orders to show the orders were verified. The nurse who received the signed copy from the physician would initial and date the orders to verify she had placed the orders in the medical record. LPN #1 stated if a resident received the wrong physician orders, wrong medication could be given, the wrong doctor or power of attorney could be called. LPN #1 stated giving the wrong medication could affect a residents allergy and possibly harm the resident. Interview with the Director of Nursing (DON), on [DATE] at 2:31 PM, revealed nurses double checked the orders and the ward clerks placed the orders in the residents records. The DON stated she had had some problems with the medical records not being accurate and being filed in the wrong resident record. No adverse outcomes had been identified. The DON stated she monitored to ensure the orders matched the right resident. The DON stated if a resident had the wrong orders on his/her record, the resident was at risk of the doctor receiving the wrong information from a nurse and then the doctor giving the wrong order, which could lead to the resident possibly passing away. The DON further stated, Resident #3's record as it was, was not complete and accurate to Resident #3's status. Interview with the Chief Executive Office (CEO), on [DATE] at 2:54 PM, revealed after reviewing Resident #3's record, the record was not complete and accurate to Resident #3's status. The CEO stated she was aware there were some problems with filing and there was some re-education completed for the staff in regards to the importance of being careful and filing correctly. Their process for placing the physician orders [REDACTED]. The CEO stated if multiple safety checks failed and they were just looking off of the chart, then yes their could be harm to the resident. 2. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE]. The resident had a Living Will that was dated 2008 and an Advanced Directive for no Cardiopulmonary Resuscitation (CPR) and executed a DNR order on [DATE]. Review of the records revealed the resident had two charts. The blue chart was for finance and the red chart was the clinical record. The blue chart had a CPR sticker and the red chart had a DNR sticker. 3. Review of Unsampled Resident A's clinical record revealed the facility admitted the resident on [DATE]. Review of the Advanced Directive form revealed the resident executed a DNR on [DATE] and indicated she/he did not want CPR. Review of the blue chart for the resident revealed a sticker for CPR and the red chart had the DNR. Interview with the DON, on [DATE] at 4:05 PM, revealed the facility used two charts for each resident. The blue chart was for finance and the red chart was the clinical record. She stated the code status was correct on the red clinical chart, but not the blue finance chart. She stated she did not know who had put the CPR sticker on the outside of the blue chart or know how it happened. She revealed the nurse who received the code status order from the physician and the Ward Clerk was responsible for placing the code status stickers on the charts. Continued interview with the DON revealed she had not conducted any audits of the charts to ensure the code status of each resident was correct. She stated the nurses would normally go by the clinical record, but she could see if the blue chart said something different, it could result in the resident being coded against their wishes. Interview with the Ward Clerk, on [DATE] at 4:20 PM, revealed she was unaware that Resident #1's and Unsampled Resident A's blue chart indicated the resident was a full code and the clinical chart had the resident as a DNR. The Ward Clerk stated when the nurse obtained the physician's orders [REDACTED]. She doesn't know how the different stickers got on the charts. She stated she did not review the charts to ensure the code stickers matched for the clinical and finance charts. She continued to say she was only responsible for placing the stickers on the charts upon receipt of the physician's orders [REDACTED]. However, she did not check the charts to ensure they matched.

Based on interview, policy review, and review of the QA Attendance Sign-In sheets, it was determined the facility failed to ensure the Medical Director documented his/her signature that they met at least quarterly for two (2) of four (4) meetings with the facility to identify, implement and evaluate any identified concerns. The findings include: Review of the Quality Assurance (QA) Policy, reviewed January 2014, revealed the purpose was to continue to improve the quality and safety of patient care and services. The policy did not outline what was expected of the Medical Director or how often the Medial Director was to meet with the Quality Assurance Committee. Review of the QA Attendance Sign-In sheet, dated for 04/25/14, revealed the Medical Director signed the Attendance Sign-In sheet. Review of the QA Attendance Sign-In sheet, on 07/22/14, revealed the Medical Director did not sign the Attendance Sign-In sheet, but the Director of Nursing (DON) signed the Medical Directors signature for proof of attendance. Interview with the DON, on 04/16/15 at 2:55 PM, revealed she had to sign the Medical Director signature because the Medical Director told her to sign the QA Attendance Sign-In sheet. She stated she approached him during his lunch to sign the Attendance Sheet and the Medical Director told her to sign. Review of the QA Attendance Sign-In sheet, on 10/24/14, revealed the Medical Director signed the Attendance Sheet. Review of the QA Attendance Sign-In sheet, on 01/21/15, revealed the Medical Director did not sign the Attendance sheet, nor was it signed by the DON of proof of the Medical Directors attendance. Interview with the Medical Director, on 04/16/15 at 2:48 PM, revealed each of the department heads met in the conference rooms. Reports were given and he helped to resolve the problems identified. The Medical Director stated he remembered missing one meeting, but did not remember which meeting. The Medical Director stated he did not remember telling the DON to sign his name on the Attendance sheet, but then thought maybe he did and agreed that he should sign his own signature. Interview with the Chief Executive Office (CEO), on 04/16/15 at 3:28 PM, revealed she thought the Medical Director had attended the QA meetings. The CEO stated if you did not place the Attendance Sign-In sheet in front of the Medical Director, he would not sign the sheet. The CEO stated she was not aware the Medical Director had asked the DON to sign for his attendance and would not approve for the DON to sign for the Medical Director. The DON did not know that her signing for the Medical Director was a concern. The CEO stated she remembered a few years ago having this same problem with the Medical Director and updating the QA policy. The CEO stated the Policy needed to be revised to ensure the frequency and a directive was given for the Medical Director. The CEO could not provide a more up-to-date policy.