Every finding on record at Buckhead Center for Nursing & Healing

Based on observations, staff interviews, and record review, the facility failed to maintain food storage, preparation, and service areas in a sanitary manner by failing to remove food products that exceeded their use-by date and by failing to maintain kitchen floors and equipment in a clean condition to prevent the accumulation of food debris and other contaminants. This deficient practice had the potential to affect 136 out of 148 residents who received nourishment from the facility kitchen.Findings include: A policy addressing the storage, preparation, and service of meals was requested during the survey but was not provided by the facility. Review of the facility document titled Cleaning and Sanitizing stated, Cleaning and sanitizing are essential to keep food safe. Dirty equipment or food contact surfaces can result in food becoming contaminated through biological, chemical, and/or physical hazards. The document further stated that kitchen equipment and surfaces should be cleaned after each use, when contamination occurs, when work is interrupted, and before changing food types. During the initial kitchen tour on 07/13/2026, at 9:00 AM, accompanied by the Dietary Manager (DM), a large container labeled corn meal was observed in the dry storage room with a dried, soiled towel resting on top. When asked about the towel, the DM immediately removed it and rolled the container out of the dry storage area. The DM was later observed emptying the contents of the container and cleaning it. A deep freezer located in the dry storage room, containing ice cream and frozen nutritional supplements, was observed with frozen accumulations of spilled liquid and soiled surfaces on the interior floor. The DM acknowledged the appearance of the spill and stated the freezer was cleaned every two weeks. A reach-in refrigerator contained a bag of coleslaw mix (cabbage and carrots) labeled with a use-by date of 07/03/2026. The cabbage appeared wilted, and moisture was present in the bottom of the bag. When asked about the product, the DM removed it for disposal and stated it had been overlooked. Further observation of the kitchen revealed accumulations of brownish-black debris along the baseboard beneath the handwashing sink and beneath and behind the fryer, range, oven, three-compartment sink, and prep sink. During meal tray service on 07/13/2026, at 12:10 PM, the DM was asked about the flooring being soiled and uneven and he expressed that they did clean it multiple times daily, but that the unevenness did make it harder to prevent pooling. Observation of a vent above the three-compartment sink on 07/13/2026, at 12:20 PM, revealed excessive dust. The DM was asked about the vent, and he stated that it was the responsibility of the maintenance team. During an interview with the Maintenance Director on 07/15/2026, at 3:34 PM, he confirmed that he was not aware of a vent in the kitchen, but that he would look into it.

Based on resident and staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plan, the facility failed to ensure the right to participate in their care planning process for two of 41 residents (R) (R101 and R30). The deficient practice placed the residents at risk of not being aware of the goals and outcomes of their care and for their care plan not to be person centered.Findings include: Review of a facility policy titled Comprehensive Care Plan dated October 2025 indicated, .It is the policy of this facility to develop and implement a person-centered care plan for each resident, consistent with resident rights.The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to.The attending physician or non-physician practitioner designee involved in the resident's care plan.A registered nurse with responsibilities of the resident.A nurse aide with responsibility for the resident.A member of the food and nutrition services staff.The resident and the resident's representative, to the extent possible. 1. Review of R101's admission Record located under the Profile tab of the electronic medical record (EMR) indicated that the resident was admitted to the facility with a diagnosis of but not limited to osteoarthritis, unspecified. Review of R101's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR dated 05/20/2026, indicated that the resident had a Brief Interview for Mental Status (BIMS)score of 11 out of 15, which revealed the resident was moderately cognitively impaired. Review of a document provided by the facility titled Care Plan Report indicated R101 attended a care plan meeting on 12/02/2025. There was no documentation R101 attended the March 2026, or June 2026, care plan meetings. Review of R101's clinical records revealed the record failed to contain evidence that the resident and/or her representative were invited to her quarterly care conferences. During an interview on 07/13/2026, at 8:49 AM, R101 stated she did not remember being invited to participate in her quarterly care conferences. During interview on 07/15/2026, at 9:16 AM, the current Social Services Director (SSD) stated the MDS Coordinator provided her with a calendar, and she would then schedule the care plan meetings. During an interview on 07/16/2026, at 11:34 AM, Administrator 1 stated all residents and/or their representatives were to be invited on a quarterly basis. The Administrator stated residents had the right to participate in their quarterly care conferences, so the resident was able to make decisions on their own healthcare. 2. Review of R30's admission Record located in the EMR under the Profile tab, revealed R30 was admitted to the facility with diagnoses including but not limited to chronic kidney disease, stage 3, type 2 diabetes mellitus, chronic pulmonary edema, lymphedema. Review of R30's annual MDS with a date of 06/22/2026, located in the EMR under the MDS tab, revealed the resident had a BIMS score of 15 out of 15, which indicated R30 was cognitively intact. During an interview on 07/13/2026, at 11:39 AM, R30 indicated that the facility does not have a quarterly care plan meeting every three months. R30 stated, .they've done that once or twice, but they don't do that every three months. During an interview with Licensed Practical Nurse (LPN) 5 on 07/14/2026, at 12:17 PM, revealed she attended care plan meetings which were held in R30's room, however she was unable to verify when the last meeting was held. During an interview with Social Services Director (SSD) on 07/14/2026, at 1:18 PM, it was revealed she was asked to provide verification of care plan meetings that included resident participation. The facility provided a copy of a letter of invitation for participation in an interdisciplinary care plan meeting for 04/03/2024. No additional documentation of a care plan meeting was provided.

Based on staff interview, record review, and review of facility policies titled, Transfer and Discharge and Bed Hold Prior to Transfer, the facility failed to provide the resident or resident representative with a written notice of transfer or discharge and failed to provide a notice of bed-hold policy and return before transfer to hospital for one of four residents (R) (R175) reviewed for discharge.Findings include: Review of the facility's policy titled, Transfer and Discharge, with a revised date of March 2025, indicated, .The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. Review of the facility's policy titled, Bed Hold Prior to Transfer, with a revised date of March 2025, indicated, .It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization. Review of R175's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility with diagnoses including but not limited to seizures, high blood pressure, type two diabetes mellitus, blood clot of lower extremity, and major depressive disorder. Review of R175's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/2025, in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating the resident was severely cognitive impaired. Review of R175's EMR revealed the resident was transferred to the hospital for evaluation on 01/05/2026 and on 01/10/2026. There was no documentation to indicate written notice of transfer was provided to the resident or their representative. A notice of bed-hold policy was provided on 01/10/2026. An interview with the Administrator on 07/15/2026, at 2:30 PM, confirmed the facility did not provide a written notice of transfer prior to R175's transfer to the hospital on [DATE] or 01/10/2026, and the facility failed to provide a notice of bed-hold policy for 01/05/2026.

Based on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were transmitted within the timeframes specified in the RAI manual for one of three residents (R) (R76) whose MDS submissions were reviewed. This failure had the potential for the discharged resident not to be able to receive services elsewhere because Medicare was not aware of the discharge status and for an inappropriate payment for services to the facility.Findings include: Review of the October 2025 RAI Manual revealed on page 2-39:09. Discharge Assessment-Return Not Anticipated . Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). Consists of demographic, administrative, and clinical items . Review of R76's electronic medical record (EMR) Progress Notes tab revealed the following: On 05/01/2026, at 6:04 PM, Nurses Note Late Entry: Note Text: Resident LOA [Leave of Absence] w/GF [with girlfriend]. On 05/02/2026, at 10:05 PM, Nurses Note Late Entry: Note Text: Resident was not present in the facility at the time scheduled medications were due; medications were not administered. 05/02/2026, at 1:53 PM, Nurses Note Text: Resident left facility yesterday at approximately 1800 (6:00 PM) and has not returned to facility at this time. Attempts made to contact closest family member/responsible party; however, number on file is not working. Resident was last observed alert and oriented with no signs or symptoms of acute distress noted prior to departure . Per review of R76's EMR, as of 07/14/2026, R76 had not returned to the facility. Review of R76's EMR MDS tab revealed the last MDS submitted was a quarterly assessment on 04/15/2026. There was no documented evidence that a discharge assessment had been completed even though the resident had not been in the facility since 05/01/2026. During an interview on 07/14/2026, at 2:48 PM, the Regional MDS Coordinator (RMDSC) reviewed R76's progress notes and stated, The progress note says LOA. The RMDSC reviewed the EMR Census tab and stated, LOA as of 5/7 then reviewed the EMR MDS tab and stated, It's [discharge assessment] missing. The last MDS was a quarterly sent in on 04/15/2026. The RMDSC stated she started a discharge return not anticipated MDS assessment during the interview. During an interview on 07/16/2026, at 2:50 PM, the Administrator stated an expectation that MDS discharge assessments would be submitted timely. During an interview on 07/16/2026, at 2:55 PM, the Regional Director of Clinical Operations reviewed R76's MDS screen in the EMR and confirmed the discharge assessment was not completed timely. During an interview on 07/16/2026, at 3:36 PM, the Regional Director of Compliance stated, The facility uses the RAI Manual in lieu of policies.

Based on observations, staff interviews, record review, and review of the facility policies titled, Comprehensive Care Plan and Proper Use of Bed Rails, the facility failed to develop and implement a comprehensive person-centered care plan for the two of 44 sampled residents (R) (R5 and R154). Specifically, the care plan did not include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs specifically related to the resident's use of bed rails and activities. This failure had the potential to affect the accuracy and complexity of resident care.Findings include: Review of the facility policy titled Comprehensive Care Plan, reviewed/revised October 2025,Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility policy titled Proper Use of Bed Rails, implemented 10/01/2022, revealed: Ongoing Monitoring and Supervision, 1. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including, but not limited to, the following information: . 1. Observation of R5's bed on 07/13/2026, at 10:42 AM, revealed a low-air-loss air mattress with bilateral assist rails towards the head of the bed. Observation on 07/15/2026, at 2:50 PM, revealed R5 in the bed with the air mattress and bilateral assist rails. Review of R5's electronic medical record (EMR), under the Care Plan' tab, revealed a care plan created on 04/10/2026, for a focus of: Bed Mobility indicated the resident requires extensive assistance times one to two staff for moving in bed. Another care plan indicated R5's is at risk for a fall related to: late effects of pontine strokes, antidepressant medication. There was no documentation of the use of bed rails being an intervention on the resident care plan. During an interview on 07/16/2026, at 2:58 PM, the Administrator stated bed rails should be care planned. 2. Review of R154's EMR, located under the MDS tab, revealed the quarterly MDS with an Assessment Reference Date (ARD) of 06/22/2026, revealed an admission date of 04/20/2026; BIMS score of 2 out of 15, indicating a severe cognitive impairment; diagnosis of encephalopathy, coronary artery disease, hyperlipidemia, depression, alcohol dependent with alcohol-induced persisting amnestic disorder; medications received antidepressant. Review of R154's EMR located under the Care Plan tab revealed the comprehensive care plan that does not include a focus on the care plan for activities. During an interview on 07/16/2026, at 11:15 AM, the DON stated that R154 should have an activities section of the care plan to ensure activities met the needs of the resident. During an interview on 07/16/2026, at 11:35 AM, the Activities Director (AD) stated that the care plan should include activities and the type of activities that were appropriate for that resident. The AD confirmed that R154 did not have an activities section on the care plan.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Smoking, the facility failed to provide adequate supervision to ensure residents smoked safely and only in designated smoking areas for one of three residents (R) (R77) reviewed for smoking practices. The facility's failure to adequately monitor and supervise R77's smoking activities placed the resident at risk for serious injury and had the potential to jeopardize the health and safety of current residents and staff. Findings include: Review of the facility's policy titled Resident Smoking, dated December 2023, indicated under Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and nonsmoking residents. Policy Explanation and Compliance Guidelines: l. Smoking is prohibited in all areas except the designated smoking area. A 'Designated Smoking Area sign will be prominently posted . 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan . Review of R77's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R77 was admitted to the facility with a diagnoses of but not limited to schizophrenia, acquired absence of the left eye, contusion of eyeball and orbital tissues of the right eye, and retinal detachment with single break of the right eye. Review of R77's annual Minimum Data Set (MDS) assessment located in the EMR under MDS tab, with an Assessment Reference Date (ARD) of 05/04/2026, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated he was moderately cognitively impaired. The MDS also indicted R77 currently uses tobacco. Review of the R77's Care Plan, initiated on 06/30/2025, located in the EMR under the Care Plan tab, revealed R77 was a current smoker with interventions that included: he would smoke only in authorized areas, would have cigarettes/lighters locked up at all times other than smoking time, smoking education was provided to resident about not smoking in the facility, and violation of smoking rules or disregard for safety rules may result in revocation of smoking privileges. Review of R77's Smoking Evaluation, dated 09/25/2025, located in the EMR under the Assmnts [assessments] tab, revealed R77 was safe to smoke with supervision and had to wear an apron for safety. Review of R77's Behavior Note, dated 05/24/2026, located in the EMR under the Prog [Progress] Notes tab, revealed Licensed Practical Nurse (LPN) 7 informed R77 sister via telephone that R77 was observed smoking in the facility lobby and that it was a serious violation that could result in the issuance of a notice of discharge in accordance with facility policy. Review of R77's Smoking Evaluation, dated 06/05/2026, located in the EMR under the Assmnts tab, revealed R77 was safe to smoke with supervision and had to wear an apron for safety. Review of R77's Smoking Evaluation located under the Assessments tab in the EMR revealed there were only two smoking evaluations completed between September 2025 and June 2026. Review of R77's Physician's Orders, started on 06/06/2026, and discontinued on 06/28/2026, located in the EMR under the Orders tab, revealed an order for Nicotine Transdermal Patch 24 hour 7 milligrams (MG)/24 hour (nicotine) apply one patch transdermally one time a day for 28 days and remove per schedule. Review of R77's Medication Administration Record (MAR), dated June 2026, located in the EMR under the Orders tab, revealed R77 refused the nicotine patch on 06/06/2026, 06/08/2026, 06/14/2026, 06/16/2026, 06/20/2026, and 06/28/2026. Review of R77's Encounter Note, dated 06/08/2026, located in the EMR under the Prog Notes tab, revealed the Nurse Practitioner (NP) offered smoking cessation and ordered the nicotine patch. Review of R77's Social Services Progress Note, dated 06/18/2026, located in the EMR under the Prog Notes tab, revealed a referral was sent to a nursing home for potential admission and transfer. Review of R77's Encounter Note, dated 06/18/2026, located in the EMR under the Prog Notes tab, revealed the NP offered smoking cessation to R77 and he declined the offer for smoking cessation. Review of R77's Behavior Note, dated 07/08/2026, located in the EMR under the Prog Notes tab, revealed R77 was seen smoking in the downstairs lobby restroom during the shift. Registered Nurse (RN) 1 informed R77 that smoking in the restroom was prohibited and was educated on the smoking policy and associated safety risks.Review of R77's General Progress Note, dated 07/09/2026, located in the EMR under the Prog Notes tab, revealed the Administrator informed the Ombudsman regarding R77 smoking in the building and was noncompliant with smoking in the designated smoking area. Review of R77's Nurses Note, dated 07/10/2026, located in the EMR under the Prog Notes tab, revealed R77's bedside table was observed with cigarette ashes and burn marks on it. RN1 educated him about maintaining a safe environment and safety concerns were reported to appropriate staff. Review of R77's Nurses Note, dated 07/13/2026, located in the EMR under the Prog Notes tab, revealed the Administrator was informed by Licensed Practical Nurse (LPN) 5/Unit Manager (UM) on the second floor, noted that R77 was found smoking in the bathroom on the first floor by the Dialysis Nurse. R77 denied smoking in the bathroom although cigarette smoke could be smelled on him. R77 was reminded of the facility policy and the Administrator was notified. Review of R77's General Progress Note, dated 07/13/2026, located in the EMR under the Prog Notes tab, revealed the Administrator emailed the Ombudsman again regarding R77 smoking in the building. Observation and interview on 07/14/2026, at 3:39 PM, with R77 by the elevator in the first-floor lobby, revealed he was sitting in a wheelchair with no burn marks on his clothing. R77 stated he had been caught smoking in the building when he was first admitted to the facility, and staff confiscated his lighter. R77 also stated that activity staff and/or certified nursing aides (CNAs)bought him a lighter and cigarettes. R77 indicated he was informed not to smoke in the building after he was caught a long time ago. Continued observation revealed the receptionist was seated at the front desk observing R77 while in the lobby area. During an interview on 07/14/2026, at 3:45 PM, Administrator 1 confirmed that the May 2026 unsafe smoking incident was not reported to her by staff, but staff reported to her within the last few weeks that R77 was seen smoking in the bathroom on the first floor. Administrator 1 stated the Social Services Director (SSD) tried to find placement for him at another facility, did not provide R77 with a 30-day discharge notice, and that she informed the Ombudsman of the incident on 07/09/2026. Administrator 1 indicated that R77 had been placed on one-to-one monitoring on 07/14/2026, due to staff reporting that he was observed smoking in the first-floor bathroom on 07/13/2026. Administrator 1 verified that either she or the Director of Nursing (DON) had investigated the July 2026 smoking incidents that were reported to her in July 2026, and did not determine who brought the cigarettes and a lighter to R77 at the facility. Administrator 1 stated the Ombudsman had not responded to her requests for assistance with R77's smoking incidents yet. During an interview on 07/14/2026, at 4:07 PM, the SSD confirmed it was reported to her that R77 had smoked in the building and she tried to find placement for him at another facility, but admission was denied. The SSD stated she completed a smoking evaluation on R77 and he was safe to smoke with supervision and an apron due to visual impairments on 06/05/2026. The SSD verified that she did not issue R77 a 30-day discharge notice after the smoking incidents. The SSD indicated that she did not know who was completing the prior smoking assessments, but they were due quarterly to determine if residents were safe to smoke. The SSD also indicated R77 did not have a behavior plan in place but had refused to take his antipsychotic medications recently and was admitted for a five day stay at a behavioral health hospital for medication management due to explosive verbally aggressive behaviors. The SSD verified R77 did not have a behavior plan in place. During an interview on 07/14/2026, at 4:24 PM, Activities Assistant (AA) 2 stated she had to take away a lighter from R77 once in June 2026, while he was smoking in the designated smoking area, because the activities staff lit their cigarettes and residents were not supposed to have lighters. AA2 also stated she reported the incident to the Activities Supervisor but did not document it. AA2 indicated that activities staff did not purchase/provide cigarettes to the resident and the family had to supply R77 with them. During an interview on 07/14/2026, at 4:28 PM, the Activity Supervisor confirmed that she confiscated a lighter from R77 in June 2026 and had to threaten to call the police for him to give it to her and she reported it to the Administrator, but she did not document the information anywhere as she did not know how to use the EMR yet. The Activity Director stated she was not aware who bought him cigarettes and lighters, but activities staff were not doing it for any of the residents. The Activity Director stated that the nurses dispensed two cigarettes per smoke break to the residents and then the activity staff and/or CNAs would light their cigarettes in the designated smoking area. During an interview on 07/14/2026, at 5:49 PM, Licensed Practical Nurse/Unit Manager (LPN/UM)7 stated that a CNA reported that she saw R77 smoke in the bathroom on the first floor, prior to the smoke break at 8:00 PM on 05/24/2026. LPN/UM7 also stated she reported the incident to the former DON. LPN/UM7 stated the resident's cigarettes were locked up on the medication cart in the medication room and two were dispensed to the residents prior to smoke breaks, and the CNA or activity staff would light the cigarettes in the designated smoking area. During an interview on 07/14/2026, at 5:41 PM, the Dialysis Nurse confirmed she observed R77's wheelchair outside of the first-floor bathroom, smelled smoke, and saw cigarette ashes after he exited the bathroom on 07/08/2026, and 07/13/2026. The Dialysis Nurse stated she reported the incidents to LPN7/UM on the second floor and Registered Nurse (RN) 1. During an interview on 07/15/2026, at 8:39 AM, LPN/UM7 on the second floor, stated she was informed by the Dialysis Nurse on 07/08/2026 and 07/13/2026 about R77 smoking in the lobby on the first floor in the bathroom. LPN/UM7 also stated she educated R77 about the safety risks while smoking in the building and R77 denied smoking in the building. LPN/UM7 indicated R77 would not let her search him, and she could not take away his smoke breaks because both were resident rights violations. LPN/UM7 stated the nurses on each floor kept the residents' cigarettes in the medication cart and gave them two cigarettes prior to the smoke break, and then the staff that took the residents on the smoke break would light their cigarettes in the outside designated smoking area. During an interview on 07/15/2026, at 8:46 AM, the DON stated she expected the staff to complete a progress note and notify the Physician, Psyche Provider, family, her, and the Administrator when R77 was found smoking in the building or had cigarettes and lighters on him. The DON also stated that it was unsafe to smoke in the building because it could start a fire. During an interview on 07/15/2026, at 9:13 AM, RN1 revealed he did not report the smoking incident to the DON or the Administrator on 07/08/2026, because he thought the Dialysis Nurse reported it to administration. RN1 indicated he educated R77 on the smoking policy, did not offer smoking cessation, or increased monitoring of R77. RN1 confirmed that he had not tried to find out who was buying cigarettes and lighters for him and bring them to him at the facility, although he had seen R77's son and sister visit him. RN1 stated that the resident's cigarettes used to be located at the receptionist desk and locked in a room, but cigarettes were disappearing, so they changed it to keeping the cigarettes on the floor where the resident resided, which were locked up on the medication cart. RN1 verified that R77 did not have a behavior plan in place but his behaviors were being monitored due to being verbally aggressive.

Based on observations, staff interviews, record review, and review of the facility policy titled, Proper Use of Bed Rails, the facility failed to ensure assessments included attempted alternatives with documented failures to bed/side rail or assist rail usage prior to the installation and use of rails for one of one resident (R) (R5) reviewed for bed/side rails out of a total sample of 44 residents. This failure had the potential to increase the risk of resident accidental entrapment or injury.Findings include: Review of the facility policy titled Proper Use of Bed Rails, implemented 10/01/2022, revealed: Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails.under Policy Explanation and Compliance Guidelines:Resident Assessment.2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include: .6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. Review of R5's admission Record from the electronic medical record (EMR) Profile tab, revealed a facility admission with medical diagnoses that included but not limited to hemiplegia and hemiparesis following a cerebral infarct (stroke), type II diabetes with polyneuropathy, spinal stenosis, and muscle weakness. Observation of R5's room on 07/13/2026, at 10:42 AM, revealed the bed had a low air loss air mattress with bilateral upper bed area assist bars. During an interview on 07/15/202,6 at 2:50 PM, R5 was in bed with the bilateral upper assist bars and air mattress. R5 stated he used the assist bars. When asked if anyone from the facility had discussed with him the risks of having assist bars, R5 stated, No. When asked if anyone from the facility had discussed the benefits of having assist bars, R5 responded, No. When asked if the facility had ever tried something other than the assist bars, like perhaps a trapeze bar, R5 stated, No. Review of R5's Bed Rail Evaluation, dated 04/09/2026, revealed a statement that the resident requested bed rails on the day of admission; and: .2. Interventions 2. Select all interventions that apply to this resident,a. Lower the bed to the floorc. Provide frequent staff monitoring at nighte. Visual and verbal reminders to use the call bell R5's name was typed into the Resident/Responsible Party Signature and Date with no date, however the form did not document advisement of risks/benefits of rail use or informed consent for rail use. During an interview on 07/16/2026, at 11:45 AM, regarding the Bed Rail Evaluation, Regional Director of Compliance (RDC) confirmed the resident name typed at the bottom of the firm was not a signed informed consent for bed rails. In a follow up interview on 07/16/2026, at 3:05 PM, the RDC completed a final review of the Bed Rail Assessment and confirmed the Resident/Representative Name Date line was not signifying informed consent. The RDC stated an expectation that there should be informed consent for bed rails and documented attempted alternatives and reason for failure.

Based on observations, staff interviews, record review, and review of the facility policy titled, Enhanced Barrier Precautions, the facility failed to ensure infection prevention and control practices were implemented for two of 71 sampled residents (R) (R12 and R140). Specifically, the facility failed to ensure appropriate personal protective equipment (PPE) was worn by staff while performing activities of daily living (ADLs) for a vulnerable resident (R12) and failed to properly disinfect a shared glucometer between resident uses. This failure has the potential to expose residents to cross contamination and the transmission of infectious organisms, including bloodborne pathogens.Findings include: Review of the facility policy titled Enhanced Barrier Precautions date reviewed/revised March 2024 states under Policy: It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.The policy defines EBP as an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for resident with any of the following: . i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO.ii. Infection or, . colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. 4. High-contact resident care activities include: a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linenf. Changing briefs or assisting with toiletingg. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubesh. Wound care: any skin opening requiring a dressing .9. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 1. Review of the Face Sheet found under the Profile tab of the electronic medical record (EMR) revealed R12 was originally admitted with diagnoses of but not limited to quadriplegia, chronic infections, pressure injuries, neuromuscular dysfunction of bladder, and malnutrition, Further review of the EMR revealed the resident's plan of care, found under the Care Plan tab, revealed the resident has an ADL care deficit along with impaired mobility, staged and unstageable wounds, a catheter, and colostomy. During an observation on 01/14/2026, at 12:51 PM, Certified Nursing Assistant (CNA) 4 was observed entering and exiting R12's several times. She grabbed items from the cart and reentered the room. Further observations revealed there was a sign on R12's door indicating the resident was on EBP and staff should wear the appropriate PPE when providing care. During an interview on 01/14/2026, at 1:06 PM, CNA4 explained she was emptying R12's colostomy bag. She was then asked about the sign on the door referencing EBP, she stated that she had not worked with R12 for some time and may not be as familiar with his care as she used to be. She admitted that she had not worn the appropriate PPE while providing care to the resident. During an interview with the Director of Nursing (DON) on 07/15/2026, at 4:30 PM, she confirmed that when providing care staff should don (put on) all appropriate PPE. She was then asked where it was located and she said it should be in the resident's storage area. She was also advised that their policy states an order would be obtained for EBP, and she confirmed that they didn't usually get orders for EBP but that any resident with wounds or that fit the criteria was automatically placed under the protocol. 2. Review of the facility policy titled Glucometer Disinfection, reviewed/revised 09/12/2022, revealed under: Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees.Definitions:Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products.Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects.Policy Explanation and Compliance Guidelines:1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected then the meter will not be used for multiple residents. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus.4. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review of the facility provided brand name glucometer Quality Assurance/Quality Control (QA./QC) Reference Manual revealed on page 19: Guidelines for Cleaning And Disinfecting The brand name Meter: To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below. The brand name Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient, . diabetes testing company has tested and validated the durability and functionality of the brand name meter with the most commonly used EPA-registered wipes. diabetes testing company recommends using these wipes to clean and disinfect the name brand meter: During an observation of blood glucose testing for R140 on 07/15/2026, at 3:50 PM. LPN 8 opened top drawer of the medication cart revealing two glucometers (one on top of the other). LPN8 removed the top one and laid it on the top of the medication cart, along with a lancet (safety device to cause a drop of blood for testing), alcohol wipe, and a jar of test strips. Upon entering the room, LPN8 verbally noted she needed to program the feeding pump for a flush because R140 got a flush with every finger stick. LPN8 laid the glucometer on R140's blanket, holding the other items; then picked up the glucometer and walked to the window side of the bed, gloved, laid the glucometer on a pillow (in case) along with the alcohol wipe package, removed a strip from the bottle, laid the bottle on the sheet (which rolled onto the blanket), wiped R140's finger with an alcohol wipe and laid the wipe on the blanket, lanced the finger and laid the lancet on the table; applied the blood drop to strip and placed the glucometer back onto the bedding. LPN8 disposed of the strip and used lancet, read the glucometer and put the strip bottle and glucometer into scrub top pocket; exited the room back to the medication cart, used hand sanitizer and pulled the strip bottle and glucometer from her pocket, placing them on the medication cart top. LPN8 retrieved an alcohol wipe from the cart drawer, gloved, and cleaned the glucometer with the alcohol wipe. Upon questioning at 3:56 PM, LPN8 verbally confirmed she was using an alcohol wipe. LPN8 then laid the glucometer on top of the medication cart, opened the top drawer and placed the uncleaned strip bottle into the drawer, removed her gloves and started typing on the laptop, checked and stated the glucose reading did not require any insulin coverage, then opened the cart drawer and laid the glucometer from the top of the medication cart on top of the other glucometer that remained in the drawer. During an interview on 07/16/2026, at 3:00 PM, the Regional Director of Operations (RDO) stated an expectation they would follow the policy for glucometer disinfection. Upon questioning on where the glucometer and items should be placed, the Regional Director of Clinical Services (RDCS)1 stated staff was to use a barrier under it. During an interview on 07/16/2026, at 4:15 PM, LPN8 confirmed she had used an alcohol wipe to disinfect the glucometer. LPN8 stated she had received education, but she knew that was the wrong thing but used it anyway, perhaps because she had been nervous. LPN8 also stated anyone in the facility that had a blood borne pathogen and received blood glucose checks had their own glucometer and they didn't share.

Based on observations and staff interview, the facility failed to maintain a safe and functional kitchen environment. The facility failed to ensure the kitchen flooring was maintained in a manner that provided stable placement of equipment, resulting in the potential for equipment instability and increasing the risk of staff injury while working in the kitchen. Findings include: During the initial kitchen tour with the Dietary Manager (DM) on 07/13/2026, at 9:00 AM, observation of the tile floor revealed multiple uneven areas. An area near the prep sink had water pooling in the grout. Other areas including uneven tiles at the entrance of the dishwashing room, near the handwashing sink and under and around the fryer, range and ovens. During a subsequent visit to the kitchen on 01/13/2026, at 11:40 AM, under one of the front legs of the convection oven, were multiple folded and stacked cardboard pieces. The DM was asked about the pieces of cardboard, and he confirmed that it was there to stabilize and ensure the oven sat evenly. The DM was asked if maintenance and the administration were aware and he stated that they were, but he was not sure what the plan was to fix the concerns. During an interview with the Maintenance Director on 07/15/2026, at 3:34 PM, he confirmed that he was aware of the concern with the flooring and the oven placed on the cardboard and that corporate was working to resolve the concern.

Based on observations and staff interviews, the facility failed to ensure that four of six resident shower rooms were free of hazards. Specifically, razors were found on the floor, dirty gloves found on a shower bed, opened bottles of bath soap were found, a bottle of chemical resistant spray was found, and a razor and hair clippers were found in a bag on the floor of a shower room. The deficient practice had the potential to cause injury to cognitively impaired residents and the possibility of the spread of infection to residents using the shower rooms.Findings include:Observation on 02/23/2026 at 9:25 AM with the 4th floor Unit Manager BB of the 4th floor shower room used by the residents revealed four razors on the floor, dirty gloves and a dirty comb were on a shower bed, floors were stained/dirty, an opened gallon bottle of complete bath soap and a bottle of chemical resistant spray were observed in the shower room. Additionally, a razor and hair clippers were found in a black bag on the floor of the shower room, and a shower cap and a toothbrush were found lying on the floor.Interview on 02/23/2026 at 10:00 AM with 4th floor Unit Manager BB revealed that the Certified Nursing Assistants (CNA)s were to clean up before showering the residents. She revealed that the items found should not be on the floor.Interview on 03/23/2026 at 10:05 AM with the Environmental Senior Director CC revealed the shower room was cleaned every day. They were responsible for cleaning the high touch areas (knobs), sweep and mop the floors, remove linen, and clean the area. He revealed that there had been no complaints about the showers not being cleaned.Observation on 03/23/2026 at 11:00 AM with the 3rd floor Unit Manger HH of the 3rd floor shower room used by residents revealed a bottle of skin and hair cleaner, one bottle of conditioner, and a bottle of skin ointment, all open. Interview on 03/23/2026 at 11:00 AM with 3rd floor Unit Manager HH revealed that the items in the shower room should be closed. She revealed that the CNA's were to clean after each resident.Observation and interview on 03/23/2026 at 11:35 AM with 2nd floor Unit Manger KK revealed two opened gallon containers of skin and hair cleaner. A strong urine odor was noted. 2nd floor Unit Manager KK revealed the soap should have a top on it and the CNAs were responsible for cleaning after each resident.

Based on observations and staff interviews, the facility failed to ensure that the staff followed standard and transmission-based precautions to prevent the spread of infection when dispensing ice to the residents on two of four floors (3rd and 4th floor).Findings include:Observation on 03/23/2026 at 9:15 AM with the 4th floor Unit Manager of the ice scoop and scoop cover revealed the ice scoop cover on top of the ice machine had black specks near the end of the scoop used to put ice in cups.Interview on 03/23/2026 at 10:00 AM with the 4th floor Unit Manager BB revealed that the scoops were cleaned once a week by the kitchen staff. She revealed that the scoop should be clean.Observation on 03/24/2026 at 10:50 AM with the 3rd floor Unit Manager HH of the ice chest/cooler used to serve residents, revealed the scoop submerged in ice and water.Interview on 03/23/2026 at 9:20 AM with the Maintenance Director AA revealed that they were required to clean the ice machine. He revealed the ice machine was checked weekly and monthly. He revealed that the nursing staff was responsible for cleaning the ice scoop and cover.Interview on 03/24/2026 at 11:00 AM with the 3rd floor Unit Manger HH revealed that the ice scoop was not supposed to be left in the cooler.Interview on 03/24/2026 at 1:00 PM with the Staff Development Coordinator (SDC)/Infection Control staff C1C revealed that all staff had been trained in infection control procedures. She revealed that the staff were educated on hand hygiene. She revealed that an in-service was provided on the handling of the ice scoop and holder. She revealed that after use the ice scoop should be placed in the scoop holder. She revealed that the ice scoop should never be left in the ice.Review of Maintenance Logbook Documentation dated February 27, 2026, indicated: Ice machine: check filters (if present), clean coils, sanitize interior, delime as necessary, this is a monthly check. All ice machines (4) of them cleaned and properly running at this time.Review of Ice Machine Cleaning Log indicated ice machine cleaned on 2nd, 3rd and 4th floor, January 14, 2026, and February 16, 2026. Ice machine cleaned in the kitchen on January 17, 2026, and February 16, 2026.Review of the staff training dated 02/16/2026 indicated an in-service on handwashing and ice scoop protocol was provided for all staff.

Based on observation and interview, the facility failed to properly label and date several items in the refrigerator. This failure had the possibility to expose 116 of 128 residents residing at the facility to food items that may have been spoiled. Findings include: During the Flash Tour of the kitchen on 9/22/2025 at 8:12 AM, there were items in the reach in fridge that were not labeled or dated. The items found were: two plates of salad, 12 small containers/bowls of dessert, and 16 small glasses of iced tea. The Dietary Manager (DM) was present and confirmed the findings. During an interview on 9/25/2025 at 8:45 AM, the DM stated the kitchen staff had been educated on labeling and dating all opened or stored items in the refrigerator. The DM explained whoever placed the items in fridge was responsible for labeling and dating those items.

Based on staff interviews, record review, and facility policy review, the facility failed to monitor and follow up on weight loss for three of six sampled residents (Resident (R) 9, R10, and R23) reviewed for weight loss. This deficient practice had the potential to allow residents to continue to lose weight and not be monitored for supplements or change in diet.Findings include:Review of the facility's policy titled, Weight Monitoring revised January 2024 revealed, Policy: Based on resident's comprehensive assessment, the facility will ensure that all residents and maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that is not possible of resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status' This process includes:a. Identifying and assessing each resident's nutritional status and risk factors.b. Evaluating/analyzing the assessment information.c. Developing and consistently implementing pertinent approaches.d. Monitoring the effectiv.r.it of interventions and revising them as necessary. 5. A weight monitoring schedule will be developed upon admission for all residents a. Weights should be recorded at the time obtained. Mathematical rounding should be utilized.(i.e., if weight is X.5 pounds [lbs.] or more, round weight upward to the nearest whole pound.If weight is X.1 to X.4 [lbs.] round down to the nearest whole pound) . c. Residents with weight loss - monitor weight weekly.Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as:a. 5% (percent) change in weight in 1 month (30 days)b. 7.5% change in weight in 3 months (90 days)c. 10% change in weight in 6 months (180 days).1. Review of the electronic medical record (EMR) for R9 located in the Profile tab revealed R9 had been admitted to the facility with diagnoses of but not limited to peripheral vascular disease, paranoid schizophrenia, and vitamin D deficiency.Review of the quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 9/3/2025 revealed R9 had a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating severe cognitive impairment.Review of R9's weights (wts) located in the EMR under the Wts/Vitals tab indicated on 6/2/2025 R9 weighed 203 lbs. and on 7/8/25 weighed 157 lbs. revealing a 22.6 % weight loss. A reweigh was conducted on 7/10/2025, indicating a 19.7 % loss, indicating a significant weight loss in one month.Review of R9's EMR located under the Progress Notes tab revealed a Nutrition/ Dietary Note, dated 7/9/2025, indicated R9 was discussed in patient review indicating a reweigh should be completed and the Registered Dietician (RD) would monitor and follow up as needed.Further review of R9's Dietary Progress Notes, indicated on 7/16/2025 recommended labs will be obtained and add patient to the weekly weights sheet.Further review of the weights for R9 revealed weekly weights were not obtained.During an interview on 9/24/2025 at 3:55 PM, the RD was asked about the weight loss. The RD stated, The resident wanted to lose weight. The RD was asked if it was appropriate to lose that much weight in a month. The RD stated that's why labs were requested. The RD was asked about the weekly weights. The RD stated the nursing staff were to conduct the weekly weights. The RD was asked how he followed up when there were no weekly weights as he recommended and as policy indicated. The RD stated the weekly weights were not done and should have been.During an interview on 9/25/2025 at 10:26 AM, Unit Manager (UM)2 was asked about weekly weights for R9. UM2 stated during the weight loss, UM2 was not the unit manager. UM2 stated, If there were any weights completed, they would have been placed in the EMR. If they are not there then it was not done.2. A review of the admission Record found in R23's EMR, under the Profile tab, indicated pertinent diagnoses included but were not limited to dysphagia, unspecified protein-calorie malnutrition, obesity, and Alzheimer's.Review of the annual MDS, with an ARD of 7/19/2025, found in R23's EMR, under the MDS tab, indicated R23 had a BIMS score of nine out of 15, which indicated the resident had moderate cognitive impairment. Further review revealed that R23 had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months and was not on a physician-prescribed weight-loss regimen.Review of R23's care plan, last revised on 9/22/2025, indicated R23 had unplanned/unexpected weight loss related to acute illness, dysphagia, advanced age, history of infection, and Alzheimer's disease. The pertinent intervention directed staff to monitor and evaluate any weight loss, determine the percentage lost, and follow facility protocol for weight loss.Review of R23's weights, dated 3/10/2025 through 9/10/2025, found in R20's EMR, under the Weights/Vitals tab, revealed R23 sustained a significant weight loss of 9.0 lbs. (5.65%) in 30 days (8/13/2025: 159.2 lbs. and 9/10/2025: 150.2 lbs.). Further review failed to reveal that the staff obtained weekly weights on R23 after noting a significant weight loss in 30 days.Review of the Patient At Risk (PAR) note, dated 9/9/2025, found in R23's EMR revealed staff discussed R23 during the weekly PAR Meeting; however, the note did not include any information related to the resident's significant weight loss, direction to reweigh R23, or obtain weekly weights.Review of the RD progress note, dated 9/17/2025, found in R23's EMR under the Progress Notes tab, indicated R23 had a significant weight loss of 5.7% in one month, 10.4% in three months, and 13.8% in six months. RD questions weights. However, weight loss was possibly related to R23's surgical wound, advanced age, history of infection, depression, and anxiety. Further review revealed that the RD reviewed R23's weight loss with the Interdisciplinary Team (IDT) during the PAR meeting. The IDT reported R23 had good oral intake, eating 75-100% of most meals. Nursing to weigh per protocol.During an interview on 9/24/2025 at 8:40 AM, the RD stated that R23 triggered for a significant weight loss. On 7/9/2025, the resident lost 9.1 lbs. (5.4%) in 30 days, prompting an increase in Med Pass (nutritional supplement) from twice to three times daily, which resulted in a minimal weight gain of 0.6 lbs. (0.38%). On 9/10/2025, the resident experienced an additional 9.0 lbs. of weight loss in 30 days, leading the RD to order a daily house shake supplement, in addition to the Med Pass. The RD confirmed that staff should weigh residents who have experienced significant weight loss, defined as 5% in 30 days, 7.5% in 90 days, or 10% in 180 days, on a weekly basis.During an interview on09/24/2025 at 10:07 AM, UM1 stated that she provided the Certified Nurse Aides (CNAs) with a list of residents whom they needed to weigh. UM1 stated that she reviews the weights to identify any discrepancies from the previous measurement and tends to reweigh residents if they have experienced significant weight loss since the last measurement. UM1 stated that if it was a true weight loss, she would notify the RD and Physician and discuss the residents with the IDT during the weekly PAR Meeting. During the PAR Meeting, the RD would notify them [unit managers] if he wants staff to reweigh the resident or obtain weekly weights. UM1 reviewed R23's weights and noted that staff did not obtain weekly weights on R23 and that no orders were written for weekly weights.During an interview on 9/24/2025 at 11:00 AM, the Director of Nursing (DON) stated that on 9/10/2025, they reviewed R23's weight loss during the weekly PAR Meeting. The DON stated that R23 had a weight loss of 9.0 lbs. in 30 days. During the PAR Meeting, the RD requested a reweigh of R23 and, depending on the results, directed staff to conduct weekly weights.During a follow-up interview on 9/24/25 at 4:15 PM, the RD stated that he reviewed the weight loss report weekly and discussed residents with weight loss during the weekly PAR Meeting. The RD stated that re-weighs should occur within 24 hours and that he did not recall if staff notified him of the results. Upon inquiry, the RD stated that he believed that he followed up on R23's reweight but could not provide any supporting documentation. The RD stated that since R23 triggered a significant weight loss, he expected staff to obtain weekly weights.

Based on observations, resident and staff interview, record review, and facility policy review, the facility failed to provide a dignified dining experience for one of five residents observed for nutrition (Resident (R) 15. This failure had the potential to negatively impact quality of life and self-esteem of R15.Findings include:Review of a facility's policy titled, Promoting/Maintaining Resident Dignity, dated March 2025 indicated .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.1. Review of R15's electronic medical record (EMR) titled, admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE].Review of R15's EMR titled quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 06/20/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which revealed the resident had moderate cognitive impairment. The assessment indicated the resident required set up assistance with his meals. During an observation on 9/22/2025 at 12:52 PM, LPN1 was in the main dining room and stood next to R15. LPN1 assisted the resident while eating his lunch meal and failed to sit across from the resident. LPN1 repeatedly provided the resident with bits of food while standing until 12:57 PM and then left the area.During an interview on 9/23/2025 at 10:25 AM, LPN1 confirmed he was standing while assisting R15 with his lunch meal and stated he should have sat across from the resident to feed the resident. LPN1 stated he needed to review the facility's policy on dignity to see if this situation was a dignity issue or not.During an interview on 9/23/2025 at 9:40 AM, LPN1 confirmed he should of sat with R15 to assist him with his meal and since standing next to the resident was a dignity issue. LPN1 stated it was more appropriate to have eye contact with the resident.2. Review of R80's EMR titled, admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE].Review of R80's EMR titled, quarterly MDS, located under the MDS tab with an ARD of 8/20/2025 indicated the resident had a BIMS score of 14 out of 15, which revealed the resident was cognitively intact.During a medication pass observation on 9/22/2025 at 4:30 PM, CNA3 was overheard behind R15 and R80's closed door. Licensed Practical Nurse/Unit Manager (UM) 3 was present. CNA3 was overheard with a loud voice behind the door. UM3 confirmed she overheard the loud voice of CNA3 while the residents' door was shut. UM3 opened the residents' door and CNA3 was on her cell phone. CNA3 then opened the residents' door and confirmed she had answered her cell phone since her child called. UM3 stated when staff use their personal cell phone in a resident room, this was considered a dignity issue. CNA3 stated she should not have been on the phone in a resident room since the residents were in the room.An interview was conducted on 9/24/2025 at 2:13 PM with R80 and he stated he remembered CNA3 on her cell phone while in his room and stated this was disrespectful. During an interview on 9/24/2025 at 2:15 PM, R15 stated he did not remember the incident with CNA3 and answered her cell phone in his room.During an interview on 9/24/2025 at 4:16 PM, the Director of Nursing (DON) stated LPN1 should have sat down next to R15 while assisting the resident during his meal since this was a dignity issue. In addition, the DON stated CNA3 should not have answered her cell phone in a clinical setting since this was a dignity issue.

Based on record review, resident and staff interviews, and review of the facility's policy, the facility failed to ensure two (Residents (R5) and R1) of a survey sample of 33 residents were invited to participate in the quarterly care plan meeting. This failure has the potential to violate resident rights, including the care plan not reflecting their preferences.Findings include:Review of R5's EMR failed to contain evidence that the resident was invited to her quarterly care conferences.During an interview on 9/22/2025 at 9:31 AM, R5 stated she did not get invited to her quarterly care conferences.During an interview on 9/23/2025 at 3:24 PM, the Director of Social Services (DSS) stated she invited residents who had a high BIMS score to their quarterly care conferences. The DSS confirmed that R5's representative was invited but not the resident.During an interview on 9/24/2025 at 2:45 PM, the DSS stated there were no prior quarterly care conferences identified for R5 in the EMR and confirmed R5 was her own representative.During an interview on 9/24/2025 at 4:16 PM, the Director of Nursing (DON) stated the residents were to be invited to their care conferences to be able to participate in the development of it. Findings include:Review of a facility policy titled, Comprehensive Care Plans, dated March 2025, indicated .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive assessment and quarterly MDS.1.Review of R5's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].Review of R5's EMR titled envelope located under the Misc (Miscellaneous) tab indicated the resident's representative was invited to the resident's care conference. Review of R5's EMR titled quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference (ARD) of 7/17/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which revealed the resident was cognitively intact. 2. Review of R37's admission Record located under the Profile tab in the EMR indicated R37 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), epilepsy, and diabetes.Review of R37's EMR revealed an annual MDS located under the MDS tab with an ARD of 8/21/2025 revealed a BIMS score of 15 out of 15, indicating intact cognition.Review of R37's EMR revealed Progress Notes located under the Progress notes tab revealed no indication of invitation or participation in any care plan conference meetings.During an interview on 9/22/2025 at 9:04 AM, R37 was asked about the care plan meetings every three months. R37 stated, I don't know anything about meetings.During an interview on 9/25/2025 at 9:30 AM, the Administrator was asked about the invitations to the care plan meetings. The Administrator stated the invitations are in the medical records but have not been scanned into the EMR yet.During an interview on 9/25/2025 at 1:30 PM, the Social Service Assistant (SSA) was asked how invitations were given to the residents. The SSA stated residents were given letters inviting them to their meetings. The SSA was asked for invitations for the last year for R37. The SSA could not provide invitations for the 6/3/2025 and 8/1/2025 meetings.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure the call light was accessible for one of 33 residents (Resident (R) 99) observed in the Initial Pool. This failure placed R99 at risk of falling and injuries or distress when he could not access the call light to alert staff of an emergency or unmet needs.Findings include:Review of the facility's undated policy titled, Answering the Call Light revealed, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.Review of R99's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted with diagnoses including but not limited to stroke affecting left non-dominant side, tracheostomy status, and gastrostomy status.Review of R99's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/8/2025, located under the MDS tab of the EMR, revealed R99's Brief Interview for Mental Status (BIMS), indicating he was rarely/never understood. R99 was dependent on staff for all the activity daily livings (ADLs) and had range of motion impairment on one side of upper and lower extremities.Review of R99's Care Plan, dated 9/25/2025 and located under the Care Plan tab of the EMR, included a care plan for The resident has an ADL self-care performance deficit revised on 6/14/2025, documented Encourage the resident to use bell to call for assistance.Review of R99's second care plan for The resident is at risk for fall r/t [related to] to impaired mobility, poor safety awareness, revised on 10/29/2024, indicated,-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.During observations in R99's room on 9/22/2025 at 9:05 AM and 9/22/2025 at 10:16 AM, R99 was lying in bed in his room and receiving tube feeding. R99's bed was against his right-side wall, and he was on a low bed with a deep blue colored floormat to his left side of floor for safety and fall protection. His call pad/light was resting on his oxygen machine on the top of his bedside table, which was located behind his bed's headboard and obscured by a curtain that he could not reach. Observed R99's call pad was in the same location, resting on his oxygen machine on the top of his bedside table, which was located behind his bed's headboard and obscured by a curtain that he could not reach from 9/22/2025 at 9:06 AM throughout 9/22/2025 at 4:20 PMDuring an observation in R99's room on 9/23/2025 at 9:00 AM, R99's bed was against his right-side wall, and he was on a low bed with the floormat to his left side of floor. His call pad/light was on the top of left corner of his bed, which he could not reach. When asked, R99's roommate, R72, stated that no staff came to pick up his call light from the floor and placed it on his bed until last night around 6:00 PM. R72 further stated that the same staff also placed R99's call pad at the current location, to the top left corner of R99's bed.During several observations R99's call pad was observed in the same location on the top of left corner of his bed, which he could not reach for three different days as follows:9/22/2025 at 10:12 AM, from 4:00 PM to 4:40 PM.9/23/2025 from 9:43 AM to 9:46 AM, at 11:24 AM, and 2:29 PM.9/24/2025 from 8:00 AM to 8:04 AM, at 8:29 AM, 8:55 AM, and from 11:06 AM to 11:17 AM.9/25/2025 at 4:27 AM and 7:00 AM.During an observation on 9/25/2025 at 7:01 AM, verified with Licensed Practical Nurse (LPN)4 in R99's room, when R99 was asked to reach and press the call pad, the resident's face looked confused and could not speak due to the tracheostomy. R99 shook his head to express he could not. When R99 was asked to raise any of his arms, he did not and shook his head to communicate he could not. LPN4 said she should put the call pad under R99's head or body.On 9/25/2025 at 3:05 PM, the Director of Nursing (DON) stated that R99 could not press the call pad by hand, and the staff should attach the call pad to his head to function properly.

Based on observations, resident, resident responsible party, and staff interviews, and record review, the facility failed to provide adequate Activities of Daily Living (ADL) care for one (R128) out of 33 sampled residents. This failure had the potential to negatively affect R128.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated April 2024 indicated, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent.neglect.Definitions.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation and Compliance Guidelines:The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. lnclude training for new and existing staff on activities that constitute.neglect.reporting procedures, and dementia management and resident abuse prevention.Review of the facility's policy titled, Activities of Daily Living undated indicated, Policy Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Activities of daily living (ADL's) include: Hygiene - bathing,.grooming.ADL care is documented every shift by the nursing assistant on an ADL flow record or in PointClickCare (PCC).Review of Resident (R) 128's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R128 was admitted to the facility with the diagnoses of but not limited to hemiparesis and hemiplegia, major depressive disorder, low vision in left eye, and dementia.Review of R128's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 6/24/2025 (quarterly), located under the RAI tab indicated R10 was supervision for eating; substantial/maximum assistance for bed mobility; dependent for oral hygiene; dressing, toileting hygiene, and bathing. The MDS indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicated R128 was moderately cognitively impaired. Review of R128's EMR under the Progress Notes tab dated 9/9/2025 indicated, SSA (Social Service Assistant) conducted care plan meeting with resident's daughter (RP128).Daughter voiced concerns and she was informed that SS (Social Services) will follow up as needed on resident's hygiene and feeding concerns. SS will continue to follow up as needed. During an observation on 9/22/2025 at 1:40 PM with R128, it was observed R128 had a dark brown substance under his fingernails. During an observation on 9/25/2025 at 11:55 AM with R128, it was observed R128's fingernails had a dark brown substance under them. During an interview on 9/22/2025 at 1:40 PM with R128, stated he received bed baths on a regular basis. During an interview on 9/24/2025 at 8:20 AM with Complainant/Responsible Party (RP) 128 stated the staff did not bathe R128. RP128 said she had witnessed a dirt build up around R128's neck and his fingernails being dirty. During an interview on 9/25/2025 at 9:25 AM with Nurse Manager (NM) 3, stated she expected that a resident's fingernails would be cleaned thoroughly during their shower/bath (scheduled for two times a week) and as needed in between. During an interview on 9/25/2025 at 12:19 PM with Licensed Practical Nurse (LPN) 5 upon visualizing R128's fingernails LPN5 stated, They need to be cleaned.

Based on observations, records review, and facility policy review, the facility failed to ensure two residents (Resident (R) 131, R152) were free from significant medication errors out of a total of 33 sample residents during one of the two residents' insulin administration observation and record reviews. These failures had the potential to cause hyperglycemia or hypoglycemia episodes in insulin-dependent residents.Findings include:Review of the facility's policy titled, Medication Errors, dated September 2023, stated the facility must ensure it is free of medication error rate of five percent (%) or greater as well as significant medication error events.- Medication error, means the observed or identified preparation or administration of medications. which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication.- Significant medication error, means one which causes the resident discomfort or jeopardizes his/her health and safety.-The facility will consider factors indicating errors in medication administration, including. Medication administered not in accordance with the prescriber's order. Examples include, butnot limited to. Incorrect dose, route of administration, dosage form, time of administration. - If a medication error occurs, the following procedure will be initiated:a. The nurse assesses and examines the resident's condition and notifies the physician or healthcare practitioner as soon as possible.b. Monitor and document the resident's condition, including response to medical treatment ornursing interventions.c. Document actions taken in the medical record.d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor andcompletes the incident or occurrence report.1. Review of R131's Face Sheet located in the electronic medical record (EMR) under the admission tab, indicated R131 was admitted to the facility with diagnoses including but not limited to type one diabetes and long-term use of insulin.Review of R131's physician's order, located under the Orders tab of the EMR, revealed an order for insulin Lispro, injection subcutaneously per sliding scale: if 180 - 210 = 2; 211 - 250 = 4; 251 - 290 = 6; 291 - 599 = 8, subcutaneously before meals and at bedtime for type one diabetes mellitus, start date 7/4/2025, scheduled for 6:30 AM, 11:30 AM, 4:30 AM and 9:00 PM.During the third-floor medication administration observation on 9/22/2025 at 9:51 AM, licensed practical nurse (LPN) 6 was observed performing a blood glucose (BG) check on R131; R131's BG was 245. LPN 6 did not follow the physician's order; he injected R131's 11:30 AM insulin order into R131's left arm earlier than the order time at 9:55 AM, and he documented it into the EMR at 10:03 AM.On 9/22/2025 at 10:15 AM, when asked, LPN6 stated that he administered the Lispro sliding scale order a little bit earlier than the order. He said R131's insulin was ordered to be given at 11:30 AM, and usually the software system would only allow him to administer it one hour earlier at 10:30 AM. However, since the software showed green and allowed him to administer it, he did.On 9/22/2025 at 11:24 AM, when asked, LPN3 stated that the sliding scale insulin for 11:30 AM should be given as early as 1 hour prior to 11:30 AM at 10:30 AM; however, lunch usually arrives around 12:30 PM, and she typically administers it at 12:00 PM (noon).On 9/22/2025 at 4:00 PM, when asked, R131 stated there was no staff rechecking his BG after receiving the Lispro 2 units at 9:55AM, and he did not eat any snacks after the insulin. The lunch that day was not served until around 1:30 PM.Review of R131's Medication Administration Report (MAR) included Location of Administration Report, dated 9/22/2025, located under the Orders tab of the EMR, revealedmore documentations that staff did not follow physicians' order to administer insulins as follows:Physician's order for insulin Lispro, injection subcutaneously per sliding scale: if 180 - 210 = 2; 211 - 250 = 4; 251 - 290 = 6; 291 - 599 = 8, subcutaneously before meals and at bedtime for type one diabetes mellitus, start date 7/4/2025, scheduled for 6:30 AM, 11:30 AM, 4:30 AM and 9:00 PM. Thirty of 67 administrations were given late, some examples included as follows:- 9/7/2025 due at 9:00 PM not administrated until 9/8/2025 at 2:28 PM.- 9/10/2025 due at 9:00 PM not administrated until 9/11/2025 at 3:34 AM.- 9/11/2025 due at 9:00 PM not administrated until 9/12/2025 at 6:01 AM.- 9/18/2025 due at 11:30 AM not administrated until 4:42 at PM.- 9/18/2025 due at 9:00 PM not administrated until 9/19/2025 at 1:45 AM.- 9/19/2025 due at 9:00 PM not administrated until 9/20/2025 at 1:16 AM.Physician's order for insulin Lispro, injection subcutaneously 8 units two times a day for type one diabetes mellitus, start 7/10/2025, scheduled at 12:00 PM and 5:00 PM. Ten of 39 administrations were given late, some examples included as follows:- 9/9/2025 due at 12:00 PM not administrated until 2:04 PM.- 9/11/2025 due at 5:00 PM not administrated until 6:26 PM.- 9/15/2025 due at 5:00 PM not administrated until 6:33 PM.- 9/18/2025 due at 12:00 PM not administrated until 4:42 PM.- 9/21/2025 due at 12:00 PM not administrated until 1:40 PM.- 9/22/2025 due at 12:00 PM not administrated until 2:16 PM.Physician's order for insulin Lantus, injection subcutaneously 10 units at bedtime for type one diabetes mellitus, start 7/10/2025, scheduled at 9:00 PM. Seventeen of 20 administrations were given late, some examples included as follows:- 9/5/2025 due at 9:00 PM not administrated until 9/6/2025 at 12:35 AM.- 9/7/2025 due at 9:00 PM not administrated until 9/8/2025 at 2:28 AM.- 9/8/2025 due at 9:00 PM not administrated until 9/9/2025 at 6:01 AM.- 9/15/2025 due at 9:00 PM not administrated until 9/16/2025 at 2:24 AM.- 9/10/2025 due at 9:00 PM not administrated until 9/11/2025 at 3:36 AM.- 9/15/2025 due at 9:00 PM not administrated until 9/16/2025 at 2:24 AM- 9/18/2025 due at 9:00 PM not administrated until 9/19/2025 at 1:46 AMPhysician's order for insulin Lantus, injection subcutaneously 20 units subcutaneously one time a day in the morning for type one diabetes mellitus, start 7/11/2025, scheduled at 7:30 AM. Twelve of 22 administrations were given late, some examples included as follows:-9/6/2025 due at 7:30 AM not administrated until 9:47 AM.- 9/7/2025 due at 7:30 AM not administrated until 10:05 AM.- 9/13/2025 due at 7:30 AM not administrated until 9:59 AM.- 9/15/2025 due at 7:30 AM not administrated until 9:07AM- 9/17/2025 due at 7:30 AM not administrated until 10:38 AM.- 9/18/2025 due at 7:30 AM not administrated until 11:03 AM.Review of R131's record revealed no documentation from the staff notifying the provider that insulin was administered early or too late. There was no documentation that R131 was being monitored for hyperglycemia or hypoglycemia.During an interview on 9/24/2025 at 4:22 PM, the Regional Director of Clinical Services (RDCS) stated if the medication was administered one hour earlier than the scheduled time, it was considered too early, and if administered after one hour past the scheduled time, it was considered late, and both were considered medication errors. The nurse should notify the provider and document it in the progress note.During an interview on 9/24/2025 at 4:44 PM, upon policy request, the Director of Nursing (DON) stated that there was no specific policy for insulin administration; instead, it should follow the Medication Administration policy. The DON stated that if a nurse administered medication late or too early, including insulin, the staff should contact the provider for further instruction, monitor the resident and document. The DON further verified the late administration of insulin injections on the MAR reports for R131. The DON stated that if the medication was given one hour before or after the scheduled time, it was considered late.2. Review of R152's Face Sheet located in EMR under the admission tab, indicated R152 was admitted to the facility on [DATE] with multiple diagnoses including type two diabetes.Review of R152's MAR included Location of Administration Report, dated 9/22/2025, located under the Orders tab of the EMR, revealed staff did not follow physicians' order to administer insulins as follows:Physician's order for insulin Glargine, injection subcutaneously 10 units at bedtime for type two diabetes mellitus, start 3/7/2025, discontinued 3/17/2025. Scheduled for 9:00 PM. Seven of 9 administrations were given late, some examples included as follows:- 3/7/2025 due at 9:00 PM not administrated until 11:42 PM.- 3/8/2025 due at 9:00 PM not administrated until 3/9/2025 12:04 PM.- 3/9/2025 due at 9:00 PM not administrated until 10:02 PM.- 3/12/2025 due at 9:00 PM not administrated until 10:05PM.- 3/13/2025 due at 9:00 PM not administrated until 10:05 PM.- 3/15/2025 due at 9:00 PM not administrated until 3/16/2025 1:16 AM- 3/16/2025 due at 9:00 PM not administrated until 10:39 PMPhysician's order for insulin Lispro, injection subcutaneously 5 units before meals for three times a day for type two diabetes mellitus, start 3/7/2025, discontinued 3/17/2025. Scheduled for 6:30 AM, 12:00 PM and 5:00 PM. Three of 29 administrations were given late, some examples included as follows:- 3/8/2025 due at 12:00 PM not administrated until 4:07 PM.- 3/8/2025 due at 5:00 PM not administrated until 6:36 PM.- 3/16/2025 due at 12:00 PM not administrated until 1:39 PM.Review of R152's record revealed no documentation from the staff notifying the provider that insulin was administered early or too late. There was no documentation that R152 was being monitored for hyperglycemia or hypoglycemia.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure that food preferences were honored for one out one of 33 sampled residents (Resident (R) 49).Findings include:Review of an undated facility policy titled, Resident Nutrition Services indicated .Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Review of R49's electronic medical record (EMR) titled, admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].Review of R49's EMR titled quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 7/19/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which revealed the resident was moderately cognitively impaired.During an interview on 9/22/2025 at 9:54 AM, R49 stated she had requested a salad for lunch and dinner and wanted this regularly.During an interview on 9/22/2025 at 12:44 PM, Certified Nurse Aide (CNA) 8 confirmed that R49's lunch tray did not have a salad. During this interview, the resident presented her lunch meal ticket, and it revealed that the resident requested a salad per meal. The resident verified there was no salad on her meal tray during this observation.During an observation on 9/23/2025 at 12:48 PM, Licensed Practical Nurse (LPN)7 confirmed R49 did not have a salad on her lunch tray. An interview was conducted with the resident immediately after this observation and she presented a copy of her meal ticket, dated 9/23/2025.During an interview on 9/25/2025 at 8:29 AM the Dietary Manager (DM) confirmed that R49 had requested salads with her meals and he forgot to add the salad to the resident's trays.

Based on observations, interviews, record review and review of facility policies and manufacturer guidelines, the facility failed to ensure the glucometer disinfection procedure and infection control practice for hand hygiene were followed during a medication administration observation for blood glucose (BG) check for one resident (Resident (R)131) and during a wound care observation for one R59 observed out of 33 sample residents. These failures placed residents and staff at risk of cross contamination and infection.Findings include:1. Review of the facility's policy titled, Glucometer Disinfection, dated 1/1/2022, stated Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. The procedure included the following: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose, testing strips, disinfecting wipes.b. Wash hands.c. Explain the procedure to the resident.d. Provide privacy.e. Put on gloves.f. Obtain capillary blood glucose sampling according to facility policy.g. Remove and discard gloves, perform hand hygiene prior to exiting room.h. Reapply gloves if there is visible contamination of the device or if the resident is HIV [human immunodeficiency virus] or H hepatitis B or C positive.i. Retrieve (2) disinfectant wipes from container.j - Using first wipe, clean first to remove heavy soil blood and/or other contaminant left on the surface of the glucometer.k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions- Allow the glucometer to air dry.l. Discard disinfectant wipes in waste receptacle. Perform hand hygiene.On 9/22/2025 at 9:49 AM, during the third-floor medication administration observation, Licensed Practical Nurse (LPN) 6, who was assigned to the Long Hall medication cart (MC) for the third floor, began to prepare a BG check for R131. LPN6 did not disinfect the glucometer. He put the glucometer, and all the BG check supplies, including a pair of gloves, alcohol wipes, test strips, and lancets (needles), in his left top scrub pocket and walked to R131's room. LPN6 placed the glucometer on R131's bedside table next to a breakfast tray without a barrier. LPN6 did not perform hand hygiene prior to putting on gloves; he did not perform any disinfecting procedures on the glucometer prior or after entering R131's room. LPN6 inserted the testing strip into the glucometer and then performed a BG check. R131's BG was 245.On 9/22/2025 at 9:55 AM, LPN6 removed the gloves and put on a new pair of gloves without performing hand hygiene. LPN6 primed the Lispro insulin and gave four units of Lispro to R131 to his left arm. LPN6 then removed his gloves, walked back to his MC and placed the glucometer on top of his MC. LPN6 documented medication administration in the computer on the MC. LPN6 did not disinfect the glucometer after use and put it back in the MC's top drawer to the right.On 9/22/2025 at 10:11 AM, when asked, LPN6 stated he was oriented upon hiring for BG checks. LPN6 stated he should have, but he did not perform hand hygiene before and after putting on and removing the gloves for the BG check and insulin administration. LPN6 said he should have but did not disinfect the glucometer prior to and after use with bleach wipes with a contact time of around thirty seconds to three minutes. LPN6 further stated he should have but he did not place a barrier between the BG check supplies and R131's bedside table.During a review of the glucometer manufacturer's cleaning instruction and the packaging copy of the bleach wipes the facility used with the DON. The DON stated that the staff should follow the manufacturer's instructions on page forty-seven, option one, which states that cleaning and disinfecting can be completed by using a commercially available EPA [environmental protection agency]- registered disinfectant detergent or germicide wipe.The DON confirmed the staff would follow the package instruction for Microdot Bleach Wipe, EPA registration #37549-1-88459, under the Directions for Use. Apply towelette and wipe desired surface.A 30 second contact time is required to kill bacteria and viruses .a 1 minute contact time is required to kill Candida albicans. and a 3 minute contact time is required to kill Clostridium difficile spores.On 9/22/2025 at 12:39 PM, the DON provided and confirmed the list of two residents who had hepatitis C, and one resident had HIV, three of them all receiving BG check and insulin injections in the facility.On 9/23/2025 at 8:38AM, the Regional Director of Clinical Services (RDCS) stated that the HIV and hepatitis C residents have their individual glucometers located in the MC at the bottom drawer.2. According to Wound Care Essentials: Practice Principles (5th ed., [NAME] & Ayello, 2020), published by [NAME] & [NAME], hand hygiene is a critical component of infection prevention during wound care procedures. The text emphasizes that healthcare personnel must perform hand hygiene both before and after any wound care activity, including between glove changes and when transitioning between wound sites. This practice is essential to prevent cross-contamination and reduce the risk of wound infection, particularly in patients with compromised immune systems or chronic wounds. The use of alcohol-based hand rubs (ABHR) is acceptable when hands are not visibly soiled, while soap and water should be used when hands are visibly dirty or after contact with bodily fluids. Importantly, glove use does not replace hand hygiene; hands must be sanitized before donning (putting on) and after removing gloves to maintain aseptic technique and ensure patient safety.Review of the admission Record, found in R59's electronic medical record (EMR), under the Profile tab, indicated that the facility admitted R59 with pertinent diagnosis including but not limited to heart failure, human immunodeficiency virus (HIV) disease, and anemia.Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/3/2025 revealed that R59 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Further review revealed R59 had three venous/atrial ulcers present upon admission.Review of R59's Care Plan, last revised on 9/16/2025, found in R59's EMR under the Care Plan tab, indicated R59 had actual impairment to skin integrity related to an atrial wound of the left and right foot. The care plan instructed staff to keep the skin clean and dry, monitor and document the location, size, and treatment of any skin injury, and report any abnormalities to the physician.Review of the Clinical Physician Orders dated September 2025, located in the EMR under the Orders tab, revealed the following wound care orders:-09/1/2025: Arterial wound to the right foot. Cleanse the area with wound cleanser, apply skin prep to the peri-wound, paint the area with betadine, cover with an ABD pad, and roll gauze. -9/1/2025: Arterial wound to the left foot. Cleanse the area with wound cleanser, apply skin prep to the peri-wound, paint the area with betadine, cover with an ABD pad, and roll gauze.During an observation on 9/23/2025 at 12:20 PM with LPN2 and Registered Nurse (RN) 2, LPN2 did not perform hand hygiene, either by washing with soap and water or using an alcohol-based hand rub (ABHR), after changing gloves between cleaning the wounds on R59's left and right feet, treating the wounds, and applying the wound dressings.During an interview on 9/23/2025 at 12:40 PM, LPN2 acknowledged that she did not perform hand hygiene, either by washing with soap and water or using an ABHR, after changing gloves between cleaning the wounds on R59's left and right feet, treating the wounds, and applying the wound dressings.During an interview on 9/23/2025 at 12:45 PM, RN2 acknowledged that LPN2 did not perform hand hygiene, either by washing with soap and water or using an ABHR, after changing gloves between cleaning the wounds on R59's left and right feet, treating the wounds, and applying the wound dressings. Upon inquiry, RN2 stated that failure to perform hand hygiene in between glove changes during wound care may lead to an increased risk of wound infection.

Based on record review, observations, and interviews, the facility failed to ensure that two of six residents (R) (R56 and R63) reviewed for pressure ulcers received consistent care and services. The facility failed to implement repositioning and offloading pressure devices resulting in harm when R56 acquired a stage 4 sacral wound and an unstageable right lower leg wound. Findings included: 1. A review of the electronic medical record (EMR) revealed that R56 was originally admitted to the facility on [DATE] with a primary diagnosis of quadriplegia. Other diagnoses included a pressure ulcer of the sacral (lower back) region (unstageable) and a pressure ulcer of the right heel (unstageable). A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2023 revealed R56 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment; R56 was totally dependent on staff for all Activities of Daily Living (ADL) care including bed mobility due to Functional Limitation in Range of Motion impairments to the upper and lower extremities on both sides; R56 had one Stage 2 pressure ulcer. The interventions listed were pressure relieving devices on the chair and bed, pressure ulcer care, and nutritional support. Turning and repositioning was not documented as an intervention. A review of the quarterly MDS assessment with an ARD of 4/24/2024 revealed R56 had one Stage 2 pressure ulcer with the interventions listed as pressure reliving devices on the chair and bed, pressure ulcer care, and nutritional support. Turning and repositioning was not documented as an intervention. A review of the quarterly MDS assessment with an ARD of 6/24/2024 revealed that R56 had a BIMS score of 15 out of 15, was at risk of developing pressure ulcers, and currently had unhealed pressure ulcers one a Stage 4 and the other unstageable. Treatments included the use of a pressure-reducing device for the bed; a turning/repositioning program; nutrition or hydration intervention to manage skin problems; and appropriate Pressure ulcer/injury care. This is the first MDS that included turning and repositioning as an intervention. This was after the pressure ulcers had progressed to Stage 4 and unstageable. A review of R56's Care Plan revealed a Focus, initiated on 10/19/2022, indicating the resident had actual impairment to skin integrity (related to) decreased mobility, history of pressure ulcers, and incontinence with concerns to the Sacrum, Right Lower Leg, and Left Anterior Knee. Interventions included: Medication and Supplements as ordered; bilateral heel boots while in bed; Pressure relieving devices as ordered (Air Mattress); Providing treatment as ordered. Turning and repositioning, pillows, wedges, and cushions were not interventions listed on this care plan. A review of the Wound Weekly Observation Tool, with an effective date of 7/17/2024, provided by the Administrator, revealed R56 had a stage 4 wound to the sacrum that was acquired on 4/18/2024. Per the document, Special Equipment/Preventative measures included: Pillow, Cushions, Wedges, Heel Protectors, and Pressure Reduction Mattresses. The document also revealed that R56 was supposed to be turned and repositioned routinely. This is the first mention of using pillows, cushions, and/or wedges and turning and repositioning for pressure reduction. A review of a Wound Weekly Observation Tool, with an effective date of 5/23/2024, revealed an unstageable Right Lower Leg Posterior acquired on 5/20/2024. Special Equipment/Preventative measures included: Pillows, Cushions, Wedges, Heel Protectors, and Pressure Reduction Mattress. A review of the EMR revealed no documentation that turning and repositioning and the use of wedges and pillows were implemented. These interventions were indicated on the Wound Weekly Observation Tool but not documented as being done by the nursing staff prior to and/or after the development of the pressure ulcers. On 7/22/2024 at 10:57 am, R56 was observed lying in bed on his back, leaning to his right side. The resident was on an air mattress with the head of the bed slightly elevated. The resident was observed to have a wedge located under his upper right side along with a pillow between his knees. It was also observed that there were therapy devices located on a counter underneath the resident's television that included heel boots. The resident stated that he has a history of bed sores and that he recently had one open up on his back. The resident was asked if the staff turns or repositions him regularly and he stated that the staff does not. On 7/22/2024 at 1:09 pm, Certified Nursing Assistant (CNA)3 and Licensed Practical Nurse (LPN)10 were observed in R56's room. The staff members confirmed they had just completed assisting the resident with his lunch meal. R56 was in bed on an air mattress and the head of the bed was slightly elevated. A wedge was observed under the resident's upper right side. On 7/22/2024 at 3:32 pm, R56 was observed resting in bed with his eyes closed, with his body positioned towards his right side. CNA3 was interviewed on 7/22/2024 at 3:34 pm and was asked if the resident was repositioned regularly. CNA3 stated that due to the resident's contractions it is difficult to reposition the resident, but that if the resident has a complaint, they will try their best to relieve any discomfort. R56 was observed on 7/23/2024 at 2:25 pm asleep in bed, lying towards his right side. During a continuous observation from 7/24/2024 at 12:00 pm through 7/24/2024 at 2:45 pm, R56 remained lying partially on his back leaning slightly to his right side. R56 was not repositioned by the nursing staff during this continuous observation. The staff entered the room once, at 1:07 pm, with the R56's meal tray. CNA3 assisted R56 with his meal from 1:07 pm to 1:14 pm. No staff returned to R56's room through the remainder of the observation on 7/24/2024 from 1:14 pm through 2:45 pm. CNA1 was interviewed on 7/24/2024 at 4:35 pm and stated that he created and used the communication binder to communicate the daily tasks for each resident and encouraged all staff to follow it. CNA1 also stated that any resident with a contracture and/or a pressure ulcer must be turned every two hours and added that even though there is not an order, the staff is aware that all residents repositioning is required every two hours if they have contractures and pressure ulcers. CNA1 confirmed familiarity with R56 and stated that the expectation is that R56 is to be repositioned every two hours, but added that they allow R56 to make his own decisions on how he wants to be positioned. CNA1 was also asked about the therapy devices located in the resident's room, specifically the boots to prevent heel pressures, CNA1 advised that staff is aware of the heel boots, and how to use them, and added that they should be in place. When asked if there is any reason that a resident would not be turned or repositioned, the staff member responded, If the repositioning causes pain to the resident, then they do not turn or reposition them. CNA1 added that all CNAs are educated on applying pressure-relieving devices and all documentation for charting turning and repositioning is in each resident's Plan of Care. CNA1 was not able to identify any documentation of turning and repositioning for R56. LPN1 was interviewed on 7/24/2024 at 5:14 pm in R56's room. LPN1 stated that R56 was severely contracted and it's difficult to reposition, but added that the resident's heel boots should be in place and that all residents should be repositioned as much as necessary to, but that standards of practice are to reposition every two hours. LPN1 confirmed the heel boots were not in place and during the interview asked the resident if he wanted the boots on. The resident stated he was told by staff that he didn't need the boots anymore because the heel wounds were healed. R56 was then advised by LPN1 that the heel boots are also to prevent the occurrence of heel wounds and R56 agreed to have them applied. During an interview on 7/25/2024 at 9:05 am, CNA3 stated that R56 typically only needed repositioning after a convulsion that caused the resident to end up leaning to his left side. The staff member also confirmed that there were no set times to reposition the resident, nor was it documented in the resident's clinical record. When asked about R56's heel boots, the staff member stated that they are placed on the resident at the end of their shift so the evening shift does not have to worry about it. During an interview on 7/25/2024 at 12:51 pm, R56 confirmed that he was ok with any interventions used to prevent pressure ulcers and is willing to do whatever is required [for care], but that staff states that he declines care, but that it is not true. The Rehabilitation Director (RHD) was interviewed on 7/25/2024 at 1:02 pm and confirmed that R56's pressure wounds could be avoided, advising that the use of the air mattress and repositioning and use of wedges for offloading are effective at preventing pressure wounds. 2. A review of R63's Admission Record revealed an initial admitted [DATE], with diagnoses that included but were not limited to, quadriplegia, muscle weakness, and fusion of the cervical (neck) spine. A review of R63's admission MDS assessment with an ARD of 12/28/2023 revealed the resident had a BIMS score of 00 out of 15, indicating R63 was severely cognitively impaired, that R63 had a pressure ulcer to the sacrum and right ischium upon admission, and that he required substantial/maximal assistance with rolling left and right. A review of R63's quarterly MDS assessment with an ARD of 6/25/2024 revealed two Stage 4 pressure ulcers that were present on admission/reentry. A review of R63's Braden Assessment Instrument dated 7/5/2024 revealed R63 was at risk of developing pressure ulcers/injuries, A review of R63's Care Plan with a revision date of 6/11/2024 indicated a focus on the sacral and ischium pressure ulcers, with a goal to reduce complications. Interventions revealed preventative skin care with turning and positioning. A review of Progress Notes dated 4/23/2024 documented that R63 was very limited to make occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. An observation on 7/24/2024 began at 11:46 am of R63's care schedule. The resident's mother was in R63's room at the bedside and stayed until 1:40 pm. Observations of R63's room continued on 7/24/2024 until 4:00 pm, revealed no staff member entered R63's room to provide care to include turning and/or repositioning of R63. During an interview on 7/24/2024 at 4:35 pm, CNA1 stated that R63 should have been turned and repositioned every two hours. CNA1 said documentation for all the charting and repositioning for each resident was in the Plan of Care (POC). CNA1 could not identify any charting for 7/24/2024 that indicated R63 had been turned/repositioned from 7:00 am to 4:30 pm. During an interview on 7/24/2024 at 5:14 pm, with the hall four-unit manager, LPN1 stated that a resident with a pressure ulcer/wound should be turned/repositioned at least every two hours or more as needed. During an interview on 7/24/2024 at 5:24 pm, the Director of Nursing (DON) stated a turning and repositioning task is communicated to staff through the Kardex system. She said, We try to implement it every two hours, no more than four hours if the CNA gets distracted or caught up with something else. She also stated that turning and repositioning a resident is a standard of practice. During an interview on 7/25/2024 at 3:38 pm, with the MDS Nurse, she stated it was a standard of practice across the board for all residents with limited movement or range of motion to be turned and repositioned every two hours or more often if needed. She said the POC is where CNA staff document their completed tasks including turning and repositioning. A review of the POC under tasks and on the Kardex revealed no documentation for turning and repositioning R63. 36917

Based on interviews, record review, and review of the facility policy titled Notification of Changes, the facility failed to notify the resident representative of a significant change in condition for two of 32 sampled residents (R) (R#20 and R#24). On 2/4/22, the facility failed to notify R#20's representative of an increase in the resident's mood and behaviors and failed to notify the resident's representative of the resident signing an Against Medical Advice (AMA) discharge form and exiting the facility. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was not able to make safe decisions about signing out AMA. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record review, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: 1. A review of policy titled Notification of Change with a revision date of January 2023, revealed the following compliance guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status, or a transfer or discharge of the resident from the facility. This policy indicated that for competent individuals, the facility must still contact the resident's physician and notify resident's representative if known. For residents incapable of making decisions, the representative would make any decisions that need to be made. A review of the clinical record for R#20 revealed he was admitted to the facility on [DATE] with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#20 presented with a Brief Interview for Mental Status (BIMS) score of six. The scale of 0-6 indicates the resident has severe cognitive impairment. A review of the discharge information from the previous skilled nursing facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needs placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Further review revealed the resident was not independent prior to admission to the previous facility and had been living with family. His discharge goal barriers included cognitive impairment and physical challenges. He was determined a fall risk and had been referred to therapy. The interventions included to continue to monitor and readjust medications as needed. A review of an initial psychiatric evaluation for R#20 dated 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that the resident had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder; and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation, and frequent reorientation to reality. A review of the clinical record for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission, and to consider Gradual Dose Reduction (GDR). Staff had reported resident was alert, confused, forgetful, was able to ambulate, and was incontinent at times. The resident was also reported to continue to wander and was not manageable at times, difficult to redirect verbally, and not co-operative with care and medications. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations, or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote, check testosterone level, consider Depo-Provera if the sexually inappropriate behavior continues, provide cognitive social stimulation and frequent reorientation to reality, and to continue close monitoring. Behavioral interventions included distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nurses note dated 2/4/23 at 3:01 p.m., revealed the following: The resident got on elevator and refused to get off. (R#20) went down to first floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect (R#20). (R#20) requesting to leave the facility. Patient spoke to the nurse, scheduler, and Doctor (Dr. ZZZ), in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility (AMA). An interview was conducted with R#20's representative on 7/12/23 at 3:13 p.m. S/he stated that R#20 was put out of the facility with a garbage bag and a wheelchair. S/he stated that s/he was told that R#20 signed a paper that was read to him. R#20's representative stated that the form had a signature on it but that it wasn't R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair and still was never told why R#20 had been discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and because he was short of breath, the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin. S/he stated that the cousin then called them of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home from the apartment. R#20's representative stated that R#20 had been with them for less than a week and had to go to the hospital. S/he also stated that R#20 was now in another facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. A phone interview on 7/12/23 at 3:50 p.m. with Dr. ZZZ revealed that he was at the facility on that day R#20 was discharged . He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and he told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ ended the phone interview stating that upon leaving the facility, he saw R#20 going up the road and he stopped R#20 and offered him some money, a ride, a call to Uber, or money to get a hotel room. He stated that R#20 refused. A phone interview was conducted on 7/13/23 at 6:15 p.m., with License Practical Nurse (LPN) CCC. She revealed that she was an agency nurse that had only worked one shift at the facility and confirmed it was Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred. She stated that the resident had become adamant that he was going home and stated that R#20 was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA form to R#20. She stated that R#20 did sign the AMA form. LPN NNN also stating that the doctor and she were standing in front of the door, and due to the resident being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN confirmed that she had not spoken with R#20's representative prior to his AMA discharge. 2. A review of policy titled Notification of Change with a revision date of January 2023, revealed the following compliance guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include accidents resulting in injury and/or potential to require physician intervention and significant change in the residents physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status which may include life-threatening conditions or Clinical complications. Circumstances that require a need to alter treatment may include new treatment, discontinuation of current treatment due to adverse consequences such as acute condition, exacerbation of a chronic condition, a transfer or discharge of the resident from the facility, a change of room or roommate assignment; and/or a change in resident rights. A review of the Electronic Medical Record (EMR) of R#24 revealed that she was admitted to the facility on [DATE] and was discharged to the hospital on 9/30/22. R#24 was admitted with diagnoses that included, but was not limited to, end stage renal disease, dependence on renal dialysis, chronic respiratory failure, dependence on oxygen, atrial fibrillation, sleep apnea, and needed assistance with personal care. A review of the MDS dated [DATE] revealed that R#24 had a BIMS score of eight, which indicated that the resident is moderately cognitively impaired, and she required extensive assistance with ADL's. During a phone interview on 7/17/23 at 5:16 p.m. R#24's responsible party, s/he stated that the facility never contacted them that the resident was sent to the hospital in September 2022. S/he was contacted by the hospital two days after the R#24 was sent to the hospital. S/he further stated that the dialysis center had contacted them regarding R#24 missing six sessions. S/he stated that s/he was told by the dialysis center that the facility never contacted them regarding the resident being COVID-19 positive and told the responsible party that they would have still treated R#24, even with the positive test for COVID-19. A review of the EMR for R#24 revealed there was no nurses note or any documentation related to when or why R#24 was sent to the hospital on 9/30/22 and no documentation that the responsible party was notified. An interview with LPN JJJ on 7/18/23 at 3:40 p.m. revealed that as long as next of kin is listed, they should be called if there is a change of condition. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23 at 3:00 p.m. with the Medical Director, Center Nurse Practitioner, Director of Nursing (DON), Unit Managers (UM), Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to notification of changes, to review the findings for the IJ, and plan for the removal of IJ issues. 2. R#20 was discharged from the facility on 2/4/23. 3. On?7/13/23,?the Center Regional Director of Operations, DON, and Regional Director of Clinical Operations reviewed the center policy?on Notification of Change.?No changes or recommendations were made or given. 4. On 7/13/23, to identify other residents that may be affected by this practice, a 100% review was completed of residents with known mood and behavioral problems with a verbal expression to leave the facility AMA by the UM (a licensed nurse) of residents for the past 30 days (6/13/23 through 7/13/23) to ensure that their responsible party or legal representative was informed of an increase in mood or behavioral related to their desire to leave AMA to ensure ongoing safety. Any resident found to have had a change in mood and behavior related to their desire to leave AMA without responsible party/legal representative being informed, responsible party/legal representative was informed by a licensed nurse on 7/14/23. 5. On 7/13/23, the DON reeducated licensed nurses on the importance of ensuring that the responsible and/or legal representatives are notified of a change in condition related to increased mood and behavioral problems with an expressed, voiced desire to leave the center without the advice of their physician to ensure safety and to reduce risk of a delay in potential interventions to establish safety. Education also included the importance of nurses to report altered mental status specific to an increase in behaviors to the resident's representative, as well as the attending physician so appropriate interventions can be initiated. Currently there are 16 of 19 licensed nurses of which 88% have been educated. Any clinical staff members who were not reeducated due to Vacation, PRN (as needed) Status, etc., will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, or Charge Nurse. Newly hired clinical staff, such as Agency or PRN's (as needed staff), will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 6. The Regional Director of Clinical Services reeducated the center DON, UM's, and MDS team on the importance of ensuring that the responsible and/or legal representatives are notified of a change in condition related to increased mood and behavioral problems with an expressed, voiced desire to leave the center without the advice of their physician in order to ensure safety, a safe discharge, and to reduce risk of a delay in potential care interventions to establish safety. 7. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on 7/14/23. 8. All corrective actions were completed on 7/14/23. 9. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the minutes from ad hoc meeting on 7/13/23 revealed that topics reviewed were concerns related to the Plan of Correction (PoC), and Quality Assurance Performance Improvement (QAPI) actions. Subject Matter: Complaint Survey 7/13/23 IJ Citations F580, F600, F624, F710, F7835. Initiated abatement. Attendance was dated 7/13/23 and signed by Medical Director, Center Nurse Practitioner, DON, UM, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members. 2. Verified census list that listed R#20 as discharged on [DATE]. 3. Reviewed attestation form attached to the policy titled Notification of Change and no changes or recommendation were made at the time of the review. This document was signed by the Regional Director of Operations, the DON, Regional Director of Clinical Operations, and the Medical Director. 4. A review of the audit revealed one resident (R#20) was identified to have increase in behaviors/risk of AMA discharge. 5. The in-service record was reviewed dated 7/13/23 related to the policy titled Notification of Changes. Policy to notify residents' responsible party, guardian, legal representatives, and physicians are notified of resident change of condition was reviewed. 6. The in-service record was reviewed related to in-service on 7/13/23 and conducted by the Regional Director of Clinical Services at 5:00 p.m. entitled Notification of Change revised date of January 2023. Reviewed importance of reporting altered mental status specific to increases in behaviors to resident's representative and the attending physician so appropriate interventions can be initiated. Document date and time of notifications. Residents with mood and behaviors expressing desire to leave AMA, ask MD, NP, and RP to consider 1013 to provide acute level of care. Interviews with the Social Service Director on 7/17/23 at 2:55 p.m., with the DON on 7/17/23 at 4:10 p.m., with LPN/UM AAA on 7/17/23 at 4:30 p.m. revealed that they had received education regarding safe discharge of residents and making sure all parties are notified during the discharge process to ensure safe discharge. 7. A review of QAPI meeting minutes dated 7/14/23 revealed the meeting included review of audits completed as part of the removal plan and plan of correction. The attendance sheet was signed by the QAPI Committee members. 8. All corrective actions was verified as being completed on/by 7/14/23. 9. The IJ was verified as being removed on 7/15/23.

Based on staff interviews, resident representative interviews, record review, and review of the facility policies titled Abuse, Neglect and Exploitation, Transfer and Discharge (including AMA), and Notification of Changes, the facility failed to protect one of 32 sampled residents (R) (R#20) from neglect by not ensuring the resident's cognitive level and mental status was appropriate for him to make an informed decision to discharge by signing an Against Medical Advice (AMA) form and exiting the facility. On 2/4/22, R#20 was allowed to sign an AMA form and then exited the facility without the knowledge or assistance from his representative or a discharge plan in place. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was unable to make safe self-care decisions. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record review, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: A review of the policy titled Transfer and Discharge (including AMA) with reviewed/revised date of January 2023 indicated: In cases of a resident desiring to be discharged AMA, the resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives of both. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of the physician's notification should be entered in the nurses' notes by the nurses' department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present. Notify Adult Protective Services, or other entity, as appropriate if self-neglect is suspected, and document accordingly. A review of the policy titled Abuse, Neglect and Exploitation with reviewed/revised date of 9/8/22 indicated: The definition of neglect is failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Components of the facility abuse prohibition plan includes the screening of prospective residents to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility. An assessment of the individuals' functional and mood/behavioral status, medical acuity and special needs will be reviewed prior to admission. The facility will also make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment. Prevention of abuse, neglect and exploitation includes the identification, ongoing assessment, care planning for the appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. A review of the policy titled Notification of Changes, with reviewed/revised in January 2023 indicated Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status, or a transfer or discharge of the resident from the facility. This policy indicates that for competent individuals, the facility must still contact the resident's physician and notify resident's representative if known. For residents incapable of making decisions, the representative would make any decisions that need to be made. A review of the clinical record revealed R#20 was admitted to the fourth floor on 12/12/22 with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. The clinical record further revealed that on 1/29/23, R#20 was moved from the 400 Hall to the less secure unit on the 200 Hall and remained on that unit until discharged on [DATE]. An interview with the Regional VP of Operations on 7/18/23 at 2:56 p.m. revealed the fourth floor is utilized for residents with cognitive or behavioral issues, such as wandering. The elevator on the fourth floor requires a code for the elevator doors to open, and to activate the elevator to go down. The first, second and third floor elevator doors will open without inputting a code and can be activated to go to the first floor without a code. Regardless of where the elevator accessed, a code is required to go up to all floors. A review of R#20's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as a six (the scale of 0-6 indicates the resident has severe cognitive impairment); that R#20 exhibited no mood or behavioral issues; no psychosis noted, and no behaviors exhibited; has limited assistance with bed mobility, transfer, walking in room, walking in corridor and locomotion; requires one-person physical assist for dressing, toileting, and personal hygiene; and needs supervision with eating. It was further noted that R#20 was not steady and only able to stabilize with staff assistance and does not use any mobility devices. The assessment noted that R#20 was receiving antidepressants. The discharge MDS dated [DATE] revealed R#20 was also receiving antipsychotics upon discharge. A review of discharge information from the previous skilled nursing facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needed placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Record review also revealed R#20 was not independent prior to admission to a previous facility and had been living with family. His discharge goal barriers included cognitive impairment and physical challenges, he was at risk for falls, and had been referred to therapy. Other goals included were to continue to monitor and readjust medications as needed. An interview on 7/18/23 at 2:45 p.m. with Occupational Therapist (OT) NNN revealed that residents with cognitive issues are usually housed on the fourth floor. The fourth floor is the only floor with elevators that require a password to open the elevator doors, and password to activate the elevator buttons to go up or down. The first, second and third floor elevators do not require a code to open the elevators doors or go down but do require a code to go up. Record review for R#20 revealed an initial psychiatric evaluation on resident on 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that R#20 had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation, and frequent reorientation to reality. A review of the provider notes for R#20 dated 2/1/23 revealed a post hospitalization status note for his return to the facility on [DATE] revealed and order for every 15-minute checks, and a new medication order for 25mg Seroquel every evening. The record revealed, Today resident is sitting up in bed, comfortable, denies pain. He is hard of hearing, confused at times, has difficulty following conversation and answering questions. The plan at readmission included, but was not limited to, dementia, continue on Razadyne, and for major depressive disorder, continue on Seroquel and Trazadone, continue to follow with psychiatry, and continue on every 15-minute checks for behaviors. A review of the progress notes for R#20 revealed that on 2/1/23 at 7:13 a.m. the resident was roaming in hallways and kept on close monitoring with every 15-minute checks. A review of the Psychiatric follow-up visits for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission and to consider Gradual Dose Reduction (GDR). Staff had reported resident to be alert, confused, forgetful, ambulates and is incontinent at times. The resident is also reported to continue wandering and is not manageable at times, difficult to redirect verbally and not as co-operative with care and medications. No suicidal or homicidal ideations. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote. Check testosterone level. Plan to consider Depo-Provera if the sexually inappropriate behavior continues. Provide cognitive social stimulation and frequent reorientation to reality, continue close monitoring. Behavioral interventions to include distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nursing note dated 2/4/23 at 11:30 a.m., revealed R#20 was on an every 15-minute observations related to behaviors. Record review for R#20 revealed that on 2/4/23 at 3:01p.m., The resident got on elevator and refused to get off. (R#20) went down to the first floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect (R#20). (R#20) requesting to leave the facility. R#20 spoke to the nurse, scheduler, and Doctor (Dr.) ZZZ, in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility against medical advice. During an interview with R#20's representative on 7/12/23 at 3:13 p.m. s/he stated that R#20's was put out of the facility with a garbage bag and a wheelchair. S/he stated that s/he was informed that R#20 signed a paper that was read to him. The R#20's representative stated that, when s/he examined the form, the signature that was on the form wasn't R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair and still was never told why R#20 was discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and because he was short of breath and the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin. S/he stated that the cousin then called them of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home from the apartment. R#20's representative stated that R#20 had been with them for less than a week and had to go to the hospital. S/he stated that R#20 was now residing in another facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. An interview on 7/12/23 at 3:50 pm. with Dr. ZZZ revealed that he was there on the day R#20 was discharged AMA. He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, he talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and that he told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ stated that upon leaving the facility, he saw R#20 going up the road, stopped and offered him some money, a ride, a call to Uber, or money to get a hotel room but R#20 refused. An interview with the Regional VP of Operations was conducted on 7/12/23 at 4:15p.m. revealed that R#20 had not had an appropriate discharge. An interview with Licensed Practical Nurse (LPN) HH on 7/12/23 at 4:45 p.m. revealed that she was the supervisor that weekend and revealed that R#20 was on every 15 minutes one-to-one watch related to the incident that occurred with the resident in January 2023. She could not recall what doctor was in the facility on 2/4/23 but does remember that it was a Saturday. She revealed that she saw R#20 leave the building and stated that the nurse on duty made the note regarding how R#20 left. LPN HH stated she had received training on handling difficult behaviors, dementia training, and AMA training. She stated that she was supposed to check what the residents BIMS score was if the resident wanted to sign out of the facility AMA, but she didn't check R#20's BIMS score because she was just the supervisor. A phone interview with CNA/Scheduler OO on 7/13/23 at 10:05 a.m. revealed that she was present but was unsure if she was the one who read the AMA form to R#20. She said that she was passing by and did not have much to do with the situation. She was not sure if she observed R#20 sign the AMA but was asked to sign the form because she was present. A phone interview was conducted on 7/13/23 at 6:15 p.m. with LPN CCC revealed that she was an agency nurse that had only worked one shift at the facility, she verified that she had worked on Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred with R#20 and stated that the resident had become adamant that he was going home and stated that he was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA paper to R#20. She stated that R#20 did sign the AMA form and that the doctor and she were standing in front of the door. Due to R#20 being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN stated that she did not see him leave with anyone or get in any car. It was determined that the temperature on 2/4/23 was between 34 degrees Fahrenheit and 46 degrees Fahrenheit. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23, at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to freedom from abuse and neglect, to review the findings for the IJ, and plan for removal of the IJ issues. 2. On?7/13/23,?the Center Director of Operations, DON, and Regional Director of Clinical Services reviewed the center policy?on Abuse, Neglect and Exploitation.? No changes or recommendations were made or given. 3. On 7/13/23, to identify other residents that may be affected by this practice, an 100% review of residents with known mood and behavioral problems with a verbal expression to leave the facility AMA were reviewed by the unit manager (a licensed nurse) of residents for the past 30 days (6/13/23 through 7/13/23) to ensure appropriate follow-up for care needs are provided and to ensure the necessary supervision is provided to prevent neglect and to provide a safe discharge for residents who express expressed a desire to leave the facility against the advice of the physician. Any resident found to have had a change in mood and behavior related to their desire to leave AMA without appropriate supervisions was investigated and corrective actions taken. 4. On 7/13/23, the UM (a licensed nurse) reeducated licensed nurses, CNA's, social services, dietary, environmental, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Currently there are 16 of 19 licensed nurses of which 88% have been educated; dietary six of seven (86%), activities staff two of two (100%); administration staff seven of eight (88%) , physician services four of four (100%), CNA's 10 of 11 (91%), CMA's four of four (100%), therapist eight of nine (89%) Respiratory Therapist two of three (67%), social services three of three (100%) and environmental services 13 of 13 (100%) staff have been reeducated. Staff members who did not attend the reeducation will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, department supervisor, or Charge Nurse. Newly hired clinical staff such as agency or as needed (PRN) staff will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 5. The Regional Director of Clinical Services reeducated the centers Interim DON, UM's, and MDS team on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. 6. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on 7/14/23. 7. All corrective actions were completed on 7/14/23. 8. The facility alleges that the IJ was removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the sign-in sheet revealed a Plan of Correction (PoC) meeting was held on 7/13/23 with Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to freedom from abuse and neglect, to review the findings of the survey, and plan for removal of IJ issues. R#20 was verified as being discharged from the Center on 2/4/23. 2. A review of the sign-in sheet revealed on 7/13/23,?the Center Director of Operations, DON, and Regional Director of Clinical Services reviewed the center policy?on Abuse, Neglect and Exploitation and no changes or recommendations were made or given. 3. A review of the census revealed 100% audit was conducted on residents with known mood and behavioral problems with a verbal expression to leave the facility AMA were reviewed by the UM (a licensed nurse) of residents for the past 30 days (6/13/23 through 7/13/23) to ensure appropriate follow-up for care needs were provided and to ensure the necessary supervision is provided to prevent neglect and to provide a safe discharge for residents who express expressed a desire to leave the facility against the advice of the physician. 4. A review of sign-in sheets revealed staff were educated 7/13/23 on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. A total of 73 staff members was documented as being in attendance. The ad hoc sign-in sheet dated 7/13/23 revealed that the Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members were in attendance. Interview with Nurse Practitioner (NP) BBB on 7/17/23 at 1:52 p.m.; with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) AAA on 7/17/23 at 2:27 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m. It was confirmed thru interviews that they had attended an ad hoc meeting and was reeducated on Abuse, Neglect and Exploitation. 5. A review of sign-in sheet revealed Clinical Services reeducated the centers Interim DON, UM's, and MDS team on 7/13/23 on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge six staff members on attendance. This was confirmed by the DON during interview. During an interview with the DON on 7/17/23 at 4:10 p.m. and with LPN/UM AAA on 7/17/23 at 4:31 p.m. it was confirmed thru interviews that they had received reeducation on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge and that they had attended the emergency ad hoc in-service with the Regional Director of Operations. 6. A review of the sign-in sheet signatures revealed Ad Hoc Quality Assurance Performance Improvement Committee was conducted on 7/14/23 to review audits and findings. 7. All corrective actions were verified as being completed on 7/14/23. 8. The IJ was verified as being removed on 7/15/23.

Based on staff interviews, resident representative interviews, record reviews, and the facility policy titled Transfer and Discharge (including AMA), the facility failed to ensure one of 32 sampled residents (R) (R#20) had an appropriate discharge by ensuring the resident's cognitive level and mental status was appropriate for him to make an informed decision for self-discharging by signing an Against Medical Advice (AMA) form and exiting the facility. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record reviews, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: A review of the policy titled Transfer and Discharge (including AMA) with reviewed/revised date of January 2023 indicated: In cases of a resident desiring to be discharged AMA, the resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives of both. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of the physician's notification should be entered in the nurses' notes by the nurses' department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present. Notify Adult Protective Services, or other entity, as appropriate if self-neglect is suspected, and document accordingly. A review of the clinical record for R#20 revealed he was admitted to the fourth floor at the facility on 12/12/22 with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. It was noted that R#20 was moved from the fourth floor to a less secured unit on the second floor on 1/29/23 and remained on that unit until discharged from the facility on 2/4/23. A review of R#20's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as a six (the scale of 0-6 indicates the resident has severe cognitive impairment); exhibited no mood or behavioral issues; no psychosis was noted and no behaviors exhibited; required limited assistance from staff with bed mobility, transferring, walking in the room, walking in the corridor and locomotion; required one-person physical assistance from staff for dressing, toileting, and personal hygiene; requires needs supervision with eating (set up only). It was also noted that R#20 was not steady and only able to stabilize with staff assistance and does not use any mobility devices. At the time of this assessment, R#20 was receiving antidepressant medication. The discharge MDS dated [DATE] revealed he was also receiving antipsychotic medication. A review of the discharge information from the previous facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needs placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Record review also revealed the resident was not independent prior to admission to a previous facility and had been living with his family. His discharge goal barriers included cognitive impairment and physical challenges. He was determined a fall risk and had been referred to therapy. Interventions included to continue to monitor and readjust medications as needed. An interview on 7/18/23 at 2:45 p.m. with Occupational Therapist (OT) NNN revealed that residents with cognitive impairments are housed on the fourth floor, which is the only floor with elevators that require a password to open the doors and requires a password to activate the elevator buttons to go up or down. OT NNN confirmed that the first, second, and third floor elevators do not require a code to open the elevators doors or go down; those elevators only require a code to go up. An interview with the Regional [NAME] President of Operations on 7/18/23 at 2:56 p.m. revealed the fourth floor is utilized for residents with cognitive or behavioral issues, such as wandering. The elevator on the fourth floor requires a code for the elevator doors to open, and to activate the elevator to go down. The first, second and third floor elevator doors will open without inputting a code and can be activated to go to the first floor without a code. Regardless of where the elevator is accessed, a code is required to go up to all floors. A review of an initial psychiatric evaluation for R#20 dated 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that the resident had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation and frequent reorientation to reality. A review of the clinical record for R#20 revealed that on 2/1/23 at 7:13 a.m. the resident was roaming in hallways and kept on close monitoring with every 15-minute checks. A review of the clinical record for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission and to consider Gradual Dose Reduction (GDR). Staff had reported resident to be alert, confused, forgetful, ambulates and is incontinent at times. The resident is also reported to continue wandering and is not manageable at times, difficult to redirect verbally and not as co-operative with care and medications. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote. Check testosterone level. Plan to consider Depo-Provera if the sexually inappropriate behavior continues. Provide cognitive social stimulation and frequent reorientation to reality, continue close monitoring. Behavioral interventions to include distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nurses note dated 2/4/23 at 11:30 a.m., revealed that R#20 was continued every 15-minute observations related to behaviors. A review of the nurses note dated 2/4/23 at 3:01 p.m., revealed the following: The resident got on elevator and refused to get off. Patient went down to 1st floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect patient. Patient requesting to leave the facility. Patient spoke to the nurse, scheduler, and Doctor (Dr. ZZZ), in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility against medical advice. An interview was conducted with R#20's representative on 7/12/23 at 3:13 p.m. S/he stated that R#20 was put out with a garbage bag and a wheelchair. S/he stated that R#20 signed a paper that was read to him but when they reviewed the form, it was not R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair, and no one explained why R#20 had been discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and, because he was short of breath, the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin and the cousin then called them to inform of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home but less than a week later, R#20 had to be taken to the hospital. S/he also stated that R#20 was now in another skilled nursing facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. An interview on 7/12/23 at 3:50 pm. with Dr. ZZZ revealed that he was at the facility on that day R#20 was discharged . He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ ended the phone interview stating that upon leaving the facility, he saw R#20 going up the road and he stopped R#20 and offered him some money, a ride, a call to Uber, or money to get a hotel room. He stated that R#20 refused. During an interview with the Regional VP of Operations on 7/12/23 at 4:15p.m. they confirmed that R#20 had not had an appropriate discharge. An interview with Licensed Practical Nurse (LPN) HH on 7/12/23 at 4:45 p.m. revealed that she was the supervisor the weekend when R#20 was discharged and stated that R#20 was on every 15 minute one to one watch related to the incident that occurred with the resident in January 2023. She could not recall what doctor was in the facility that day but does remember that it was a Saturday. She revealed that she saw R#20 leave the building and stated that the nurse on duty made the note regarding how R#20 left. She confirmed that she had received AMA training and that she was supposed to check the residents BIMS score if the resident wanted to sign out of the facility AMA. She confirmed that she didn't check R#20's BIMS score because she was just the supervisor. A phone interview was conducted on 7/13/23 at 6:15pm, with LPN CCC revealed that she was an agency nurse that had only worked one shift and revealed that the one shift that she worked was on 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred. She stated that the resident had become adamant that he was going home and stated that he was growing more and more agitated. LPN NNN revealed that the doctor and herself read the AMA paper to R#20. She stated that R#20 did sign the AMA form. LPN NNN also stating that the doctor and herself were standing in front of the door, and due to the resident being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN stated that she did not see him leave with anyone or get in any car. LPN NNN confirmed that she had not spoken with R#20's representative prior to his AMA discharge. The facility implemented the following actions to remove the IJ: 1. An Ad hoc meeting was held on 7/13/23, at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, UM's, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to safe resident discharge, to review the findings for the IJ, and plan for removal of IJ issues. 2. R#20 discharged from the center on 2/4/23. 3. On?7/13/23,?the Center Regional Director of Operations, DON, and Regional Director of Clinical Operations reviewed the center policy?on Transfer and Discharge (including AMA). No changes or recommendations were made or given. 4. On 7/13/23, the Regional Director of Clinical Operations reeducated the DON on the importance of ensuring a safe, appropriate discharge process and procedures for residents with mood and behavior who express a desire to leave the facility against the medical advice of their physician to ensure the health and safety of residents and so that residents continue to receive necessary medical interventions upon discharge. 5. On 7/13/23, the UM (a licensed nurse) reeducated licensed nurses, certified nursing assistants, social services, dietary, environmental, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Currently there are 16 of 19 licensed nurses of which 88% have been educated; Dietary six of seven (86%), Activities staff two of two (100%); Administration staff seven of eight (88%), Physician Services four of four (100%), CNAs 10 of 11 (91%), CMAs four of four (100%), Therapist eight of nine (89%) RT two of three (67%), and Social Services three of three 100% have been reeducated. Any staff members who were not reeducated due to vacation, PRN (as needed) status, etc., will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, department supervisor, or Charge Nurse. Newly hired clinical staff such as Agency or PRN staff will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 6. To identify other residents with the potential to be affected by this practice, the DON or a Licensed Nurse reviewed 100% of AMA discharges from 2/4/23 through 7/13/23 to ensure residents with mood and behaviors who expressed a desire to leave the center against the advice of their physician were discharged safely. Any resident that was identified with mood and behavior expressing a desire to leave the center AMA responsible party was contacted to ensure continuity of care could be provided to establish or maintain safety of the resident. 7. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee on 7/14/23. 8. All corrective actions were completed on 7/14/23. 9. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Record Review of the Plan of Correction (PoC) book revealed QAPI meeting minutes with signature sheet of staff in attendance for an Ad hoc QAPI meeting held on 7/13/23 with Medical Director, DON, UM, Regional Director of Operations for Georgia, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members reviewed topics: concerns, Plan of Correction, and QAPI action items. Interview with Nurse Practitioner (NP) BB on 7/17/23 at 1:52 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) on 7/17/23 at 2:27 p.m. revealed they had all received the in-service on safe discharge. 2. Record review of the census list indicated R#20 was discharged from the facility on 2/4/23. 3. Record Review of the PoC book revealed the Regional Director of Operations, the DON, and the Regional Director of Clinical Operations reviewed and approved the policy and procedures on 7/13/23 related to Transfer and Discharge (including AMA) with no changes or recommendations made or given. 4. Record Review of the PoC book revealed record of in-service sheet dated 7/13/23 with the DON signature and educational materials attached indicated she received education related to safe discharge. Interview with the DON on 7/17/23 at 4:10 p.m. revealed she received education from the Regional Director of Clinical Services on behavior changes to notify physician's and responsible party and on safe discharge. 5. Record Review of PoC book revealed record of in-service sheet dated 7/13/23 with staff signatures and educational materials attached indicated the UM (a licensed nurse) reeducated licensed nurses, CNA's, social services, dietary, environmental, and facility administrative staff on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Interview with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m. Revealed they had been reeducated related to safe discharges. 6. Record Review of PoC revealed the DON and a Licensed Nurse reviewed 100% of AMA dated 7/13/23 listed discharges from 2/4/23 through 7/13/23. Interview conducted on 7/17/23 at 4:30 p.m. with LPN AAA reported she conducted the 100% AMA discharge audit. She reported they only had one resident (R#20) to discharge since 2/4/23. She confirmed she received education over the discharge process. She reported if a resident is not able to make decisions, they would be not allowed to sign out AMA. She reported they would notify the physician, family, and if necessary, the police. She reported they would not allow them to leave but keep them safe. 7. Interview conducted on 7/17/23 at 3:50 p.m. with the Regional Director of Operations reported that he reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee on 7/14/23. Record Review of PoC revealed QAPI Meeting Minutes dated 7/14/23 with signatures of staff in attendance and topics reviewed: Concerns included PoC and QAPI action items in addition to review of audits that were completed as a part of the removal plan and PoC. 8. All corrective actions was verified to have been completed on 7/14/23. 9. It was verified that the IJ was removed on 7/15/23.

Based on staff interviews, resident representative interviews, record reviews, and the facility policy titled Transfer and Discharge (including AMA), the physician failed to assess one of 32 sampled residents (R) (R#20) to ensure the resident's cognitive level and mental status was appropriate for him to make an informed decision for self-discharge by signing an Against Medical Advice (AMA) form and exiting the facility. On 2/4/23, the resident was allowed to sign an AMA form and then exited the facility without the knowledge or assistance from his representative or a discharge plan in place. A review of Psychiatric Evaluations and facility assessments revealed that R#20 was unable to make safe self-care decisions. On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record reviews, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: A review of the clinical record for R#20 revealed he was admitted to the facility on [DATE] with diagnoses of, but was not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, hypertensive heart disease with heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, major depressive disorder, muscle weakness, peripheral vascular disease, abnormalities of gait and mobility, epilepsy, and anemia. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#20 presented with a Brief Interview for Mental Status (BIMS) score of six. The scale of 0-6 indicates the resident has severe cognitive impairment. A review of the discharge information from the previous skilled nursing facility for R#20 revealed the reason for resident transfer to an alternate facility on 12/12/23 was that the resident was a safety/elopement risk and needs placement in a memory care unit. A recap of the resident's stay revealed that the long-term care resident had safety/elopement risks, and transfer to another facility that could best meet his needs. Further review revealed the resident was not independent prior to admission to the previous facility and had been living with family. His discharge goal barriers included cognitive impairment and physical challenges. He was determined a fall risk and had been referred to therapy. The interventions included to continue to monitor and readjust medications as needed. A review of an initial psychiatric evaluation for R#20 dated 1/19/23 with the referral for dementia and behavioral disturbances. Psychiatric history revealed that the resident had a diagnosis of alcohol abuse, behavioral disturbances, dementia, history of wandering, exit seeking, and elopement risk. During the psychiatric evaluation he was noted to be confused, disoriented, forgetful and hard of hearing. Assessment and recommendations revealed: Neurocognitive disorder, early onset, moderate to severe; behavioral disturbances; alcohol use disorder; and history of wandering. Recommendations were to monitor closely, provide adequate cognitive social stimulation, and frequent reorientation to reality. A review of the clinical record for R#20 revealed that on 2/2/23, a psychiatric follow-up visit was completed for dementia, behavioral disturbances, history of alcohol, sexually inappropriate behaviors for medication monitoring, prevent avoidable decline, hospital readmission, and to consider Gradual Dose Reduction (GDR). Staff had reported resident was alert, confused, forgetful, was able to ambulate, and was incontinent at times. The resident was also reported to continue to wander and was not manageable at times, difficult to redirect verbally, and not co-operative with care and medications. At the time of the psychiatric exam, the resident was found to be confused with no recall of behaviors. He was unable to answer any questions when asked about depression, suicidal or homicidal ideations, or psychosis. The resident was also reported to not engage in conversation. Recommendations included to discontinue Seroquel and restart on Depakote, check testosterone level, consider Depo-Provera if the sexually inappropriate behavior continues, provide cognitive social stimulation and frequent reorientation to reality, and to continue close monitoring. Behavioral interventions included distraction and validation strategies to de-escalate behaviors, use of stress balls, soothing music, family, and entertainment videos to keep patient meaningfully occupied to decrease negative behaviors. A review of the nurses note dated 2/4/23 at 3:01 p.m., revealed the following: The resident got on elevator and refused to get off. (R#20) went down to first floor trying to leave the facility. Nurse and scheduler tried for 30 minutes to redirect (R#20). (R#20) requesting to leave the facility. Patient spoke to the nurse, scheduler, and Doctor (Dr. ZZZ), in the building. AMA form read to (R#20) in the presence of the writer, scheduler, and (Dr. ZZZ). Patient signed form and left facility (AMA). An interview was conducted with R#20's representative on 7/12/23 at 3:13 p.m. S/he stated that R#20 was put out of the facility with a garbage bag and a wheelchair. S/he stated that s/he was told that R#20 signed a paper that was read to him. R#20's representative stated that the form had a signature on it but that it wasn't R#20's signature. The R#20's representative stated that s/he was never contacted and that there was never a phone call or in-person meeting about discharge planning. R#20's representative stated s/he did return to the facility a week later to return the wheelchair and still was never told why R#20 had been discharged . R#20's representative revealed that s/he was told that R#20 went to some apartments and because he was short of breath, the manager let him in. R#20's representative was also told that the only number R#20 could remember was the phone number of a cousin. S/he stated that the cousin then called them of R#20's location. When R#20's representative arrived, the police were at the apartments. R#20's representative took R#20 home from the apartment. R#20's representative stated that R#20 had been with them for less than a week and had to go to the hospital. S/he also stated that R#20 was now in another facility because the hospital helped find him placement. R#20's representative revealed that s/he could not care for R#20. A phone interview on 7/12/23 at 3:50 p.m. with Dr. ZZZ revealed that he was at the facility on that day R#20 was discharged . He stated that it was a Saturday, and he was called because R#20 did not want to comply. Dr. ZZZ stated that he walked into the situation and tried to diffuse it, talked with R#20 for a few minutes, and stated that R#20 then cussed him out. Dr. ZZZ stated R#20 wanted to leave and he told R#20 that if he was going to leave, that he would have to leave AMA. Dr. ZZZ revealed that he did ask R#20 some questions and they were answered appropriately. Dr. ZZZ stated he knew R#20 had dementia but didn't have time to assess him any further. Dr. ZZZ confirmed that R#20 did sign the AMA form. Dr. ZZZ ended the phone interview stating that upon leaving the facility, he saw R#20 going up the road and he stopped R#20 and offered him some money, a ride, a call to Uber, or money to get a hotel room. He stated that R#20 refused. A phone interview was conducted on 7/13/23 at 6:15 p.m., with License Practical Nurse (LPN) CCC. She revealed that she was an agency nurse that had only worked one shift at the facility and confirmed it was Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred. She stated that the resident had become adamant that he was going home and stated that R#20 was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA form to R#20. She stated that R#20 did sign the AMA form. LPN NNN also stating that the doctor and she were standing in front of the door, and due to the resident being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN confirmed that she had not spoken with R#20's representative prior to his AMA discharge. A phone interview with CNA/Scheduler OO on 7/13/23 at 10:05 a.m. revealed that she was present but was unsure if she was the one who read the AMA form to R#20. She said that she was passing by and did not have much to do with the situation. She was not sure if she observed R#20 sign the AMA but was asked to sign the form because she was present. A phone interview was conducted on 7/13/23 at 6:15 p.m. with LPN CCC revealed that she was an agency nurse that had only worked one shift at the facility, she verified that she had worked on Saturday, 2/4/23. LPN CCC revealed that she remembered the resident and the incident that had occurred with R#20 and stated that the resident had become adamant that he was going home and stated that he was growing more and more agitated. LPN NNN revealed that the doctor and she read the AMA paper to R#20. She stated that R#20 did sign the AMA form and that the doctor and she were standing in front of the door. Due to R#20 being agitated, she stepped to the side and allowed R#20 to go out the door pushing his wheelchair. LPN NNN stated that she did not see him leave with anyone or get in any car. It was determined that the temperature on 2/4/23 was between 34 degrees Fahrenheit and 46 degrees Fahrenheit. A review of the policy titled Transfer and Discharge (including AMA) reviewed/revised in January 2023 indicated: In cases of a resident desiring to be discharged AMA, the resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives of both. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of the physician's notification should be entered in the nurses' notes by the nurses' department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present. Notify Adult Protective Services, or other entity, as appropriate if self-neglect is suspected, and document accordingly. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23 at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, Unit Managers (UM), Regional Director of Operations, VP of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to physician services, to review the findings for the IJ and plan for removal of the IJ issues. 2. Physician CCC no longer serves as an attending physician for any residents at the center and is no longer a provider at the center. 3. R#20 discharged from the center on 2/4/23. 4. On 7/13/23, to identify other residents with the potential to be affected by this practice, an 100% review of residents with known mood and behavioral problems who express a desire to leave the facility against the advice of their physician was completed to ensure ongoing safety of residents who discharged from the center. Any resident identified will be assessed by the Medical Director. 5. On 7/13/23, the Regional Director of Operations, Chief Medical Officer, and Regional Director of Clinical Operations reviewed and reapproved the policy on Medical Staff Credentialing and Privileging. No changes or recommendations were made or given. 6. On 7/13/23, the Chief Medical Officer educated the Medical Director and attending providers on the policy on Physician Services, the importance of ensuring that residents receive appropriate supervision, and medically necessary physician services including participating in the assessment and care planning, monitoring changes in residents' medical status, and providing consultative treatment as needed for residents with mood and behaviors problems who express a desire to leave the center against the advice of their physician in order to ensure ongoing safety and a safe and orderly discharge. 7. Currently, there are four medical providers of which four Medical Providers (100%) were educated. 8. On 7/13/23, to identify other residents with the potential to be affected by this practice, the UM (a licensed nurse) conducted an 100% audit of residents who discharged AMA from 2/4/23 through 7/13/23, were reviewed for appropriate physician services prior to discharge. 9. The Regional Director of Operations reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee on 7/14/23. 10. All corrective actions were completed on 7/14/23. 11. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the Plan of Correction (PoC) book revealed that an ad hoc meeting was held on 7/13/23 with the following staff member present which included the Medical Director, MDS Coordinator, District Leader, Admissions Concierge, LPN UM, Wound Care Nurse, Dietary Manager, LPN, QOL Director, Social Service Director, DON, Human Resource Director, RN, Regional Director of Clinical Operations, VP of Clinical Operations. All staff listed had a signature on the Attendance Sheet. The ad hoc meeting was held on 7/13/23 to address the IJ concerns. The IJ was called on 7/13/23 at 2:19 p.m. The IJ concerns included Physician Services. Interview with Nurse Practitioner (NP) BBB on 7/17/23 at 1:52 p.m., with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) AAA on 7/17/23 at 2:27 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m., with the Director of Nursing (DON) on 7/17/23 at 4:10 p.m. revealed they had received the reeducation and was able to verbalized knowledge related to the training. 2. A review of the facility's tool titled Healing Medical Professionals revealed as of 7/13/23, at 7:43 p.m. Physician CCC had no residents in the facility assigned to his care. During an interview on 7/17/23 at 2:53 p.m. with the Interim Administrator, he revealed that the report was ran on 7/13/23 at 7:43 p.m. that Physician CCC no longer had any resident under his services at the facility. Administrator further stated that Physician CCC was not on staff prior to 7/13/23 and he was not sure of the last date of service. Administrator stated that he is not sure if there was a written notification provided or if the Medical Director gave Physician CCC verbal notification regarding his services at the facility. During an interview on 7/17/23 at 5:11 p.m. with VP of Operations revealed that Physician CCC's R#34 discharged from the facility on 2/9/23 and R#33 discharged from the facility on 2/11/23. He stated that these were the last two residents who were cared for under Physician CCC's services. He further stated that the Chief Medical Officer pulled Physician CCC from the facility's services per a verbal conversation on 2/21/23. 3. A review of the facility's tool titled Healing Census List revealed R#20 had an effective date of discharge from the facility on 2/4/23 at 3:05 p.m. 4. A review of the facility's tool titled Healing Daily Census Audit was conducted on 7/13/23 of all residents who were currently residing in the facility. A review of the audit revealed one resident was identified with increased behaviors and to be at risk of AMA. 5. A review of the facility's policy titled Medical Staff Credentialing and Privileging revealed that on 7/13/23 the policy was reviewed and reapproved with no changes or recommendations made. There were signatures for the Regional Director of Operations, DON, Regional Director of Clinical Operations, and Chief Medical Officer. 6. A review of the facility's tool titled Record of Service dated 7/13/23 revealed the Chief Medical Officer conducted an training titled Physician Services. The content contained the following information: It is important to ensure that residents receive appropriate supervision, and medically necessary physician services including participating in the assessment and care planning, monitoring changes in resident's medical status, and providing consultative treatment as needed for residents with mood and behaviors problems who express a desire to leave against the advice of their physician in order to ensure ongoing safety and a safe and orderly discharge. It is important to document to document your assessment of the resident and to include social services in residents who express a desire to leave the center against medical advice. In addition, the policies on Notification of Change, Abuse, Neglect and Exploitation, Transfer and Discharge Policy and Medical Staff Credentialing/Privileging were discussed. There were four providers listed on the in-service attendance sheet including two Physicians and two Nurse Practitioners. 7. A review of the facility's tool titled Record of Service dated 7/13/23 revealed the Chief Medical Officer conducted a training titled Physician Services. The content contained the following information: It is important to ensure that residents receive appropriate supervision, and medically necessary physician services including participating in the assessment and care planning, monitoring changes in resident's medical status, and providing consultative treatment as needed for residents with mood and behaviors problems who express a desire to leave against the advice of their physician in order to ensure ongoing safety and a safe and orderly discharge. It is important to document to document your assessment of the resident and to include social services in residents who express a desire to leave the center against medical advice. In addition, the policies on Notification of Change, Abuse, Neglect and Exploitation, Transfer and Discharge Policy and Medical Staff Credentialing/Privileging were discussed. 8. A review of the facility's tool revealed that LPN UM AAA conducted an 100% audit of residents who discharged from the facility AMA from 2/4/23 through 7/13/23. The audit concluded with only one resident, R#20, who discharged AMA during the timeframe. During an interview conducted on 7/17/23 at 4:30 p.m. with LPN AAA she reported she conducted the 100% AMA discharge audit. She reported they only had one residents R#20 to discharge since 2/4/23. She confirmed she received education over the discharge process. She reported if a resident is not able to make decisions, they would be not allowed to sign out AMA. She reported they would notify the physician, family, and if necessary, the police. She reported they would not allow them to leave but keep them safe. 9. A review of the PoC audits were reviewed and shared with the Ad Hoc QAPI Committee on 7/14/23 with staff members present including the Medical Director, MDS Coordinator, District Leader, Admissions Concierge, LPN UM, Wound Care Nurse, Dietary Manager, LPN, QOL Director, Social Service Director, DON, Human Resource Director, RN, Regional Director of Clinical Operations, VP of Clinical Operations. All staff listed had a signature on the attendance sheet. 10. All corrective actions were verified as being completed on 7/14/23. 11. The IJ was verified as being removed on 7/15/23.

Based on record review, review of the Nursing Home Administrator and Director of Nursing (DON) job descriptions, and staff interviews, the facility administration failed to effectively oversee the facility's discharge process resulting in an unsafe discharge for one of 32 sampled residents (R) (R#20). On 7/13/23, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Regional Director of Operations (Interim Administrator), the [NAME] President (VP) of Clinical Operations, and the Regional Director of Clinical Operations were informed of the Immediate Jeopardy (IJ) on 7/13/23 at 2:19 p.m. The noncompliance related to the IJ was identified to have existed on 2/4/23. An acceptable removal plan was received on 7/15/23. Based on observation, record reviews, review of facility policies as outlined in the removal plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 7/15/23. Findings included: The facility job description for Administrator revealed that the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The facility job description for DON revealed that the position purpose is planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents.' Facility Administration, specifically the Administrator and DON, failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to ensure the resident representative was notified of an increase in R#20's mood and behaviors and failed to notify the resident's representative of resident signing an AMA and was being discharged from the facility. Cross refer to F580. 2. Administration failed to ensure that R#20 was protected from neglect by facility staff. Cross refer to F600. 3. Administration failed to ensure a safe and orderly discharge from the facility for R#20. Cross refer to F624. 4. Administration failed to ensure that R#20 was medically evaluated, supervised, and monitored by the Physician. Cross refer to F710. An interview on 7/12/23 at 4:15 p.m. with the Regional Director of Operations (acting as interim Administrator) revealed R#20 was not appropriately appropriate discharge. The facility implemented the following actions to remove the IJ: 1. An ad hoc meeting was held on 7/13/23, at 3:00 p.m. with Medical Director, Center Nurse Practitioner, DON, Unit Managers (UM), Regional Director of Operations, [NAME] President of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members to address concerns identified during the survey process related to administration to review the findings for the IJ and plan for removal of the IJ issues. 2. R#20 was discharged from the center on 2/4/23. 3. On?7/13/23,?the Center Regional Director of Operations, Chief Medical Officer, and Regional Director of Operations reviewed the center policies?on Notification of Change, Abuse and Neglect, and Transfer, Discharge (including AMA).? No changes or recommendations were made or given. 4. On 7/13/23, the Regional Director of Clinical Services reeducated the center's administration to include Nursing Administration, Social Services on the importance of implementing effective processes for residents with mood and behaviors who express a desire to leave the center against the medical advice of their physician to ensure family/responsible party is notified, implementing care consistent with the resident's care plan, and to arrange a safe and orderly discharge. Education included making sure nursing staff is knowledgeable about safe discharge practices. 5. On 7/13/23, the UM (a licensed nurse) reeducate licensed nurses, Certified Nursing Assistants (CNA's), social services, dietary, environment, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Education was also conducted to licensed nurses on the importance of notifying the responsible party/family member of residents with mood and behaviors who expressed a desire to leave the center against the medical advice of their physician. Education was also conducted on providing a safe and orderly discharge for residents with mood and behavioral problems to ensure ongoing safety and to provide continuity of care after discharge to the facility staff. Currently there are 16 of 19 licensed nurses of which 88% have been educated; dietary staff six of seven (86%), activities staff two of two (100%); administration staff seven of eight (88%), physician services four of four (100%), CNAs 10 of 11 (91%), Certified Medication Assistants (CMAs) four of four (100%), therapist eight of nine (89%), Respiratory Therapist two of three (67%), social services three of three 100% and environmental services 13 of 13 (100%) of staff have been educated. Any staff members who were not reeducated due to vacation, as needed (PRN) status, etc., will be reeducated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor, department supervisor, or Charge Nurse. Newly hired clinical staff such as agency or PRN staff will be reeducated during orientation or prior to assuming the responsibilities of their designated shift by the DON or Nurse Manager. 6. On 7/13/23, the Regional Director of Clinical Services educated the DON on addressing behaviors changes that can lead to unsafe resident discharges. Education also included responsible party notification and physician notification of change in behaviors. 7. On 7/13/23, the Regional Director of Operations reviewed job descriptions for Administrator and DON to ensure that they understand their duties and responsibilities. Review shows that Administrator and DON can carry out their job duties. 8. The Regional Director of Operations reviewed the results of the findings from the facility's oversight and shared the findings with the Ad Hoc QAPI Committee on 7/14/23. The Regional Director of Operations will share the findings of audits related to proper notification to responsible parties and/or legal representatives with the QAPI Committee. 9. All corrective actions were completed on 7/14/23. 10. The facility alleges that the IJ is removed on 7/15/23. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the ad hoc sign-in form dated 7/13/23 revealed that the Medical Director, Center Nurse Practitioner, Director of Nursing, Unit Managers, Regional Director of Operations for Georgia, [NAME] President of Clinical Services, Regional Director of Clinical Operations, Maintenance Director, and other center management team members had attended the meeting. Interviews with Nurse Practitioner (NP) BBB on 7/17/23 at 1:52 p.m., with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Maintenance Director (MD) on 7/17/23 at 2:17 p.m., with LPN Unit Manager (UM) AAA on 7/17/23 at 2:27 p.m., Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m., DON on 7/17/23 at 4:10 p.m. revealed they had received education on the five IJ citations and was able top verbalize the information revealed in the training. 2. A review of electronic health records revealed R#20 left the facility AMA on 2/4/23. A review of PoC book revealed the facilities census list indicated discharge date of [DATE] for R#20. 3. A review of PoC book revealed Regional Director of Operations, DON, and Regional Director of Clinical Operations reviewed and approved the Transfer and Discharge (including AMA) policy and procedures on 7/13/23 and there were no changes or recommendations made or given. 4. A review in-service sheet dated 7/13/23 revealed the Regional Director of Clinical Services reeducated the center's administration to include Nursing Administration, Social Services on the importance of implementing effective processes for residents with mood and behaviors who express a desire to leave the center against the medical advice of their physician to ensure family/responsible party is notified, implementing care consistent with the resident's care plan, and to arrange a safe and orderly discharge. Education included making sure nursing staff is knowledgeable about safe discharge practices. 5. A review of the in-service sheet dated 7/13/23 with staff signatures and educational materials attached indicated the UM (a licensed nurse) reeducated licensed nurses, CNA's, social services, dietary, environmental, and facility administrative staff on abuse prevention, recognition, and prevention of neglect and on the importance of providing a safe discharge for residents with mood and behavior that express a desire to leave the center against the advice of their physician to ensure a safe discharge. Interview with the Dietary Manager (DM) on 7/17/23 at 2:09 p.m., with the Admissions Concierge (AC) on 7/17/23 at 2:37 p.m., with the Director of Social Services (DSS) on 7/17/23 at 2:55 p.m. revealed they had received the in-serviced by the Director of Nursing and Regional Director of Clinical Operations and were able to verbalize knowledge and understanding. 6. A review of sign in sheet dated 7/13/23 revealed an in-service conducted by the Regional Director of Clinical Services provided to the DON. Interview with the DON on 7/17/23 at 4:10 p.m. revealed she received education from the Regional Director of Clinical Services on behavior changes to notify physician's and responsible party on 7/13/23. 7. A review of the job description for the Administrator and DON revealed that it was reviewed by the Regional Director of Operations on 7/13/23 to ensure that they understand their duties and responsibilities. Review shows that Administrator and DON can carry out their job duties. 8. Interview conducted on 7/17/23 at 3:50 p.m. with the Regional Director of Operations reported that he reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee on 7/14/23. A review of the PoC revealed QAPI Meeting Minutes dated 7/14/23 with signatures of staff in attendance and topics reviewed: Concerns, PoC, and QAPI action items in addition to review of audits that were completed as a part of the removal plan and plan of correction. 9. All corrective actions were verified to have been completed on 7/14/23. 10. It was verified that the IJ was removed on 7/15/23.

Based on record review, review of facility policy titled Comprehensive Care Plans and staff interviews, the facility failed to develop a person-centered comprehensive care plan with interventions that specified the need for monitoring for a resident with side rails, assessment of the need for side rails, alternatives to side rails that had been attempted, education of the family member requesting the side rails, and the increased risk of using an air mattress with side rails for one resident (R) (#23) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J) C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J). The facility had not provided a Removal Plan at the time of exit on 7/10/19 therefore the IJ is ongoing. Findings include: A review of the facility policy titled Comprehensive Care Plans revised on 7/19/18 revealed the following: A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs . Each resident's Comprehensive Care Plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. j. Reflect currently recognized standards of practice for problem areas and conditions. The interventions will reflect action, treatment or procedure to meet the objectives toward achieving the resident goals. The care plan should reflect the current status of the resident and be updated with changes in resident status. The attempts to find alternative means to address the identified need/risk shall be documented in the care plan. Review of the clinical record revealed R#23 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Event Manager revealed the above incident occurred on 4/1/19 for R#23 as follows: R#23 was observed on floor on buttocks with neck lodge (sic) between bed and railing. Fall mats were documented in place next to the bed and the bed was in low position. The attending Physician for R#23 was notified on 4/1/19 at 6:23 a.m. and the Responsible Party (RP) was notified on 4/1/19 at 6:40 a.m. R#23 was transported to the hospital. A description of precipitating factors included the air mattress on bed was inflated high. Continued review of the Event Manager revealed a staff member, Certified Nursing Assistant (CNA) DD, documented that the air mattress sometimes inflates too high and moves the patient. The room mate of R#23 had notified LPN GG that R#23 was on the floor. LPN GG documented that there was no injury. Review of R#23's comprehensive care plans revealed side rails had not been included in any problem areas on the electronic medical record or on the care plan in the paper clinical record. A comprehensive care plan for Activities of Daily Living (ADL), dated 11/4/15, included an intervention, dated 3/23/17, for side rails to be used as an enabler. Review of an interdisciplinary care plan for falls revealed on 5/28/19 R#23 fell without injury. Interventions on this care plan included half (1/2) side rails to define bed boundaries. There was no further mention of side rails on this care plan. Review of the undated Certified Nursing Assistant (CNA) Care Card, found in a binder at the Nurses Station for R#23, revealed under the heading of Safety/Positioning Devices, Side rails were to be kept down. Interviews conducted with CNA XX on 6/26/19 at 9:32 a.m., CNA YY on 6/26/19 at 9:35 a.m., and CNA ZZ on 6/26/19 at 9:35 a.m. revealed they keep the side rails up when R#23 is in bed. The CNA's revealed that the resident has always had half side rails since they started working with her, except for a few weeks after she fell and was caught in them. The CNA's also revealed the CNA care plans are not kept up to date and they do not check them because they get their information from other CNA's and the nurses. The CNA's revealed they had never seen R#23 move and did not know how she fell out of bed twice. During an interview on 7/2/19 at 9:00 a.m., Licensed Practical Nurse (LPN) BBB revealed she has worked with R#23 intermittently for nine years. LPN BBB stated R#23 has always had two top half side rails, for as long as she can remember, and half rails are all she has seen in the facility. LPN BBB revealed she will sometimes update the CNA care plans, but the Unit Manager and the DON usually take care of that. LPN BBB revealed she does not see the CNA's checking their care plans very often. An interview was conducted on 7/2/19 at 3:30 p.m. with the former Director of Nurses (DON). The former DON reviewed the CNA care plan for R#23 and revealed she had updated the CNA care plan when R#23 fell and was entrapped in the rail on 4/1/19. She revealed they had fastened R#23's rails so they could not be raised, then a few days later when the family gave permission the Maintenance Director removed the rails. The former DON revealed she had not updated the CNA care plan when the resident fell again on 5/28/19 and the family requested the side rails be reinstalled. The former DON reviewed the paper care plan for R#23 and stated this was the current updated care plan and acknowledged there was no problem listing for side rails. The former DON then reviewed the policies for bed safety and comprehensive side rails. She stated since the policies did not specifically state that side rails were to be care planned as a problem with interventions to keep the resident safe from injury or entrapment, she thought the care plans were adequate and did not need to include the side rails as a problem with potential risks. The former DON revealed she was aware that side rails do present a risk to some residents. A resident with side rails should be monitored more frequently and positioned away from the edges of the bed. The rails should be checked for gaps, wear and loosening periodically. If an air mattress is used concurrently there is additional risk because the edges of air mattresses compress and can cause a resident with no independent movement to be rolled off the bed. The former DON refused to answer if any of this missing information should have been included in a person-centered care plan, or if the care plans for R#23 were person centered. The former DON revealed she expected the Unit Managers to provide the interdisciplinary team with care planning needs for all residents, to review and identify both comprehensive and CNA care plans that needed updating, and to identify residents that have potential problems and immediate risks that should be care planned. Cross refer to F700

Based on observation, staff interviews, facility and hospital clinical record review, review of the facility policy titled Bed Safety, and review of the Food and Drug Administration (FDA) guidelines titled Recommendations for Health Care Providers about Bed Rails, the facility failed to provide an environment free from the risk of entrapment within the side rail or between the side rail and air mattress for two residents (R) (#23 and #24) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J) C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J). The facility had not provided a Removal Plan at the time of exit on 7/10/19 therefore the IJ is ongoing. Findings include: Review of the facility policy titled Bed Safety revised 1/2/19 revealed the interdisciplinary team shall assess the residents sleeping environment, with input from the resident and family. If side rails are used their use must be reevaluated quarterly and as needed (prn). If a bed rail is to be used it will be installed when the attempt to use an appropriate alternative has not been effective and did not meet the resident's needs. Review of Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued 3/10/06 revealed reassessment of bed safety programs may be appropriate when accessories such as mattress overlays are added. Powered air mattress replacements are easily compressed by the weight of a patient and may pose additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bed rail may increase and pose an additional risk of entrapment. When rail entrapment occurred the most commonly injured body parts were the head and neck and 143 out of 145 events resulted in fatalities. Use of bedrails should be based on patient's assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bedrail effectiveness should be reviewed on a regular basis. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of [REDACTED]. Monitoring of the bed, mattress and accessories should be ongoing. Review of the undated FDA document titled Recommendations for Health Care Providers about Bed Rails revealed the facility should inspect and regularly check the mattress and bedrails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body . Inspect, evaluate, maintain and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement, or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or water bed. 1. A review of the clinical record revealed R#23 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Quarterly and Annual Minimum Data Sets ((MDS) dated [DATE], 2/5/19 and 5/7/19 revealed R#23 had a Brief Interview for Mental Status Score of 00, indicating severe cognitive impairment. R#23 was also assessed to require extensive two person assist for bed mobility, was totally dependent for transfers and had impaired movement of both upper and lower extremities on both sides. A review of Physician's Orders for R#23 revealed an order dated 1/15/19 for quarter side rails bilateral/enabler. On 4/16/19 the Physician ordered to discontinue (dc) side rails, continue air mattress with bolsters. On 6/4/19 the Physician ordered may have bilateral half (½) side rails to define bed boundaries, per family request. There were no orders prior to 1/15/19 for side rails. Review of the Evaluation for Use of Side Rails dated 10/31/18 and 11/8/18 revealed side rails were being considered to allow resident increased bed mobility. No was checked indicating the side rails would not assist the resident with bed mobility, transfer, avoiding rolling out of bed, or provide a sense of security. Recommendation was that side rails were not indicated at this time. One-fourth partial rails and one-half partial rails were checked on the 11/8/18 assessment but not addressed on 10/31/18. Side rails precautions and alternatives to side rails was not checked as being discussed with the resident or family/resident representative. Review of the Evaluation for Use of Side Rails dated on 4/10/19 (five months from the previous assessment and nine days after the entrapment of R#23) continued to reveal that side rails were not assisting the resident, that side rails were not indicated, and documented no reason for the side rails. The evaluation dated 4/10/19 indicated bilateral bolsters were added to the overlay and precautions and alternatives to side rails had been discussed with the resident and family/representative. There were no documented alternatives. The size of the rails was not addressed. Review of the Evaluation for Use of Side Rails dated 4/16/19 revealed the family agreed to the use of bolsters for the air mattress and continued to include that alternatives had been discussed with the family. The Physician discontinued the side rails on this date. A Social Service Progress Note dated 4/17/19 at 8:29 p.m. revealed on 4/8/19 a care plan meeting had been conducted with R#23's son and the Social Service Director (SSD), Director of Nurses (DON), Unit Manager, Wound Care Nurse, and a Certified Nursing Assistant (CNA). The fall risk, interventions in place due to the fall risk, and the risk of the side rails were discussed with the son and he agreed to allow the rails to be removed. There were no previous Social Service progress notes in the clinical record that referred to informing R#23's family of risks of side rails. A review of the care plan for R#23 revealed on 11/4/15, Activity of Daily Living (ADL) was identified as a problem. Interventions for this problem included assist with all transfers, turn and reposition, shifting weight to enhance circulation, range of motion (ROM) provided during ADL care, and on 3/23/17 side rail(s) as an enabler. A fall care plan developed on 11/4/15 revealed R#23 was at risk for fall related injury. On 4/1/19, the fall care plan problem was updated with a fall on 4/1/19 related to poor bed mobility and cognitive deficits. Interventions for fall risk updated on 4/1/19 included side bolsters to mattress and landing mat. Additionally, on 4/1/19, keep side rails down had been crossed through and updated with removed, indicating there were no side rails, dated 4/9/19. There was no other mention of side rails in any other care plans. Review of Event Manager revealed an incident occurred on 4/1/19 for R#23 as follows: R#23 was observed on floor on buttocks with neck lodge (sic) between bed and railing. Vital signs were as follows: blood pressure 146/87, temperature 97.5, pulse 68 and oxygen saturation 96%. R#23 had no falls in the last 90 days. Fall mats were documented in place next to the bed and the bed was in low position. The attending Physician for R#23 was notified on 4/1/19 at 6:23 a.m. and the Responsible Party (RP) was notified on 4/1/19 at 6:40 a.m. R#23 was transported to the hospital. No time was provided for this transfer. A description of precipitating factors included the air mattress on bed was inflated high. Continued review of the Event Manager revealed a staff member, Certified Nursing Assistant (CNA) DD, documented that the air mattress sometimes inflates too high and moves the patient. The roommate of R#23 had notified LPN GG that R#23 was on the floor. LPN GG documented that there was no injury. A review of the hospital clinical record revealed R#23 arrived in the ED on 4/1/19 at 7:40 a.m. and was seen by the ED Physician at 8:03 a.m. R#23 was transported by Emergency Medical Services (EMS). The ED Physician's History revealed the patient was found on the ground that morning with her neck between the bed rails. The ED Physicians Physical examination revealed R#23 had a contusion on the left parietal region (bruise on the left side of the top of her head). The radiologist's interpretation of a Computerized [NAME]ography (CT) scan for R#23 revealed she had a left frontoparietal scalp hematoma, otherwise no acute intracranial abnormality. The ED Physician also ordered a cervical spine CT scan. The radiologist's interpretation revealed R#23 had a history of [REDACTED]. R#23 was stable for discharge at 9:23 a.m. A list of active rentals of air mattresses as of 6/27/19 was reviewed and R#23 had been provided with her current air mattress on 8/19/18. The manufacturers recommendations for the brand of air mattress that was indicated on the above list of active rentals for R#23 were requested on 6/26/19 at 1:35 p.m.; however, were not received until 7/1/19 at 2:09 p.m. and included the following: * When using side rails and/or assist devices, use a mattress thick enough and wide enough so that the gap between the top of the mattress and the bottom of the side rails and the gap between the side of the mattress and the side rails is small enough to prevent a patient from getting his or her head or neck between the mattress and the side rail. Failure to do so could result in serious patient injury or death. * Failure to use bed rails in raised position could lead to accidental falls. Air mattresses have soft edges that may collapse when patients roll to that edge. A review of air mattress audits by the former wound care nurse for R#23 revealed the following: On 8/20/18 the air mattress of R#23 was documented on the audit sheet. Her documented weight was 119.5 pounds (lbs.) with a question mark and the bed setting was not documented. On 9/25/18 the air mattress of R#23 was listed on the audit sheet with a weight of 116.8 and a mattress setting of 150 lbs. On 10/5/18, R#23's air mattress audit was documented with a weight of 113.3 lbs. and no mattress setting. On 10/3/18, 10/15/18, 10/22/18, and 10/29/18, there were no initials to indicate who performed the audit. R#23's weight was documented as 113.3 lbs. and her low air loss mattress was set at 150 lbs. On 11/6/18, 11/12/18, 11/19/18 and 11/22/18, there were no initials on the audit sheet to indicate who performed the audit. R#23's weight was documented as 115.8 lbs. and the air mattress setting documented was 150 lbs. On 1/14/19, 1/20/19, and 2/5/19, the documentation of the audits of the air mattress had no mattress setting. There were no other audits of air mattress settings for R#23. A review of Quality Performance/Peer Review, Facility Plan of Action/ Continuous Quality Improvement dated 4/1/19 revealed the facility documented on 4/4/19 R#23's incident. Side rails on beds with air mattresses were reviewed and removed if possible. Manufacturers guidelines for all models of air mattresses being used in the building will be obtained and placed at the Nurse's Station. Licensed Nurses and CNA's will be educated on the location of manufacturer guidelines for air mattress use. Licensed Nurse will be educated on checking air mattress setting every shift, checking setting upon notification of problem and checking setting as patients weight changes .Licensed Nurse will be educated . not to use side rails with air mattress unless approved by the Chief Executive Officer (CEO) after entrapment zone review. Licensed Nurses will be educated on side rails: use, assessment, consents, Physician (MD) orders, and care plans. This education was documented initiated on 4/12/19. CNA's, Housekeeping, and Maintenance will be educated to only allow settings to be adjusted by Licensed Nurse or Equipment technician, and to notify Nurse if setting is bumped or changed. This education was documented initiated on 4/10/19. Review of educational records related to side rail entrapment, eliminating side rails, side rail use update, and air overlay with bolsters and positioning in bed properly for R#23 and a town hall meeting on 4/23/19 revealed 57 of 204 staff were educated. This equals 27.94% of all staff educated on side rail safety from 4/1/19 through 5/15/19. Review of the Evaluation for Use of Side Rails dated 6/14/19 revealed side rails for R#23 were evaluated again and included that her son preferred R#23 to have side rails to define the bed edge. The size of the rails indicated upper half rails were to be used. Alternatives to side rails were documented as addressed with the resident and family, but no alternatives were documented. The side rails were evaluated again on 6/20/19 for R#23 and were considered to allow resident increased bed mobility as an enabler/safety. The side rails were to assist the resident to avoid rolling out of bed and provide a sense of security. Observations were conducted as follows: On 6/26/19 at 9:40 a.m., R#23 was up in chair in room. There were half side rails on both sides of the upper half of her bed. A foam pressure relief mattress was on the bed. On 6/26/19 at 2:30 p.m., R#23 was centered in bed on left side with two top half side rails raised. On 6/27/19 at 7:45 a.m., R#23 was turned to the left and was in the center of the bed with two top half side rails raised. On 7/2/19 at 10:35 a.m., R#23 was turned to the right and was in the center of the bed with two top half rails raised. During an interview on 6/26/19 at 7:50 a.m., the former DON revealed R#23 has a history of traumatic brain and cervical spine injury from a motor vehicle accident eleven years ago and has been in this facility since her discharge from the hospital. R#23 has very little movement and requires total care. On 4/1/19, R#23 somehow rolled out of her bed and became entrapped with her head and neck between the side rail and the mattress. R#23 was sent to the hospital and had no injury. The RP received education related to the corporate policy to not have side rails on the beds of residents with air mattresses and he allowed the facility to remove the side rails. Then on 5/28/19, R#23 rolled out of bed again and had no injury, but the son requested the side rails be returned to the bed. The former DON revealed he consented to the air mattress being removed and a pressure relief mattress was put on the bed. The former DON revealed the air mattress on R#23's bed, and the other air mattresses in the facility, had no settings for variable air pressure that were accessible from the outside of the control panel, and there was no bed in the facility that was set on intermittent air pressure. The former DON revealed there was no possibility the air mattress had been set to maximum inflation. During an interview on 6/26/19 at 9:32 a.m., CNA XX revealed she received education related to the proper positioning of residents on air mattresses and watching for gaps between resident's side rails and mattresses that they could become trapped in and injured. CNA XX confirmed the education also included not changing any settings on the control panel and to notify the nurse immediately of the settings were accidentally changed or the mattress seemed to be over inflated. CNA XX revealed she has worked with R#23 for years and she has always had half side rails except for a few weeks after she was caught in the side rails, and also that she has never seen R#23 move her body or extremities independently. During an interview on 6/26/19 at 9:35 a.m., CNA YY revealed she has worked with R#23 many times and she was aware R#23 slid from her bed and her head and neck were caught in her side rail. CNA YY revealed she did not know how this happened because R#23 does not move at all. CNA YY revealed she has never seen R#23 use her side rails for any bed mobility. CNA YY revealed she did not remember attending education related to side rails and the danger of entrapment, and the increased risk of entrapment with air mattresses. CNA YY revealed she was aware that she should always observe for gaps that any resident could become entrapped in between the mattress and side rails, to not touch the control panel settings and to observe for air mattress over inflation and report to the nurse immediately if an air mattress seemed to be malfunctioning. CNA YY revealed R#23 has always had two top half side rails except for a few weeks after she fell the first time. Interview with the new Wound Care Nurse, LPN BB on 6/26/19 at 10:42 a.m. revealed she has been employed by the facility for three weeks and there were no user manuals or factory recommendations attached to the mattress, control panel, or in her office. The Wound Care Nurse revealed she had received education in orientation related to the risks of side rail entrapment and the risks of using air mattresses. Interview on 6/27/19 at 4:55 p.m. with the former DON revealed after reviewing the current and overflow clinical records for R#23, there was no consent for side rails or any indication the RP for R#23 had been informed that the side rails posed a risk for entrapment and that the addition of an air mattress increased the risk for entrapment. The former DON revealed that R#23 had probably had side rails for the [AGE] years she had been a resident in this facility. The former DON acknowledged that there were no side rail assessments found for R#23 prior to (MONTH) (YEAR), and that there is no documentation related to the alternatives to side rails that were attempted or discussed with the RP. The former DON revealed the resident representative had requested side rails after R#23 fell out of bed on 5/28/19. The former DON revealed she expected the Wound Care Nurses to explain the increased risk of using side rails with an air mattress to the resident/resident representative, and to monitor the settings on the air mattress control panels weekly. She revealed she had not reviewed the monitoring of the settings but was aware the former Wound Care Nurse kept them in her office. The former DON revealed she had not in-serviced the new Wound Care Nurse, here for three weeks, related to the weekly monitoring of the air mattress control panel settings. During a telephone interview on 6/27/19 at 5:39 p.m., the former Wound Care Nurse, LPN AAA revealed she remembers R#23 and remembers discussing the air mattress with the RP when it was applied to the bed last summer. LPN AAA revealed she had not provided any information to the resident/resident representative related to the increased risk of entrapment in side rails when used in conjunction with an air mattress. She did not consider that R#23 would have any increased risk because she had contractures of all four extremities and she could not move. LPN AAA revealed she monitored air mattress settings every Monday on every resident with an air mattress and filled out check lists that are located in the Wound Care office. LPN AA revealed she was Wound Care Nurse here for three and a half years and had never seen R#23 move and she had always had bilateral top half rails. She revealed she had never found any of the air mattress settings changed. She had never been told that R#23's air mattress could have been over inflated, and she had not received any education related to the increased risk of entrapment when air mattresses are used for residents with side rails before or after R#23 had been entrapped in her side rail. An interview was conducted on 6/28/19 at 7:16 a.m. with CNA DD. CNA DD was assigned to the care of R#23 on the morning of 4/1/19. CNA DD revealed the roommate of R#23 had called for help when R#23 was found on the floor with her head and neck entrapped in her side rail. LPN GG went to the room first and called for help. The resident was in a praying position on the floor with her head between the air mattress and the side rail which was up. CNA DD stated R#23 could not get up and the air mattress was inflated a lot. LPN GG adjusted the setting to what it should be. CNA DD revealed the resident was last seen by LPN GG at approximately 6:00 a.m. when she administered medications and the roommate called for help between 6:30 a.m. and 6:45 a.m. During an interview on 7/2/19 at 9:00 a.m., LPN BBB revealed she has worked with R#23 intermittently for nine years and she does not move on her own and she has always had two top half rails. LPN BBB revealed she was on duty when R#23 returned from the hospital after entrapment in her side rail and had not noted any bruising or swelling on her head. She revealed she had attended education a few days after the incident related to checking the settings on the air mattress control panel every shift or more often and checking for gaps between the side rails and the mattress and bed frame. An interview with the Staff Development Coordinator (SDC) on 7/2/19 at 9:50 a.m. revealed she had not included information related to the risks of side rails and air mattresses in CNA orientation prior to 4/1/19. The SDC revealed most of the CNA orientation is clinical and the orienting CNA's are provided with mentors and she did not know if any of the mentors mentioned side rail or air mattress risks. The SDC revealed since R#23 was entrapped she has started including information related to risks of side rails and air mattresses in the licensed nurse's orientation and does include their role in monitoring and adjusting settings on the air mattresses as well as monitoring the side rails for gaps and secure placement. An interview was conducted with the Customer Service Representative for the air mattress supplier on 7/3/19 at 11:33 a.m. The Representative revealed he does not recommend any specific setting for air mattresses and leaves this up to the facility and they should adjust according to the resident's comfort and body shape. The Representative revealed the weight settings are just a guide and he has seen them set as much as fifty pounds over what the resident weighs with no issues with the resident's safety. The Representative revealed the weight settings, maximum inflation and alternating pressure are all accessed from the control panel and can be easily changed. The Representative revealed there was always a chance of the resident rolling off the air mattress with the firmer settings and the resident should ideally sink into the mattress about four inches. Further interview with the former DON on 7/2/19 at 3:30 p.m. revealed she expected the Unit Managers, Charge Managers and the Interdisciplinary Team (IDT) to review all new orders and if the order is not appropriate such as ordering quarter rails as an enabler for R#23, this should be brought to the attention of the Physician and corrected. The former DON acknowledged that there are no quarter rails in the facility, only half rails and that R#23 is not capable of using side rails as an enabler. An interview was conducted on 7/2/19 at 4:20 p.m. with the third floor Unit Manager LPN FF. LPN FF was unable to locate any manufacturers guidelines or operators' manuals for the air mattresses for the residents on the third floor. An interview on 7/3/19 at 9:00 a.m. with the Therapy Manager revealed the therapy department has no part in side rail assessments. The Therapy Manager revealed she is very familiar with R#23 and is aware that R#23 does not have the capability to move due to cervical spine and traumatic brain injuries eleven years ago. The Therapy Manager stated she does not know how it would be possible for R#23 to independently move enough to fall off her bed twice. During an interview on 7/3/19 at 1:59 p.m., the Interim DON reviewed the air mattress setting audits conducted by the former Wound Care Nurse for R#23 and confirmed there were many blanks where the weight setting should be filled in, and there were many dates when the weekly monitoring was not completed. When monitoring was completed it did not always include R#23. The Interim DON revealed that education related to air mattresses and side rail risks, documentation and management that was initiated on 4/5/19 was still ongoing. The Interim DON revealed during her review of the audits of documentation she had found many residents without orders, with incomplete and incorrect assessments, and without informed consents for side rails. The Interim DON revealed that she is not sure all the documentation concerns have been corrected. During a telephone interview on 7/5/19 at 12:09 p.m., LPN GG confirmed she was on duty on 4/1/19 at 6:30 a.m. and had been passing medications on the fourth floor. LPN GG revealed she had given a medication in the room of R#23 at approximately 6:15 a.m. and then continued administering medications to other residents on the same hall when approximately 15 minutes later, R#23's roommate came out of the room and said loudly that R#23 was on the floor. LPN GG revealed she immediately went into the room and found R#23 sitting on her bottom on the landing mat beside her bed with her body facing the door and her head caught between the side rail and the mattress with her face turned to face the head of the bed. Her chin was resting on the bottom horizontal rail of the side rail and the bed was in the lowest position. R#23 was not making a sound, her eyes were open, and she was breathing without effort. LPN GG stated she shouted for CNA DD who came right away. They were able to slide the mattress over, put down the rail and get R#23 back into bed. LPN GG revealed the air mattress had felt tight like it was too full. LPN GG checked the settings on the air mattress control panel and the settings were the same as always. Maximum inflation and alternating pressure had not been activated. LPN GG revealed she remembered the weight setting was also where it always was whenever she checked it, on 120 lbs. She had not touched the settings but had reported she and CNA DD had both thought the mattress was over inflated and may have malfunctioned. She had worked with R#23 intermittently for over a year and had never seen R#23 move and could not think of how she could fall. LPN GG revealed she had performed a head to toe assessment and checked vital signs and there was no indication R#23 was injured. An interview with the Medical Director on 7/10/19 at 9:07 a.m. revealed she remembers discussing side rails at Quality Assurance meetings and agreed with the recommendations the committee made to reduce the use of side rails. The Medical Director was not able to remember discussing R#23 being entrapped in her side rail on 4/1/19. The Medical Director revealed she is involved in care planning for all aspects of resident care and expects care plans to reflect any risk to the resident's wellbeing, with side rails as a risk, and the additional risk of an air mattress. These risks should be considered problems for the care plans and require interventions for the resident's safety. The Medical Director confirmed this should be explained to all residents and families that are consenting to side rails. An interview on 7/10/19 at 10:10 a.m. with the Administrator revealed her first day in facility was 6/4/19 and she was not given any information that a resident had been entrapped in side rails until the surveyors arrived. Meetings take place daily related to preventing falls, assessing individual needs, care planning and accuracy of orders. The Administrator revealed she attends at least three clinical meetings a week. The Unit Managers are expected to provide accurate updates and provide the Interdisciplinary team with new problems and risks for any resident whose care plan does not represent accurate information related to risks such as side rails and air mattresses. 2. Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan dated 12/22/18 noted R#24 was at risk for falls related to weakness. Interventions included side rails bilateral (enabler). Review of the Evaluation for Use of Side Rails for R#24 dated 1/20/19 revealed the use of side rails were being considered for R#24 to allow resident increased bed mobility. However, the same document indicated the resident's mobility is very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. In addition, the Quarterly MDS assessment dated [DATE] Section G0110A Bed mobility revealed that R#24 requires total assistance to move in bed. Section C0500 Brief Interview for Mental Status is coded 00 which indicates R#24 was severely cognitively impaired and unable to be interviewed. Review of a document dated 1/30/19 titled Daily Skilled Nursing Note revealed R#24 is alert and responsive, non-verbal. Requires total dependence on staff for all ADL's and transfers. Review of the Progress Note for R#24 dated 2/3/19 at 11:19 p.m. revealed residents right leg caught in bed rail. No bruising noted. Right leg and ankle [MEDICAL CONDITION]. No obvious signs of injury. Review of the Physician's telephone order dated 2/4/19 revealed Right Knee x-ray 2 views and Right ankle x-ray 2 views, indication: pain and swelling. Review of document titled SHC NP (Nurse Practitioner) Medical Partners dated 2/4/19 revealed, Chief Complaint/History of Present Illness, lower leg pain, Patient noted with right leg caught in side rail of bed, onset of symptom -1 day ago. Mechanism of injury-direct trauma. Severity -mild, Pertinent Findings- swelling, denies bruising, denies decreased range of motion, denies pain with movement and denies warmth. Review of page 3 of 3 included the NP's Plan; right leg pain, X-ray right knee and ankle continue to monitor for changes/worsening and symptoms, Nursing to continue assistance with ADL's and care, Tylenol as needed for pain, Elevate extremity and rest. Will

Based on interview and record review, the facility failed to ensure residents were provided with interventions as outlined on the care plan for 1 of 12 sampled residents (R4). Resident (R) 4 sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization (Cross Reference F323). Findings include: Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The 3/7/16 admission Minimum Data Set (MDS) assessment indicated the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) - meaning moderate cognitive impairment. Review of the 3/9/16 care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party. Review of the electronic skilled nurses' notes with the Staff Development Coordinator (SDC) revealed a nurse's note dated 3/23/16 timed at 4:15 p.m. indicating R4 was found on the floor. The care plan was updated on 3/23/16, indicating that the resident's fall was related to her leaning over in her wheelchair to pick up her remote control and an intervention was added instructing maintenance to assess the resident's wheelchair for proper functionality and to keep items within reach. Interview with the Maintenance Director on 9/1/16 at 12:30 p.m. regarding his assessment of the resident's wheelchair revealed he had a Maintenance Log Book kept at each nurses' station. He said the Maintenance Book was checked frequently. The Maintenance Director said staff were instructed to document any maintenance request in the book, but staff were inconsistent with documenting their requests. He further reported most staff would simply tell him what needed to be fixed while passing in the hallways or elevator. When asked if he ever assessed a wheelchair on behalf of R4, he reported he remembered the resident when she was in the facility but did not recall a request to assess the wheelchair. He further stated he and the therapy department worked together on wheelchairs and he would double check the Maintenance Log Book. On 9/1/16 at 12:40 p.m. the Maintenance Director reported he was never informed of a request to look at R4's wheelchair and never assessed her wheelchair for proper functioning; the resident's care plan was not implemented.

Based on interview and record review, the facility failed to ensure residents were provided with interventions and supervision to prevent repeat falls for 1 of 12 sampled residents (R4). Resident (R4) sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization . Findings include: Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 3/7/16 admission Minimum Data Set (MDS) assessment revealed the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) - meaning moderate cognitive impairment. Closed record review for (R4) on 8/31/16 at 9:40 a.m. revealed upon admission the resident was assessed for falls and a care plan was generated on 3/9/16. Review of the care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party. Review of the electronic skilled nurses' notes with the Staff Development Coordinator (SDC) revealed a nurse's note dated 3/23/16 timed at 4:15 p.m. indicating R4 who is a bilateral above the knee amputee was heard in her room screaming for help. A Certified Nurse Aide (CNA) went to R4's room and alerted the nurse to come and assist because the resident had fallen and help was needed to get the resident off the floor. Review of a form in the closed record labeled Nursing Assessment dated 3/23/16 revealed the resident sustained [REDACTED]. The resident was seen by the facility's physician and an X-ray was obtained with negative finding. An updated plan of care dated 3/23/16 revealed the resident fall was related to her leaning over in her wheelchair to pick up her remote control and an intervention was added instructing maintenance to assess the resident's wheelchair for proper functionality and keep items within reach. There was no documented evidence of determining the root cause of the fall or implementing other interventions to prevent future falls. Interview with the Maintenance Director on 9/1/16 at 12:30 p.m. regarding his assessment of the resident's wheelchair revealed he had a Maintenance Log Book kept at each nurses' station. He said the Maintenance Book was checked frequently. The Maintenance Director said staff were instructed to document any maintenance request in the book, but staff were inconsistent with documenting their requests. He further reported most staff would simply tell him what needed to be fixed while passing in the hallways or elevator. When asked if he ever assessed a wheelchair on behalf of R4, he reported he remembered the resident when she was in the facility but did not recall a request to assess the wheelchair. He further stated he and the therapy department worked together on wheelchairs and he would double check the Maintenance Log Book. On 9/1/16 at 12:40 p.m. the Maintenance Director reported he was never informed of a request to look at R4's wheelchair and never assessed her wheelchair for proper functioning. During an interview with the SDC on 9/1/16 at 10:30 a.m. she reported, according to the resident's electronic record, the SBAR (Situation, Background, Assessment and Recommendation) note dated 4/5/16 timed 8:00 a.m. revealed the resident again fell from her wheelchair and sustained an injury. The resident was found in her room lying on the floor on her left side. Resident stated she finished brushing her teeth by the bathroom sink and was wheeling herself back to her table when she leaned forward too far and fell . Nurse's notes revealed the resident's injuries consisted of blood coming from her nose and a laceration noted on the bridge of her nose. A hematoma was noted above and around the resident's left eye. Two staff assisted the resident from the floor into the bed and the bleeding stopped. The Nurse Practitioner was in the facility, assessed the resident and instructed staff to send the resident to the hospital for evaluation and treatment. A detailed review of the hospital notes revealed the resident presented to the hospital per stretcher after her fall in the facility. According to the Emergency Physician notes dated 4/5/16, the resident had facial injury and bruising, left facial swelling and nose bleed. Results of Computed Tomography (CT scan) revealed mildly displaced fracture of the left orbital and medial wall. HemoSinus due to trauma, Left periorbital and frontal soft scalp tissue hematoma, Irregularity of the nasal bone and questionable age indeterminate nasal bone fractures. R4's pain was documented in the ER as moderate. The ER physician described the findings as suspicious and documented his concern for the resident safety. The resident did not return to the Nursing Center according to the closed record. She was discharged home from the ER with family and home health on 4/5/16.